Name: Transcanalicular Diode Laser-assisted Dacryocystorhinostomy for the Treatment of Primary Acquired Nasolacrimal Duct Obstruction (Video) | JoVE Journal
Uploaded: 2017-10-13T12:30:00.000+00:00
Duration: 7 min 30 s
Description: Learn transcanalicular diode laser-assisted dacryocystorhinostomy for treating primary acquired nasolacrimal duct obstruction. This minimally invasive technique creates a safe bypass with lower complication rates than traditional surgery.

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5 minutes

Deutsche Forschungsgemeinschaft (German Research Association; FOR 2240 "(Lymph)Angiogenesis And Cellular Immunity In Inflammatory Diseases Of The Eye" to LMH; HE 6743/2-1 and HE 6743/3-1 to LMH), GEROK program of the University of Cologne to KRK and LMH. Our gratitude goes to Dr. K&#252;hner for technical support.

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
<ol>
	<li>Perform a thorough ophthalmic examination (with special attention to eyelids, upper and lower punctum, and tear drainage) including irrigation and probing to test for PANDO10.
	<ol>
		<li>For standardized irrigation, insert a Bangerter probe into the upper and, subsequently, lower punctum. Begin by inserting it vertically, then tilt it toward the temple into a horizontal position to follow the physiological formation of the canaliculus. When the probe is in position, carefully inject saline to test for lacrimal duct obstruction. 
		NOTE: In infrasaccal PANDO, the Bangerter cannula will easily reach the lateral nasal wall without a bouncy resistance (&#34;hard stop&#34;). Trying to irrigate will result in contralateral reflux through the opposite punctum without any fluid reaching the patient&#39;s pharynx10.</li>
	</ol>
	</li>
	<li>Rule out acute infections, tumors of the tear drainage system as well as traumatic, congenital or presaccal obstruction.
	<ol>
		<li>To rule out acute infections, look for painful reddening, swelling or purulent discharge of the tear drainage. To rule out tumors, look for indolent swelling, ulceration or pigmentation. Presaccal obstruction results in a bouncy resistance when trying to advance the Bangerter Probe into the lacrimal sac (&#34;soft stop&#34;). Congenital and traumatic obstruction can be ruled out by taking patient history10,19,20.</li>
	</ol>
	</li>
	<li>Rule out intranasal rhinological pathologies, e.g. severe septum deviation. This should be done by taking the patient&#39;s history in combination with a rhinological inspection of the nasal cavity 21.</li>
	<li>Put the patient under general anesthesia, e.g. by intravenous injection of propofol, remifentanil, and atracurium for induction and inhalation of desfluran plus intravenous remifentanil for maintenance, using standard weight-adapted dosing10. Intubation should be performed, but use of a larynx mask is also possible. 
	NOTE: Anesthetics as well as dosages may vary between clinics. No specific anaesthesia protocol is required for laser-assisted DCR.</li>
</ol>
2. Laser-assisted DCR
<ol>
	<li>Insert the video-assisted endoscope into the nasal cavity by carefully advancing it through the nostril. Visualize the anterior margin of the middle turbinate by slightly tilting the endoscope towards the lateral nasal wall.</li>
	<li>Set up the laser equipment and laser settings to the correct values. Put on protective glasses.
	<ol>
		<li>Connect the laser fiber optic (diameter 400 &#181;m) to the diode laser (wavelength 810 nm). Set the diode laser settings to 6 - 8 W, 200 ms pulse duration, 100 ms exposition pause.</li>
		<li>Fit the laser fiber optic into the hand-piece for maneuvering and through a blunt cannula. Let 2 - 3 mm of the fiber stick out at the tip of the cannula.</li>
		<li>Perform carbonization of the laser fiber tip by holding it on a wooden spatula and applying laser energy for a few seconds until the tip is sufficiently blackened. 
