NESOS E-Mag

Volume 1, No. 1, Jan-Jun, 2021

HTo“fTeaighrhes”way

an Official biannual
e-Magazine by:

Reaching People. Touching Lives.

OUR OPHTHALMIC RANGE

NESOS E-MAG

NESOS e-Mag is the official biannual electronic magazine of the Nepalese Society for
Oculoplastic Surgeons (NESOS). This e-Magazine will be a concoction of scientific publi-
cations such as articles, reviews, opinions, tips and tricks, interesting cases, and out-of-
the-track contents like interviews of eminent Nepalese oculoplastic surgeons, success
stories, photo gallery and oculoplastic news.

The aim of the e-Magazine is to provide a platform for the oculoplastic surgeons from
Nepal and abroad to discuss and engage on topics related to orbit, ophthalmic plastic and
reconstructive surgeries, oculofacial aesthetics and ophthalmic oncology. This will also
provide a platform for young oculoplastic surgeons and aspirants to learn from the expe-
rienced ones in the field. The e-Magazine also aims to disseminate important information
and messages regarding the NESOS activities including the news and events.

INFORMATION TO THE • Original research articles tion of 2–3 sentences related
AUTHORS: • Case report/ case series to the photograph and the
• Picture essay - Interesting name of the photographer.
Subscription information:
The e-Magazine is available oculoplastic pictures with Please note:
to download free of charge short explanation 1. This is not a peer reviewed
from www.nesosnepal.org.np,
& www.nesosemag.medium. 2. Word count: publication. Published ar-
com. While the word count is not ticle will not be counted as
rigid, it is advised that the academic achievement.
Guidelines for articles sub- authors follow following word 2. It is the responsibility of
mission: limit for their articles. the author to obtain ap-
• Major review and original propriate consent for the
1. Articles structured in appro- publication of the patient
priate academic English lan- research articles — maxi- details and patient photo-
guage and well referenced for mum 3000 words graphs.
factual data or claims should • Expert opinion, tips and 3. The articles need to be
be submitted along with au- tricks — maximum 2000 in standard English and
thor details and photograph to words referenced for any claims
[email protected] or as • Case report and series — or factual data presented
per the submission procedure maximum 1000 words in the article.
stated in the NESOS website • Picture essay — maximum 4. The opinions and any
(www.nesosnepal.org.np). 500 words claims made in the mag-
The articles can be one of the azine would be the liabil-
following: 3. Interesting photographs ity of the authors solely
• Reviews, expert opinion, related to oculoplasty, ocu- and NESOS or Editorial
loplasty surgery or surgeon, board would not bear any
history of surgery, and those depicting success responsibilities for any
tips/tricks stories in Oculoplasty are disputes arising thereof.
also welcomed. Photographs 5. The editorial committee
should have a brief descrip-

Volume 1, No. 1 (Jan-Jun, 2021) NESOS E-Mag 01

deserves the right to reject COPYRIGHTS:
an article at any stage of
editing. The contents published in the
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7. Plagiarism is strictly pro- tee and the respective author.
hibited.
DISCLAIMER:

ADVERTISEMENTS: All the information and opin-
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The NESOS e-Mag accepts e-Mag reflect the views of the
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rial committee deserves the or the NESOS. Any disputes
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ment considered unsuitable responsibility of the respective
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Department of Oculofacial
All the advertisements would plastic surgery
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NESOS e-Mag “The High-
way of Tears”
Year 1, Volume 1, Issue 1

02 NESOS E-Mag Volume 1, No. 1 (Jan-Jun, 2021)

EDITORIAL COMMITTEE

Dr Ben Limbu Dr Basant Raj Sharma Dr Rohit Saiju Dr Naresh Joshi
Patron Patron Patron Patron

Dr Jyoti Baba Shrestha Dr Aashish Raj Pant Dr Hom Bahadur Gurung

Editor-in-Chief Editor Editor

Dr Triptesh Raj Pandey Dr Prerana Kansakar Dr Suresh Rasaily
Associate Editor
Associate Editor Associate Editor

Dr Aric Vaidya Dr Santosh Chaudhary
Associate Editor Guest Web Editor &
Graphic Design

IN THIS ISSUE:

07. Guest Editorial: Bloodless External Dacryocystorhinostomy:TIPS AND

TRICKS. Srujana Laghmisetty, Milind N Naik, MD

12. Review: Anatomical Considerations for Successful External DCR Sur-

gery: A Review. Dr Aric Vaidya, Hirohiko Kakizaki, MD

18. Trend in Ophthalmology: Post-COVID Rhino Orbital Mucormycosis:

A Case Report. Dr Tina Shrestha, MD

20. TO DO or NOT TO DO: Non Endoscopic Endo Nasal DCR (NEENDCR). Dr Bas-

ant Raj Sharma, MD

22. Non-Endoscopic Endonasal DCR (NEENDCR), The Learning Curve: My Experi-

ence. Dr Binita Bhattarai, MD

24. Interview: Heart to heart with Prof Dr Rohit Saiju

27. Pearls: Tips for Traumatic Canalicular Lacerations Repair
29. “DCR on DCT” and lacrimal surgery practices during COVID-19 pandemic: An

experience of an oculoplastic surgeon from a tertiary eye care center of eastern
Nepal. Dr Aashish Raj Pant, MD

32. Endoscopic Endonasal Dacryocystorhinostomy Experience: A learning curve

in the Eastern Nepal. Diwa Hamal, Prerna Arjyal Kafle, Hony KC, Afaque Anwar

37. Update: Dacryocystorhinostomy: An Update National and Global Scenario.
41. Update: NESOS in Pandemic. Dr Ranjana Sharma, MD

43. The I-Stories: Oculoplasty in Photography

COVER PAGE STORY:

Courtesy Ben Limbu, MD
Bilateral Simultaneous DCT: A sacrifice to restore vision in a 87 years elderly blind
patient due to cataract during COVID Pandemic. Lacrimal sac demonstrating inner

lining of sac with common enlarged canalicular opening

04 NESOS E-Mag Volume 1, No. 1 (Jan-Jun, 2021)

MESSAGE :
FROM THE PRESIDENT OF
NESOS

I would like to congratulate the NESOS e mag team BEN LIMBU, MD
for the successful launch of its maiden issue.
President
Dacryology has grown as a separate entity in Ocu- Nepalese Society for
loplasty in recent years. Different surgeries dedicated Oculoplastic Surgeon
to the lacrimal system have always intrigued Ocu-
loplastic surgeons and general ophthalmologists
alike. This issue dedicated to dacryology with the
theme of “the highway of tears” has been justified by
the writers. I am glad to see renowned Oculoplastic
surgeons like Milind Naik and Kakizaki contribute
to the first issue. Research, opinions and teaching
learning process should always go hand in hand with
clinical practice.

I believe NESOS emag will be a sustainable, perma-
nent platform for Oculoplastic surgeons and enthu-
siasts to share and learn their knowledge and experi-
ence.

My best wishes to the editorial team.

Volume 1, No. 1 (Jan-Jun, 2021) NESOS E-Mag 05

EDITORIAL

It is with profound pleasure and anticipation that we celebrate the launch of the
maiden issue of “NESOS e-Mag”: an official biannual e-Magazine of the Nepalese
Society for Oculoplastic Surgeons (NESOS). The objective behind the introduction
of the e-Mag is to provide an ideal forum for exchange of information on oculoplas-
ty through research papers, reviews, case study/ series, reports on promising de-
velopments, practice articles written by prominent oculoplasty surgeons/ experts,
tutorials on newer technical breakthrough, etc.

The theme for this issue is “The highway of Tears” which signifies the lacrimal
drainage system. As it is evident, lacrimal drainage pathway disorders result in a
myriad of ocular problems ranging from persistent watering and discharge to cor-
neal ulcer and blindness! In fact, dacryocystitis, if severe and untreated may lead
to orbital cellulitis and complications arising thereof may even lead to the loss of
life! Besides, lacrimal problems need to be addressed before any ocular surgeries
can be performed to avoid postoperative infections such as sight threatening en-
dophthalmitis. Thus, this seemingly small issue of disorder in the lacrimal drain-
age system may have serious sight and life threatening consequences! Hence, this
e-Magazine hopes the readers regarding importance and the ugly eventuality of the
ostensibly naïve blockage of “the highway of tears”!

This issue is a concoction of original articles, reviews, opinions, tips and tricks,
interviews and much more interesting stuff as you would expect from a magazine.
Articles from Prof. Milind Naik (India) and Prof. Hirohiko Kakizaki (Japan) have
certainly added essence to this issue. As the founder president of NESOS and an
ever supportive senior colleague, we decided to have a heart to heart talk with Pro-
fessor Dr Rohit Saiju which we hope will be an interesting and insightful read to our
readers.

We appreciate the efforts of all the members of the NESOS executive committee,
our esteemed authors, designers, and the sponsors for the tremendous support.
Feedbacks and suggestions are always welcome. You can contact us at ne-
[email protected].

Hope you have a happy reading.

Jyoti B Shrestha, MD
Editor-in-Chief
NESOS e-Mag

06 NESOS E-Mag Volume 1, No. 1 (Jan-Jun, 2021)

GUEST EDITORIAL:

Bloodless External
Dacryocystorhinostomy:
TIPS AND TRICKS

Srujana Laghmisetty, MD, Milind N Naik, MD

LV Prasad Eye Institute, Hyderabad, India

ABSTRACT
Dacryocystorhinostomy (DCR) is one of the commonest surgical procedures per-
formed by Ophthalmologists and Oculoplastic surgeons. Bleeding during DCR
surgery can affect visualization and the surgical outcomes. It also can demotivate
a budding ophthalmolo gist from choosing a career in Oculoplasty. Performing a
bloodless DCR is simple to achieve. This article highlights simple steps to perform
an external DCR, and the ways to minimize blood loss during the procedure.

