Endoscopic dacryocystorhinostomy (DCR)
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This is Richard Allen at the University of Iowa.
This video demonstrates an endoscopic dacryocystorhinotomy (DCR).
The endoscope is introduced into the left nares where the middle turbinate and middle meatus are noted. Inferiorly, the inferior turbinate is demonstrated. Inferior to the inferior turbinate resides the inferior meatus where the nasolacrimal duct exits. The upper punctum is dilated with a punctal dilator. A light pipe is placed through the upper punctum and canaliculus to illuminate the lacrimal sac. This is demonstrated by dimming the light of the endoscope. The area of the lacrimal sac fossa is illuminated. The middle turbinate is displaced medially so that the area of the middle meatus can be visualized. The middle meatus is then infiltrated with lidocaine with epinephrine. The middle turbinate is also infiltrated with the same anesthetic mixture. Due to the close proximity of the middle turbinate to the area of the lacrimal sac fossa in this case, a partial turbinectomy will be performed. This is performed with front-biting forceps.
A 66 Beaver blade on a long handle is then used to make an incision along the anterior extent of the lacrimal sac fossa which corresponds to the anterior lacrimal crest. The freer periosteal elevator is then used to elevate the nasal mucosa from the underlying bone. The freer is then used to break through the thin bone of the posterior extent of the lacrimal sac fossa. A Hardy sella punch is then used to remove the bone of the lacrimal sac fossa. Additional bone is removed to expose the entire extent of the lacrimal sac. The goal here is to insure that the superior and anterior bone is removed adequately to attain an appropriately sized ostium. The light pipe is used periodically to demonstrate the extent of the bone removal and the amount of the lacrimal sac exposed. Once all bone of the lacrimal sac fossa is removed, the light pipe can demonstrate the entirety of the lacrimal sac. A small defect in the lacrimal sac is demonstrated. The 66 Beaver blade is then used to make a vertical incision along the length of the lacrimal sac. Anterior and posterior incisions are then used so that the interior of the lacrimal sac can be visualized. The light pipe is then able to be placed through the area of the incision. This shows a good opening of the lacrimal sac.
A Crawford stent is then placed through the upper punctum and canaliculus and through the ostium. It is visualized and retrieved from the nose with the Crawford hook. The other end of the stent is then placed through the lower punctum and canaliculus and retrieved from the nose. A Watzke sleeve is placed over the stents and tightened so that it resides in the area of the ostium. At the conclusion of the case the Crawford stents will be tied together. The stent will remain in placed for approximately four months and then be removed.