		NOTE: This will limit unwanted energy distribution to the tissue of the lacrimal sac.</li>
	</ol>
	</li>
	<li>Position the laser fiber correctly at the lateral nasal wall.
	<ol>
		<li>Use a lacrimal probe to dilate the&#160;lower punctum (Figure 2a). Insert the probe in a vertical orientation at first and then bring into a horizontal orientation before further advancing it towards the lacrimal sac. This will allow for the laser fiber to be inserted smoothly in the next step.</li>
		<li>Insert the laser fiber into the lower canaliculus (Figure 2b, 2c). Begin by inserting it vertically, then tilt it toward the temple into a horizontal position to follow the physiological formation of the lower canaliculus.</li>
		<li>Carefully advance the laser fiber into the lacrimal sac until it touches the lateral nasal wall, i.e. the medial lacrimal saccal wall. There, aim the tip in an antero-inferior direction so that it points to the anterior margin of the middle turbinate.</li>
		<li>Verify correct positioning endoscopically by monitoring transluminescence of the aiming beam at the height of the anterior margin of the middle turbinate (Figure 2d).</li>
	</ol>
	</li>
	<li>Create a sufficient nasolacrimal bypass by application of pulsed laser energy to the nasal wall.
	<ol>
		<li>Apply laser energy (using the parameters set above), keeping constant contact to the wall without pressure, aiming for the anterior margin of the middle turbinate. The laser will vaporize the tissue directly in front of it, creating a nasolacrimal bypass (Figure 2d, 2e). 
		NOTE: The total energy required ranges between 0.9 - 1.8 kJ and tends to vary between patients.</li>
		<li>Ensure that the fiber tip is not actively pressed against the wall. Be careful not to let the tip slip back into the metal cannula as this will cause thermal injury due to heating of the metal. Also avoid sideways movements as the tip can break off.</li>
		<li>Upon penetrating the lateral nasal wall, pull the laser fiber back a bit and enlarge the ostium by carefully vaporizing the margins in a circular manner. Try to create as large a bypass as possible (Figure 2f).</li>
		<li>Aim for a total diameter of 5 mm for the ostium.</li>
		<li>Stop applying energy and remove the laser fiber together with the hand-piece and the cannula by carefully retracting the equipment.</li>
	</ol>
	</li>
	<li>Verify the patency of the ostium by saline irrigation using a Bangerter probe as described in 1.1.1. If a patent ostium was created, successful irrigation should be visible endoscopically.</li>
	<li>Remove the Bangerter probe.</li>
	<li>Place the silicon tube (Figure 2g).
	<ol>
		<li>Through the lower punctum, insert a monocanalicular silicon tube and carefully advance it until the leading metal tip passes the bony ostium and protrudes into the nasal cavity.</li>
		<li>Use Blakesley forceps to grab the tip from inside the nasal cavity and pull the silicon tube out of the nose and into position (Figure 2h).</li>
		<li>Use a pair of scissors to shorten the silicon tube. The end should not be sticking out of the nose.</li>
		<li>Perform silicon intubation via the upper canaliculus as well (following steps 2.7.1 through 2.7.3) (Figure 2h).</li>
	</ol>
	</li>
	<li>Remove the nasal endoscope.</li>
</ol>
3. Post-op Care and Follow-up
<ol>
	<li>After surgery, initiate treatment with antibiotic eye drops (e.g. ofloxacin), decongestant eye drops (e.g. xylometazolin) and steroidal eye drops (e.g. prednisolone acetate). Antibiotics can be stopped after one week, while steroidal and decongestant eye drops should slowly be weaned off over the course of one month.</li>
	<li>Follow-up at six weeks and three months after surgery. Look for resolution of symptoms, silicon tube prolapse, infection, and secretion.</li>
	<li>Remove silicon tubes at three months after surgery by simply grabbing the T-shaped end at the height of the puncta and carefully pulling them out.</li>
</ol>

