Endoscopic Conjunctivo-DCR: Surgical Scenario 1
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Conjunctivodacryocystorhinostomy or CDCR is a surgical procedure where a new passage is created for drainage of tears from the conjunctival cul-de-sac directly into the nasal cavity. The procedure can be performed via an external approach (external CDCR), an endoscopic approach (endoscopic CDCR), or a minimally invasive approach (MICDCR) or diode laser-assisted (LCDCR) and endoscopic conjunctivorhinostomy (CR) without a DCR. Though the procedure is useful with a success rate hovering around 90%, large series have shown two major complications, namely, extrusion of the tube ranging from 28% to as high as 51% and tube malposition ranging from 22 to 28%. In order to avoid these complications, numerous modifications of the bypass tube have been published including additional flanges, wide medial ends, angulated tubes, and porous polyethylene-coated tubes.
This video elucidates fundamentals of CDCR, its indications, contraindications, techniques, complications and outcomes assessment that will provide a great learning experience to ophthalmology and otolaryngology surgeons.
This video serves as a useful link to the chapters with similar titles in the 2nd edition of the textbook ‘Principles and Practice of Lacrimal Surgery’ and also ‘Atlas of Lacrimal Drainage Disorders’, both edited and authored respectively by the author of this video, Dr Mohammad Javed Ali and published by Springer. The reader gets great details and bibliography, and images from these sources in addition to the surgical steps illustrated in the video for complete knowledge.
This video presents surgical approach to conjunctivodacryocystorhinostomy or CDCR and associated complications along with their management.
About The Author
Mohammad Javed Ali is an internationally recognized clinician-scientist and currently heads the Govindram Seksaria Institute of Dacryology and is also the alumni chair of ophthalmology at the L.V. Prasad Eye Institute, India. He is currently the Hong-Leong Professor at NUHS, Singapore, and Gast Professor at FAU, Germany. Javed is among the rare recipients of the Senior Alexander Von Humboldt Award and the Shanti Swarup Bhatnagar Prize, the highest multi-disciplinary scientific award by the Government of India. He described 3 new diseases of the lacrimal system along with their classifications and clinicopathologic profiles. He was honoured by the 2015 ASOPRS Merrill Reeh Award for his path-breaking work on etiopathogenesis of punctal stenosis and 2020 American Academy-ASOPRS Lester Jones Award for outstanding contributions to the field of ophthalmic plastics and reconstructive surgery. His textbook “Principles and Practice of Lacrimal Surgery” is considered to be the most comprehensive treatise on the subject and his other treatise ‘Atlas of Lacrimal Drainage Disorders’, is the first of its kind. He has to his credit 438 publications at the time of this writing and 9 editorial board positions and has delivered 315 conference lectures, including 12 keynote addresses. He has conducted 25 instruction courses and 29 live surgical workshops and has been honored with 34 national and international awards.
About this video
- Mohammad Javed Ali
- Online ISBN
- Total duration
- 18 min
- Springer, Singapore
- Copyright information
- © Producer, under exclusive license to Springer Nature Singapore Pte Ltd. 2021
- Prof. Mohammad Javed Ali
- MD Mohammad Javed Ali
- Livio Presutti
- Francesco Mattioli
Hello, everyone. Today we will be discussing a little uncommonly performed surgery, but a very important surgery in the armamentarium of a lacrimal surgeon. That is an endoscopic conjunctivo dacryocystorhinostomy. We will discuss the surgical techniques and complications thereof.
I am Mohammad Javed Ali, and I head the Govindram Seksaria Institute of Dacryology at the LV Prasad Eye Institute. I practice both clinical and basic sinuses related to the lacrimal drainage system as my focused area.
The outline of this talk would be, briefly, the indications and equipment that are needed for an endoscopic CDCR before we move on to discuss the video subsequently. And then we will also discuss surgical techniques and complications thereof. The below-mentioned references will give you further details on this topic.
Other indications for an endoscopic CDCR would be many. But the common ones are punctal and canalicular agenesis, proximal bicanalicular obstructions, lacrimal pump failure before or after CDCR, and post-dacryocystectomy habilitation.
Obviously, for an endoscopic CDCR, we need a good endoscopic system with a debrider and a drill system that you see in the picture on the left. And it goes unsaid that a thorough preoperative nasal evaluation is mandatory for any CDCR surgery.
