Indian Journal of Ophthalmology

: 1967  |  Volume : 15  |  Issue : 3  |  Page : 81--85

Dacryocystorhinostomy - a new technique of suturing the flaps by using modified sewing machine needle

RN Mathur, PT Chakko, R Ebenezer, Gowri Kumar 

Correspondence Address:
R N Mathur

How to cite this article:
Mathur R N, Chakko P T, Ebenezer R, Kumar G. Dacryocystorhinostomy - a new technique of suturing the flaps by using modified sewing machine needle .Indian J Ophthalmol 1967;15:81-85

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Mathur R N, Chakko P T, Ebenezer R, Kumar G. Dacryocystorhinostomy - a new technique of suturing the flaps by using modified sewing machine needle . Indian J Ophthalmol [serial online] 1967 [cited 2021 Jun 17 ];15:81-85
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Although lot of technical improve­ments have been achieved in dacryo­cystorhinostomy operation from the time of Toti (1904), still suturing the mucosal flaps offers difficulty and make this, otherwise simple operation, not quite so popular. Modified sewing ma­chine needles of our design have sim­plified this suturing of the flaps. We would like to share our experience with a review of 255 D.C.R. operations done in 223 patients at the Schell Eye Hospital of the Christian Medical Col­lege, Vellore.

 Modified Sewing Machine Needles

These needles come in many sizes ranging from No. 9 to No. 25. We prefer No. 14 as adequate for our work. These can be modified very easily in any theatre. The lip is grinded short and resharpened. These are heat­ed over spirit lamp or any flame and bent at 120˚ and 45˚ angles to make for posterior flaps and anterior flaps, respectively [Figure 1]

These can be fixed on Elliots tre­phine holders [Figure 2] or artery forecep. Capt. Subramaniyam of Madras had made a nice holder for these, like the one used for holding laryngoscope mirror. These needles combine the advantage of Reverdin's needle and Dupuy-Dutemps miniature aneurismal needles and Sarda's needle and at the same time laceration of even a fragile flap is infrequent. These are very cheap and locally available in all places.

Views about the earliest time one may do the operation have been modi­fied ever since the time of Toti (1904) and Dupuy-Dutemps (1920). We feel that 2 years (Stallard-1958) is too young an age while we may operate at 3 years of age.

Today most types of lacrimal sac affections can be managed much better by D.C.R. and dacryocystectomy has very few indications.

Operative Technique:

In most patients the operation was performed under local anaesthesia, ex­cept in children where general anes­thesia was administered by endotra­cheal route. Nose is packed with ane­thaine 1 with adrenaline before the operation. We premedicate our patients with Largactil 50 mg. 2 hours before operation.

Exposure of Sac:

We prefer to make the incision well forward, straight and boldly down to the bone in one sweep. (Hallum, 1943, 1948). A vertical incision is made 2 cm. long with its upper limit 1 mm. above the level of the inner canthus, and 1 cm. nasally. With a periosteal elevator the entire bony surface is ex­posed and soft tissues including the lacrimal sac arc retracted laterally. This exposes the lacrimal fossa upto the posterior lacrimal crest. Wound edges are retracted with sutures an4 clamped further forwards.

 Bone Resection

Many methods are available using chisel and hammer (Jain, Sethi and Prakash, 1955) dental drill, hand and electric trephine or drill. We found it much simpler to break the lacrimal part of the fossa, which is very thin, by lacrimal curette. This makes the opening big enough to introduce Citelli's punch. Enlarging the same, an osteum measuring about 1.5 x I cm. is made. The nasal pack is re­moved.

Incision for making Flaps

A probe is passed through the in­ferior punctum and the canaliculus into the sac and pushed medially to elevate the medial sac wall. A stab wound is made in it with an used ca­taract knife and enlarged up and down with scissors, the ends being cut in "I" shape. This results in two window flaps in the medial sac wall. [Figure 3].

The nasal mucous membrane flaps are made in the same way, the vertical cut being such that the anterior flap is bigger than the posterior. This may have to be modified according to indi­vidual case.