<ol><li>Toti, A., et al. Nuovo metodo conservatoire di cura radicale delle suppurazioni croniche del sacco lacrimale (dacriocistorinostomia). Clin. Mod. Pisa. 1 (10), 385-387 (1904).</li>
<li>Alnawaiseh, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Long-Term+Outcomes+of+External+Dacryocystorhinostomy+in+the+Age+of+Transcanalicular+Microendoscopic+Techniques%5BTitle%5D)+AND+%22J.+Ophthalmol%22%5BJournal%5D)">Long-Term Outcomes of External Dacryocystorhinostomy in the Age of Transcanalicular Microendoscopic Techniques.</a> J. Ophthalmol. , (2016).</li>
<li>Tooley, A. A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Dacryocystorhinostomy+for+Acquired+Nasolacrimal+Duct+Stenosis+in+the+Elderly+%28%E2%89%A580+Years+of+Age%29%5BTitle%5D)+AND+%22Ophthalmology%22%5BJournal%5D)">Dacryocystorhinostomy for Acquired Nasolacrimal Duct Stenosis in the Elderly (≥80 Years of Age).</a> Ophthalmology. , (2016).</li>
<li>Detorakis, E. T., Drakonaki, E., Papadaki, E., Pallikaris, I. G., Tsilimbaris, M. K. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Watery+eye+following+patent+external+DCR%3A+an+MR+dacryocystography+study%5BTitle%5D)+AND+%22Orbit%22%5BJournal%5D)">Watery eye following patent external DCR: an MR dacryocystography study.</a> Orbit. 29 (5), 239-243 (2010).</li>
<li>Kakizaki, H., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((The+lacrimal+canaliculus+and+sac+bordered+by+the+Horner%27s+muscle+form+the+functional+lacrimal+drainage+system%5BTitle%5D)+AND+%22Ophthalmology%22%5BJournal%5D)">The lacrimal canaliculus and sac bordered by the Horner's muscle form the functional lacrimal drainage system.</a> Ophthalmology. 112 (4), 710-716 (2005).</li>
<li>Emmerich, K. H., Ungerechts, R., Meyer-Rüsenberg, H. W. <a target="_blank" href="https://www.ncbi.nlm.nih.gov/labs/articles/19280195/">Mikroendoskopische Tränenwegschirurgie.</a> Ophthalmologe. 106 (3), 196-204 (2009).</li>
<li>Emmerich, K. H., Lüchtenberg, M., Meyer-Rüsenberg, H. W., Steinhauer, J. <a target="_blank" href="https://www.ncbi.nlm.nih.gov/labs/articles/9498188/">Dacryoendoskopie und Laserdacryoplastik: Technik und Ergebnisse.</a> Klin. Monatsbl. Augenheilkd. 211 (6), 375-379 (1997).</li>
<li>Meyer-Rüsenberg, H. W., Emmerich, K. H., Lüchtenberg, M., Steinhauer, J. Endoskopische Laserdacryoplastik - Methodik und Ergebnisse nach 3 Monaten. Ophthalmologe. 96 (5), 332-334 (1999).</li>
<li>Emmerich, K. H., Ungerechts, R., Meyer-Rüsenberg, H. W. <a target="_blank" href="https://www.ncbi.nlm.nih.gov/pubmed/22241541">Transcanalicular microendoscopic laser DCR: technique and results.</a> Klin Monbl Augenheilkd. 229 (1), 39-41 (2012).</li>
<li>Koch, K. R., Cursiefen, C., Heindl, L. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Transcanalicular+Laser+Dacryocystorhinostomy%3A+One-Year-Experience+in+the+Treatment+of+Acquired+Nasolacrimal+Duct+Obstructions%5BTitle%5D)+AND+%22Klin.+Monbl.+Augenheilkd%22%5BJournal%5D)">Transcanalicular Laser Dacryocystorhinostomy: One-Year-Experience in the Treatment of Acquired Nasolacrimal Duct Obstructions.</a> Klin. Monbl. Augenheilkd. 233 (2), 182-186 (2016).</li>
<li>Koch, K. R., Kühner, H., Cursiefen, C., Heindl, L. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Significance+of+transcanalicular+laser+assisted+dacryocystorhinostomy+in+modern+lacrimal+drainage+surgery%5BTitle%5D)+AND+%22Ophthalmologe%22%5BJournal%5D)">Significance of transcanalicular laser assisted dacryocystorhinostomy in modern lacrimal drainage surgery.</a> Ophthalmologe. 112 (2), 122-126 (2015).</li>