INTRODUCTION trol of blood pressure helps mini- tive emergencies in special cases.
mize blood loss. Patients who are
A bloodless surgical field during on blood thinners like Aspirin, SURGICAL STEPS:
an external DCR surgery is any Clopidogrel need to discontinue Nasal packing:
oculoplastic surgeon’s dream. these medications well before the Preparing the nasal mucosa is an-
Efforts to minimize blood loss proposed surgery date as per phy- other important step to perform a
during DCR surgery are highly sician’s advice. bloodless DCR. Nasal mucosa is
rewarding. For optimum surgical one of the most vascular tissues
outcome the surgeon should make Before taking up the patient for in the human body. Attaining
an effort to maintain adequate DCR presence of any bleeding or adequate vasoconstriction and
blood flow to the tissue and at the coagulation disorder needs to be blanching the mucosa minimizes
same time should try to avoid ex- ruled out. Investigations to look bleeding. This can be achieved by
cessive blood loss. In this article for bleeding time, clotting time spraying the nasal mucosa with
we will discuss various tips and and prothrombin time is impor- 10% lignocaine 1-2 puffs fol-
tricks to perform an almost blood- tant. In known cases of bleeding lowed by packing the nasal cavity
less external DCR surgery. disorders adequate backup meas- with 4% lignocaine and 0.5% xy-
ures like reserving coagulation lometazoline soaked gauze. Alter-
PREOPERATIVE ASSESS- factors/ whole blood / blood prod- natively topical lignocaine spray
MENT ucts should be undertaken. Have along with topical xylometazoline
Patients with hypertension can the backup of an anesthesia team can be used without packing the
bleed more, hence adequate con- to help deal with any intra-opera- nasal cavity.

Volume 1, No. 1 (Jan-Jun, 2021) NESOS E-Mag 07

Figure 1: Nasal packing tech-
nique. Top panel shows the
wrong technique, where the roller
gauze is inserted vertically. Note
that the pack lies in inferior
meatus (arrow), away from the
location of DCR ostium. The
correct technique is to direct it
upwards, towards the medial
canthus (lower panel), where it
currently lodges in front of the
root of middle turbinate.

The technique of packing is im-
portant, when performed with a
roller gauze. The correct method
of packing is to direct the roller
gauze upwards towards the medi-
al canthus, rather than posteriorly
(Figure 1). This ensures that the
part of the lateral nasal wall just
anterior to the root of the mid-
dle turbinate (area of the DCR
ostium) receives the adrenaline
well.

Figure 2: Nerve blocks for Exter- Figure 3: Incisions for External Local anesthesia
nal DCR surgery. Infratrochlear DCR. The J-shaped incision is The infiltration anaesthesia can
nerve block is given between the most popular, and runs along the contain a short acting and long
two palpable landmarks: medial anterior lacrimal crest. It also acting local anesthetic along
canthal tendon, and the trochlea is the least aesthetic one, and with a vasoconstrictor agent like
(top panel). Infraorbital nerve can cause webbing of the scar. adrenaline to have a bloodless
block is given after palpating the The straight incision is placed surgical field. A preparation com-
infraorbital foramen, and decen- more medially, is cosmetically monly used is a combination of 2
tered slightly medially to target superior, but can be bothered % lignocaine with 0.5% Bupiv-
medial branches (middle panel). by the spectacle nose-pad. The acaine with or without adrenaline.
Anterior ethmoidal nerve can be sub-ciliary incision is technically The nerves to be blocked include
easily blocked trans-caruncular, difficult, requires practice, but the infra-trochlear, the infra-or-
directing the needle tip towards gives the best camouflage for the bital (medial branches), and the
posterior lacrimal crest (bottom scar. anterior ethmoidal (Figure 2). In
panel). addition, local infiltration along
the anterior lacrimal crest helps.

Incision
The incision can be planned as
per the need of the patient. There
are three possible skin incisions

08 NESOS E-Mag Volume 1, No. 1 (Jan-Jun, 2021)

Figure 4: Exposing the lacrimal sac. J-shaped Figure 5: Extent of the bony ostium. Anteriorly, the
incision is extended deeper with monopolar radi- ostium can extend 10-12mm anterior to the anteri-
ofrequency cautery (top left). Periosteal incision or lacrimal crest (top left). Superiorly, the medial
just along the anterior lacrimal crest (top right). canthal tendon can be the limit (top right). Inferi-
Exposure of the lacrimal fossa by retracting the orly, the ostium can extend upto the sac-nasolac-
sac laterally (bottom left), Bone punching begins rimal duct junction. Anterior flap of the lacrimal
at the junction of frontal process of maxilla, and sac created by one vertical, and two horizontal
lacrimal bone (bottom right). incisions (bottom right).

in external DCR surgery (Figure be separately coagulated. Monop- and cauterized.
3). The classic J-shaped incision olar radiofrequency cautery is the
is marked along the anterior lacri- author’s choice, as it coagulates Creation of the bony ostium
mal crest. A more vertical incision small vessels while cutting the The lacrimal fossa is exposed
medially is cosmetically superior, tissues. If required, cotton pellets upto the maxillary-lacrimal suture
but may come under the nose-pad dipped in dilute adrenaline can (identified as a junction of white
of most spectacles. The best cos- also be used during this step to and blue bone). This is where the
metic external incision is sub-cil- obtain a bloodless surgical field. ostium creation begins. Kerrison
iary, and has been published ear- A well powered suction appara- bone punch is then inserted to
lier. tus with appropriately sized metal make the first bone punch at this
suction tips will help in keeping a suture line. At the onset of this
Exposure of lacrimal sac and clean surgical field. step, there is always a concern
fossa about accidental punching of na-
After the skin incision (J-shaped Once the ALC is reached, a per- sal mucosa. Options to minimize
in this case), a layered approach iosteal incision is placed 1-2mm this complication include removal
should be followed in the direc- away from the sac, starting from of nasal pack at this step, and gen-
tion of the anterior lacrimal crest the medial canthal tendon, ex- tle insertion of Kerrison punch.
(ALC). The orbicularis fibres can tending down for 12-15mm along The size of the ostium determines
be separated either by a monopo- the ALC (Figure 4b). The perios- the success rate, and therefore it
lar cautery (Figure 4a), or by blunt teum is lifted off the bone as one is important to create a large os-
dissection with a Q-tip. Angular enters the lacrimal fossa (Figure tium. The extent of the ostium is
vessels and their branches are en- 4c). Any bony perforator/bleeder explained in Figure 5. Sometimes
countered in this region and can at this stage is promptly identified one may encounter bleeding from

Volume 1, No. 1 (Jan-Jun, 2021) NESOS E-Mag 09

the bony edges. Manual pressure, this incision, a horizontal incision are sutured with 2-3 interrupted
broad-tipped monopolar cautery, is to be placed to create anterior 6-0 Vicryl sutures (Figure 7b).
or minimal bone wax can help. flap (Figure 6c). Passing a probe Orbicularis fibers can be approx-
to ensure its visibility within the imated or left alone, and skin inci-
Creating flaps and anastomo- sac lumen confirms anterior flap sion is closed (Figure 7c,d).
sis creation. A similar anterior nasal
Bleeding is commonly encoun- mucosal flap is raised, as a mirror Postoperative care
tered while making nasal mucosal image (Figure 6d). Bleeding from Nasal packing with roller gauze
flaps owing to the highly vascular the cut mucosal edges is usually soaked in Betadine ointment, and
nature of nasal mucosa. Infiltrat- temporary, but if in excess, can dilute oxymetazoline will help
ing the nasal mucosa with lig- be controlled with gentle surgi- prevent nasal bleeding. Deep
nocaine and adrenaline mix will cel packing. If Mitomycin C is packing should be avoided to pre-
blanch the mucosa making it a planned (recommended), Q-tips vent inadvertent damage to the
bloodless and pain-free procedure soaked in it can be placed at this anastomosis. Topical antibiotic
(Figure 6a). stage for the desired duration of drops for 1-2 weeks,
time (Figure 7a). Similarly, if in-
Distending the lacrimal sac with tubation is planned (for canalicu-
fluorescein-impregnated viscoe- lar pathology), it can be done pri-
lastic helps create a sac flap. or to flap suturing.
A vertical incision is first placed
along the length of the sac, as far Closure
posteriorly as possible (to create The sac flaps are approximated,
an anterior flap). At either end of excess if any is trimmed, and they

Figure 6: Creation of flaps. The nasal mucosa is Figure 7: Wound closure. Mitomycin-C pledgets
blanched with local anaesthetic to minimize bleed- can be placed prior to flap suturing (top left).
ing and improve patient comfort (top left). Anterior Flaps are checked for excess/laxity, and after
lacrimal sac flap is then created by incising the trimming the excess, are sutured by 2-3 6-0 Vicryl
sac as posteriorly as possible (top right). Sac flap sutures (top right). Orbicularis and skin is then
creation is confirmed by passing a probe from the closed separately (bottom left and right).
upper canaliculus (bottom left). Anterior nasal
mucosal flap is then created (bottom right).

10 NESOS E-Mag Volume 1, No. 1 (Jan-Jun, 2021)

CONCLUSION Suggested reading:
In order to perform a DCR with
minimal blood loss, a surgeon 1. Ali MJ, Naik MN, Honavar SG. External dacryocystorhinostomy: Tips
should have a good knowledge of and tricks. Oman J Ophthalmol 2012;5:191-5.
anatomy, and proper preoperative
evaluation of the patient for po- 2. Jane M. Olver (2005) Tips on How to Avoid the DCR Scar, Orbit, 24:2,
tential bleeding causes. And one 63-66
should be equipped with a well
powered suction, a monopolar 3. Hart R.H., Powrie S., Rose G.E. (2006) Primary External Dacryocyst-
cautery machine and topical he- orhinostomy. In: Cohen A.J., Mercandetti M., Brazzo B.G. (eds) The Lac-
mostatic agent.With good prepa- rimal System. Springer, New York, NY
ration, the surgery is uneventful,
and a delight to watch! 4. Dave TV, Javed Ali M, Sravani P, Naik MN. Subciliary incision for exter-
nal dacryocystorhinostomy. Ophthalmic Plast Reconstr Surg. 2012 Sep-
Oct;28(5):341-5.

Volume 1, No. 1 (Jan-Jun, 2021) NESOS E-Mag 11

REVIEW

Anatomical Considerations
for Successful External DCR
Surgery: A Review

Aric Vaidya, MD,1,2 Hirohiko Kakizaki, MD, Phd1

1Department of Oculoplastic, Orbital & Lacrimal Surgery, Aichi
Medical University Hospital, Aichi, Japan
2Department of Oculoplastic, Orbital & Lacrimal Surgery, Rapti
Eye Hospital, Dang, Nepal

ABSTRACT
Dacryocystorhinostomy (DCR) has various surgical success rates being reported
in the literature, and osteotomy size and position are the most important factors
influencing the surgical outcomes of DCR. For increasing the success rate of DCR
a proper understanding of the updated relevant anatomy is necessary along with
making a bony window as far as the common canalicular orifice is completely ex-
posed. External dacryocystorhinostomy (ex-DCR) is considered as a gold standard
procedure for treating nasolacrimal duct obstruction, with success rates of more
than 90%. Hence, in this review article we present the various updated anatomical
considerations for increasing the success rate of ex-DCR.

