What Is a Dacryocystorhinostomy?

Dacryocystorhinostomy is a surgical method applicable to all chronic dacryocystitis.

Dacryocystorhinostomy

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Dacryocystorhinostomy is a method that works for all

Dacryocystorhinostomy

Dacryocystorhinostomy; dacryocystostomy; dacryocystostomy; dacryocystostomy

Ophthalmology / Lacrimal Surgery

09.8101

Chronic dacryocystitis is a common disease in ophthalmology and is more common in women and the elderly. Due to the ineffectiveness of drug treatment, the effects of probing and intubation are not ideal, and the effect of laser treatment is difficult to determine. Currently, surgical treatment is still the main treatment. Dacryocystorhinostomy is a classic surgical method, the purpose of which is to directly anastomosis the lacrimal sac with the nasal mucosa, so that secretions and tears from the lacrimal sac directly into the middle nasal passages, in order to eliminate the lacrimal sac purulent lesions and relieve tear overflow.

Dacryocystorhinostomy for all chronic dacryocystitis:

Chronic dacryocystitis and nasolacrimal duct obstruction. If the lacrimal sac has been significantly reduced or has atrophic rhinitis, the effect will be affected, and the effect is difficult to be sure.

The day before surgery, the lacrimal sac was rinsed, and antibiotic eye drops were dripped into the conjunctival sac.

The lacrimal sac has acute inflammation.

1. First check the condition of the nose and sinuses. If there are nasal polyps or sinusitis, they should be treated first.

2. Squeezing the lacrimal sac, if the amount of secretion is very small, lacrimal sac should be performed.

3. Use antibiotic eye drops 1 week before surgery, and if necessary, wash the lacrimal duct with normal saline and antibiotic eye drops two days before surgery.

Local infiltration and nerve block anesthesia. Anesthesia was injected along the incision line of the skin before the needle was injected, and then injected about 10 mm above and below the medial condylar ligament, reaching the orbital marginal periosteum; then, anesthesia was performed under the orbital, undercarriage, and anterior ethmoidal nerve blocks. Ephedrine and tetracaine cotton tablets were placed in the middle nasal passages and turbinates.

The lacrimal sac surface is anesthetized by subcutaneous anesthesia in the lacrimal sac area, the top of the lacrimal sac, and the upper mouth of the nasolacrimal duct. The middle nasal passage and the front of the middle turbinate were filled with cotton pieces dipped in 1% dicaine and 0.5% ephedrine for 10 minutes.

Figure 1 Figure 2

For anterior ethmoidal nerve anesthesia, touch the pulley on the affected side with your finger, use a 25-gauge injection needle, pierce about 20mm vertically at the lower edge of the pulley, and inject 1.5% 2% lidocaine (a small amount of 1: 1000 adrenaline is added).

1. Make a skin incision on the nasal side of the medial condyle, 5mm above the medial condylar tendon, parallel to the anterior lacrimal condyle, and curved slightly to the temporal side in an arc. It is about 20mm long and reaches the full thickness of the skin.

2. Isolate the subcutaneous tissue and muscles, place a lacrimal stent expander, and expose the anterior lacrimal condyles and medial patellar tendons. The periosteum was incised before the tears. Does not cut the internal patellar tendon.

Figure 3 Figure 4

3. Push the periosteum to the sides with a small periosteal separator. Divide the nose first and push about 4mm away.

4. Separate the dacryocystic periosteum and dacryocystic wall. The periosteal separator should be close to the bone wall. Tears to the back and back to the top of the lacrimal sac, and down to the upper nasolacrimal duct.

Figure 5 Figure 6

5. The osteotomy window is located at the lower part of the anterior lacrimal fossa, as low as possible, approximately 2 mm ahead of the anterior lacrimal condyle. First use a curved pipe clamp to break the bone wall at the lower part of the lacrimal fossa to form a small hole with a diameter of about 3 mm. × 12mm to prevent biting of the nasal mucosa.

6. Use a lacrimal probe to insert from the lacrimal canaliculus, and eject the lacrimal nasal side wall. Use a razor blade to make a horizontal incision in the apical portion of the lacrimal sacral wall, and make another parallel incision in the lacrimal sac as low as possible.

Figure 7 Figure 8

7. Make a vertical incision between the two horizontal incisions of the lacrimal sac to make the incision "I" shaped. A corresponding "I" -shaped incision was made on the nasal mucosa.

8. Suture the lacrimal sac and posterior nasal mucosa flap with 6-0 nylon suture, and suture 3 stitches intermittently.

Figure 9 Figure 10

9. Take out the cotton piece blocked in the nasal cavity, and put it into the vaseline gauze strip with gun-shaped forceps.

10. Pull some gauze into the lacrimal sac.

Figure 11 Figure 12

11. Suture the lacrimal sac and anterior nasal flap with 5-0 silk or nylon suture. Suspend 3 stitches. Each stitch should be brought to the periosteum in front of the foramen. For easy suture, you can tie together after 3 stitches.

12. Suture the periosteum with 3-0 nylon thread, and suturing the end of the medial patellar tendon firmly to the periosteum.

Figure 13 Figure 14

13. Suture 3 or 4 stitches of orbicularis oris muscle with 5-0 suture. Suture the skin for 3 to 5 stitches.

14. Monocular bandaging, bandaging with light pressure bandage.

The internal iliac arteries and veins must be protected. If the blood vessel is ruptured, it will cause trouble to the operation. It should be ligated or the rupture place should be under the lacrimal stent spreader. Bone window edge bleeding can be oppressed with cotton pads moistened with a little adrenaline.

Antibiotics were applied throughout the body for 3 to 5 days, and the dressing was changed the next day. After 2 days, the nasal gauze was removed and the lacrimal duct was flushed for the first time. In the nasal cavity, ephedrine furacicillin nasal drops are taken 5 to 8 times a day for 4 weeks. After 4 to 5 days, remove the skin line. Antibiotics and dexamethasone eye drops were dripped into the conjunctival sac for 2 to 4 weeks.

The main complication is surgical failure and reoperation.

1. Bone hole method The earliest bone window method used osteotome. The main disadvantages of this method are the large vibration and the patient's discomfort. When cutting bones, the bone wall is easy to chip into pieces, causing damage to the nasal mucosa and bleeding, which brings trouble to the operation. Bone windows are not easy to make neat and smooth, which affects the effect of surgery. In the future, bone drilling was advocated, but it was often inconvenient because of soft tissue being bitten. It is not easy to make the bone holes tidy. Bone crimping is the best method to date.

Figure 15

2. Mucosal pore making method Toti originally proposed this method to make a circular hole in the lacrimal sac and nasal mucosa. After that, there are many improved methods, including: "", "]]", "] 0", and "] [" shape incision method.

3. The suture method is not initially sutured; two flaps are usually sutured, where the anterior flap is sutured with the periosteum in front of the bone hole; one flap is also sutured and the other flap is pressed against the bone window by a nasal gauze; No sutures were pressed against the bone window by nasal gauze.

4. Whether to cut the internal patellar tendon The internal patellar tendon should be cut off, depending on whether it is convenient during surgery. When the periosteum incision is made on the nasal side of the attachment point of the medial patellar tendon, there is no problem of cutting the medial patellar tendon. However, if the internal patellar tendon is severed, it must be re-stitched when the operation is complete.