<li>Uludag, G., Yeniad, B., Ceylan, E., Yildiz-Tas, A., Kozer-Bilgin, L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Outcome+comparison+between+transcanalicular+and+external+dacryocystorhinostomy%5BTitle%5D)+AND+%22Int.+J.+Ophthalmol%22%5BJournal%5D)">Outcome comparison between transcanalicular and external dacryocystorhinostomy.</a> Int. J. Ophthalmol. 8 (2), 353-357 (2015).</li>
<li>Ozcimen, M., Uysal, I. O., Eryilmaz, M. A., Kal, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Endocanalicular+diode+laser+dacryocystorhinostomy+for+nasolacrimal+duct+obstruction%3A+short-term+results+of+a+new+minimally+invasive+surgical+technique%5BTitle%5D)+AND+%22J.+Craniofac.+Surg%22%5BJournal%5D)">Endocanalicular diode laser dacryocystorhinostomy for nasolacrimal duct obstruction: short-term results of a new minimally invasive surgical technique.</a> J. Craniofac. Surg. 21 (6), 1932-1934 (2010).</li>
<li>Drnovsek-Olup, B., Beltram, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Transcanalicular+diode+laser-assisted+dacryocystorhinostomy%5BTitle%5D)+AND+%22Indian.+J.+Ophthalmol%22%5BJournal%5D)">Transcanalicular diode laser-assisted dacryocystorhinostomy.</a> Indian. J. Ophthalmol. 58 (3), 213-217 (2010).</li>
<li>D'Ecclesia, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Endoscopic+laser-assisted+dacryocistorhinostomy+DCR+with+the+placement+of+a+customised+silicone+and+Teflon+bicanalicular+stent+Endoscopic+laser-assisted+dacryocystorhinostomy+%28DCR%29%5BTitle%5D)+AND+%22Clin.+Ter%22%5BJournal%5D)">Endoscopic laser-assisted dacryocistorhinostomy DCR with the placement of a customised silicone and Teflon bicanalicular stent Endoscopic laser-assisted dacryocystorhinostomy (DCR).</a> Clin. Ter. 165 (6), e391-e394 (2014).</li>
<li>Ayintap, E., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Analysis+of+age+as+a+possible+prognostic+factor+for+transcanalicular+multidiode+laser+dacryocystorhinostomy%5BTitle%5D)+AND+%22J.+Ophthalmol%22%5BJournal%5D)">Analysis of age as a possible prognostic factor for transcanalicular multidiode laser dacryocystorhinostomy.</a> J. Ophthalmol. , (2014).</li>
<li>Dogan, R., Meric, A., Ozsütcü, M., Yenigun, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Diode+laser-assisted+endoscopic+dacryocystorhinostomy%3A+a+comparison+of+three+different+combinations+of+adjunctive+procedures%5BTitle%5D)+AND+%22Eur.+Arch.+Otorhinolaryngol%22%5BJournal%5D)">Diode laser-assisted endoscopic dacryocystorhinostomy: a comparison of three different combinations of adjunctive procedures.</a> Eur. Arch. Otorhinolaryngol. 270 (8), 2255-2261 (2013).</li>
<li>Plaza, G., Beteré, F., Nogueira, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Transcanalicular+dacryocystorhinostomy+with+diode+laser%3A+long-term+results%5BTitle%5D)+AND+%22Ophthal+Plast+Reconstr+Surg%22%5BJournal%5D)">Transcanalicular dacryocystorhinostomy with diode laser: long-term results.</a> Ophthal Plast Reconstr Surg. 23 (3), 179-182 (2007).</li>
<li>Heindl, L. M., Junemann, A., Holbach, L. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((A+clinicopathologic+study+of+nasal+mucosa+in+350+patients+with+external+dacryocystorhinostomy%5BTitle%5D)+AND+%22Orbit%22%5BJournal%5D)">A clinicopathologic study of nasal mucosa in 350 patients with external dacryocystorhinostomy.</a> Orbit. 28 (1), 7-11 (2009).</li>
