Dacryocystectomy

What is a DCT?

Dacryocystectomy or DCT refers to a complete surgical extirpation of the lacrimal sac. Indications for dacryocystectomy include malignant tumours of the lacrimal sac, recurrent dacryocystitis in the presence of severe dry eyes or cicatrizing autoimmune disorders like granulomatosis, patients with debilitating systemic comorbidities and bleeding diathesis, multiple time failed dacryocystorhinostomies, and severe atrophic rhinitis. Only malignant tumours are an absolute indication; the rest is relative. There are two clear goals of dacryocystectomy procedure. First is to have a clear plane of sac excision and avoid injury to periorbita and surrounding bones. Second is to have a complete excision of the sac along with the nasolacrimal duct without leaving any remnants behind. Since both these purposes are well served by an external route, it is the preferred approach. There are exceptional indications for an endoscopic DCT as well. Following extirpation, all the lacrimal sacs should be subjected to a histopathological examination.

Why one might need a DCT?

The Procedure is done with such goal as:

• Primary
  Removal of the lacrimal sac
  Removal of Lacrimal sac tumour
• Secondary:
  To prevent Further Episodes of dacryocystitis

DCT is required for Patients with Following Indications:

• Suspected or confirmed lacrimal sac tumour
• Chronic dacryocystitis following failed dacryocystorhinostomy (DCR)
• Dacryocystitis without a history of epiphora
• Dacryocystitis in the setting of chronic dry eye syndrome (DES)
• Dacryocystitis in patients with a high risk of anaesthesia in an effort to avoid the need for further surgery
• Patients who are unable to tolerate potential side effects of nasal packing such as, tachycardia and hypertension
• Dacryocystitis in the setting of granulomatosis with polyangiitis (Wegener's granulomatosis) that is refractory to conventional management

The following are the Contraindications:

Relative:
Primary treatment of nasolacrimal duct obstruction that does not fall into the above-mentioned categories
Lacrimal sac tumour that has extended beyond the sac where en bloc or further resection is necessary

What is the pre-procedure evaluation of DCT?

Complete history with particular attention to

• Epiphora
• Ocular surface disease and DES
• History of cancer, particularly sinus or facial
• Presence of bloody tears
• Palpable masses in the medial canthal region
• Prior lacrimal surgery
• Facial trauma
• Aspirin/Anticoagulant therapy
• History of systemic rheumatologic disease

Clinical examination

• Complete periorbital and anterior segment examination
• Assess for DES including evaluation of tear lake, tear break up time, and basic secretion testing.
• Complete lacrimal evaluation with probing and irrigation
• Lacrimal sac tumour suspected
• Orbital evaluation including measurement of exophthalmometry
• Motility evaluation
• Palpate lacrimal sac and look for purulent or sanguineous reflux from punctum
• Examine for the fullness of lacrimal sac extending superior to the medial canthal tendon
• Intranasal exam with endoscope or speculum looking for a nasal extension

Imaging

• Indicated for suspected lacrimal tumours to determine the extent and characteristics of the lesion
• In cases of severe dacryocystitis, imaging can also be useful to determine the presence of orbital extension or abscess
• Imaging options
• Computed tomography (CT) of the orbit and sinuses
• Magnetic resonance imaging (MRI) of the orbit and sinuses
• Dacryocystography
• Radionuclide dacryoscintigraphy

What is the Alternative Procedure?

Chronic dacryocystitis

Observation

• Medical treatment of dacryocystitis
• Primary or repeat external or endoscopic DCR
1. +/- Mitomycin C
2. +/- Silastic intubation

Suspected tumour

• Palliative radiation and/or chemotherapy following lesion biopsy
• En bloc resection

What happens during a DCT?

Anaesthesia

• Monitored anaesthesia care (MAC)
  • i.e., 50/50 mixture of 2% lidocaine with epinephrine and 0.5% Marcaine with epinephrine
• Local anaesthesia infiltration to medial canthal region
• Typically provides adequate anaesthesia given that there is no bone removal and decreased risk of aspiration compared to DCR
• General anaesthesia
• If unable to tolerate MAC
• Possibility of larger resection with bone removal or intranasal involvement
• Consider infiltration with the above local mixture for hemostasis and postoperative comfort

Technique

• 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.
• The 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 a needle tip.
• 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 a 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 tumour.
• If a tumour is present and contained within the lacrimal sac, it is recommended to leave the sac intact to the best extent possible. If a tumour 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 the 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.
• 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.
• 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.

What happens after a DCT?

Postoperative Instructions

Postanesthesia precautions

• No heavy lifting or bending
• Do not rub the incision
• Sleep with head of the bed elevated
• Ice packs to the surgical site for 15 minutes every hour while awake for 3 days
• Resume anticoagulation on a postoperative day one

Medications prescribed

• Analgesia
• Often require the only acetaminophen
• Cautious use of narcotics for older patients
• Consider ophthalmic antibiotic ointment to the incision.
• Consider oral antibiotics in the setting of chronic dacryocystitis.

Other considerations

Depending on the outcome of the intraoperative frozen section biopsy, the patient may require referral to oncology and/or otolaryngology for further surgical and medical management.

Common treatment responses, follow-up strategies

Chronic dacryocystitis

• Erythema and pain should improve considerably over 1–2 weeks postoperatively.
• Purulent discharge should improve immediately, although patients will likely have irritation and discharge for 1–2 weeks.

Suspected or unsuspected lacrimal tumour

• The patient will have pain and erythema associated with surgery that should resolve over 1–2 weeks.
• Patients that had partial or no obstruction of the nasolacrimal system, as is common with lacrimal sac tumours, will likely have increased epiphora postoperatively.
• As mentioned above, management will vary based on the results of the biopsy and there will likely be further management and referral.

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