The Great Debate: External Versus Endonasal Dacryocystorhinostomy

Abstract

The principles of standard surgery for blockage of the lacrimal outflow tract probably dates back 1,000 years now when the twelfth-century Andalusian Oculist Mohammad Ibn Aslam Al Ghafiqi described a small spear-shaped instrument perforating the lacrimal bone in a nasal direction “until blood flows through the nose and mouth with care given not to direct the instrument downward as this would be the incorrect direction.” The probe was then wrapped in cotton that was either dry or soaked in ox fat. This would then be exchanged every day in order to maintain the patency of the created fistula [1]. This principle remains the same to date as that for contemporary conjunctivo-dacryocystorhinostomy. Modern dacryocystorhinostomy (DCR), however, dates back to the dawn of the twentieth century [1–4]. In terms of anatomic goals, the aims of surgery are simple: The lacrimal sac is connected directly to the nose by removal of the separating bone and mucosa. A fistula is hence formed that allows tears to pass directly into the nasal vault through the lateral nasal wall. This must occur at a level above the mechanical obstruction in order to bypass it [5]. The traditional popular method has been through an external approach as described by Toti [3] and modified by Dupuy-Dutemps [4]. Although the endonasal approach was described perhaps prior to this [2] it is only in recent decades with the introduction and development of the endoscope, that attention has turned to endoscopic DCR for both primary procedures and to revise failures [6]. DCR is indicated for patients with lacrimal sac or nasolacrimal duct obstruction (NLDO) causing either epiphora or dacryocystitis (infection).