Keywords: External dacryocystorhinostomy, nasolacrimal duct obstruction, common
canalicular orifice, medial canthal tendon, osteotomy

INTRODUCTION

The approach to external dacryocystorhinostomy (ex-DCR) was first mentioned in the literature by the Ital-
ian surgeon Toti, who described exposure of the sac via a small skin incision and absorption of that part of
the sac adjacent to the canaliculi into the nasal cavity.1 Later, Dupuy-Dutemps and Bourguet modified this
technique, who recommended an edge-to-edge anastomosis between the lacrimal sac and the nasal mucosa
(via flaps) over the bony margins of the formed ostium, hence, constructing an epithelium lined tract.2

Ex-DCR has been the gold standard procedure for most cases of lacrimal drainage obstruction, includ-
ing distal canalicular obstruction, common canalicular obstruction, and nasolacrimal duct obstruction
(NLDO).3,4 The success rates for DCR, whether performed externally or endonasally, range from 69.9%

12 NESOS E-Mag Volume 1, No. 1 (Jan-Jun, 2021)

to 100%, depending on many fac- columnar epithelium16 and con- close to the posterior lacrimal
tors.5,6 Although endonasal DCR tains goblet cells, cilia, and serous crest, a surgeon occasionally feels
(en-DCR) has become more pop- glands.17 Microvilli are found difficulty to perform the osteot-
ular over the last decade, many over the epithelial surface.18,19 omy. However, it is better not to
oculoplastic surgeons still do Although the sac wall consists of extend the osteotomy toward the
external over en-DCR, reporting a cavernous structure, it is fairly ethmoid sinus to prevent bleeding
a higher success rate in the for- thin and less developed than that from the ethmoid mucosa.23
mer.7 Also, the ex-DCR allows of the nasolacrimal duct.17,20
good exposure of the surgical area The lateral aspect of the sac wall Anatomy of the Nasolacrimal
to accurately identify anatomical is covered by a fascia, and its Duct (NLD) and Canal
landmarks, allowing the surgeon posterior portion consists of a Anatomically, the “nasolacrimal
to create a well-positioned oste- common fascia with the Horner’s duct” (mucosal portion) is the part
otomy and formation of the mu- muscle, which is called the “lacri- inferior to the superior opening of
cosal anastomosis.8 mal diaphragm”.15 the nasolacrimal canal (bony por-
tion).15 The nasolacrimal canal
Success in DCR surgery also de- The lacrimal sac fossa comprises is formed by the lacrimal bone
pends on the condition of the mu- of the anterior frontal process of superonasally, the inferior turbi-
cosal anastomosis at the bony os- the maxillary bone and the pos- nate bone inferonasally, and the
tium.9-11 Exposed bone marrow terior lacrimal bone.21 There are maxillary bone temporally.22 The
without mucosal lining results ridges anteriorly and posteriorly, nasolacrimal canal empties into
in granulation tissue formation, which are called the anterior and the superior part of the inferior
causing re-obstruction at the oste- posterior lacrimal crests (Figure meatus. The NLD usually con-
otomy site.9,10,12 1), respectively.22 The superoin- tinues for several millimeters be-
ferior length of the lacrimal sac neath the nasal mucosa after leav-
Common variations of this sur- fossa is 12–15 mm, anteroposte- ing its osseous channel20,26-28
gery include a transcutaneous ex- rior 4–9 mm, and the width 2–3 and this part has a valve called the
ternal approach with anterior- and mm.21,23 The lacrimal sac fos- valve of Hasner (Figure 2).23 The
posterior-flap anastomosis (2-flap sa has a shorter anteroposterior total length of the NLD is 15–18
ex-DCR), 3-flap ex-DCR, 8-flap length superiorly.24,25 mm and it is longer than its bony
ex-DCR and an endonasal ap- canal.23 The shape of the NLD
proach without mucosal flap (no- As the lacrimal bone is too thin opening into inferior meatus are
flap en-DCR)13,14 In this review with its thickness around 0.1 of 4 types: adhesive type (66%),
article, we will be talking about mm,22 an osteotomy is made sleeve-like type (14%), wide-
the various updated anatomical from the lacrimal bone in both open type (12%) and valve-like
considerations for the successful ex- and en-DCR. When a lacri- type (8%).28
outcomes of ex-DCR surgery. mo-maxillary suture is situated

Anatomy of the Lacrimal Figure 1. Anatomy of lacrimal sac Figure 2. View of lacrimal sac,
Sac and Its Fossa fossa and its surroundings. nasolacrimal duct and valve of
The lacrimal sac and the nasol- Hasner on cadaveric dissection.
acrimal duct are a continuous
structure.15 The part of the sac
superior to the medial canthal
tendon (MCT) is called the fun-
dus, which has a vertical length
of 3–5 mm.15 The body of the
sac lies inferior to the MCT
with its length about 10 mm.
The sac is lined by a stratified

Volume 1, No. 1 (Jan-Jun, 2021) NESOS E-Mag 13

Anatomy of the Medial Can- ANATOMICAL CONSIDER- opening, but be narrow enough to
ATIONS DURING EX-DCR prevent any facial or medial can-
thal Tendon (MCT) SURGERY thal deformity. Such a defect can
DCR has various surgical suc- be referred to as a ‘critical size
Classically, MCT is known to cess rates being reported in the bone defect’, which does not heal
have two limbs, i.e., the anterior literature, and osteotomy size spontaneously.45 The study done
and posterior.15 Although many and position are significant fac- by Argin et al. proposed creation
anatomists have worked on the tors influencing the surgical out- of a 2×2 cm bone defect by de-
anatomy of the MCT, we re-ex- comes of DCR.14,35-41 Success taching the anterior crus of the
plored the anterior limb and found in DCR surgery also depends on medial canthal tendon.46 At the
out that it consists of two lamel- the condition of the mucosal anas- end of the procedure reinsertion
lae, i.e., the anterior and posteri- tomosis at the bony ostium.9-11 of the anterior crus should be car-
or.29 The anterior lamella is the Occasional failures are also expe- ried out to avoid the risk of a de-
tendon of the pretarsal part of the rienced because of various condi- formity, and to ensure there is no
orbicularis oculi muscle (OOM) tions such as untreated common damage to orbicularis oculi pump
whereas the posterior lamella is canalicular obstruction, fibrosis of function.46
the musculotendinous junction of a small anastomosis, and obstruc-
the preseptal and orbital parts of tion of the bony window with new The absence of a posterior flap
the OOM.29 A thick fibrous lac- bone formation.42 does not adversely affect surgical
rimal diaphragm,15 namely, the outcome in ex-DCR.9,14,47-49
common fascia between the lac- The size of the ostium has often On the other hand, the anterior,
rimal sac and Horner’s muscle, been described as an important superior, and inferior portions
was noted around the posterior factor in determining the suc- were the most common sites of
lacrimal crest (Figure 3), which cess in DCR surgery33,35,43,44 granulation tissue formation with
appeared to be continuous with and creating a large osteotomy the no-flap technique, and they
Horner’s muscle fascia and was is one of the considerations for
indistinguishable from the mus- increasing the success rate for
cle’s tendon.23 This thick, fibrous ex-DCR.44 Theoretically, the
diaphragm, similar to Horner’s created defect should be large
muscle tendon, may have been re- enough to facilitate the flap
garded mistakenly as the posterior anastomosis during the opera-
limb of the MCT.28 tion and maintain the long-term

Figure 4. Intraoperative photo show-
ing medial canthal tendon (MCT).

Figure 3. Important bony landmarks around the Figure 5. Intraoperative photo showing bony window

medial canthal tendon. up to the medial canthal tendon.

14 NESOS E-Mag Volume 1, No. 1 (Jan-Jun, 2021)

need to be completely covered upper edge of the MCT
with the mucosal flaps for suc- can be safely done for
cessful outcome.14 complete exposure of
the CCO without CSF
During ex-DCR, some oculoplas- leakage.51,60
tic surgeons prefer to use the MCT
as a reference of the superior limit
of creation of the bony window
(Figure 4), 10,14,47,50 although
this is not routinely practiced
worldwide.

