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repeat surgeries. Dacryocystorhinostomy is a bypass procedure that creates an

anastomosis between the lacrimal sac and the nasal mucosa via a bony
ostium. It may be performed through an external skin incision or endo-nasally
with or without endoscopic visualization or via the transcanalicular approach. The
most commonly done approach is the External DCR which is still considered as a gold
standard in management of chronic dacryocystitis.

Standard procedure

1. Adequate nasal decongestion and nasal packing preoperatively is helpful.
2. Anesthesia can be local or general. Local anesthesia includes topical in
conjunctival cul-de-sac, infratrochlear block and local infiltration.
3. Skin incision either straight or curvilinear can be used.
4. Periosteum over the anterior lacrimal crest is raised and the lacrimal sac is
reflected laterally.
5. A large bony osteum is created respecting the anatomic boundaries.

6. Flaps of nasal mucosa and lacrimal sac raised. Posterior flaps are excised.
7. Adjunctive pharmacotherapy or intubation is done if needed.
8. Anterior flaps are sutured with 6-0 vicryl and skin is sutured with 6-0 silk or
prolene.
9. Nasal packing is done to soak the blood and hemostasis.

Standard Operating Procedure
a. In Patient :
 Admit patients after the surgical procedure to monitor the vitals and signs of

bleeding especially if they are from far off places.
 Admit patients with complications like orbital cellulitis or severe acute dacryocystitis
for intravenous antibiotics.
b. Out Patient: Not applicable.
c. Day Care: Patients after the surgical procedure are kept under observation for 4-5
hours for any bleeding and then can be discharged if they are stable.

d) Referral criteria:

 Lacrimal obstruction at multiple sites.

 Failed Dacryocystorhinostomy.
 Complications of chronic dacryocystitis like recurrent acute exacerbations or orbital
cellulitis.
 Chronic dacryocystitis associated with systemic diseases like sarcoidosis or wegeners
granulomatosis.

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