Transcanalicular Diode Laser-assisted Dacryocystorhinostomy for the Treatment of Primary Acquired Nasolacrimal Duct Obstruction

Summary

The goal of this protocol is to present transcanalicular laser-assisted dacryocystorhinostomy as a minimally invasive approach in the treatment of primary acquired nasolacrimal duct obstruction.

Abstract

Today's gold standard in the treatment of infrasaccal primary acquired nasolacrimal duct obstruction (PANDO) is external dacryocystorhinostomy (DCR), a relatively invasive procedure that can be performed after failure of recanalizing treatments. However, with progress in the field of diode laser technology, new approaches have emerged. Laser-assisted transcanalicular DCR with subsequent bicanalicular silicon intubation is a new option showing great promise as a viable minimally invasive procedure. Under permanent endoscopic visual control from the nasal cavity, a diode laser fiber is inserted into the lacrimal sac and laser energy is applied to create a bony ostium between the lacrimal sac and the nasal cavity. Since no skin incision needs to be made, advantages of this method comprise the sparing of the skin as well as the medial palpebral structures and the physiological palpebral-canalicular pump mechanism. The duration of surgery as well as reconvalescence is generally shorter than with external DCR. Complications include silicon tube prolapse, mild swelling and, rarely, canalicular infection and thermal injury. One-year functional success rates, defined as complete resolution of symptoms and ostium patency, are high, yet still range behind those of external DCR. However, secondary external DCR after failure of laser-assisted DCR can be performed without difficulty. Thus, laser-assisted transcanalicular DCR is a valid option that should be considered as a second-step procedure after failure of recanalization procedures and before external DCR.

Introduction

Infrasaccal primary acquired nasolacrimal duct obstruction (PANDO) is a common disorder in middle-aged and older patients leading to chronic epiphora and blepharitis as well as recurring or chronic dacryocystitis. Most commonly, patients develop an infrasaccal obstruction of one or both nasolacrimal ducts, resulting in insufficient tear drainage.

In the treatment of PANDO, external dacryocystorhinostomy (DCR) is still considered to be the gold standard, even though this procedure historically dates back over a hundred years to when it was first performed¹. After skin incision and preparation of the nasal wall of the ....

Protocol

For this procedure, informed consent is required and has been obtained for every patient who has undergone surgery in the Department of Ophthalmology, University of Cologne, Cologne, Germany. All examinations and surgical interventions were executed in accordance with national laws and the declaration of Helsinki from 1975 in its current version.

NOTE: Unless indicated otherwise, instructions will always only refer to the side on which the procedure is being performed. Use sterilized equipment.

1. Patient Preparation

1. Perform a thorough ophthalmic examination (with special attention to eyelids, upper a....

Results

Optimal result:

The procedure as described above takes about 10 - 25 min and is usually tolerated very well. Upon examination the next day, a little swelling of the eyelid can be present in about 60% of cases. This little swelling always resolves completely within a maximum of three days. Patients do not complain about pain, silicon prolapse or signs of injury or infection. However, due to bicanalicular silicon intubation being per.......

Discussion

Transcanalicular laser-assisted DCR as described above is a fairly quick, minimally invasive way to treat absolute infrasaccal nasolacrimal duct obstruction effectively without the need for skin incision, thus sparing not only the skin but also the medial canthal tendon and the physiological canalicular pump mechanism. While the procedure is well suited for patients with primary acquired nasolacrimal duct obstruction, pathologies other than idiopathic stenosis do not qualify for this procedure. This is owing, in part, to.......

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
C1.multi	LUT	05.0082h.1	Endoscope camera
HL 250	LUT	95.2048n	Endoscope light source
MD-19E	ACL GmbH	1119	Endoscope screen
FOX (laser)	A.R.C. Laser GmBH, Nürnberg, Germany	n/a	Diode laser
Laser fiber	A.R.C. Laser GmBH, Nürnberg, Germany	LL13001s	Laser fiber
Laser handpiece	A.R.C. Laser GmBH, Nürnberg, Germany	n/a	Handpiece
Wide Collarette Monoka	Fa. FCL, Paris, France	S1.1630	monocanalicular silicon tube
Suction elevatorium	Storz	474015	For intranasal use
Forceps (Grünwald)	Storz	426620	For intranasal use
Forceps (Blakesley-Wilde)	Storz	456502	To grab the silicon tube
Lacrimal canula	Storz	81071	Blunt cannula
Bangerter probe cannula	Storz	81055	Bangerter probe cannula
Wooden spatula	any	n/a	Wooden spatula
Xylometazolin 0.05% eye drops	GlaxoSmithKline Consumer Healthcare	n/a	Decongestant eye drops
Dexapos comod eye drops	Ursapharm	n/a	steroid eye drops
Floxal eye drops	Dr. Gerhard Mann	n/a	antibiotic eye drops