However, occasionally we en- Figure 6. Appearance of the skull
counter cases in which the com- base showing cribriform plate,
mon canalicular orifice (CCO) crista galli and optic nerve.
is not exposed after making the
bony window up to the MCT aries of the DCR ostium, the Figure 7. Complete exposure
(Figure 5). bone removal is recommended of common canalicular orifice
to extend superiorly to the lower (CCO).
The cadaveric study done by margin of the MCT, inferiorly to
Vaidya et al.51 found out that the the entrance of the bony nasolac- CONCLUSION
CCO was located above the low- rimal canal, anteriorly to the me- A bony gap of an appropriate size
er edge of the MCT in 62 orbits dial part of the vascular sulcus of and location, along with a tech-
(82.7%), which was in contrary to the frontal process of the maxilla, nically correct anastomosis, are
the previous notion of some ocu- and posteriorly to the posterior expected to lead to a long term
loplastic surgeons that creation of lacrimal crest.14,47 But, a previ- anatomical and functional success
the bony window superiorly up to ous study by Kumar et al.56 rec- in ex-DCR. The various anatom-
the inferior margin of the MCT is ommends to extend the ostium at ical considerations including the
sufficient in ex-DCR to complete- least 2–3 mm beyond the posterior updated findings have been brief-
ly expose the CCO.10,14,47,50 edge of the sac in order to create a ly presented in this review article,
For this purpose, it is better to 5 mm border around the CCO.42 which will be helpful for perform-
temporarily disinsert the MCT to For increasing the success rate of ing a safe and successful ex-DCR
remove the bone more superiorly DCR, there is a need to make a surgery.
during ex-DCR.48,52-55 bony window as far as the CCO
is completely exposed (Figure
The studies done by Rootman et 7).11,43,51,57,58 Therefore, the
al.55 and Welham and Wulc42 bone removal superiorly till the
also tend to suggest that the posi- level of around 3 mm above the
tion of the ostium is more critical
than the size. Cerebrospinal fluid REFERENCES:
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be hesitant to go much above the 1904;10:385–9.
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HK. Surgical outcomes of external dacryocystorhinostomy and risk
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my: is it really less successful? Arch Ophthalmol 24. Kakizaki H, Iwaki M, Asamoto K, Nakano T. Ana-
2004;122:108–10. tomical basis for an appropriate initial osseous hole
9. Serin D, Alagöz G, Karshoğlu Ş, Celebi S, Kükner in external dacryocystorhinostomy. Nihon Ganka
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thal Plast Reconstr Surg 2007;23:28–31. H, Nakano T, Asamoto K, Iwaki M. Anatomical
10. Yazici B, Yazici Z. Final nasolacrimal ostium after relationship of Horner’s muscle origin and pos-
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2003;121:76–80. 2012;28:66–8.
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Mito H. Prevention of re-obstruction in watery eye is composed of anterior and posterior lobes in Japa-
treatment: three-flap technique in external dacryo- nese eyes and fixes the eyelid complementarily with
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15. Jones LT. The cure of epiphora due to canalicular tional anatomy of the human efferent tear ducts :
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Heinemann;2002.p.8–14. 32. Balikoglu-Yilmaz M, Yilmaz T, Taskin U, Taska-
17. Narioka J, Ohashi Y. Changes in lumen width of pili M, Akcay M, Oktay MF, Eren S. Prospective
nasolacrimal drainage system after adrenergic comparison of 3 dacryocystorhinostomy surgeries:
and cholinergic stimulation. Am J Ophthalmol external versus endoscopic versus transcanalicu-
2006;141:689–98. lar multidiode laser. Ophthal Plast Reconstr Surg
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33. Malhotra R, Wright M, Olver JM. A consideration of flap anastomosis: comparison of surgical outcomes.
the time taken to do dacryocystorhinostomy (DCR) J Craniofac Surg 2015;26:1290–3.
surgery. Eye 2003;17:691–6. 48. Elwan S. A randomized study comparing DCR with
and without excision of the posterior mucosal flap.
34. Erdoğan G, Unlü C, Vural ET, Aykut A, Bayramlar Orbit 2003;22:7–13.
H. Inferior flap anastomosis in external dacry- 49. Bukhari AA. Meta-analysis of the effect of posterior
ocystorhinostomy. Ophthal Plast Reconstr Surg mucosal flap anastomosis in primary external dacry-
2010;26:277–80. ocystorhinostomy. Clin Ophthalmol 2013;7:2281–5.
50. Holt GR, Holt JE. Dacryocystorhinostomy utilizing
35. Dave TV, Mohammed FA, Ali MJ, Naik MN. Eti- an anterior lacrimal sac flap to periosteum tech-
ologic analysis of 100 anatomically failed dacryo- nique. Otolaryngol Head Neck Surg 1979;87:174–
cystorhinostomy. Clin Ophthalmol 2016;10:1419– 82.
22. 51. Vaidya A, Ohmichi Y, Naito M, Nakano T, Kakizaki
H, Takahashi Y. Positional relationship between me-
36. Gökc ek A, Argin MA, Altintas AK. Comparison dial canthal tendon and common canalicular orifice:
of failed and successful dacryocystorhinostomy by A cadaveric study. Ann Anat 2020 Jan;227:151432.
using computed tomographic dacryocystography 52. Baldeschi L, Nardi M, Hintschich CR, Koornneef L.
findings. Eur J Ophthalmol 2005;15:523–9. Anterior suspended flaps: a modified approach for
external dacryocystorhinostomy. Br J Ophthalmol
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Robson AK. A retrospective comparison of en- 53. Boboridis KG, Bunce C, Rose GE. Outcome of
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Allied Sci 2002;27:347–51. Am J Ophthalmol 2005;139:1051–5.
54. Evereklioglu C, Öner A, Somdas MA, Ketenci I,
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Martin PA, Lertsumitkul S, McCluskey P, Ghabrial mattress suture technique for anterior flap suspen-
R. External dacryocystorhinostomy: assessing fac- sion to overlying tissues in external dacryocystorhi-
tors that influence outcome. Orbit 2010;29:291–7. nostomy. Am J Ophthalmol 2007;143:328–33.
55. Rootman D, DeAngelis D, Tucker N, Wu A,
39. Simon GB, Brown C, McNab AA. Larger osteoto- Hurwitz J. Cadaveric anatomical comparison of
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40. Tarbet KJ, Custer PL. External dacryocystorhinos- 56. Kumar GC, Kumar A, Nayak SR, Krishnamurthy
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cadaver. Bratisl Lek Listy 2009;110:740–3.
41. Tsirbas A, Davis G, Wormald PJ. Mechanical 57. Chong KKL, Abdulla HAA, Ali MJ, in press. An
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Surg 2004;20:50–6. lacrimal abscess. Ann Anat 2019.
58. Dolman PJ. Techniques in endonasal dacryocyst-
42. Welham RA, Wulc AE. Management of un- orhinostomy. In: Guthoff R, Katowitz J (Eds.), Es-
successful lacrimal surgery. Br J Ophthalmol sentials in Ophthalmology: Oculoplastics and Orbit.
1987;71:152e7. Springer, Berlin, pp.71–82.
59. Massoud VA, Fay A, Yoon MK. Cerebrospinal
43. Ali MJ, Psaltis AJ, Wormald PJ. Dacryocystorhi- fluid leak as a complication of oculoplastic surgery.
nostomy ostium: parameters to evaluate and DCR Semin Ophthalmol 2014;29:440–9.
ostium scoring. Clin Ophthalmol 2014b;8:2491–9. 60. Rajak SN, Psaltis AJ. Anatomical considera-
tions in endoscopic lacrimal surgery. Ann Anat
44. Ezra E, Restori M, Mannor GE, Rose GE. Ultra- 2019;224:28–32.
sonic assessment of rhinostomy size following
external dacryocystorhinostomy. Br J Ophthalmol
1998;82:786–9.

45. Schmitz JP, Hollinger JO. The critical size de-
fect as an experimental model for cranioman-
dibulofacial nonunions. Clin Orthop Relat Res
1986;205:299e308.

46. Argin A, Görür K, Ozcan C, Arslan E, Ozmen C,
Vayisoglu Y. The role of larger osteotomy in long
term success in external dacryocystorhinostomy. J
Plast Reconstr Aesthet Surg 2008 Jun;61(6):615-9.

47. Takahashi Y, Mito H, Kakizaki H. External dacry-
ocystorhinostomy with or without double mucosal

Volume 1, No. 1 (Jan-Jun, 2021) NESOS E-Mag 17

TREND IN OPHTHALMOLOGY:

Post-COVID Rhino Orbital Mucormycosis:
A Case Report

Tina Shrestha, MD

Department of Ophthalmlology, Dhulikhel Hospital

INTRODUCTION CASE DESCRIPTION was 6/36 with no improvement on
refraction. There was complete
The havoc of the COVID-19 A 32-years male presented to ophthalmoplegia and proptosis of
pandemic seems to have no end the outpatient department of our the left eye.There was left sided
with definitive treatment yet to hospital with complaints of de- nasal bleed with left nasal pain.
be discovered till date. Although creased vision in left eye (LE), Magnetic Resonance Imaging of
vaccination seems to be prom- forward bulging of the LE and the Brain/orbit/paranasal sinus-
ising, prevention is still the best inability to move the eye.He was es revealed sinusitis involving
option. Numerous cases of COV- a known case of recently treated maxillary, ethmoid and sphenoid
ID 19 pneumonia have been re- COVID-19 with oxygen therapy, sinuses. Nasal swab for KOH
ported with secondary infections steroids and Remdesevir for In- mount microscopy from the in-
in around 10-30 % of the admit- terstitial pneumonia. He was also ferior turbinate was suggestive
ted cases, fungus being 10 times a known Diabetic presenting with of Mucormycosis. Functional
more common. [1] Drugs like Diabetic Ketoacidosis at the time Endoscopic sinus surgery and de-
corticosteriods which inhibit the of COVID-19 pneumonia diagno- bridement of nasal turbinates was
inflammatory cascade, and re- sis. performed with biopsy for culture
duce the progression to respirato- revealing Fungal culture - Rhizo-
ry failure have been the mainstay On ophthalmic examination, the pus spp.
for the management of moderate visual Acuity in RE was 6/6 & LE
to severe COVID-19, but there
are several downsides of steroid
therapy such as diabetes mellitus,
weight gain, and dizziness. [2] We
describe a case of Rhino-Orbital
mucormycosis in a 32 years old
male teacher from Janakpur with
recently diagnosed diabetes with
acute interstitial pneumonia and
COVID-19.

18 NESOS E-Mag Volume 1, No. 1 (Jan-Jun, 2021)

Ophthalmic management includ- per million person globally and CONCLUSION
ed Retrobulbar injection of lipo- fatality rate is 46 percent [3]. But
somal Amphotericin B (1 ml= if it involves orbit and intracrani- Timely diagnosis and appropriate
3.5 mg), every alternate day till ally, the fatality rate rises to 50-80 multidisciplinary management in-
5th dose. Further intervention percent. [4] If the diagnosis and volving Ophthalmologists, ENT
was done by the ENT and Oph- treatment is delayed by a week, surgeons, Physicians and neuro-
thalmology team which included the mortality rate doubles from 35 surgeons is the most important
FESS with Orbital decompres- to 66 percent [3]. Even with ear- aspect of management of Rhi-
sion in Left side and nasal de- ly combined surgical and medical no-orbito-cerebral mucormycosis
bridement only in the right side. therapy, prognosis is very poor in patients.
Internal medicine team kept the mucormycosis. [4]
patient on intensive insulin thera-
py for blood sugar control and IV
Amphorericin B 300mg/day. Al-

though the patient lost his vision
in LE, the patient responded well
to the systemic therapy with the
patient’s life salvaged due to the
multidisciplinary team approach.