<li>Heindl, L. M., Treutlein, E., Jünemann, A. G., Kruse, F. E., Holbach, L. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Selective+lacrimal+sac+biopsy+for+external+dacryocystorhinostomy%3A+a+clinical+pathological+study%5BTitle%5D)+AND+%22Ophthalmologe%22%5BJournal%5D)">Selective lacrimal sac biopsy for external dacryocystorhinostomy: a clinical pathological study.</a> Ophthalmologe. 107 (12), 1139-1144 (2010).</li>
<li>Aziz, T., Biron, V. L., Ansari, K., Flores-Mir, C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Measurement+tools+for+the+diagnosis+of+nasal+septal+deviation%3A+a+systematic+review%5BTitle%5D)+AND+%22J+Otolaryngol+Head+Neck+Surg%22%5BJournal%5D)">Measurement tools for the diagnosis of nasal septal deviation: a systematic review.</a> J Otolaryngol Head Neck Surg. 43, 11(2014).</li>
<li>von Goscinski, C., Koch, K. R., Cursiefen, C., Heindl, L. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Tumors+of+the+lacrimal+drainage+system%5BTitle%5D)+AND+%22HNO%22%5BJournal%5D)">Tumors of the lacrimal drainage system.</a> HNO. 64 (6), 386-393 (2016).</li>
<li>Heindl, L. M., Jünemann, A. G., Kruse, F. E., Holbach, L. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Tumors+of+the+lacrimal+drainage+system%5BTitle%5D)+AND+%22Orbit%22%5BJournal%5D)">Tumors of the lacrimal drainage system.</a> Orbit. 29 (5), 298-306 (2010).</li>
<li>Kaynak, P., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Transcanalicular+diode+laser+assisted+dacryocystorhinostomy+in+primary+acquired+nasolacrimal+duct+obstruction%3A+2-year+follow+up%5BTitle%5D)+AND+%22Ophthal+Plast+Reconstr+Surg%22%5BJournal%5D)">Transcanalicular diode laser assisted dacryocystorhinostomy in primary acquired nasolacrimal duct obstruction: 2-year follow up.</a> Ophthal Plast Reconstr Surg. 30 (1), 28-33 (2014).</li>
<li>Goel, R., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Transcanalicular+Laser-Assisted+Dacryocystorhinostomy+With+Endonasal+Augmentation+in+Primary+Nasolacrimal+Duct+Obstruction%3A+Our+Experience%5BTitle%5D)+AND+%22Ophthal+Plast+Reconstr+Surg%22%5BJournal%5D)">Transcanalicular Laser-Assisted Dacryocystorhinostomy With Endonasal Augmentation in Primary Nasolacrimal Duct Obstruction: Our Experience.</a> Ophthal Plast Reconstr Surg. , (2016).</li>
<li>Yildirim, Y., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Comparison+of+Transcanalicular+Multidiode+Laser+Dacryocystorhinostomy+with+and+without+Silicon+Tube+Intubation%5BTitle%5D)+AND+%22J+Ophthalmol%22%5BJournal%5D)">Comparison of Transcanalicular Multidiode Laser Dacryocystorhinostomy with and without Silicon Tube Intubation.</a> J Ophthalmol. , (2016).</li>
<li>Kar, T., Yildirim, Y., Topal, T., Çolakoğlu, K., Ünal, M. H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Efficacy+of+adjunctive+mitomycin+C+in+transcanalicular+diode+laser+dacryocystorhinostomy+in+different+age+groups%5BTitle%5D)+AND+%22Eur.+J.+Ophthalmol%22%5BJournal%5D)">Efficacy of adjunctive mitomycin C in transcanalicular diode laser dacryocystorhinostomy in different age groups.</a> Eur. J. Ophthalmol. 26 (1), 1-5 (2016).</li>
<li>Ozsutcu, M., Balci, O., Tanriverdi, C., Demirci, G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Efficacy+of+adjunctive+mitomycin+C+in+transcanalicular+diode+laser+dacryocystorhinostomy%5BTitle%5D)+AND+%22Eur.+Arch.+Otorhinolaryngol%22%5BJournal%5D)">Efficacy of adjunctive mitomycin C in transcanalicular diode laser dacryocystorhinostomy.</a> Eur. Arch. Otorhinolaryngol. 274 (2), 873-877 (2016).</li>
</ol>

