**2. Diagnostics**

Two basic causes of tearing exist. Epiphora that is associated with blockage of the lacrimal system and excessive lacrimation (hyperlacrimation) which is a less common cause. Hyperlacrimation is caused by corneal irritation. Unilateral hyper lacrimation is caused by trigeminal sensory nerve stimulation.

Epiphora is tearing caused by a reduced tear transport mechanism or a defective tear drainage outflow. Epiphora can on occasion be caused by a combination of both.

## **2.1 Goals of diagnostics are the following**


#### **2.2 The diagnostic tests are divided into the following**

a. Anatomical tests for investigation of morphological disorders and location of the site of obstruction as in punctal and canalicular pathologies, nasolacrimal duct obstruction (PANDO) and nasal pathologies.

 \* Corresponding Author

patency.

cotton patties.

puncta.

adrenaline solution.

cover the opening created in the lacrimal sac.

turn could result in stenosis of the puncta.

**4.2 Goals of surgery**  1. Cessation of Epiphora 2. Patency of the neo-ostium

**4.3 Results** 

A pack was placed which can be removed 12 hours later.

3. There should be no further attacks of dacryocystitis.

different techniques from January 1994 to December 2007 **(4)**.

they inserted stents. All the data was then analyzed statistically.

**4.1 Surgical technique** 

Endoscopic Dacryocystorhinostomy 47

The authors in their series of over one thousand consecutive endoscopic DCRs found that the best technique for achieving consistently good reliable results was the removal of the medial wall of the lacrimal sac allowing it to heal in close conjunction with the mucosa of the nasal cavity. This was possible in a majority of cases as the lacrimal sac was large. When the lacrimal sac was small fibrosed and cicatrized stents were needed to maintain

The surgeons preferred to operate under local anesthesia. An external block was given with .5% bupivacaine. The nasal cavity was anesthetized and decongested with 4% xylocaine

The area of the Agger Nasi air cells was infiltrated with 2% xylocaine with 1 in 200,000

Once this was achieved then the medial wall of the lacrimal sac was removed. The medial wall was removed in such a way that it lies flush with the osteotomy. The nasal mucosa was then trimmed so that no bone was left bare. This step in particular is important because it has reduced the formation of granulomas. Care was taken such that the nasal flap did not

The patient is instructed not to blow his nose. Careful nasal toilette ensures removal of crusts/ debris. This nasal toilette also prevents the occurrence of synechiae. The puncta are not flushed as the authors believe that this could result in trauma to the puncta which in

The authors reported their results in a series of 1450 consecutive endoscopic DCRs using 4

In one set of patients they merely incised and drained the lacrimal sacs, in another they inserted grommets. In a third set they removed the medial wall of the LS and in a fourth set

The flap anterior to the Middle turbinate was elevated. The periosteum was also elevated. The lacrimal bone was drilled out with a large diamond polishing burr. A large osteotomy was performed until the entire limits of the lacrimal sac was seen and clearly identified. Once the lacrimal sac was clearly identified its medial wall was excised. Methyline blue was carefully and gently flushed from both puncta to ascertain clear passage through both


#### **2.3 The clinical tests are the following**

Anatomical tests include palpation of the lacrimal sac, examination of the eyelids and condition of the puncta, syringing (irrigation), diagnostic probing, dacrycystography, nasal examination, and CT scanning and MRI.

Physiological tests are:- Fluorescein dye disappearance, scintigraphy Jones dye I, saccharin test.

Tests of secretion include:- Schirmirs tests, Bengal rose test, tear film break up and tear lysozyme test.

## **3. Surgery**

#### **3.1 Endoscopic DCR surgery versus external DCR?**

Endoscopic DCR has gained wide spread acceptance and is now considered the surgical approach of choice **(1)**, **(2).** 

The reasons why the external approach has declined is because (a) There is a facial scar following External DCR and (b) It is difficult to revise.

Endoscopic DCR is attractive because


#### **3.2 The role of stents**

Stents can be used for small fibrotic lacrimal sacs to make sure that the neo-ostium remains patent **(3)**. The authors prefer to reserve stents for this situation only because (1) Removal causes the opening to close, (2) The possibility of corneal opacity should the stent move its position. Surgery was successful as long as the stent was in situ. When stents were removed the sac obstructed again. Therefore the authors decided to leave the stents in situ indefinitely as long as there were no problems caused by the stent. An exact time frame for removal of the stents could not be given to patients.

#### **4. The use of 5 fluorouracil and mitomicin**

The authors have found that these substances do not add to the success of patency in their series.

b. Functional (physiological) tests for drainage of tears under normal conditions as in lacrimal pump insufficiency due to incorrect eyelid closure,, ectropion , enteropion etc.

Anatomical tests include palpation of the lacrimal sac, examination of the eyelids and condition of the puncta, syringing (irrigation), diagnostic probing, dacrycystography, nasal

Physiological tests are:- Fluorescein dye disappearance, scintigraphy Jones dye I, saccharin

Tests of secretion include:- Schirmirs tests, Bengal rose test, tear film break up and tear

Endoscopic DCR has gained wide spread acceptance and is now considered the surgical

The reasons why the external approach has declined is because (a) There is a facial scar

6. Small fibrotic lacrimal sacs which cannot be operated upon by the external approach

Stents can be used for small fibrotic lacrimal sacs to make sure that the neo-ostium remains patent **(3)**. The authors prefer to reserve stents for this situation only because (1) Removal causes the opening to close, (2) The possibility of corneal opacity should the stent move its position. Surgery was successful as long as the stent was in situ. When stents were removed the sac obstructed again. Therefore the authors decided to leave the stents in situ indefinitely as long as there were no problems caused by the stent. An exact time frame for

The authors have found that these substances do not add to the success of patency in their

c. Secretion: tests for assessment of secretion.

**3.1 Endoscopic DCR surgery versus external DCR?** 

following External DCR and (b) It is difficult to revise.

4. It can be performed on patients of all ages.

7. Complications like bleeding are much less. 8. Endoscopic DCRs take much less operating time.

removal of the stents could not be given to patients.

**4. The use of 5 fluorouracil and mitomicin** 

1. The results are equal to if not better than External DCR.

5. It can easily be learnt and can be done safely and reliably.

can be operated upon using the endoscopic approach.

**2.3 The clinical tests are the following** 

examination, and CT scanning and MRI.

test.

lysozyme test.

**3. Surgery** 

approach of choice **(1)**, **(2).** 

2. There is no facial scar. 3. It can be revised easily.

**3.2 The role of stents** 

series.

Endoscopic DCR is attractive because

The authors in their series of over one thousand consecutive endoscopic DCRs found that the best technique for achieving consistently good reliable results was the removal of the medial wall of the lacrimal sac allowing it to heal in close conjunction with the mucosa of the nasal cavity. This was possible in a majority of cases as the lacrimal sac was large. When the lacrimal sac was small fibrosed and cicatrized stents were needed to maintain patency.
