**4.1 Surgical technique**

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 cotton patties.

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

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 puncta.

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 cover the opening created in the lacrimal sac.

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

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 turn could result in stenosis of the puncta.

### **4.2 Goals of surgery**


## **4.3 Results**

The authors reported their results in a series of 1450 consecutive endoscopic DCRs using 4 different techniques from January 1994 to December 2007 **(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 they inserted stents. All the data was then analyzed statistically.

**1. Introduction** 

**2. Anatomy** 

**2.1.1 Lacrimal gland** 

Mytomycin C are included, too.

each gland contains 2 cell types:

**2.1 Lacrimal gland and excretory system** 

**4** 

*Iran* 

**Endoscopic** 

Farhad Farahani

**Dacryocystorhinostomy** 

Endoscopic DCR has gained a lot of attention among otolaryngologists since the outcomes are comparable to the external approach. Advances in surgical technique and a better

The main goal of this chapter is to acquaint readers with the anatomy and function of lacrimal system, the newly emerged technique of endoscopic DCR and its related topics.

In this chapter, the anatomy of the lacrimal system will be discussed in detail. Then, the conditions needing surgical manipulation will be noted in addition to assessing the patients with such problems. Surgical indications and techniques of DCR will be explained. Some topics such as the advantages, results and complications of the surgery and the role of

The main lacrimal gland is located in a shallow depression along the superior lateral orbit. There is fibroadipose tissue between the gland and the orbit. The gland is divided into 2 parts by a lateral expansion of the levator apeunorosis. An isthmus of glandular tissue

Many accessory lacrimal glands can be found along the inner surface of the eyelids. A variable number of thin-walled excretory ducts, blood vessels, lymphatics, and nerves pass from the main orbital gland into these accessory lacrimal glands. The ducts continue downward, and about 12 of them empty into the conjunctival fornix approximately 5 mm above the superior margin of the upper tarsus. Because the lacrimal excretory ducts pass through the palpebral portion of the gland, biopsy of the lacrimal gland is usually

The lacrimal glands are exocrine glands, and they produce a serous secretion. The body of

understanding of the anatomy have resulted in improvement of outcomes.

occasionally exists between the palpebral lobe and the main orbital gland1.

performed on the main part to avoid sacrificing the ducts1.

acinar cells, which line the lumen of the gland

*Hamedan university of Medical Sciences* 

It was found that the best results were achieved with removal of the medial wall allowing the LS to get marsupialized. Stenting the LS also provided good results but had the disadvantage of causing corneal opacities especially if the stent moved from its position**(5)**.

Inserting grommets or incising and draining the LS gave poor results. Removal of the medial wall of the LS allowing it to fistulize into the nasal cavity was statistically more successful and was found to be statistically significant.

## **5. Conclusions and summary**


#### **6. References**