Suturing of Mucosal Panel Flaps:

This is the most difficult part of the operation. Movements of ordinary needles are difficult to manipulate in the depth and in this restricted area. We have modified a Singer sewing machine needle which has eased this otherwise difficult operation. [Figure 1],[Figure 2]

The posterior flap suturing needle has an obtuse angle of about 120° and anterior one of about 45 degree. We have been using these since 1960 and in no case we found difficulty. Lacera­tion which occurs with the Dupuy-­Dutemps miniature aneurismal needle and Reverdin's needle is absent. The posterior and anterior flaps of sac and nasal mucous membrane are sutured using 4 Zero silk or catgut as illus­trated in [Figure 4],[Figure 5],[Figure 6],[Figure 7].

Closing of incision:

The wound is sutured in two layers. First the retracted periosteum, medial palpebral ligament and muscles are sutured, using few interrupted catgut stitches. The wound is dusted with sulfa powder. The skin wound may be closed by subcuticular continuous stitches using 000 black silk. Terramy­cin ointment is applied into the con­junctival sac. Gauze dressing is applied and the wound bandaged.

Postoperative Management:

Many surgeons recommend syring­ing the duct from the 4th day using steroids. In our experience it is not necessary. The bandage is removed after 48 hours and wound allowed to heal by leaving it open, cleaning every day with alcohol. On the 6th post­operative day sutures are removed and the first syringing is done. Next day the patient goes home with zinc adre­naline drops for home use.


Hemorrhage from the skin incision was rare and incision being more medial, angular vein is hardly ever in­volved.

Fracture of the lacrimal bone which occurs during chiselling is absent using the punch technique in making the osteum.

Laceration of the nasal mucosa or the sac itself can occur if no care is taken to retract it while using the punch. Using these modified sewing needles laceration is infrequent while suturing.


The followup of these cases are very difficult once they are discharged from the hospital. But surely they come back if any trouble persists. Hence our results are mainly seen postope­ratively. Two cases were definite fai­lures and excision of the remains of the sac was done. 8 cases had mild block which cleared with probing once and syringing for 3-4 days.

Skin wound becomes inconspicuous within 2-3 months of the operation.


Although chronic dacryocystitis and mucocele with atonic sac offer the most favourable prognosis, with more and more experience good results with relief of epiphora may be obtained even in cases of chronic dacryocystitis with fistula and pseudo sac after dacryocystectomy. We had good re­sults in 20 such cases in this series.

Obstruction in the common canali­culus was regarded in the past as con­traindication, however Berrie Jones, Canaliculodacryocystorhinostomy and polyethylene intubation has improved the success rate in these cases. We used epidural tube in 10 cases with blocked lower canaliculus. 7 were reoperated cases, 2 injury and one pseudosac. The tube was left through the D.C.R. open­ing into the nose and removed after 3 months.

D.C.R. is not favoured in quite young children but even in them it is not contraindicated. (Stallard, 1958). 19 of our patients were under 15 years of age and youngest was 4 years. We think 2 years is rather too young an age but we have done D.C.R. in 3 year olds. The results are yet to be known, hence they are not included in this series.

[Table 2] shows the relative age and sex incidence.

Youngest patient in this series is 4 years and oldest 78 years. There is a relatively higher incidence among fe­males (69%).

A more medially placed incision (Hallum 1948) well forward (1 cm. medial to the inner can thus) made straight and boldly down to the bone has its advantage, that exposure of sac is best, angular vein is not cut, and Mongoloid folds (as reported by Keith-­Lyle, Cross, Simpson and Frazer, 1946) are absent in a medially placed inci­sion. As the skin incision and sutured flaps are at different levels, blockage by the development of scar tissue is infrequent. The success of operation largely depends upon correct apposi­tion of the flaps, suturing of flaps with­out laceration which is facilitated by the use of these modified sewing ma­chine needles. It is difficult to agree with Shuttleworth (1949) that the exact technique of operation does not affect the ultimate result.

Subcuticular skin stitches render the incision line inconspicuous and in our opinion a few deep catgut sutures go a long way towards producing a nor­mal canthal appearance.[9]


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8Sarda, R. P. Et al. Brit. Jn. Ophthal. (1961) 45, 138-143.
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