BLOOD LESS AND PAIN LESS DACRYOCYSTORHINOSTOMY (DCR)

External Dacryocystorhinostomy under local anesthesia is not a favorite surgery among ophthalmologists. The two obvious reasons are pain and bleeding. Bloodless and painless DCR surgery under local anesthesia may be possible only in a perfect world but our patient as a living being bleed and feel pain. The aim is to achieve perfect DCR with minimum bleeding and minimum pain. Few steps to decrease the pain and bleeding outlined below. 

1. Know your patient: 

• Meticulous history and work up for bleeding disorders,  
• Previous surgeries (repeat surgeries are painful),  
• History of hypertension, blood thinners,  
• Pain threshold (some are more tolerant to pain some would rather prefer general anesthesia),  
• Trauma history (traumatic NLDO has disrupted anatomy and will have more bleeding). 
• A calm patient and a calm surgeon is a perfect combination. Counseling with realistic expectations and warnings about surgery will decrease anxiety as well as create bonds of trust. A mild sedative on the day of surgery may help. 

Fig: Bone anatomy for DCR

2. Pre-operative preparation –  

• Lignocaine spray and Nasal packing with 0.5% oxymetazoline and 4% lignocaine/proparacaine decongests the nasal mucosa  

3. Instrumentation  

• Sharp sterile instruments - periosteal elevator, bone punch 
• Good lighting system and magnification (preferably loupe) 
• Good monopolar and bipolar cautery and suction machine

4. Know the bleeders  

• Orbicularis (blunt dissection and holding with cat’s paw retractor decreases bleeding) 
• Angular vessels (better avoided at approx 10 mm nasal to medial canthus but can be sacrificed with cauterization) 
• Bony perforators (suture of notha)  
• Perisac plexus  
• Lacrimal mucosa (infiltrate with local anesthesia, will aid in analgesia and homeostasis) 
• Nasal mucosa (infiltrate with local anesthesia, will aid in analgesia and homeostasis) 

5. Local anesthesia

• Infratrochlear nerve block
• Infraorbital nerve block
• Ethmoidal nerve block
• Dorsal nasi nerve block

Fig: Nerve Block

Proper planning as such incision site, bone nibbling area,  knowledge of anatomy, meticulously following each step and  patiently dealing with bleeders (pressure, cautery or ligation) 
will make DCR surgery less stressful. DCR surgery is another rewarding surgery only second to cataract surgery with visible  results. With proper planning and execution, DCR can be happy surgery for both the surgeon and the patient. 

Further Reading

https://www.youtube.com/watch?v=_7qQLGpW9ro 

https://www.ncbi.nlm.nih.gov/books/NBK557851/ 

https://www.nysora.com/techniques/head-and-neck-blocks/nerve-blocks-face/ 

Ali MJ, Naik MN, Honavar SG. External dacryocystorhinostomy: Tips and tricks. Oman J Ophthalmol. 2012 Sep;5(3):191-5. doi: 10.4103/0974-620X.106106. PMID: 23440476; PMCID: PMC3574519 

Figure 1-http://www.oculist.net/downaton502/prof/ebook/duanes/pages/v8/ch002a/008f.html 

Figure 2 -https://webeye.ophth.uiowa.edu/eyeforum/tutorials/retrobulbar-nerve-blocks.htm