Dr. Sandip Chaurasia
Dacryocystorhinostomy is the treatment of choice for patients with chronic stenosis and obstruction of the nasolacrimal duct. There are different approaches to opening the nasolacrimal duct. But external DCR Surgery as performed routinely by ophthalmologists remains the gold standard in terms of success rates, which are in excess of 90 %. However, this high success rate is compromised by several problems with the technique. It is long, there is a lot of bleeding, theatre sterility gets compromised, and facial scarring is unavoidable.
Laser Venflon DCR is the procedure in which laser DCR is followed by insertion of venflon No.22. With venflon tube in position after DCR we are doubly sure regarding maintenance of patency of the fistula created. The procedure is very short and convenient.
Indications:-
1. Chronic DC
2. Failed DCR
Case Selection:
1. Patient should have less or no deviated nasal septum (DNS).
2. Patient should not have canaliculous blockage.
3. Patient should not have developed any nasal fistula.
4. Patient should not have mucopurulent discharge.
Age Group: 5 years and above (as we have done in our series)
OT requirements:-
Xylocaine 4% with adrenaline, Xylocaine spray 10%, Specially designed 980 nm Diode Laser machine with handpiece, 22 Gauge Cannula (Blunt), Proparacaine Drop, Punctum Dialator, 320 Micron fibre optic cable, Betadine 5% solution, Nasal Endoscope with Camera (Zero & Thirty Degree), 22 number Venflon
Technique:-
Lasers have been used, especially in combination with the endonasal approach to perform the osteotomy. Now-a-days we use a 980nm infrared diode laser in a transcanalicular approach. The 980nm wavelength is rather unique in the sense that it has high absorption in both hemoglobin and water, which means that optical coagulation is achieved along with efficient vaporization of bony and soft tissues. We are aided by the new developments in micro optical fiber, wherein thin fibers of 320 micron diameter (Inside the 22G cannula) can be used with 980nm diode laser. The thin fiber allows very high energy density at the laser tip, which allows quick vaporization of the bone at low laser power.
The technique is performed under local anesthesia. Nasal cavity of the affected side is packed with Xylocaine 4% with adrenaline, 8-10 minutes prior to surgery. Proparacaine eye drops are also instill in the eye. We also inject 1ml Xylocaine 2% with adrenaline in the sac area. Lower or upper punctum is dilated with punctum dilator and different Bowman's probe. Then a 22 gauge canula along with laser fiber inside that introduced through lower punctum (upper punctum can also be used) into the sac. Once it touches the bone, the canula is turned in the downward direction 45 degree to vertical axis. A 0 degree/ 30 degree rigid nasal endoscope is used for direct visualization. The red aiming beam of laser is switched on and this can be seen as a red light intra nasally through the endoscope on the TV monitor connected with endoscope. Confirm the correct position. The red aiming beam should be in front of the anterior end of the middle turbinate. Once the location of the light is positioned correctly then the laser is fired at an energy of 5-7 Watt till the optical fiber pierces the bone & nasal mucosa. During the procedure only a moderate pressure should be applied against the bone with the DCR cannula. As the action of the laser is in contact mode, the canula is withdrawn a little back and repeat firing should be done along the margins of the newly made ostium to enlarge it up to 8mm diameter or one can make 4-5 opening & join them by making opening between them, the whole procedure should be done under supervision through direct CCTV video assisted endoscope for proper position & best results. Once, a satisfactory ostium is created normally 6-8 mm, syringing should be done with normal saline to check the patency of the ostium. A free flow of fluid in the nose is desirable from the eye.
Now a 22 G venflon (make guiding needle tip blunt by filing) is taken and introduced into the lower canaliculus & passed through the newly made ostium. The needle is removed and the tube is cut just near the punctual opening on lower lid. Make sure that the cut end does not remain out side the punctum, otherwise it may cause corneal abrasion. By leaving the venflon tube in the position we are doubly sure regarding maintenance of patency after the procedure. This tube remains there for three to four weeks. Sometimes it slips down of its own in the nasal cavity otherwise it can be removed through nose.
Advantages of this Laser Venflon DCR are:-
1. It is simple and short.
2. It can be performed under local anesthesia on an outpatient basis.
3. It leaves no visible scars.
4. It can also be used in cases of failed DCR surgery.
5. Maintained patency.
6. Repeated syringing & regular follow up not required.
7. Prevent stenosis at common canaliculus.
We have performed this Laser DCR in 50 cases out of which 20 without venflon tube. In these 20 cases success rate is 60-70%. But with venflon tube success rate is almost 100%.
However the right site and the right size of the ostium made with venflon in situ for at least 3 weeks is the key for achieving best result.
We are continuing to modify and improve the procedure.