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  • When to Consider Endoscopic DCR

    “It’s hard to argue with success. The published success rates with external DCR [dacryocystorhinostomy] are upward of 90%. So why would we mess with success?” said Bradford William Lee, MD, MSC, to begin his Oculoplastics Subspeciality Day talk on Saturday. He discussed the benefits of and surgical considerations for endoscopic DCR.

    External DCR problems. There are potential problems with external DCR, said Dr. Lee. It can lead to visible hypertrophic or hyperpigmented scars. It can also heal poorly, particularly in patients of color. Because of the cutaneous incision, sutures and wound care are needed, and patients have to be careful about infection at the surgical site. There is also weaking of orbicularis and potential lagophthalmos.

    Why perform endoscopic DCR? For starters, use of the endoscope allows for better illumination and magnification, which makes it ideal for educational purposes to boot. Compared with external DCR, the endoscopic procedure can potentially shorten surgical time and expedite healing and recovery, with minimal bruising and swelling. It also gives physicians an early treatment option for acute dacryocystitis. “Knowledgeable patients who’ve studied the different approaches may request it, and just be averse to the idea of a scar on their face,” Dr. Lee said.

    Hesitant about endoscopic DCR? “Well, obviously, we’re ophthalmologists, eye specialists. So we have limited experience in the nose except for this surgery,” said Dr. Lee. Controlling bleeding can be an additional challenge. Another downside: The equipment is pricey. But it is our job to educate patients about their options, he said, and even if you don’t offer the procedure yourself, you can refer patients to an ENT specialist or an oculoplastic colleague.

    Although there are reports of high success rates (90%-95%) with endoscopic DCR, some other reports show much lower success rates, said Dr. Lee, who attributed the lower rates to limited experience and proficiency. Be mindful that there’s a steep learning curve. “This is not the type of surgery that you can learn on TikTok or on YouTube,” he warned.

    Preoperative considerations. Ask patients about prior facial trauma and nasal or sinus surgery that could make endoscopic DCR more challenging. Check the patient’s anatomy; in some patients the anatomy is favorable, while in others it might be an “uphill battle.” The patient should not be on blood thinners. Dr. Lee said that he generally performs these surgeries under general anesthesia if the patient is healthy enough, “but I certainly have done numerous ones under IV sedation with nerve blocks.”

    A few extra tips:

    • Before surgery, he uses Afrin, an over-the-counter oxymetazoline nasal spray, to decongest the patient and pack the nose with nasal decongestant.
    • He shared his preferred equipment and instruments. His secret weapon: “Some people call me a caveman, but I like the osteotome and mallet for that thick bone way at the top.”
    • Lee said that there are some surgical variations, and generally many of them work.
    • Beyond discontinuing blood thinners, controlling blood pressure aggressively, and positioning the patient in a reverse Trendelenburg, he advises packing the nose with concentrated epinephrine to manage bleeding. He has also started using more tranexamic acid.

    The key to success: Clear the bone! Really insert the Bowman probe horizontally and visualize the level because that’s your surgical endpoint. “Whatever you need to do, do it. So whether you need a drill or ultrasonic aspirator or whether you prefer an osteotome, just make sure you clear the bone,” he emphasized.

    Postoperative regimen. Patients should use fluticasone nasal spray, saline nasal spray, or sinus rinses to help decongest and clear clots and crusts.

    Tips for unfavorable anatomy. There are adjunctive steps you can take. Partial middle turbinectomy and anterior ethmoidectomy are helpful. Dr. Lee doesn’t do nasal septoplasty, but if you are comfortable, it may help.

    “Certainly, you should consider external DCRs whenever it’s appropriate,” Dr. Lee advised. “And if needed, you can always call your ENT buddy and do it as a combined case—or just let them do it.”

    Along with coding tips, Dr. Lee shared some alternatives to DCR:

    • Dacryocystectomy can be appropriate for some patients, particular elderly populations.
    • He has moved away from injecting onabotulinumtoxin (Botox) into the lacrimal gland and prefers partial excision of lacrimal gland.
    • “If you have older patients, sometimes less is more, and I may say ‘if it’s not bothering you too much, maybe we just live with it.’” —Kanaga Rajan

    Financial disclosures: Dr. Lee: None.

    Watch online. If you are registered for AAO 2022 or AAO 2022 Virtual, log in at, search for event code “Ocu05,” where you can watch a video of Oculoplastic Surgery Subspecialty Day’s Section IV: Pediatric/Lacrimal Essentials. At 19 minutes into the video, Dr. Lee walks through an example of endoscopic DCR, pointing out noteworthy steps along the way.

    Read more news about Subspecialty Day and AAO 2022.