DISCUSSION REFERENCES

Rhino orbital cerebral Mucormy- 1. Superinfections and coinfections in COVID-19 MedPage Today. https://
cosis [ROCM] is a rare, oppor- www.medpagetoday.com/infectiousdisease/covid19/86192.
tunistic , invasive, fatal infection
caused by a filamentous fungus 2. Methylprednisolone for patients with COVID-19 severe acute respirato-
belonging to the order Rhizo- ry syndrome - full text view ClinicalTrials.gov https://clinicaltrials.gov/
pus affecting immunosuppressed ct2/show/NCT04323592
patients such as those suffering
from diabetes mellitus, cancer, 3. W. Jeong, C. Keighley, R. Wolfe, et al. The epidemiology and clinical
organ transplantation, leukemia, manifestations of mucormycosis: a systematic review and meta-analysis
etc. It is rapidly fatal without an of case reports Clin. Microbiol. Infect., 25 (2019), pp. 26-34 5.
early diagnosis and treatment.
Incidence of ROCM is 0.005-1.7 4. Mucormycosis with orbital compartment syndrome in a patient with
COVID-19 Am. J. Emerg. Med., 42 (2021), pp. 264.e5-264.e8

Volume 1, No. 1 (Jan-Jun, 2021) NESOS E-Mag 19

ARTICLE

TO DO or NOT TO DO:
Non Endoscopic Endo Nasal DCR
(NEENDCR)

Basant Raj Sharma, MD

Shri Badri Eye Care Centre, Bhairahawa, Nepal

As ophthalmologists we have en- of the procedure
joyed this unique perspective by and surgical
virtue of which majority of the outcomes that
time we have the privilege of di- are comparable
rect observation of pathology and to other proce-
their management , whether in the dures.
form of surgery or otherwise.
External DCR Figure 1. General OT set up for NEENDCR
Any time we have to deviate from
this behaviour we are uncomfort- (EXDCR) is Having said that, we still need to
able as we are so accustomed to seen as the gold move ahead in our medical prac-
visualization of ocular disease up standard and still remains the tice, and that is where the role of
front. For example, though the most widely performed in Ne- NEENDCR lies. It provides the
retina sits way back in the eye pal. But we are not here to argue option of a non expensive alter-
but still we are able to visualize it the advantages and disadvantag- native to Endoscopic DCR that
pretty easily and develop our ini- es of EXDCR or for that matter is cost effective, with the learn-
tial management and diagnosis by Endoscopic ENDCR, because ing curve being shorter and less
direct observation. On the other as far as Nepal is concerned, the steep. Nevertheless work still
hand those not trained in Orbital fact remains that EXDCR is the needs to be done, of which the
disease management tend to get preferred choice of surgery for first and foremost is getting used
baffled by the various patholog- Naso Lacrimal Duct Obstruction. to the nasal anatomy, you will
ical presentations where the dis- There should always be a realiza- literally have to work from the
ease is not quite apparent and you tion among young surgeons that opposite end of what you were
need a battery of tests to get to a we live in a country with limit- doing in EXDCR (Figure 1, 2).
provisional diagnosis and may ed resources, the issue is not the Furthermore one will need to
require further interventional pro- adoption of newer but appropriate swap ophthalmic instruments for
cedures before we can clinch the technology that is most beneficial ENT and Neurosurgical ones,
diagnosis. These ideas of simplic- for our patients and can be imple- hence will require some getting
ity may not sound appealing but mented widely. No point in pro- used to. I feel that these would be
that is the whole idea of NEEND- pounding a procedure that will be the primary hurdles for adopting
CR, to simplify things and at the limited to few institutions in the NEENDCR, which is surgical
same time maintain the standard country. anatomy and instrumentation.

20 NESOS E-Mag Volume 1, No. 1 (Jan-Jun, 2021)

Figure 2a. Nasal mucosal Figure 2b. Creating bony Figure 2c. Fashioning Lacri-
opening opening mal sac flaps

It is not possible to describe all the steps of the proce-
dure here, nor is it possible to discuss the pros and cons
of NEENDCR. Those interested can look up the articles
given below and other texts that are available. These ar-
ticles not only deal with the steps of the surgery in detail,
but shed light on our past experiences with NEENDCR,
and also compare surgical outcomes with EXDCR (Fig-
ure 3: Surgical outcome NEENDCR).

Suggested reading:

1. Dolman PJ. Comparison of external dacryocystorhinos-
tomy with nonlaser endonasal dacryocystorhinostomy.
Ophthalmology 2003;110:78-84.

2. Dolman PJ. Techniques in endonasal dacryocystorhinos-
tomy. In: Guthoff R, Katowitz JA, editors. Oculoplastics
and Orbit. Heidelberg:Springer-Verlag; 2006.p.71-82.

3. Non endoscopic endonasal dacryocystorhinostomy ver-
sus external dacryocystorhinostomy. Sharma B. Kath-
mandu University Medical Journal (2008), Vol. 6, No. 4,
Issue 24, 437-442

4. Razavi ME, Eslampoor A, Noorollahian M, O’Donnell
A, Beigi B. Non-endoscopic endonasal dacryocystorhi-
nostomy – Technique, indications, and results. Orbit
2009;28:1-6.

5. Ganguly A, Videkar C, Goyal R, Rath S. Nonendoscopic
endonasal dacryocystorhinostomy: Outcome in 134 eyes.
Indian J Ophthalmol 2016;64:211-5.

Volume 1, No. 1 (Jan-Jun, 2021) Figure 3a. Preoperative lacrimal abscess 21
Figure 3b. First post-operative day
Figure 3c. Two weeks post-operative

NESOS E-Mag

ARTICLE

Non-Endoscopic Endonasal DCR
(NEENDCR), The Learning Curve:
My Experience

Binita Bhattarai, MD

Orbit and Oculoplasty Surgeon, Lumbini Eye Institute, Bhairahawa, Nepal

Curiosity is the hunger of the hu- We needed some additional in- Xylocaine and 0.5% Bupivacaine
man mind. My first posting was struments as a nasal speculum, injection is injected in nasal mu-
in Department of Oculoplasty as a thin long needle, light source, cosa and nasal packing is done.
a new resident at Lumbini Eye retinal light pipe, a suction ma- We then keep nasal pack for five
Institute (LEI) nine years back. chine, head light, ethmoid forceps minutes. We can now do the scrap-
I was excited by the plethora of and sickle knife (Fig 1). We were ing for the procedure. The light
procedures performed in the de- lucky to have these instruments source is a retinal pipe through
partment led by Dr Basanta Raj available in our hospital. To start upper canaliculi which is held in
Sharma. He used to try alterna- with we should always stand op- place by an artery forceps over the
tives of classic external DCR. posite to the site we are operating drape. This illuminates surgical
After he left the institution, Curi- this makes the visibility good, but site and will guide the procedure.
osities brew within me as we were since we are right handed we can Nasal speculum is held in place
bound to do External DCR for all do it standing on right side too. for better access to surgical space.
cases with no alternatives. My With the help of headlight and na- This is important for good visi-
dreams materialized with the ar- sal speculum for better view, 2 % bility and passage of instruments.
rival of Dr Peter Dolman 5 years
later, an expert on Non Endo-
scopic Endonasal DCR (NEEND-
CR), all the way from Vancouver.
NEENDCR sounded fascinating
and I was not sure if I could do
it. Under Dr Peter’s supervision
we performed few cases every
day. When he left after a week,
he was confident that we could
do it independently. We started
doing NEENDCR gradually and
since I was confident with exter-
nal DCR,I could easily convert it
if I couldn’t complete it or if any
complications happen midway.

22 NESOS E-Mag Volume 1, No. 1 (Jan-Jun, 2021)

We need a sickle knife to cut the most difficult step for me as it was and can lead to failure later on. If
nasal mucosa. It can be difficult as difficult to see the location of small we do not handle the instruments
the site is distant from where we prick. Once we find it, we cut the properly there can be bleed from
hold the handle and the cut can be whole length with the sickle knife. medial turbinate.
small, misplaced or multiple and Due to limited visibility, begin- With time and experience we
bleeding may occur leading to ners tend to tent sac at different will learn to deal with all minor
blurring. Once we cut the mucosa angle and repeat the procedure difficulties. The same small sur-
we hold it with ethmoid forceps with multiple cuts. We can push gical space will feel like enough
and pull it out. For beginners the the retinal pipe through and con- to deal with. Cutting the sac will
mucosa can slip from the forceps firm that the sac is completely cut. be clearer and complete. Wound
or the cutting may not be enough. Syringing both from upper and healing will be faster as there
After we remove the mucosa, the lower punctum will also confirm will be limited manipulation, less
site will look brighter making us the complete opening of sac. Si- bone nibbling and minimal inju-
more comfortable with the field lastic tubes are intubated as in ex- ry to surrounding structures. We
of surgery. Then we clean the site ternal DCR. We didn’t encounter could do the procedure even in
by suction. Once the surgical site any problem during this step. In saddle shaped nose with success.
is clean and we start nibbling the difficult cases with squeezing the No scar is an added bonus. With
bone towards the light source. We nose, we can use the tip of metallic proper supervision and guidance,
can move the light source to con- suction pipe to retrieve the silastic NEENDCR is a doable, cost ef-
firm our site. The light pipe can be tube through nose. Initially the fective and useful skill for all oc-
poked out from the bone deficient procedure takes longer time than uloplastic surgeons. I would like
part. It should look brighter at the for external DCR. We are used to to thank my mentor Dr Peter Dol-
side of bone loss. We then free the doing external DCR working on man and Seva Foundation for the
sac site by nibbling 3-4 times that bigger area, where anatomy is on opportunity.
is less than what we do for exter- display and our hand movements “I could do it, so you can too.”
nal DCR. One should be care- are free. Endonasal approach has
ful not to break the retinal pipe a longer learning curve because
while nibbling. The probe should the operating site is a bit distant
be freely moving horizontally and area is limited. It is very hard
(straight to the canaliculi). Next to hold the nasal speculum in
step is cutting the sac. We make a place for uncooperative patients
prick at the point where the pro- who keep squeezing their nose.
trusion of retinal pipe is seen with The retinal light pipe is obscured
sickle knife. The knife is insert- even with slight bleeding making
ed through the prick and whole it difficult. Complete cutting of
length of the sac is cut. It was the the sac can be missed sometimes

Volume 1, No. 1 (Jan-Jun, 2021) NESOS E-Mag 23

INTERVIEW

Heart to Heart with

Prof Dr. Rohit Saiju

Founder President of Nepalese Society for
Oculoplastic Surgeons (NESOS). Currently, he
is the President of Nepal Ophthalmic Socie-
ty (NOS). A great human being and a superb
mentor to many of us.

