External Dacryocystorhinostomy and Its Variants

Stenosis or occlusion of the nasolacrimal duct is associated with one or both of “flow” symptoms (variable blurring of vision and spillage of tears due to an overfull tear film) and “volume” symptoms, due to reflux of mucoid debris from the lacrimal sac into the tear lake (with smearing of the vision, morning stickiness of the eyelids, recurrent conjunctivitis or dacryocystitis). It is possible to achieve a total cure of the volume symptoms with an adequately performed external dacryocystorhinostomy (DCR) but, even with a freely-patent anastomosis, flow symptoms—that are greatly dependent on the rate of tear production relative to limits of canalicular conductance and tear evaporation—cannot be relieved in all cases. Relief of volume symptoms and signs can be accomplished by creating a wide anastomosis that incorporates the lacrimal sac into the lateral wall of the nose, thereby removing any space for collection of debris. This requires a wide osteotomy with anterior ethmoidectomy, and suturing of both the anterior and posterior mucosal flaps to promote primary intention healing with minimal scar formation.