- Monitored anesthesia care (MAC)
- Local anesthesia infiltration to medial canthal region
- i.e., 50/50 mixture of 2% lidocaine with epinephrine and 0.5% Marcaine with epinephrine
- Typically provides adequate anesthesia given that there is no bone removal and decreased risk of aspiration compared to DCR
- General anesthesia
- If unable to tolerate MAC
- Possibility of larger resection with bone removal or intranasal involvement
- Consider infiltration with above local mixture for hemostasis and postoperative comfort
- Skin marking uses an Iliff type incision starting at the superior border of the medial canthal tendon and curving downward along the anterior lacrimal crest.
- Better aesthetic results are obtained by aligning this incision with the patient's natural relaxed skin tension lines (Figure 2).
- Incision can be made with a 15 blade.
- CO2 laser, monopolar needle tip, radiofrequency wire, or other devices are preferred by some surgeons.
- Dissect down to the anterior lacrimal crest.
- Incise the periosteum using a monopolar cautery with needle tip (Figure 3).
- Use a Freer periosteal elevator to elevate the lacrimal sac from the lacrimal fossa
- Insert a Bowman probe and visualize in the sac.
- Free the lacrimal sac superiorly.
- Take care not to enter the nasal cavity, particularly if there is concern for a lesion. The posterior portion of the dissection encounters the ethmoid bone, which is very thin, so use caution.
- Isolate the anterior crus of the medial canthal tendon and cut using Westcott scissors to improve visualization and removal of the lacrimal sac.
- Baddeley et al. reported using viscoelastic to aid in visualization and dissection of the lacrimal sac.
- The upper punctum is clamped with a bulldog clip and viscoelastic is injected through the lower.
- The lower punctum is then clamped with a bulldog clip.
- The authors do not recommend this technique if there is a known or suspected lacrimal sac tumor.
- If a tumor is present and contained within the lacrimal sac, it is recommended to leave the sac intact to the best extent possible. If a tumor has eroded through the lacrimal sac, biopsy with frozen section analysis may be indicated.
- The lacrimal sac is then amputated from the nasolacrimal duct as inferiorly as possible.
- The lacrimal sac is sent to pathology for permanent histopathological analysis.
- In some cases, fresh tissue analysis for flow cytometry in cases of suspected lymphoproliferative disorders may be indicated.
- Frozen section analysis may be used as well.
- In setting of dacryocystitis, copious irrigation of the fossa with saline or antibiotic solution is indicated.
- Confirm the sac has been removed by placing a Bowman probe in the lower punctum and visualizing it exiting the common canaliculus (Figure 4).
- The superior opening of the nasolacrimal duct, now exposed, should be sealed to prevent reflux of nasal contents into the lacrimal sac fossa.
- This can be accomplished with the monopolar cautery.
- The same technique can be used to seal the common canalicular opening/common internal punctum.
- Repair the medial canthal tendon using a 5-0 polyglactin or polypropylene suture in a horizontal mattress fashion.
- Medial orbital fat can be mobilized and secured to the periosteum using 6-0 polyglactin suture to fill the lacrimal sac fossa and reduce or eliminate dead space (Figure 5).
- Orbicularis is closed using buried 6-0 polyglactin suture.
- Skin is closed using 6-0 plain gut or polypropylene suture in a running or interrupted fashion.
Figure 2. Patient marked using a modified Iliff incision.
Figure 3. Incision along anterior lacrimal crest.
Figure 4. Following removal of the lacrimal sac, the Bowman probe is seen exiting the common canaliculus/common internal punctum.
Figure 5. Transfer of medial orbital fat into dead space.
Shams and Selva published a case in 2013 using an endoscopic approach for chronic dacryocystitis following a failed external DCR in which a demented patient aggressively agitated the incision leading to dehiscence and wound infection. The endoscopic approach was performed to avoid an external incision and was successful. The common canaliculus was treated with local cauterization.