Prerana Kansakar, MD

Grande International Hospital, Nepal

“Mission to

Your work in Oculoplasty is establish Prof Dr Rohit Saiju
exhilarating. What inspired Oculoplasty in
you to take up Oculoplasty as Founder President
a subspecialty? Nepal” (NESOS)

It was never planned as such. I was surgery and I wanted to do fron- President (NOS- Nepal
inspired to become a Vitreo-Reti- tier job in a virgin land. Tilganga Ophthalmic Soceity)
nal surgeon initially. Things took was in dire need of Oculoplasty
a turn when a visiting SICS train- services so I chose Oculoplasty
ee, Dr Ivan Gan from Rotterdam and I am fortunate to be the first
Eye Institute, Netherlands, and one year Fellowship trained Orbit
I crossed paths. I got to witness and Oculoplastic Surgeon for the
many eyelid surgeries and new country. And since then there has
techniques that grabbed my atten- been no looking back!
tion; I learnt from him the leva-
tor resection procedure for ptosis How has your journey as an
correction. He was a good friend Oculoplastic surgeon been?
of well-known Dutch oculoplastic
surgeon Dion Paridaens. At that I should say it’s been rather lux-
point, Tilganga Eye Center was urious. I was awarded a highly
expanding subspecialty services competitive and prestigious
and all complicated cases were fellowship at the Royal Victorian
being referred to TUTH. My men- Eye Hospital in Melbourne affil-
tor, Dr. Sanduk Ruit, offered me iated to Melbourne University. I
to pursue my career either in Oc-
uloplasty or Neuro-Ophthalmol-
ogy. I was always interested in

24 NESOS E-Mag Volume 1, No. 1 (Jan-Jun, 2021)

OUTSIDE THE BOX

had excellent mentors like Alan McNab who is so SINGER YOU LOVE LISTENING TO?
well known for his orbital skills and other teachers Rahat Fateh Ali Khan/ Nusharat Fateh
were Charles Su, Roger Davis, Peter Henderson Ali Khan
and Mary Lastelmach who are pioneers in the field FAVOURITE ACTOR/ACTRESS?
of lacrimal and endoscopic surgeries. On my return, There are many. Some of them are Na-
I established an independent Orbit, Plastic and talie Portman, Kevin Costner, Chiyaan
Lacrimal (OPAL) unit at Tilganga Eye Center in the Bikram
year 2004. I gave my heart and soul to the depart- STRESS BUSTER?
ment and with the belief that hard work pays off, I Just sleep with soothing music
moved on. The more good work you do, the more ROOTING ANY TEAM IN EURO 2020?
appreciation you get hence you get more referrals! Italy
I used to see around 60-70 OPAL cases a day. And BEST DIET YOU CAN COOK AT
spending a day at OPD would yield enough surgi- HOME?
cal cases for the next 2 weeks so you can imagine Kheer
the workload then. That’s when I decided I need to HEALTH, WEALTH OR HAPPINESS?
build colleagues because it could not be done single Health and happiness, sometimes
handedly. Knowledge should always be shared and wealth
I’ve always aspired to be a good mentor. In the year QUOTE YOU LIVE BY?
2006, we started short term training programs and “You only live once, but if you do it right,
in the earlier days, I trained a couple of surgeons once is enough” - Mae West
from East Timor, Bangladesh and Nepal. Finally in ANY HIDDEN TALENT PEOPLE DON’T
2008-2009 we started a structured Fellowship Pro- KNOW ABOUT YOU?
gram (Short and Long term). Our programs have I can predict the time of few hours after
been extremely successful because we have enough looking once at the watch
resources in terms of patient numbers with a wide Pencil sketch
variety of cases. My fellows hence get ample cases
to work up and operate on. Oculoplasty is one such surgeon, how would you define beauty?
field where hands-on training is of utmost impor-
Beauty I believe is a feeling or perception. It’s not
tance and just visual but begins from the soul. Beauty grows
I am glad I from a life of giving yourself to others, it is an
have been attraction to those who value and seek it.
able to pro-
vide that to If not an Ophthalmologist, what would Rohit
them. I am Saiju be?
very proud
of the Probably an Engineer! As a kid I was interested in
fact that making houses/ cars/ assembling things and I was
many of pretty good in mathematics too. But god had dif-
my trained ferent plans. My parents wanted me in the medical
fellows field and I enrolled at TUTH. I worked as a Health
are now Assistant for a few years until I was awarded a
prominent government scholarship to pursue MBBS in Russia.
surgeons I remember just 2 days after my return; I joined
in NESOS TUTH as a medical officer in the General Surgery
and over- department. There were no residency programs
seas.

Being an
aesthetic

Volume 1, No. 1 (Jan-Jun, 2021) NESOS E-Mag 25

then and with limited manpower we had very hectic to protect and facilitate society members but to
duty schedules sometimes extending 36 hours and contribute in academics nationally/internationally.
beyond! NESOS is one of the most active Nepalese societies
in the Asia Pacific region and I could not be more
How do you maintain a work-life balance? proud!

Time management is crucial for work-life balance. What is the future of Oculoplasty in Nepal and
As years pass by, responsibilities add up both in your advice to junior colleagues?
professional and personal life. My advice would
be to divide time proportionately for family, work, Oculoplasty is a brilliant subspecialty in Ophthal-
social relations as well as leisure. We Nepalese are mology with a bright future. Also it is the most
very hesitant to say no even in situations where we diverse one ranging from orbit to lacrimal to eye-
are not able to fulfill it. But once you learn to say lids to esthetics and reconstruction which connects
“no”, you will be in comfort and become a happy many parts of the body like bone to brain or nose
person. to the eye. It involves a lot of interdisciplinary
work with maxillo-facial, plastics and neurosurgery
As a Founder President of Nepalese Socie- team. It is an excellent subject if you love it and are
ty for Oculoplastic surgeons (NESOS), what passionate in this field. Like cataract surgery, we
are your dreams and expectations from this get instant results on table. DCR surgery I feel is
society? the most rewarding surgery in Oculoplasty. There
are many competent oculoplastic surgeons coming
My mission was to establish Oculoplasty in Nepal. up in the country who are being trained by mentors
It is indeed a proud and happy moment for me as from all around the world. If we work hard and
I see NESOS flourishing the way I had imagined love what we do, we will definitely go a long way.
when we founded it back in July 2014. In Oct 2010, When you’re able to get satisfaction and happiness
we organized the first National Oculoplastic meet- from professional life, you will be happy and con-
ing along with Nepal Ophthalmic Society. I was the tent in life!
Joint Secretary and the then president Dr. Jeevan
Shrestha, encouraged me to promote our society at
national and international level. With the help and
support of international colleagues like Dr.Naresh
Joshi, Dr. Garry Davis, Dr,
A.K Grover, Dr. Kasturi
Bhattacharya, we were able
to conduct a successful
meeting and promote our
services in the internation-
al platform. Many young
graduates fell in love with
Oculoplasty after that and
saw a future possibility in
this field. Since then we’ve
organized second and third
National Oculoplasty Con-
ferences in 2014 and 2017
respectively with renowned
oculoplastic surgeons from
all around the world. The
aim of NESOS is not only

26 NESOS E-Mag Volume 1, No. 1 (Jan-Jun, 2021)

PEARLS

Tips for Traumatic
Canalicular Lacerations
Repair

Triptesh Raj Pandey, MD,1 Prerna Arjyal Kafle,
MD2

1 Mechi Netralaya
2 Biratnagar Eye Hospital

Repair of canalicular injury, in it- 2. Try to preserve as Figure 1. Canalicular injury
self, is a great challenge for any much eyelid tissue repair with mini-monoka
experienced oculoplastic surgeon, as possible stent
let alone for general ophthalmolo-
gist. Timely and meticulous repair • Save all eyelid tissue as
of canalicular injury forms the ba- much as possible, as high
sis for successful outcome. vascularity often allows for
viable approximation.

One can experience a frustrating 3. Wound inspection, cleaning status of the patient is ad-
time while exploring an injured and documentation. visable.
canaliculus especially when the
injury occurs deep within the • Wounds should be copious- 5. Check integrity of the tear
medial canthal complex close to ly irrigated and explored, outflow system.
the lacrimal sac. However, one with removal of any foreign
can follow the following tips for material. • Blunt injury to the medial
successful outcome of canalicular eyelid with resultant eyelid
laceration repair: • The presence of orbital fat laceration almost always
raises the risk of deeper in- tears the canaliculus,
1. Always rule out multi- jury and foreign bodies.
ple/occult injuries or other • In eyelid lacerations medial
life-threatening problems • Photograph all preopera- to the puncta, the canaliculi
tive injuries and immediate should be probed to assess
• Evaluate and confirm ABC postoperative results. integrity.
(Airway, breathing and cir-
culation). 4. Use of prophylactic antibi- 6. Identify severed canalicular
otics +/- Tetanus prophylaxis ends
• Perform a complete eye ex-
amination. • Based on attending physi- • Canalicular Injury! Injured
cian’s expertise and opin- distal canaliculus identifica-
• For full-thickness eyelid in- ion, broad spectrum antibi- tion – An Enigma!
juries, be sure to check for otics can be used.
globe perforation.
• Tetanus prophylaxis de-
pending upon vaccination

Volume 1, No. 1 (Jan-Jun, 2021) NESOS E-Mag 27

• Great mimicker! Canthal can also be found by inject- 8. Follow-up.
tendon fibers convincingly ing air, fluorescein-dyed hy- • Keep the canalicular stent
mimic the cut edge of the aluronic acid or non-stain- for at least 6 weeks to 3
canalicular mucosa during ing colored irrigant through months. Always attempt
exploration. the uninvolved canaliculus. stent repositioning in case
of stent migration.
Few tips for identification 7. Repair injured canalicu-
of canalicular ends are: lar ends using the canalicular
stent in layers
• Magnified view under sur-

Figure 2. Left lower lid
laceration with canthal
injury pre and post repair

gical microscope with tilt-

ing of head increases the

likelihood of finding the

distal canaliculus .

• Avoid using an excess

amount of local anesthetic

infiltration. General anes-

thesia may be beneficial as

no local anesthetic infiltra-

tion is used.

• Use cotton-tipped applica- Figure 3. Left upper lid laceration with canali-
tors for any exploration of cular injury pre and post repair
the deeper soft tissue injury.

