Endoscopic Dacryocystorhinostomy: Anatomic Considerations, Surgical Technique, and Controversies

PROGRAM DESCRIPTION: Nasolacrimal duct obstruction is manifested by epiphora and infection. Conservative treatments only achieve temporary relief of symptoms, thus surgery is the treatment of choice. Dacryocystorhinostomy (DCR) is recognized as the most suitable treatment for patients with obstructions of the lacrimal system at the level of the sac or in the nasolacrimal duct. The aim of this operation is to create a bypass between the lacrimal sac and the nasal cavity. This has traditionally been a procedure perform by Ophthalmology. Advances in rigid endoscopic equipment and technology along with advances in endoscopic sinus surgery have led to the development of endoscopic DCR, a minimally invasive technique to address nasolacrimal duct obstruction. Otolaryngologists, particularly rhinologists, are commonly performing endoscopic DCR. However, knowledge and expertise in endoscopic DCR among otolaryngologists is variable in clinical practice and post-graduate training. The technique and peri-operative management for endoscopic DCR continues to evolve, and there are some areas of controversy regarding the use of lacrimal stents and topical antimetabolites. This presentation will review the relevant anatomic considerations, outline the surgical technique, and review the current controversies in contemporary management of endoscopic DCR. We will review the above in the context of both primary and revision endoscopic DCR. At the end of this session, attendees (1) will be able to identify the relevant anatomic landmarks on endoscopy and CT imaging for endoscopic DCR; (2) describe the surgical steps of endoscopic DCR including the tools/technology that can be used at each step; and (3) discuss use of lacrimal stents and topical antimetabolites (e.g. mitomycin C) from an evidence-based and practice-patterns-based perspective for endoscopic DCR. In addition, we will briefly discuss coding and reimbursement for DCR. Attendees will have the knowledge and expertise to add endoscopic DCR into their surgical armamentarium.