No conflict of interest.

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...

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 lacrimal sac, a drill is used to create a bony ostium leading to the nasal cavity, thus bypassing the obstructed duct. Functional success rates above 85% have been reported for this method2,3. These results, however, come at the cost of performing a relatively invasive procedure that puts at risk the medial structures of the eyelid including the physiological canalicular pump mechanism4,5 and may leave patients with an unwelcome scar, although modern nasojugal skin incisions have improved results. These risks are potentially avoidable by performing less invasive techniques or choosing an endonasal approach.
In order to circumvent invasive surgery, much work has been done in the field of minimally invasive tear drainage recanalization. Two methods in particular have been established as potential first-step procedures: microdrill dacryoplasty and laser-assisted dacryoplasty. These procedures are based on transcanalicular endoscopy of the tear drainage system and can be performed to treat for short-segment membranous stenoses of the nasolacrimal duct. Though only minimally invasive and characterized by quick reconvalescence, a common drawback of these recanalizing techniques are the relatively low functional success rates with regard to long-term outcomes6,7,8,9.
In an effort to fill the void between these first-step procedures and external DCR as a definitive treatment, new approaches have recently been developed. The most promising of which is laser-assisted DCR for the treatment of absolute infrasaccal PANDO. Like with all aforementioned approaches, patients are recommended to be put under general anesthesia for this procedure. A diode laser fiber is inserted via either canaliculus and is then advanced into the lacrimal sac. Next, laser energy is applied to the lateral nasal wall until a bony ostium is created, connecting to the nasal cavity at the height of the middle turbinate&#39;s anterior margin10,11. All the while, constant visual control is kept using endonasal endoscopy. The newly formed anastomosis serves as a bypass for the tear drainage. After successful irrigation, bicanalicular silicon intubation is performed to prevent early scarring of the newly formed ostium. Postoperative treatment consists of decongestant, steroidal and antibiotic eye drops to prevent swelling, inflammation, and infection, respectively.
The duration of surgery as well as reconvalescence is generally shorter than with external DCR (10 - 25 min in laser-assisted DCR vs. 35 - 75 min in external DCR). Complication rates are relatively low, the most common being discrete swelling of the eyelids and silicon tube prolapse. Canalicular infection and thermal injury are rare events10. One-year functional success rates of 74 - 88% have been reported10,11,12,13,14,15,16,17,18, thus ranging closely behind those of external DCR without suffering the disadvantages of the external surgical approach. However, long-term results remain yet to be provided. Additionally, even after failure of laser-assisted DCR, secondary external DCR can still be performed without difficulty. Consequently, laser-assisted DCR qualifies as a viable second-step procedure that should optimally be performed after failure of recanalization surgery and before external DCR.

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

transcanalicular diode laser-assisted dacryocystorhinostomy for the treatment of primary acquired nasolacrimal duct obstruction

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

Today&#39;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.

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...

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.

Today&#39;s gold standard in the treatment of infrasaccal primary acquired nasolacrimal duct obstruction (PANDO) is external dacryocystorhinostomy (DCR), ...

