**4. Assessment of the patient**

## **4.1 Physical examination**

A comprehensive ophthalmologic examination is mandatory in the primary evaluation of every patient with lacrimal system obstruction. An examination with the slit lamp can reveal the normal or abnormal tear film over the conjunctiva and if the thickness of the tearfilm is more than usual, it can be a sign of lacrimal drainage system obstruction. In addition, the ocular surface, eyelid structures, visual acuity, extraocular motility, and visual field should be tested and documented before surgery.

Gentle pressure over the sac produces reflux of mucopurulent material suggestive of lower sac obstruction (regurgitation test).

Irrigation test is another useful test in assessing patients. In this test, an appropriate lacrimal syringe is passed through the inferior lacrimal punctum and 2-5 ml of sterile distilled water is injected and pushed though the inferior canaliculus. If the water passes easily into the nose and the patient senses that, the patency of the system is confirmed. Otherwise, it is one of the most reliable signs of lacrimal system obstruction. Some authors recommend that after either external or endoscopic DCR, this test can be performed indicating the patency of the system.

Nasal examination, especially nasal endoscopy, should be obligatory for every lacrimal obstruction patient. The examination of the lacrimal area with the nasal speculum and headlight provides only a poor view of this region and is not sufficient; Endoscopy provides a clear diagnostic look for nasal polyps, imporant anatomic variations, tumors, and other pathological endonasal conditions such as septal deviation.

Endoscopic Dacryocystorhinostomy 55

contraindication to any surgical intervention7. Nuclear lacrimal scan has been found to be helpful especially in difficult cases with incompletely obstructed pathways in which DCG could not be interpreted in a satisfactory manner to determine whether surgery should be

Computed tomography (CT) can be helpful in assessing the structures intimately associated with the nasolacrimal drainage system. The CT scanning is used mainly when an extrinsic disease is suspected and is of great help to the patients with paranasal sinus or facial pathology associated with the lacrimal system (tumor, rhinosinusitis, facial trauma,

Magnetic resonance is not used in practice in lacrimal diagnostics and is reserved only for

DCR is the treatment of choice for those patients who present with persistent epiphora or chronic dacryocystitis from nasolacrimal duct obstruction. The obstruction is usually due to a primary acquired condition of unknown etiology. The other causes are trauma, infection,

Dacryocystorhinostomy can be performed both externally and as an endoscopic approach. The external approach is commonly done by ophthalmologists. In external approach, an incision is made between the medial canthus and the nasal dorsum. Then the lacrimal sac is exposed and elevated from the lacrimal fossa. The lacrimal bone with an almost diameter of 1 cm is drilled. Hence, two anterior and posterior lacrimal flaps are created which are sutured to the flaps made from nasal mucosa. Finally, two silicone tubes (Budkin's tubes)

The endoscopic approach, however, has gained much attention among ENT surgeons. Endoscopic DCR can be performed under either local or general anesthesia. It is recommended to have a video camera attached to the endoscope so that the assistant

The patient is placed in a supine position with the head slightly elevated to decrease the venous pressure at the operation site. To decongest the mucosa, vasoconstrictors are applied through pledgets in the nose. Then, injections composing of 1% lidocaine and 1:100000 epinephrine must be performed. Usually, superior to the axilla and anterior to the uncinate

Sometimes, an endoscopic septoplasty is needed to reduce the complexity of the procedure11, 12. If required, appropriate injections in the septum must be done, too. The septoplasty is usually limited and just the superior and anterior portions of the bony septum

are passed through the superior and inferior canaliculi and fixed in the nose.

surgeon can observe the maneuvers on a video monitor.

the special cases, e.g., for differentiation of masses of the lacrimal sac8.

undertaken or not9.

**4.5 Computed tomography and MRI** 

following facial surgery, etc.)10.

**5. Surgical indications** 

neoplasm, and lacrimal stones.

**6. Surgical technique** 

process are injected.

are corrected.

Diagnostic nasal endoscopy is performed with a rigid endoscope or flexible endoscope which can be used without any difficulties in small children, too.

The rigid endoscopes are 4-mm in diameter, with 0 or 30° viewing angle. The 2.7-mm diameter endoscope can be advantageous, especially in children and some adults with narrow nasal cavities. The inferior and the middle meatus are better viewed if some decongestants are introduced into the nose.

#### **4.2 Radiologic evaluation**

Radiological tests should be done before DCR which include dacryocystography (DCG), nuclear lacrimal scintigraphy (dacryo scintillography), computed tomography (CT), and magnetic resonance imaging (MRI).

Dacryocystography is an anatomical investigation and is indicated if there is a block on syringing in the lacrimal system, and thus it can help in creating an image of how the internal anatomy of the lacrimal system looks.

Scintigraphy is a functional test and is useful in assessing the site of a delayed tear transit, i.e., it is useful only if the lacrimal system is patent on syringing.

Both CT and MRI are used very seldom and are reserved only for some patients with preceded trauma, facial surgery, tumor, or in whom sinus diseases are suspected.

