Endoscopic dacryocystorhinostomy (DCR) #2
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This is Richard Allen at the University of Iowa.
This is an additional example of an endoscopic dacryocystorhinostomy (DCR).
The area of the middle meatus is demonstrated with the middle turbinate centrally and the nasal septum medially. A light pipe will then be placed through the upper punctum and canaliculus. Intranasal examination demonstrates illumination of the lacrimal sac and lacrimal sac fossa. This provides an outline of the area of the bone to be removed. A 66 Beaver blade on a long handle is then used to make an incision through the nasal mucosa along the anterior extent of the lacrimal sac fossa, corresponding to the anterior lacrimal crest. The Freer periosteal elevator is then used to elevate the nasal mucosa from the underlying bone. There is not a lot of space in this nose, but it appears to be adequate for this endonasal procedure. The thin bone of the posterior portion of the lacrimal sac fossa can often be broken by the Freer.
A drill will be used in this procedure to remove some of the bone of the lacrimal sac fossa. This is useful especially for the superior thick bone which can often be difficult to remove with the rongeurs. Examination of the area shows that the lacrimal sac has been exposed. A Hardy sella punch is then used to remove additional bone. Again, superiorly this can be difficult, but this is likely the most important area of the bone removal to perform. The light pipe is now visible as well as the lacrimal sac. Additional drilling is performed to remove bone. Success of this procedure will be dependent on the construction of a generous ostium. The light pipe is used to demonstrate the extent of the bone removal. A Beaver blade is used to make an incision through the lacrimal sac. The light pipe is used to demonstrate the opening in the lacrimal sac. This opening will be further enlarged with the Beaver blade as well as 45 degree sinuscopy forceps. Once the ostium and opening in the lacrimal sac are adequate, Crawford stents will be placed through the system. These are retrieved from the nose with the Crawford hook. The stents will be tied together and will be removed in approximately 4 months.