West JM, A window resection in the nasal duct in cases of stenosis. Trans Am Ophthalmol Soc 1910;12:654–8. Kept at Royal Society of Medicine in London.

The spectrum of lacrimal disease was significantly more severe in the pre-antibiotic area. The French Impressionist artist Camille Pissarro (1830–1903) apparently suffered from recurrent chronic dacryocystitis, an illness which prevented him from working for some periods of time and which is said to have influenced his paintings.

The most common cause of a watering eye (epiphora) is a blocked nasolacrimal duct. Simple watering eye from a narrowed nasolacrimal duct (stenosis or partial nasolacrimal duct obstruction) is also an indication for DCR. The spectrum of disease has changed from dacryocystitis to simpler partial nasolacrimal duct obstructions and hence the threshold for surgery changed to include operating on lesser degrees of obstruction. The sophistication of lacrimal surgery has also advanced using more precise and delicate surgical techniques with miniature powered intranasal tools. This shift is very similar to the shift in cataract surgery also seen over the last 20 years, from intracapsular to extracapsular cataract extraction for dense white cataracts or dark nucleosclerosis, then to phaco-extraction for nucleosclerosis and subtle lenticular opacity. Patient expectation of surgery has increased and quality of life studies show that a real benefit can be obtained for patients with watering eyes by dacryocystorhinostomy surgery, whether it is by the external or the endonasal approach.

In many centers lacrimal surgery is now done almost exclusively endonasally and predominantly endoscopically (a microscope can be used instead), using powered tools and functional endoscopic sinus surgery instruments for adult and pediatric DCR. Endonasal endoscopic monitoring of syringe and probing and endoscopic placement of Jones glass bypass tubes are also standard.

However, the external approach DCR through the skin remains a useful operation where endonasal equipment and skills are not available, and can be particularly important for learning the anatomy of the medial canthus and sac area.

Definitions

There are various abbreviations and different operations.

• A dacryocystorhinostomy (DCR) is an operation to drain the tears from the lacrimal sac into the nose to treat a watering eye from a blocked nasolacrimal duct. Dacryo means ‘tear’, cysto means ‘sac’, and rhinostomy means ‘hole in nose’ (Fig. 52.2). This comes from Greek words (Table 52.1).

• A conjunctival dacryocystorhinostomy or CDCR is an operation which links the conjunctiva and tears to the nose and is done when there is extreme canalicular blockage, which is bypassed with a Jones’s tube.

• A canaliculo-dacryocystorhinostomy may also be abbreviated as C-DCR. This is done when just a segment of obstructed canaliculi is excised and the open end joined to the lacrimal sac and the inside of the nose.

• Canaliculotomy is making an opening into the canaliculus.

• Dacryocystectomy is the surgical removal of the entire lacrimal sac.

• Nasolacrimal duct intubation is the placement of soft silicone tubes from the conjunctival fornix via the canaliculi, via the lacrimal sac and down the nasolacrimal duct, to emerge in the inferior meatus.

• Endosnasal refers to via the nose and does not necessarily include endoscopic. It is the same as transnasal.

• Endoscopic transcanalicular is when a fine 1 mm diameter endoscope is passed via the punctum down the canaliculus into the lacrimal sac.

• Endoscopic transcanalicular DCR is a DCR performed via the canaliculus from the inside of the lacrimal sac into the nasal space across the maxilla and lacrimal bone.

• Endoscopic endonasal DCR (EE-DCR) is a DCR performed via the nasal space using a rigid Hopkins endoscope as a light source.

• Jones tube is a short (8–18 mm ) hand blown glass tube used as a bypass route for the tears to drain from the conjunctival fornix through to the nasal space, when there is severe obstruction of the canaliculi or lacrimal pump failure.

• Congenital nasolacrimal duct obstruction (CNLDO) is the common occurrence of an unopened valve of Hasner at the lower end of the nasolacrimal duct at birth.

Fig. 52.2 Dacryocystorhinostomy (DCR).

Courtesy of Santiago Ortiz-Perez.

Table 52.1 Etymology of the term Dacryocystorhinostomy

4 parts: dacro – cysto – rhino – stomy
Ancient Greek	Transliteration	Translation
	dakruon	tear
	kustis	bladder, sac
	rhis	nose
	stoma	mouth

History of modern DCR

Dacryocystorhinostomy was first described in 1893 by Caldwell using a nasal approach to lacrimal duct obstruction. West developed this further in 1913 with a window resection of the upper nasolacrimal duct. Toti advocated the external approach DCR, which was developed by Dupuy-Dutemps in the early 19th century and became the foundation for late 20th century external DCR.