The overall goal of this procedure is to create a tier bypass in cases of absolute infrasacal nasolacrimal duct obstruction. This modern procedure offers the possibility to effectively treat nasolacrimal duct obstruction safely and quickly, while at the same time reducing complication rates when compared to established protocols. The main advantage of this technique is that it is minimally invasive.After putting the patient under general anesthesia, according to the text protocol, insert the video-assisted endoscope into the nasal cavity by carefully advancing it through the nostril. Tilt the endoscope towards the lateral nasal wall to visualize the anterior margin of the middle turbinate. Next, put on protective glasses and set up the laser equipment by connecting the laser fiber optic to the diode laser.Set the diode laser to six to eight watts, 200 millisecond pulse duration and 100 millisecond exposition pause. Fit the laser fiber optic into the handpiece for maneuvering and then through a blunt cannula. Let two to three millimeters of the fiber stick out at the tip of the cannula.Perform carbonization of the laser fiber tip by holding it on a wooden spatula and applying laser energy for a few seconds, until the tip is sufficiently blackened. This will limit unwanted energy distribution to the lacrimal sac. Next, to dilate the upper and lower punctum, insert a lacrimal probe, vertically at first, and then position it horizontally before further advancing it towards the lacrimal sac.Begin by vertically inserting the laser fiber into the lower canaliculus before tilting it toward the temple horizontally, to follow the physiological formation of the lower canaliculus. Carefully advance the laser fiber into the lacrimal sac until it touches the lateral nasal wall, i.e. the medial lacrimal sacal wall.Then, aim the tip in an anteroinferior direction so that it points to the anterior margin of the middle turbinate. To create a sufficient nasolacrimal bypass while maintaining constant contact to the nasal wall while not applying pressure, vaporize the tissue by applying laser energy. It is very important that the laser fiber is not actively pressed to the wall or subjected to lateral stress.This is because retraction or breaking of the fiber may cause heating of the metal cannula, therefore causing thermal injury. When the lateral nasal wall has been penetrated, pull the laser fiber back a bit and enlarge the ostium by carefully vaporizing the margins in a circular manner. Try to create as large a bypass as possible.Using a Bangerter probe, verify the patency of the ostium by saline irrigation. If a patent ostium was created, successful irrigation should be visible endoscopically. Through the lower punctum, insert a monocanalicular silicone tube and carefully advance it until the leading metal tip passes the bony ostium and protrudes into the nasal cavity.Use Blakesley forceps to grab the tip from inside the nasal cavity and pull the silicone tube out of the nose and into position. And then, use a pair of scissors to cut them short. Perform silicone intubation via the upper canaliculus and remove the endoscope.Then, use a pair of scissors to shorten the silicone tubes so that the ends are not sticking out of the nose. Carry out postoperative care according to the text protocol. Upon examination, the day after transcanalicular laser-assisted DCR, a little swelling of the eyelid can be present in about 60%of cases.This slight swelling always resolves completely within a maximum of three days. However, because bicanalicular silicone intubation is performed during the procedure, epiphora may persist until the tubes are removed. This table gives an overview of the results.Functional success, meaning complete resolution of symptoms at the six months mark, can be achieved in 78%of patients. In about 22%of cases, restenosis may occur. The most likely reason is scar tissue forming in the bony ostium and secondary external DCR can become necessary.Serious complications are rare, however, when the utilized laser equipment is not handled carefully, the tip of the laser fiber can slip back into the metal cannula, which will cause heating of the metal. This results in thermal injury to the canaliculus or lacrimal sac. In conclusion, laser DCR is a minimally invasive technique with high functional success rates, few complications and no need for a skin incision.Once mastered, this technique can be done in 15 to 25 minutes if it is performed properly. While attempting this procedure, it's important to remember to create as large an ostium as possible since smaller diameter osteotomies facilitate early scarring. If following this procedure, restenosis occur, secondary external dacryocystorhinostomy can still be performed without an increase in complication rates.After its development, this technique paved the way for researchers in the field of oculoplastics to further explore laser-assisted lacrimal bypass surgery and its possible combinations with the use of fibrosis inhibiting drugs and internasal apparatus. After watching this video, you should have a good understanding of how to perform transcanalicular dacryocystorhinostomy using a diode laser to create nasal lacrimal bypass. Don't forget that working with lasers can be hazardous and precautions, such as wearing protective goggles, should always be taken while performing this procedure.

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Learn transcanalicular diode laser-assisted dacryocystorhinostomy for treating primary acquired nasolacrimal duct obstruction. This minimally invasive technique creates a safe bypass with lower complication rates than traditional surgery.

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

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