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What happens in combined external and endoscopic DCR? Part 2

In a combined endoscopic and endonasal DCR for watering eyes, a small opening is made in the tear trough to get to the lacrimal fossa and also simultaneously an endoscope is used in the nose to visualise the nasal mucosa adjacent to the sac. The lacrimal sac is gently teased away from the lacrimal fossa wall and opened and the tubes pre-placed. Subsequently, a little bit of bone is removed from the lacrimal fossa and the nasal mucosa is opened. The endoscope becomes most useful at this stage as it provides additional illumination. It allows you to see at high magnification from inside the nose exactly what the flaps look like and ensures that not only is the opening into the nose but that there are no residual fragments of tissue that could block up the opening. The tubes are then passed down the nose and flap sutured appropriately; often just the anterior flap needs suturing, and the skin is closed. The skin is best closed with sutures deep to the orbicularis and then four or five sutures to the skin.
With the endoscopic endonasal DCR combined with the external, I am now getting results which are in the range of 99%.
By success with tear duct surgery, I mean a patient who has no longer got a watering eye, has had no complications and anatomically has a functioning DCR. There must not be any visible scar.
I can test whether the tear drainage is normal after DCR surgery by using a small drop of fluorescein which is popped into the conjunctival just inside the lower eyelid and is seen to drain immediately into the nose. The orange coloured fluorescein drop drains quickly away from the eye into the nose if all is working, or remains with a high tear meniscus and only slowly drains away if not working.
At Clinica London, I do combined external endoscopic DCR which is called LighTears, which is via a small tear trough incision and nasal endoscopic approach under local anaesthetic with sedation as a day case. Which is better, external DCR or endoscopic endonasal DCR? Both are very good but combined external and endoscopic DCR is better. All DCR surgeries carry risks including a little nose bleeding after surgery.

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