• Use of toothed forceps and (Picture Courtesy: Diwa Lamichhane, MD)
retractors should be limited

to skin retraction alone as

their use during deeper soft

tissue exploration results in REFERENCES
further splaying and distor-

• tion of the medial canthal 1. Burroughs JR, Soparkar CNS, Patrinely JR, Williams PD, Holck DEE.
complex. Periocular Dog Bite Injuries and Responsible Care. Ophthalmic Plastic
Resist the temptation to Reconstr Surg 2002;18:416-9.

pass a Bowman probe in 2. Quickert MH, Dryden RM: Probes for intubation in lacrimal drainage.
an impatient and haphazard
Trans Am Acad Ophthalmol Otolaryngol 1970;74:431-3.

fashion into soft tissue that 3. Burroughs JR, Soparkar CNS, Patrinely JR. The Buried Vertical Mat-

looks like it might be the tress: A Simplified Technique for Eyelid Margin Repair. Ophthalmic

canaliculus – May create Plastic ReconstrSurg.

false passage 4. https://www.reviewofophthalmology.com/article/7-tips-for-traumat-

• Severed canalicular ends ic-eyelid-lacerations (reviewofophthalmology.com)

28 NESOS E-Mag Volume 1, No. 1 (Jan-Jun, 2021)

ARTICLE

“DCR on DCT” and lacrimal surgery
practices during COVID-19 pandemic: An
experience of an oculoplastic surgeon from
a tertiary eye care center of eastern Nepal

Aashish Raj Pant, MD

Cataract and oculofacial plastic surgeon
Mechi Eye Hospital, Jhapa, Nepal

The Corona Virus Disease 2019 gone through several phases with tral Hospital of China, popularly
(COVID-19) which has rampaged new evidence redefining our prac- known as the “Chinese whistle-
the lives of many around the tices at such times. This article in- blower doctor”. Oculoplastic
world through the first and sec- tends to take the readers through surgeons are at much higher risk
ond waves, and further counting, this journey/ experience of an due to the lacrimal procedures
needs no introduction. More than oculoplastic surgeon working at such as syringing & probing and
183 million infections and 3.9 a high volume tertiary eye care Dacryocystorhinostomy surgery
million deaths worldwide speaks centre at eastern region of Nepal which directly exposes them to
volumes (Worldometer, 2021). regarding the lacrimal surgical the nasal cavity, at a shorter dis-
Nepal is 40th most affected coun- practices during the COVID pan- tance and with chances of induced
try in the world with more than demic. The article also discusses sneezing and coughing during the
64000 cases and 9100 deaths as the possibility of “DCR on DCT” procedures. DCR has a further
of 30th June 2021 (Worldometer, being useful in such scenarios. increased risk due to the long ex-
2021). This novel strain of the posure time. (Kowalski LP et al,
coronavirus has not only affected Ophthalmologists are at high risk 2020)
the lives of people worldwide but of contracting coronavirus during
also severely affected the health- routine ocular examinations such Mechi Eye Hospital is a not-
care delivery system. Ophthalmic as slit lamp examination and di- for-profit community-based eye
services, which are often non-life rect ophthalmoscopy due to the hospital catering services to the
threatening, were mostly halted proximity needed for examina- needy patients of eastern region
during the first national lockdown tions. Another mechanism could of Nepal and India (238,468 pa-
in Nepal. Like the mutations be contact through the ocular tients in OPD and 28,714 patients
leading to change in the strains secretions during examinations. in OT in 2018). The COVID
of coronavirus - since it was first First doctor to die due to COV- lockdown started in Nepal from
isolated by Tyrell and Bynoe in ID was a 33-year young ophthal- March 24th, 2020, and the situa-
1966 - the healthcare service de- mologist, Dr Li Wenliang (12 tion has not been better since then
livery system during COVID-19, October 1985- 7 February 2020) regarding lacrimal surgeries. This
specifically ophthalmic, has also who worked at the Wuhan Cen- hospital has also been performing

Volume 1, No. 1 (Jan-Jun, 2021) NESOS E-Mag 29

huge volumes of lacrimal surger- The problems created by the lack of failed DCR at OT table and ef-
ies – 663 DCRs, 617 DCTs and of evidence for restarting lacrimal fect on outcomes after variations
22 other lacrimal surgeries in a surgeries led to delayed start of in revision DCR surgeries such
single calendar year. (Mechi Eye such surgeries at MEH. Notably, as Silicone Tube, Flap recreation,
Hospital Annual Report, 2019). In DCT was started earlier and pro- Mitomycin use, etc. Interestingly,
the 15 months of the COVID era moted as an alternative to DCR we also explored the outcomes
(1 April 2020 till 30 June 2021); in needful situations as there of DCR after previous DCT in
only 148 cases of DCT and 121 was no exposure to nasal cavi- patients less than 60 years of age
cases of DCR were performed in ty. However, this led to DCT in who were unsatisfied due to the
the Mechi Eye Hospital which is even earlier age group especially persistent watering after DCT.
on stark contrast to 771 DCT and young adults, especially in sight The ‘DCR after DCT’ was a Tot-
828 cases of DCR in the preced- threatening conditions. Based on ti’s surgery (no flap technique)
ing 15 months before the COVID the preliminary results of a later- modified with use of Mitomycin
pandemic and lockdown (Mechi al prospective study being con- C (injected at remnant nasal mu-
Eye Hospital Internal audit data). ducted at Mechi Eye Hospital, cosa circumosteally, total 0.4 ml
the Mechi Eye Hospital DCR/ of 0.04% MMC) followed by
The effect of COVID-19 and its DCT on DCR Stusy (ME-DODS) lacrimal intubation with Silicone
consequences on lacrimal sur- (Pant AR, 2021), we started DCT tube removed after 3 months.
geries at Mechi Eye Hospital is now - DCR later protocol for
shown below in figure 1. even young adults with relative The finding till date regarding
confidence. Whether this will be a DCR after DCT has been prom-
ising. Out of 11 cases of repeat
DCR over previous DCT who
fulfilled the criteria for the study,
all of them had anatomical suc-
cess and 9 cases yielded function-
al success (81.81%) at 3 months
of follow-up. ST was removed
at 3 months. During the COVID
pandemic, we performed ‘DCR
on DCT’ in 2 cases. A complete
success (anatomical and function-
al) was achieved on follow-up at
3 months when the tube was re-
moved. A few others did not come
for follow-up/ did not opt for sec-
ond surgery probably due to the
COVID restrictions being contin-
ued/ restarted.

Figure 1. Timeline of conse- success or failure is yet to be seen To conclude, COVID-19 pandem-
quences of COVID-19 in lacrimal with second wave coming very ic has severely affected the lacri-
practice at Mechi Eye Hospital soon. mal surgical practices. Innovative
techniques such as ‘DCR on DCT’
What is ME-DODS? DCR after can be helpful in sight threatening
DCT? cases with dacryocystitis or recur-
This is an ongoing prospective rent acute dacryocystitis where
lateral study exploring the causes ‘DCT now – DCR later’ can be
of huge importance considering

30 NESOS E-Mag Volume 1, No. 1 (Jan-Jun, 2021)

*DCR in adults during COVID-19 pandemic: Protocol of Mechi Eye Hospital:
Selection of cases - Only cases of ROPLAS positive (pus or mucopurulent). CC block and clear fluid
on regurgitation were postponed.
1. Negative PCR test report for COVID-19 obtained within 48 hours before hospital admission for

surgery.
2. The patient should gargle with Povidone-Iodine (PVP-I) 1% mouthwash (commercially availa-

ble) for 5 minutes at ward before entering the OT.
3. Surgeon and assistant should wear the disposable gown and wear N95 masks, goggles, and face

shield for the surgery.
4. Whole face to be painted with PVP-I 5%, once at preop room and again before OT, leaving for 5

minutes each time.
5. Use of 0.5% PVP-I (2ml 5% PVP-I added to 18 ml of NS in a 20ml syringe) at OT table for:

• Soaking the nasal packing ribbon (dried before packing)
• Preoperative lacrimal sac syringing
• Preoperative use of PVP-I for drop-by-drop nasal irrigation through the externally visualized

ribbon gauze tip (appx 0.5-1ml). Counsel the patients thoroughly.
6. If lacrimal intubation needs to be done, immediately place fresh ribbon gauze (as prepared previ-

ously) after intubation.
7. Avoid splashes of blood, syringe fluids, etc. Use suction as required. Counsel the patient to avoid

coughing or sneezing and be calm.
8. COVID-19 precautions should be taken, and guidelines made by the hospital and local authori-

ties should be always followed.

the lower risk of COVID in DCT REFERENCES
compared to DCR.
1. Mechi Eye Hospital (2019). Mechi Eye Hospital Annual Report. Pub-
lished by Mechi Eye Hospital Sangh.

2. Kowalski, L.P., Sanabria, A., Ridge, J.A., Ng, W.T., de Bree, R., Rinal-
do, A., Takes, R.P., Mäkitie, A.A., Carvalho, A.L., Bradford, C.R. and
Paleri, V., 2020. COVID‐19 pandemic: effects and evidence‐based rec-
ommendations for otolaryngology and head and neck surgery practice.
Head & neck, 42(6), pp.1259-1267.

3. Pant AR. (2021). Mechi Eye Hospital DCR on DCR/DCT Study (ME-
DODS) (unpublished)

4. Tyrrell, D.A.J. and Bynoe, M.L. (1966). Cultivation of viruses from a
high proportion of patients with colds. Lancet, pp.76-7.

5. Worldometer (2021). Coronavirus [online]. https://www.worldometers.
info/coronavirus/ (date accessed 30th June 2021)

Volume 1, No. 1 (Jan-Jun, 2021) NESOS E-Mag 31

ARTICLE

Endoscopic Endonasal Dacryocystorhinos-
tomy Experience: A learning curve in the
Eastern Nepal.

Diwa Hamal, MD, Prerna Arjyal Kafle, MD, Hony KC, MD, Afaque Anwar, MD

Biratnagar Eye Hospital, Biratnagar, Nepal

ABSTRACT

Introduction: Dacryocystorhinostomy (DCR) is the treatment of choice for nasolacrimal duct
obstruction (NLDO). While some studies have shown external DCR as the gold standard,
many others have established comparable or greater success rates with endoscopic en-
donasal DCR (EEDCR). The study aimed to evaluate the surgical outcome of EEDCR surgery
with tubes done by oculoplastic surgeons immediately after completion of the fellowship.

Methods: This is a retrospective, descriptive cross-sectional study conducted at a tertiary
eye care centre from 2018 Jan- 2018 Dec after ethical approval from the ethical review
board of the institute. All the patients diagnosed with primary acquired nasolacrimal duct
(PANDO) who underwent EEDCR and completed 6 months’ follow-up examinations were
included whereas previously failed DCR, lacrimal fistula, acute dacryocystitis, severe nasal
deviations, and failed to consent for the study were excluded. Data based on demographic
profile, types of anaesthesia, intra and post-operative complications, duration of surgery
were entered into customized data spread of Microsoft Excel 2016 and analyzed using sta-
tistical package for the social sciences(SPSS) version 19.

Results: A total of 200 eyes in 196 patients had undergone EEDCR. Of the total,147 (73.5%)
operations were done in females and 53(26.5%) males. Out of the total, Ninety-four (47%)
operations were done in the right eye, 102, (51%) left eye, and 4(2%) both eyes. More than
80% of patients were adults, and the rest of the patients were paediatric. However, more
than 80% of cases were operated under local anaesthesia(LA), only 4% of cases required
general anaesthesia(GA), and 15% cases under assisted LA. Only 3% of cases encountered
intra-operative complications and 4.5% of cases had post-operative complications. The
overall success rate was 194/198(98 %) and the failure rate 4/198(2%).

Conclusions: EEDCR can be done under GA or LA depending on the surgeon’s comfort level
and the patient’s choice. The success of Endonasal DCR entirely depends on the experience
of the surgeon.

Keywords: DCR, Endoscopic Endonasal DCR, Nasolacrimal duct obstruction.

