How to manage Dacryocystorhinostomy (DCR)?

Management of Dacryocystorhinostomy (DCR)

Endoscopic dacryocystorhinostomy is the preferred surgical approach for treating nasolacrimal duct obstruction, with success rates of 90-95% when performed with proper technique and appropriate patient selection. 1

Surgical Approaches

• Endoscopic endonasal DCR has become the standard approach, offering comparable success rates to external DCR while avoiding external scarring 2, 1
• External DCR remains a valid alternative with historically high success rates (>90%) but results in visible scarring 3
• The choice between approaches should prioritize surgeon expertise and anatomical considerations rather than arbitrary preference 1

Preoperative Assessment and Planning

• CT scan with fine-cut protocol is essential for surgical planning to evaluate paranasal sinuses, identify anatomical variants, and detect any erosive processes 4
• Preoperative workup should include:
  • Fluorescein dye testing (Jones test)
  • Probing and irrigation of lacrimal pathways
  • Nasal endoscopy to evaluate intranasal anatomy 1

Anesthesia Considerations

• Most DCR procedures can be performed under local anesthesia without sedation, particularly in older patients 5
• General anesthesia may be preferred for younger patients, with studies showing slightly higher success rates (96.7% vs 84.9%) 5
• The choice of anesthesia should consider patient age, anxiety level, and anatomical complexity 5

Surgical Technique

• Preservation of both nasal and lacrimal mucosa is critical for optimal outcomes:
  • Create posteriorly hinged lacrimal sac and nasal mucosal flaps
  • Manual osteotomy of the frontal process of the maxilla
  • Removal of the lacrimal bone 2
• Silicone stent placement is recommended in most cases, with removal typically after 3 months 1
• Meticulous surgical technique focusing on creating adequate bony window and proper mucosal flap apposition is essential for success 2, 1

Management of Acute Dacryocystitis

• Primary endoscopic DCR is effective for managing acute dacryocystitis and lacrimal abscess 6
• Initiate antibiotics immediately or one day before surgery and continue postoperatively 6
• Be prepared for increased intraoperative bleeding in acute cases 6
• Symptomatic relief typically occurs within 3 days, with complete resolution within a week 6

Postoperative Care

• Regular follow-up at 1 week, 1 month, and 3 months post-surgery 2
• Evaluation should include:
  • Assessment of subjective symptoms of epiphora
  • Lacrimal irrigation to confirm patency
  • Endoscopic evaluation of the surgical site 2, 1
• Nasal saline irrigations are beneficial for postoperative care to improve mucociliary clearance 4

Outcomes and Success Rates

• Anatomical success (patent ostium on irrigation): 89-92% for primary DCR, 85-89% for revision cases 1
• Functional success (resolution of epiphora): 85-90% for primary DCR, slightly lower for revision cases 1
• Common causes of failure include cicatricial closure of the ostium and inadequate bony window creation 6
• Patient satisfaction is typically high (>95%) with proper technique and follow-up 3

Complications and Their Management

• Hemorrhage (3-4% of cases): typically managed with nasal packing 3
• Scarring (2-3% with external approach): minimized with endoscopic approach 3
• Ostium stenosis: may require revision surgery 1
• Careful attention to hemostasis and proper mucosal flap creation reduces complication rates 2, 1