EDCR is standard procedure for treating primary acquired NLD obstruction. The success rate of EDCR ranges from 90 to 100%. [1] Many authors have suggested different ways of doing EDCR by using lacrimal stent, microdebrider dacroendoscope, electrocautery, application of mitomycine C laser etc. But in my experience results are equal or better than these techniques using simple combination of mechanical and powered instruments. I also described the probabale factors that improve surgical outcome.

Assessment began with examination of eyes or lids for any deformity or purulent discharge at medial canthal area. ROPLAS TEST was done as diagnosis of NLD block. This was followed by probing and syringing. Examination of nose was done as next step by doing anterior rhinoscopy to rule out any obvious nasal pathology except anatomical variations. Patients with presacal disease were not included in the study. Hundred and twenty-seven patients who underwent EDCR were included in the study. These patients were operated from july 2020 to august 2022.Out of these 127 patients 3 patients were operated under GA and remaining were operated under local anaesthesia. [Dextomed [ 0.3 µ gm /kg/hr with dazocine.].

At first the nasal cavity is prepared using cottonoid soaked In 4% xylocaine with adrenaline. I used two ampoules of adrenaline in 30ml of xylocaine in young patients and without medical disease and one ampoule of adrenaline in elderly patients associated with medical condition. This packing is kept for ten minutes which gives adequate congestion of nasal mucosa. Then the nasal pack is removed and fresh tapegauze soaked in 4% xylocaine with adrenaline is kept in the nasal cavity in such way that posterior choana, posterior part of middle meatus, inferior part of nasal cavity is obliterated so that nasal bleeding and nasal secretions doesn’t enter into the oral cavity by postnasal route.

Then the mucosa of sac area is infiltrated with 2% xylocaine with adrenaline. Similarly anterior end of middle turbinate and anterior part of septum is also infiltrated with 2% xylocaine with adrenaline. Remaining nasal cavity was then packed with separate tapeguaze which was removed at the beginning of operation. Clinical application of dextomed combined with dazocine was used with LA. Lacrimal sac area was exposed by posterior sac technique. [2] depending upon the availability of space I used a no 15 blade or sickle knife or circular knife for taking incision. Majority of time additional space can be created by infracture of inferior turbinate or medialisation of middle turbinate so that minor anatomical variations need not be treated as an additional procedure. Mucoperiosteal flap is elevated posteriorly without disturbing uncinate process. Sac is exposed by removing the bone from ascending process of maxilla and paper-thin lacrimal bone. I used 3 mm Kerrison’s punch and micromotor with drill [3mm diamond burr] for removing the bone. After exposing the sac and NLD incision is taken on medial wall of sac and NLD using no. 12 surgical blade. Sac and nasolcrimal duct marsupalised. Anterior and posterior flaps of the sac were prepared.

Similarly superior and inferior flaps off mucosa prepared. Anterior and superior flaps and posterior and inferior flaps are approximated properly. Anterior nasal packing is done whenever required.

POST OP CARE AND FOLLOW UP:

1. Nasal cavity and crust removed from nasal cavity on day 2 without disturbing operative area.
2. Analgesics and antibiotics are given for 5 days.
3. Antibiotic and steroids eye drops for 1 month.
4. Patient is reviewed at the end of one week, two-week, one month, six months and one years.
5. Everytime patient attends opd I do NE and syringing of the patient.
6. Any minor complications like adhesions, granulation tissue formation are taken care of and treated simultaneously at the time of follow up.

In this study, 127 patients of chronic dacryocystitis presented to me with chief complaints of epiphora with duration of 6 months to 8 years. Some patients presented with complaints of pus at the medial canthus of eye, mucocele, pyocoele, cutaneous fistula, periorbital cellulitis. Five patients had bilateral disease, as shown in Table 1.

Table 1: Shows the distribution of the study participants.

Out of 127 patients 46 were male and 81 were female patients between the age group of 13years to 85 years. [Mean -44 years] Total 132 EDCR were carried out.63 were performed on right side and 69 were performed on left side. Male patients operated were 46 and female 81, as shown in Table 2.

Table 2: Demography of sex and age:

In my series minimum age of patient was 13 years and maximum age was 85 years. Out of 127 patients three patients were operated under GA one patient of bilateral congenital chronic dacryocystitis and two patients of severe deviated nasal septum were operated under general anaesthesia. Rest of the patients were operated under LA. Four patients of bilateral chronic dacryocystitis were operated under LA in phased manner.

Table 3: Age demographics.

Maximum peak of incidence was in the age group 51 to 60. In these 132 EDCR done 12 patients needed revision surgery. Out of these 12 patients two patients had canalicular block which was missed during initial diagnosis, as shown in Table 3. Five patients refused revision surgery and in remaining five patients’ revision surgery was done. In revision cases four patients are doing well at the end of one year but one patient still redeveloped stoma closure. While operating these patients I noticed significant anatomical variations in twelve patients compromising the sac area.

Table 4. Significant nasal anatomical variations

All these anatomical variations treated simultaneously except canalicular stenosis and these patients with canalicular block were referred to an ophthalmologist. Twenty-one patients had complications like closure of stoma due to cicatrisation , granulation tissue formation, adhesion between septum and inferior turbinate and adhesions between middle turbinate and lateral wall of nose, crust formation over stoma and these complications were handled simultaneously during follow up, as shown in Table 4.