The principle of DCR surgery, whether by the external skin incision approach or by the endonasal approach, is similar. It is to create a good opening for the entire vertical height of the lacrimal sac, into the lateral nasal wall through which the tears can drain unimpeded by mucosal or bony fragments or adjacent nasal structures.

Endonasal approach lacrimal surgery has developed further in the last 15 years using endoscopic techniques and visualization with a Hopkins rigid nasal endoscope (Fig. 52.3). Endoscopic endonasal dacryocystorhinostomy (EE-DCR) is a primary treatment for nasolacrimal duct obstruction with a number of advantages compared with the traditional external approach. These advantages include avoidance of a cutaneous scar, direct visualization of nasal anatomy, and preservation of medial canthal tendon and pump function. The success rate for primary endonasal DCR surgery is comparable to the external approach.

Fig. 52.3 Comparison of (A) external and (B) endonasal endoscopic approach DCR.

Courtesy of Santiago Ortiz-Perez.

Normal anatomy

Tear drainage

The tears normally drain through the puncta to the nose where they can be seen in the inferior meatus (Fig. 52.4).

Fig. 52.4 (A) Normal tear drainage. (B) Anatomy of lacrimal system.

Courtesy of Santiago Ortiz-Perez.

Before any lacrimal surgery is undertaken, a thorough knowledge of the normal nasal anatomy and the relationship of the soft tissues and bones of the lateral nasal wall is required. With this knowledge abnormal variations will then be easily recognized.

Nasal anatomy

Soft tissue and bones of the lateral nasal wall

The main soft tissue structures of the lateral nasal wall are:

• Turbinate: (superior rare), middle, and inferior (Fig. 52.5)

• Meatus: middle and inferior

• Other swellings produced by ager nasi (ethmoid), uncinate process, and bulla ethmoidalis

• Openings in middle meatus: frontal sinus, hiatus semilunaris and infundibulum, maxillary sinus additional opening (accessory opening).

Fig. 52.5 (A–D) Normal anatomy turbinates. (A) Left nasal space normal middle turbinate. (B) Right nasal space concha bullosa of the middle turbinate. This is an aerated middle turbinate. (C) Left nasal floor with Freer’s elevator underneath the inferior turbinate. The middle turbinate is seen in the distance. (D) Infract of the left inferior turbinate to show the inferior meatus and the opening of the nasolacrimal duct.

The main bones of the lateral nasal wall are (Fig. 52.6):

Fig. 52.6 (A–D) Anatomy of the lateral nasal wall. (A) Lateral nasal wall showing middle and inferior turbinates and position of underlying lacrimal sac. (B) The middle turbinate and part of the inferior turbinate have been removed to reveal the length of the nasolacrimal duct. (C) Diagram showing bones. (D) Blue probe in nasolacrimal duct showing its relation to the bones and its posterior directed angle.

• Maxilla

• Lacrimal bone

• Uncinate process

• Perpendicula plate of the ethmoid (middle turbinate)

• Inferior turbinate.

Etiology and assessment of watering eye

Blocked nasolacrimal duct in adults

The causes of a watering eye include hypersecretion and epiphora. Causes of hypersecretion (conjunctivitis, keratitis, corneal foreign body, etc.) should be excluded (Fig. 52.7A–D). Surgery of the lacrimal system is for epiphora, which is an outflow problem cause by a stenosis or obstruction of the lacrimal excretory system or very poor functional drainage, as for instance may occur in facial nerve paralysis.

Fig. 52.7 (A–D) Causes of hypersecretion. (A) Conjunctivitis. (B) Corneal epithelial erosions. (C) Corneal foreign body. (D) Herpes simplex keratitis.

The periorbital area should be examined and a mucocoele, dacyocystitis (Fig. 52.8), and fistula from the lacrimal sac should be excluded. Eyelid position, particularly punctual apposition to the globe, should also be recorded.

Fig. 52.8 (A&B) Dacryocystitis. (A) Right dacryocystitis. (B) Left previous acryocystitis with lacrimal sac fistula.

Canaliculitis is an often missed yet relatively common condition (Fig. 52.9). It is a simple diagnosis because the small swelling is medial to the punctum, which commonly has with some yellow discharge. It can be chronic and partially responsive to topical medication, with surgery the definitive treatment.