Operative Technique

In principle, performing an endoscopy in the lacrimal system is no more invasive than a deep probing of the lacrimal system. The puncta have to be dilated and it is useful to use an astringent solution some minutes before the endoscopy starts. Irrigating softly, the endoscope is inserted via the upper or lower canaliculus. The endoscope is pushed forward as far as possible as in normal lacrimal systems down to the inferior meatus, in other cases up to the point of stenosis. Unlike the endoscopies of the gastrointestinal system, the complete lacrimal passage can be judged by retracting the endoscope with simultaneous irrigation. Retracting and advancing the endoscope requires a certain amount of experience to obtain good pictures and to avoid a false passage. The learning curve is comparable to that for other endoscopic procedures such as gastroscopy, but even experienced examiners are not always able to get good pictures. In nearly every case, however, the additional information on the lacrimal system is useful.

In children under the age of 2 years the small diameter of the lacrimal system, especially of the punc-tum, increases the risk of injury; therefore, a purely diagnostic endoscopy should only be carried out in exceptional cases. Nevertheless, diseases of the lacrimal system in early childhood are mainly caused by malformations and in these cases the endoscopy cannot provide any essential additional information for the therapeutic procedure. Only in cases of failure following prior procedures should an endoscopy with subsequent endoscopic rechannelizing be performed to avoid a pediatric DCR [5].

10.2.5.1 Normal Findings

The endoscopic examination consists of observing various parts of the lacrimal system with different tissue formations such as the nasolacrimal duct, the lacrimal sac, and the canaliculi. In normal findings, the canalicular mucosa appears white and smooth. The canaliculi have a narrow lumen and a homogeneous structure of the walls (Fig. 10.5). The mucosa of the lacrimal sac is reddish, the lumen is wide, and the wall is structured by flat valves. During endoscopy, the production of mucus can soon be seen. After touching the mucosa, a small amount of bleeding on the surface can be noticed. If there is an inflamed sac,

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