Core Messages

■ Make certain of a diagnosis of distal nasolacrimal duct obstruction as a DCR does not help proximal obstruction and is less effective if there is a functional problem.

■ Although rare, it is important to exclude pathology such as malignancy in the nasolac-rimal sac or paranasal sinuses. Results are poorer in sarcoidosis and surgery should be avoided in active Wegener's granulomatosis.

■ Laser DCR has many advantages over conventional methods when a patient is anticoagulated or has a coagulopathy.

■ Laser DCR is more amenable to being performed under local anesthetic than other techniques, which is useful in those patients unfit for a general anesthetic.

■ Laser DCR can be used to resolve cases of acute dacryocystitis.

■ A relative indication for laser DCR is for revision surgery for a failed external DCR when there is often only a thin membrane blocking the rhinostomy.

■ Suitable lasers include the KTP/532, Holmium:YAG, and diode laser.

■ Laser DCR long-term patency rates are generally not as good as external DCR or endoscopic DCR using conventional instruments.

Contents

7.1 Introduction and Background of Technique 74

7.1.1 Types of Laser 74

7.1.2 Laser vs Non-laser Endonasal DCR 74

7.1.3 Team Approach 74

7.2 Indications for Endoscopic Laser Dacryocystorhinostomy 76

7.3 Contraindications for Endoscopic

Laser Dacryocystorhinostomy 76

7.4 Patient Assessment: Case History 77

7.4.1 Investigations 78

7.5 Instrumentation 78

7.6 Anesthesia 78

7.6.1 Local Anesthetic 78

7.6.2 General Anesthetic 78

7.6.3 Operative Technique 78

7.6.3.1 Preparation 79

7.6.3.2 Access to the Operating Site 79

7.6.3.3 Insertion of the Light Pipe 79

7.6.3.4 Localization of the Transilluminated Site 79

7.6.3.5 Laser Vaporization of Mucosa and Bone 79

7.6.3.6 Opening of the Lacrimal Sac and Creation of the Rhinostomy 80

7.6.3.7 Syringing the System 81

7.6.3.8 Insertion of the Stent 81

7.7 Potential Problems 81

7.7.1 Narrow Punctum 81

7.7.2 Poor Surgical Access 81

7.7.3 Intraoperative Bleeding 81

7.7.4 Aiming Beam Reflection 81

7.7.5 Poor Transilluminated Light Beam Spot 82

7.8 Highlights 82

7.9 Post-operative Care 82

7.10 Results 83

7.11 Management of Failures of Laser DCR 83

7.12 Post-operative Complications 83

7.12.1 Hemorrhage 83

7.12.2 Granuloma Formation 83

7.12.3 Synechia 84

7.12.4 Stent Migration 84

7.13 Variations in the Standard Procedure 84

7.13.1 Avoidance of Stenting 84

7.13.2 Combined Laser and "Cold" Instrument Surgery 84

7.13.3 Antimitotic Application 84

7.14 Conclusion 84

Reference 85

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Essentials of Human Physiology

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