|Year : 1972 | Volume
| Issue : 3 | Page : 127-129
GC Sood, BK Sofat, SK Mehrotra, RD Chandel
Department of Ophthalmology, Himachal Pradesh Medical College, Simla-1, India
G C Sood
Department of Ophthalmology, Himachal Pradesh Medical College, Simla-1
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Sood G C, Sofat B K, Mehrotra S K, Chandel R D. Modified dacryo-cysto-rhinostomy. Indian J Ophthalmol 1972;20:127-9
From the time TOTI  described external Dacryo - cysto-rhinostomy (D.C.R.) operation, several modifications have been suggested either to improve the results or to facilitate and simplyfy the otherwise hazardous technique. We carried out a modified method in our cases with very gratifying results; the same is being presented here.
| Method|| |
The cases of chronic dacryocystitis were investigated and only those with obstruction in nasolacrimal duct (N.L.D.) or at the junction of lacrimal sac and N.L.D. were selected. Before undertaking the operation, any pathology of the nasal passages was excluded and if present was duly rectified. The operations were carried out under general anaesthesia, however, this surgery can be safely performed under local anaesthesia in co-operative patients. The nasal cavity on the side of the operation was packed with gauze strip soaked in 2% xylocaine with adrenaline.
The lacrimal sac and fossa are exposed by the usual incision and dissection. Lacrimal sac is retracted laterally and periorbita removed from lacrimal fossa and adjoining region. A circular osteotomy hole about 1.8 to 20 mm is made in the medial wall of the orbit, such that its lower end corresponds with the junction of lacrimal sac and nasolacrimal duct. The nasal mucosa opposite the osteotomy hole is deliberately removed. Now a transverse cut is made in the middle of medial wall of sac and its anterior and posterior limits are extended both upwards and downwards, thus fashioning an upper and lower flap. [Figure - 1].[Figure - 2]. The upper flap is sutured to the periorbita and soft tissues around the upper margin of bony opening with 3 x 0 plain catgut. Similarly the lower flap is sutured to the periorbita and soft tissues near the lower margin of the opening. Thus the interior of the sac forms a well epithelialized surface opposite the osteotomy opening and no cul-de-sac is left in the dependent portion of the sac. Medial palpebral ligament is sutured by plain catgut and skin incision closed with interrupted or subcuticular 3 x 0 silk sutures. Nasal pack is removed and pressure bandage given. Dressing is removed on the next day, conjunctival sac cleaned with normal saline and an antibiotic cream applied. Nasal cavity is examined by anterior rhinoscopy and any blood clot or crust if present is removed gently by swabing. Syringing of the sac with crystalline penicillin lotion in normal saline (10.000 units/ml) is started on the fourth postoperative day and repeated once or twice a week for about two months. While syringing, the tip of the lacrimal cannula is pushed beyond the osteotomy hole and gently moved from side to side with the object of dislodging any blood clot if present and prevent the formation of fibrous membrance Ephedrine saline drops 1 % are given 2 to 3 times a day as a routine measure to prevent nasal congestion and oedema. Skin stitches are generally removed on the seventh day.
| Observations|| |
So far we have operated upon six patients by this method. The age ranged from 16 to 55 years. In all the cases post-operative recovery was uneventful, epiphora disappeared and on syringing, fluid readily passed into the nasal cavity indicating patency of lacrimo-nasal passage.
| Discussion|| |
TOTI's  original technique of external dacryo-cysto-rhinostomy was improved upon by MOSHER  who recommended removal of medical wall of lacrimal sac and nasal mucosa from the osteotomy hole, without putting sutures. As the results were not very satisfactory and frequently the opening was blocked, DEPUY DUTEMPS  made anterior and posterior flaps in the medial wall of lacrimal sac and nasal mucosa and sutured them separately. WRIGHT  also preferred the two-flap method. Frequent injury of friable nasal mucosa during osteotomy and suturing, made these operations extremely difficult. TRAQUIR,  PRASAD AND BAJPEYI (1966) sutured anterior flaps only. GILL  inserted a rubber catheter in the lacrimal sac and brought the other end from the nostril. This method besides being cumbersome and unpleasant for the patient is likely to produce chronic nasal discharge. SUMMERSKILL , suggested two methods of D.C. R. by intubation. The results again were not satisfactory and in many cases progressive cicatrization pushed the tube into the lacrimal sac. Moreover polyethelene tube tends to produce foreign body reaction, chronic inflammation, sloughing of medial wall of sac, excessive cicatrization and closure of the opening. Drill dacryocysto-rhinostomy through transcanalicular approach of NAGPAL, MATHUR AND BALDHA  has been described, but has the disadvantage of being a blind procedure, produces a small opening with possibility of injury to the cannaliculus and nasal septum and early closure. WEST'S  method of performing D.C.R. though nose really never became popular with ophthalmologists because of limited field for surgery and difficulty in establishing anastomosis. In most of the procedures, the greatest difficulty arises in preserving the nasal mucosa and placing sutures through the flaps and often it becomes impossible to achieve this. The chief advantage of the present procedure is that it obviates the necessity of preserving and suturing the friable nasal mucosa. Upper and lower flaps of lacrimal sac are easy to suture. Besides it prevents the formation of a cul-de-sac in the dependent portion, where accumulation of tears can otherwise be a constant source of recurrent infection. Drainage is facilitated by the action of gravity.
| Summary|| |
A modified technique of dacryocysto-rhinostomy is described in which the nasal mucosa opposite the osteotomy hole is deliberately removed. Upper and lower flaps are fashioned in the medial wall of lacrimal sac and are sutured to the periorbita and soft tissues near the upper and lower margins of the opening. The advantages of such a procedure are (1) Cul-de-Sac does not remain, (2) application of the sutures is easier.
In six patients who were operated by this method epiphora ceased and the ostrum remained patent during the follow-up period.
| References|| |
Dupui-Dutemps; cited by Stallard in 6, p. 327 (1933).
Gill, W. D.: Dacryocystorhinostomy, Simplified Technique. Amer. J. Ophth., 30, 198, (1947).
Mosher: cited by Speath in 7, p. 114, (1921).
Nagpal, P. N.; Mathur, R. N. and Baldha, C. R.: Drill Dacryocystorhistostomy J. All India Ophth. Soc., 17, 226, (1969).
Prasad, P. N. and Bajpeyi, S. P.: One flap Dacryocystorhinostomy. J. All. India Ophth. Soc. 14. 176, (1966).
Speath, E. A.: The principles and Practice of Ophthalmic Surgery, 3rd edit., Lea & Febiger, Philadelphia (1944).
Stallard, H. B.: Eye surgery, 3rd edit. John Wright & Sons, Bristol, (1958).
Summerskill, W. H.: Dacryocystorhinostomy. Trans. Ophth. Soc. U.K., 69, 494, (1949).
Summerskill, W. H.; Dacryocystorhinostomy by intubation. Brit. J. Ophth., 36, 240, (1952).
Toti, A.: Clin. Med. Firenze, 10, 385, cited by Summerskill in 9.
Traquair, H. M.: External Dacryocystorhincstomy. Trans. Ophth. Soc. U.K., 52, 149, (1932).
West, P.: cited by Speath in 6, p. 117, (1932).
Wright, R. E.: Dacryocystorhinostomy. Loncet, ii, 250, July (1937).
[Figure - 1], [Figure - 2]