#### **4.3 Dacryocystography**

Dacryocystography is a method in which injection of the radio-opaque water-soluble fluid is instilled into either lower or upper canaliculus taking magnified images. The digital subtraction technique is preferred because it gives an image of better quality. A DCG better evaluates the lacrimal sac and duct anatomy, but it evaluates worse canalicular anatomy. It outlines diverticulae and fistulae, and shows intrasac pathology (dacryoliths or tumor) and the sac size. A DCG is not routinely performed. It is seldom necessary with a complete obstruction in the non-traumatic situation. It can be especially useful in patients with previous trauma to localize the position of bone fragments or, after previously unsuccessful lacrimal surgery, to determine the size of the sac. With patency to syringing, the DCG helps to determine whether the stenosis is in the common canaliculus or sac, and it can rule out the presence of a lacrimal sac diverticulum6. A DCG can often find drainage abnormalities present in patients with "functional obstruction"6.

#### **4.4 Nuclear lacrimal scintigraphy**

Nuclear lacrimal scintigraphy is a simple, non-invasive physiological test that evaluates patency of the lacrimal system. Scintigraphy uses a radiotracer (technetium-99m pertechnetate), which is very easily detectable with a gamma camera. While a DCG is usually preferred especially in a complete obstruction, scintigraphy is useful only in those patients whose lacrimal system is patent to syringing in the presence of constant epiphora. The test is more physiological than DCG, anatomical information is lacking, and fine anatomical details are not available in comparison with DCG7. Correlation of the anatomical study (DCG) and functional study (scintigraphy) may be necessary in planning surgery8; However, it is important to bear in mind that a normal result is considered to be a

Diagnostic nasal endoscopy is performed with a rigid endoscope or flexible endoscope

The rigid endoscopes are 4-mm in diameter, with 0 or 30° viewing angle. The 2.7-mm diameter endoscope can be advantageous, especially in children and some adults with narrow nasal cavities. The inferior and the middle meatus are better viewed if some

Radiological tests should be done before DCR which include dacryocystography (DCG), nuclear lacrimal scintigraphy (dacryo scintillography), computed tomography (CT), and

Dacryocystography is an anatomical investigation and is indicated if there is a block on syringing in the lacrimal system, and thus it can help in creating an image of how the

Scintigraphy is a functional test and is useful in assessing the site of a delayed tear transit,

Both CT and MRI are used very seldom and are reserved only for some patients with

Dacryocystography is a method in which injection of the radio-opaque water-soluble fluid is instilled into either lower or upper canaliculus taking magnified images. The digital subtraction technique is preferred because it gives an image of better quality. A DCG better evaluates the lacrimal sac and duct anatomy, but it evaluates worse canalicular anatomy. It outlines diverticulae and fistulae, and shows intrasac pathology (dacryoliths or tumor) and the sac size. A DCG is not routinely performed. It is seldom necessary with a complete obstruction in the non-traumatic situation. It can be especially useful in patients with previous trauma to localize the position of bone fragments or, after previously unsuccessful lacrimal surgery, to determine the size of the sac. With patency to syringing, the DCG helps to determine whether the stenosis is in the common canaliculus or sac, and it can rule out the presence of a lacrimal sac diverticulum6. A DCG can often find drainage abnormalities

Nuclear lacrimal scintigraphy is a simple, non-invasive physiological test that evaluates patency of the lacrimal system. Scintigraphy uses a radiotracer (technetium-99m pertechnetate), which is very easily detectable with a gamma camera. While a DCG is usually preferred especially in a complete obstruction, scintigraphy is useful only in those patients whose lacrimal system is patent to syringing in the presence of constant epiphora. The test is more physiological than DCG, anatomical information is lacking, and fine anatomical details are not available in comparison with DCG7. Correlation of the anatomical study (DCG) and functional study (scintigraphy) may be necessary in planning surgery8; However, it is important to bear in mind that a normal result is considered to be a

preceded trauma, facial surgery, tumor, or in whom sinus diseases are suspected.

which can be used without any difficulties in small children, too.

i.e., it is useful only if the lacrimal system is patent on syringing.

decongestants are introduced into the nose.

internal anatomy of the lacrimal system looks.

present in patients with "functional obstruction"6.

**4.4 Nuclear lacrimal scintigraphy** 

**4.2 Radiologic evaluation** 

**4.3 Dacryocystography** 

magnetic resonance imaging (MRI).

contraindication to any surgical intervention7. Nuclear lacrimal scan has been found to be helpful especially in difficult cases with incompletely obstructed pathways in which DCG could not be interpreted in a satisfactory manner to determine whether surgery should be undertaken or not9.

## **4.5 Computed tomography and MRI**

Computed tomography (CT) can be helpful in assessing the structures intimately associated with the nasolacrimal drainage system. The CT scanning is used mainly when an extrinsic disease is suspected and is of great help to the patients with paranasal sinus or facial pathology associated with the lacrimal system (tumor, rhinosinusitis, facial trauma, following facial surgery, etc.)10.

Magnetic resonance is not used in practice in lacrimal diagnostics and is reserved only for the special cases, e.g., for differentiation of masses of the lacrimal sac8.