32 NESOS E-Mag Volume 1, No. 1 (Jan-Jun, 2021)

INTRODUCTION low-up, and were Figure 1. Shows instruments used
Dacryocystorhinostomy (DCR) is not willing to for endoscopic endonasal DCR
the treatment of choice for nasol- participate were surgery
acrimal duct obstruction (NLDO). excluded from
While some studies have shown the study. local anaesthesia) as per decided,
external DCR as the gold stand- nasal mucosal flap preparation,
ard, many others have established Surgical pro- osteotomy, opening the lacrimal
comparable or greater success cedure- All the sac, and intubation. Nasal pack-
rates with endoscopic endonasal EEDCR were ing was done with 4%Xylocaine
DCR (ENDCR). [1] Although performed by
there are different surgical tech- two oculoplastic
niques, all create an anastomosis surgeons in our
between the lacrimal sac & the hospital using
nasal cavity through a bony os- Karl Storz endo-
tium. The difference in techniques scope with a telescope of 4mm
is whether one utilizes an intrana- diameter. Marathon drill with di-
sal or transcutaneous approach. amond burr was used to smooth-
[2] en the bony irregularities and re-
move the maxilla’s hard frontal
EEDCR is a simple, less process. All the steps of endona-
time-consuming, safe but skilful, sal endoscopic DCR are as shown
scar-free, and highly satisfying in Figure 2.
surgery. There has not been any
study on the surgical outcome of
EEDCR for PANDO from East-
ern Nepal to date. So we conduct-
ed this study to evaluate surgical
outcome and complications of
EENDCR surgery done by sur-
geons in the early stage of their
career post-fellowship.

METHODOLOGY Figure 2. Shows the steps of endoscopic endonasal DCR surgery. Af-
In this retrospective cross-section- ter removal of nasal pack local aesthesia, formation of nasal mucosal
al study, all the consecutive cases
diagnosed with PANDO who un- flap, osteotomy, making sac flap with crescent blade, intubation with
derwent EEDCR from January Crawford’s bicanalicular stent, placement of gelfoam and injection
2018 to December 2018 in one of with triamcinolone diacetate at the end of surgery.
the tertiary centres in eastern Ne-
pal were reviewed. The study was The procedure included anaes- with Adrenaline 1:10000 IU for
conducted after ethical approval thesia (general, local, assisted 30 minutes before surgery. Local
from the ethical review board of anaesthesia was given with 2%
our institute and well-informed
consent was taken from each par-
ticipant. However, patients with
acute dacryocystitis, previous-
ly failed DCR, lacrimal fistula,
severely deviated nasal septum,
failed to complete 6 months’ fol-

Volume 1, No. 1 (Jan-Jun, 2021) NESOS E-Mag 33

xylocaine, 0.5% bupivacaine with 250mg and Cloxacillin 250mg), Data based on demographic pro-
adrenaline 80,000 IU, and hyalu- topical antibiotic with steroid file, types of anaesthesia, duration
ronidase for blocking the infraor- (Ciprofloxacillin 0.3% and dex- of surgery, intra and post-opera-
bital, infra trochlear, and dorsal amethasone 0.1%), analgesics tive complications were collected
nasal nerve trans-cutaneous and (Paracetamol 325mg with Ibupro- in customized proforma in Mi-
anterior to axilla of the middle
turbinate, above the inferior tur- Figure 3. Shows canalicular crosoft Excel and analysed using
binate and over the nasal septum laceration, nasal mucosal statistical package for the social
intranasal five minutes before the sciences(SPSS) version 19.
surgery. Assisted local anaesthe- granuloma, punctal granuloma The surgically failed cases were
sia was given with iv Pethidine in upper punctum. evaluated endoscopically while
1mg/kg & Ondansetron 0.15 mg/ performing revisional EEDCR
kg. General anaesthesia was giv- fen 400mg), nasal decongestant and causes of failure were noted.
en with Pethidine 1mg/kg, propo- (Oxymetazoline Hydrochloride RESULTS
fol 2.5mg/kg, vecuronium 0.1mg/ 0.05%) drops were advised with Two hundred eyes of 196 patients
kg, and maintenance with isoflu- advice to review after 2weeks, within the age range of 12-45
rane 1 MAC. Lacrimal irrigation 1 month, 3 month then every years of age had undergone EED-
was done to confirm the site of 6 months. The Silicon tube was CR. Out of the total, 174 (87%)
obstruction on the table. removed after 3 months. At each operations were performed on
visit, slit lamp examination was adults and 26 (13%) pediatric
The nasal mucosal flap was made done and syringing was only done patients. More than two-thirds of
10 mm superior and 10 mm an- when the patient complained of operations were performed in fe-
terior to the middle turbinate and watering.
up to the junction of upper one-
third and lower two-thirds of the The surgical failure was defined
inferior meatus. The flap was ex- as subjective complaint of water-
cised. Lacrimomaxillary suture ing and regurgitation of saline on
was identified, cracked and bone lacrimal irrigation while surgical
punched with the Kerrison’s ron- success was defined as no sub-
geur exposing the whole of the jective complaint of watering and
lacrimal sac. The superior fron- patent on irrigation. The duration
tal process of the maxilla was of surgery from nasal mucosal in-
removed by a drill when it was cision to silastic intubation was
not possible with a rongeur. The recorded. The surgical success
lacrimal sac was incised vertical- and failure rates were calculated.
ly down extending from the fun-
dus to the nasolacrimal duct after
tenting by a bowman’s lacrimal
probe. The anterior flap was ex-
cised. Crawford’s double-armed
intubation system was used to
intubate the lacrimal system from
the punctum to the nasal cavity.
Gelfoam was put at the site of the
ostium and 1cc of injection tri-
amcinolone diacetate was inject-
ed. Nasal packing was done and
was removed the next morning.
Systemic antibiotic (Ampicillin

34 NESOS E-Mag Volume 1, No. 1 (Jan-Jun, 2021)

males. Ninety-four (47%) surger- fer an external approach. In the Studies reported that the place-
ies performed in RE, 102 (51%) external approach, the nasal side ment of the tube increases the suc-
left eye, and (4, 2%) both eyes. is not taken care of. Endoscopy cess rate. [11] Syed MI et al, 2013
Nearly 90% of cases were symp- helps to visualize the anatomy [12], reported that they achieved
tomatic for more than 6 months. of the lateral wall of the nose a success rate of (31/33) 94% in
The majority of operations were that determines the anatomical END-DCR in which they used a
performed under LA 162(81%) variation of the sac helping in silicone tube and a success rate
followed by assisted LA 30(15%) achieving near 100% success. In of (25/30) 83% in END-DCR in
and GA 8(4%). However, 6 (3%) this study, there were 200 eyes of which no silicone tube was used;
cases encountered intraoperative 196 patients within the age range however, this difference was not
bleeding and 2 were converted to of 12-45 years of age. One hun- statistically significant. The re-
external approach. Of the total, dred and seventy-four (87%) pa- moval of the silicone tubing ear-
9(4.5%) operations had post-op- tients were adults and 26, (13%) lier than 2 months had a positive
erative complications that includ- patients were of paediatric age effect on the success rate [13]
ed bleeding in 6(3%), granuloma group. There were 147, (73.5%) There are also studies reporting
formation in 2(1%) and cheese female patients and 53, (26.5%) that the granulation tissues around
wiring 1(0.5%) as shown in Fig- male patients. According to many the tube depending on keeping
ure 3. The overall success rate kinds of literature published most the silicone tube for longer than
was 194/198(98%) and failure NLDO patients are females, and 3 months are among the causes
rate 4/198(2%). Most of the failed they prefer an external scar-free that increase failure.[14] Wheth-
cases were female and the most endoscopic endonasal DCR sur- er to preserve or not to preserve
common cause of failure was na- gery having given the choice of the mucosal flap of the lateral
sal mucosal fibrosis. Endoscopic endonasal or an Ex- nasal wall over the lacrimal sac
ternal DCR. Females have signif- area has always become the top-
DISCUSSION icantly smaller dimensions within ic of discussion. In this study, the
Endonasal DCR is much superi- the lower nasolacrimal fossa and nasal mucosal flap was removed.
or to external DCR. [3] We had middle duct. Hormonal chang- Ramakrishna et al, 2007[15] per-
73.5% female eyes included in es that bring about a generalized formed 27 Endoscopic DCR’s in
this study. Most NLDO patients de-epithelization in the body can 20 patients without mucosal flap
are females so if we can do scar- cause the same within the lacri- preservation. There was 100%
free surgery will be a better op- mal sac and duct. An already nar- anatomic success and 93%func-
tion. [4] Females have signifi- row lacrimal fossa in women can tional success. They concluded
cantly smaller dimensions within be obstructed by the sloughed-off that mucosal preservation isn’t
the lower nasolacrimal fossa and debris. [5] In this study, Craw- essential to realize an honest suc-
middle nasolacrimal duct. Hor- ford’s silicon tubes were placed cess rate.
monal changes that bring about in all the eyes and that was re-
a generalized de-epithelization moved after 3 months with a suc- In our study, six (3%) had intraop-
in the body can cause the same cess rate of (194/198) 98 %. We erative complications that includ-
within the lacrimal sac and duct. had tube-related complications ed bleeding in three cases. Two
An already narrow lacrimal fos- in 3 eyes. Punctal granuloma in of them had to be converted to an
sa in women can be obstructed two eyes each one with upper external approach and one case
by the sloughed-off debris. [5] In and lower punctum involved, needed a power drill. It is essen-
external DCR medial canthal lig- canalicular laceration by tube in tial to remove the bone overlying
ament may be incised to approach one eye. Routine use of stents is the lacrimal sac until the entire
the sac, the pumping system has beneficial especially in cases of medial wall and most of anterior
interfered. [6] The circumferen- ENDCR as it helps to maintain wall of the lacrimal sac is visible
tial orbicularis oculi muscle and the patency of the internal ostium to achieve a high success rate in
the lacrimal muscle acting on and keep the flaps of the lacrimal Endoscopic DCR. [16] Howev-
the medial canthal ligament suf- sac from sealing together. [7-10] er, by using a Kerrison punch

Volume 1, No. 1 (Jan-Jun, 2021) NESOS E-Mag 35

one can achieve this with ease CONCLUSION
just like in our technique, help- The EEDCR has several advan-
ing us to achieve a high success tages like higher success rate and
rate. Sometimes the hard frontal few minor complications. It can
process of maxilla may not be be performed under GA, LA and
removed by the rongeur alone, in assisted LA as per patient’s pref-
such cases bone drill is the choice. erences and surgeon’s comfort.
Conflict of Interest: Nil
The current study revealed a sur-
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36 NESOS E-Mag Volume 1, No. 1 (Jan-Jun, 2021)