Table 5: Complications of EDCR

In my series eight patients didn’t improve at the end of one year. Overall success rate is 93.4%EDCR as shown in Table 5.

Chronic dacryocystitis is one of the most common causes of excessive tearing. External DCR was the standard surgical procedure for chronic dacryocystitis for most of the years in 20th century. External DCR has failure rate ranging from 60 to 95 % [3]. After the advances in nasal endoscopic surgery EDCR gained more popularity. EDCR avoids external incision hence avoids external scar. It preserves the pumping action of the orbicularis oculli muscle. It can be performed in active infection of the sac which is relative contraindication for external DCR. It is particularly useful in the revision of the external DCR, as it avoids another external incision and subsequent further scarring.[1] Majority of patients were operated under LA. LA with dexmed and dazocine as adjuvant in EDCR has more stable haemodynamics and reduces the stress response during perioperative period. This anaesthesia also achieves better post operative sedation and analgesics effects, reduces post operative complications and improves the quality of awakening from anaesthesia.LA is safe and comfortable for patients with high risk of GA.[4] While operating these patients I noticed that many times complete exposure of the sac is not possible by simple mechanical instruments only. Like in situations where I encountered that, complete exposure of sac is not possible by mechanical instruments s.a. [Fig. 1] because upper portion of sac is covered with thick bone.  where ascending portion of maxilla is very thick and does not come under the punch. [Fig.2] whole sac is covered with thick bone; the use of powered instrument is must to optimize the result. Apart from above mentioned situations I noticed other advantages of using drill with diamond burr. It helps to smoothen the bony edges so that flaps fall properly on lateral wall of nose and approximate properly. Due to this healing is proper which avoids postoperative complications. Diamond burr helps to reduce bleeding from bone [Fig. 3] very well tolerated by the patient, no complaint of pain even under local anaesthesia. 

In early part of surgery, I used kerrison’s punch to remove bone which reduces the time taken for surgery. References have suggested separate use of mechanical and powered instruments. In my series I have used this combination in every patient and encountered its advantages. [5 ,6 ,7 ] It was found that improper selection of cases accounted for 3.3% of total failed cases. So, cases with presacal disease should be excluded to avoid failures unless we have expertise in treating presacal disease. [8]

In my series in two patients’ failure was due to canalicular block which was obviously missed during initial examination. I encountered significant anatomical variations in twelve patients [10%] which need simultaneous treatment. I noticed failure in two patients due to severe DNS which was not treated by the first surgeon. [9, 10 ].

Eight patients had severe attack of acute on chronic dacryocystitis with pyochelin, cutaneous fistula and pus with orbital cellulitis. In these patients my strategy was to treat these patients conservatively for three days followed by EDCR. I noticed several advantages of early intervention in these patients. s. a. [A] it keeps overlying skin intact and helps avoid fistula formation. [B] rapid reduction of swelling and periorbital edema due to drainage of sac abcess. [C] it prevents adhesions of sac wall. [D] identification of sac lumen is easy. [E] duration and expenditure of treatment reduced. Jay Yun Sung et al have also suggested primary early EDCR is safe and effective procedure for treatment of AD. Very early DCR performed within three days leads to faster recovery and shortens the course of antibiotic treatment. [11]

In the article by Lee JJ et al mentioned that a surgeon is required to perform at least 30 EDCR to obtain stable surgical results for this procedure. [12] In my series also I noted that experience of the surgeon does matter. I have noted that in two patients there was severe DNS and first surgeon attempted DCR, but he could not expose the sac properly due to inadequate space and patient needed revision surgery. One patient in my series was operated first by an ophthalmologist with an external approach and then by an ENT surgeon endoscopically with no result. But when I explored the patient’s sac it was easily identifiable and patient was doing well at the end of the year.

In American journal of rhinology and allergy it is mentioned that in DCR failure with intranasal adhesions was more likely to occur when surgery was performed through an external approach rather than an endoscopic approach. Endoscopic instruments allowed for identification and correction of intranasal pathology at the time of surgery. [13] From my series of patients I am convinced that the involvement of an ENT surgeon is must for optimal results in DCR patients as twelve patients needed simultaneous correction of anatomical factors for the success of surgery. I have realised that proper approximation of sac flaps and mucousal flaps is essential for proper article by Tarjani et al., in their study of etiological analysis of anatomically failed dacryocystostomies.

they have mentioned approximation of flaps in a proper way is one of the key factors to facilitate healing by primary intention without scarring. [ 14 ].

In my experience frequent follow, up in early postoperative period reduces or eliminates the persistence of complications like adhesions and granulation tissue formation and thus reduces the failure rates.

EDCR is safe and effective procedure in both primary and revision cases. It can be done safely under LA in majority of cases. In my experience following factors help to improve results of EDCR. [A] Proper selection of patient. [B] Wide exposure of sac and NLD using combination of mechanical and powered instruments. [C] Proper approximation of mucosal and sac flaps. [D] Frequent follow up and syringing to avoid complications and closure of stoma. [E] Treatment of nasal anatomical factors causing obstruction of sac and duct or hindrance to approach of sac area. [F] Early intervention in patients of AD. [G] Without involvement of ent surgeon it is impossible to give optimal results. [H] This technique is cheaper and at par with any other technique of DCR. However other modalities like stenting laser may be tried in refractory cases.

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