Now the stents that are used are, commonly, the Lester Jones stents that you see on the left side and the Gladstone-Putterman tubes on the right side. The Lester Jones, if you see, has a large ocular flange, and the nasal end is a little beveled. These are straight tubes. Now, they can come with a lot of modifications. Like you see on the image on the right, that this is a Gladstone-Putterman’s tube, which has an additional flange, where you also see that the distal end is frosted.
This is a typical example of an endoscopic CDCR tray, where you can have all those tubes here. In this example, all of them are Gladstone-Putterman tubes. You can see that you have those measurements– 3.5 and to 14. 3.5 is the diameter of the tube, and 14 is the length of the tube. So like that, you can have variable lengths placed in those cabinets, which are designed for that. And you also see three gold dilators and two measuring slabs. Now, this whole thing can be autoclaved and can be ready in a sterile condition when we want to select any of those tubes.
The basic principle of any endoscopic CDCR, or for that matter, any CDCR, is to create a bypass from the congenital cul-de-sac directly into the nasal cavity with the help of certain tubes that we just discussed. So we would go ahead, from the anesthesia point of view, from the nasal-deconditioned point of view, we just go as a regular endoscopic DCR. And we go ahead and create an osteotomy and make the lacrimal-sac flaps, just like we do in any endoscopic DCR.
Once we do that, we come to the conjunctival site approximately 3 to 4 millimeters beneath the caruncle. We take an incision on the conjunctival side, and then you go ahead and enlarge that incision using a tenotomy scissor that you see in the image on the right side. And once you decently create a track, you can either use an Bowman’s probe or a large-bore needle, like a 14-gauge needle, which I’m showing you in this image.
Now, I prefer using a needle because it also helps in getting the track a little bit more clean for the incoming tube. And once that is done, you take the tube, or a Bowman’s probe somewhere up to a midpoint between the septum and the lateral wall. And that amount of the probe or the needle is measured for determining the size of the tube that one may use.
Here, you see a measuring that point of the needle. And based on whatever measurement we have, once we select the Jones tube and mount it on a Bowman’s probe, to go ahead and fix it in the track.
There you see a picture on the left. We have put up the Jones tubes, like somewhere between the middle– midway between the osteotomy– that one we have created– and the septum. And once that is there, we can go ahead and secure it with sutures. I’ll show all these steps once I take you through subsequent different techniques of this surgery.
Now, postoperative management of a CDCR is a very important maneuver, and this is something that we need to be well aware of it. This is one of the patients that you see postoperatively. The right-side stent is in a good position, to Jones tube, and secured by the PROLENE suture. So what do we do postoperatively?
It’s a good idea to use nonviscous lubricants or sterile water, at least in the initial phase, to just place it a little bit into your operative eye, and then close the contralateral nostril. And then sniff so that the negative pressure in the nasal cavity can drain the fluid from the ocular surface into the nasal cavity, and simultaneously, also keep the tube clean and prevent it from getting clogged.
Occasionally, to check the patency of the Lester Jones tube, one can directly irrigate with a blunt cannula, as you can see here. And somewhere around six weeks postoperatively, once the healing is complete, you can go ahead and remove the PROLENE suture.
The outcomes of CDCR are usually very good. As you can see here, most of them are somewhere above 90%, which is a good thing. But simultaneously, there are a lot of complications. The two most common complication that you see are extrusions or malposition.
These are examples of malpositions. The picture on to the left shows an inferior displacement, where you don’t even see the tube in the middle fornix. The picture on the right demonstrates a lateral tube malposition, where the tube is coming towards the ocular surface.
The picture on the left shows numerous granulomas all around the tube. This is a common complication. And this is something that one needs to watch out for. Rarely, that might be a pressure necrosis of the conjunctiva, like you see in the picture on the right. This usually happens if the tube is very tight and is under a lot of pressure over the conjunctiva.
Now, tube dislocations into the nasal cavity or tube impaction, like you see in the nasal cavity on the left picture with the granulation in the nasal cavity, is not something uncommon. And the picture on the right shows the well-functioning Jones tube, but there’s a huge granuloma all around it. We will discuss this and its management in subsequent videos.
So I think this will be a very nice and exciting series of videos, and let us learn together some important things. And I’m I’m sure all of us are going to enjoy this.