What is the treatment for nasolacrimal duct obstruction using DCR (Dacryocystorhinostomy)?

Treatment of Nasolacrimal Duct Obstruction with Dacryocystorhinostomy (DCR)

For primary acquired nasolacrimal duct obstruction (PANDO), endoscopic endonasal DCR should be considered the primary treatment approach, offering comparable success rates to external DCR (90-94% anatomical success) with faster recovery and no external scarring. 1

Surgical Approach Selection

Endoscopic Endonasal DCR (EN-DCR)

• Achieves 90.7% functional success and 93.5% anatomical success rates at 6 months postoperatively 1
• Provides significantly faster symptom relief (1.7 weeks versus 3.7 weeks for external approach) 1
• Avoids external skin incision, preserving medial palpebral structures and the physiological palpebral-canalicular pump mechanism 2
• Requires permanent endoscopic visual control from the nasal cavity during the procedure 2
• Should be performed with bicanalicular silicone intubation for optimal outcomes 2

External DCR (EX-DCR)

• Achieves 90.1% functional success and 95.8% anatomical success rates 1
• Remains the traditional gold standard with slightly higher long-term success for postsac obstructions (91% at initial follow-up, declining to 80% at 3 years) 3
• Should be reserved for cases where EN-DCR fails or when endoscopic visualization is inadequate 2
• Requires skin incision with associated risks of wound dehiscence and keloid formation 1

Technical Considerations

Laser-Assisted Transcanalicular DCR

• Represents a minimally invasive alternative using diode laser technology to create a bony ostium between the lacrimal sac and nasal cavity 2
• Should be considered as a second-step procedure after failure of recanalization procedures and before external DCR 2
• Offers shorter surgical duration and reconvalescence compared to external DCR 2
• One-year functional success rates are high but still range behind external DCR 2

Microsurgical DCR-Anastomosis (DCR-A)

• Involves end-to-side anastomosis under microscopic visualization through circumferential suturing 4
• Eliminates raw surfaces that may lead to reocclusion from postoperative granulation tissue 4
• Demonstrates superior outcomes compared to conventional DCR with no requirement for additional postoperative therapy 4

Location-Specific Success Rates

Postsac Obstructions

• Achieve significantly better outcomes with external DCR (91% initial success, 80% at 3 years) 3
• Both endoscopic and external approaches show comparable high success rates 1

Presac Obstructions

• Show significantly worse outcomes (67% initial success, declining to 47% at 3 years with external DCR) 3
• Presac delays demonstrate statistically significant association with postoperative recurrence of epiphora (p = 0.04) 3
• Require careful patient counseling about lower success rates and may need alternative surgical approaches 3

Special Populations

Sarcoidosis-Related Obstruction

• EN-DCR achieves 100% success rates at mean 11.3 months follow-up when performed with either powered-type or mechanical technique 5
• Characteristic findings include yellowish, crusty, edematous, and friable appearance of lacrimal sac and nasal mucosa (83% of cases) 5
• Nasal congestion is a frequent associated symptom (57% of patients) 5
• Perioperative oral prednisolone (30-60 mg tapered over 10 days to 8 weeks) should be considered, though successful outcomes may not depend on intensive long-term steroid therapy 5

Postoperative Management

Silicone Intubation

• Should be maintained for appropriate duration to prevent ostium closure 3, 1
• Early canalicular stent dislodgement occurs in approximately 6% of cases (4% EN-DCR, 6% EX-DCR) 1

Complications to Monitor

• Silicon tube prolapse, mild swelling, and rarely canalicular infection or thermal injury with laser-assisted procedures 2
• Postoperative nasal bleeding (rare with EN-DCR) 1
• Skin wound dehiscence and keloid formation (specific to external approach) 1

Success Assessment Criteria

Anatomical success requires: Patent ostium on intranasal endoscopic inspection and successful lacrimal irrigation 1

Functional success requires: Complete resolution of epiphora and positive fluorescein dye disappearance test at 6 months postoperatively 1

Critical Pitfall

The most important caveat is that presac delays have significantly worse outcomes regardless of surgical technique, with success rates declining from 67% initially to 47% at 3 years. 3 Preoperative lacrimal scintigraphy should be performed to identify presac versus postsac obstruction, as this significantly impacts surgical planning and patient counseling. 3