Endoscopic Orbital Surgery: The Rhinologist’s Perspective

Endoscopic Dacryocystorhinostomy

Before the endoscopic age, attempts to surgically treat orbital disease through a transnasal approach were often fraught with poor visualization and poor outcome. The best documented attempt to perform a dacryocystorhinostomy (DCR) through the nose was described in 1921 by Harris P. Mosher, who then served as chairman of the Department of Otology and Laryngology at Harvard Medical School. Using a headlight and nasal speculum, he described the drainage of pus from the infected lacrimal sacs of 12 patients. Although this intranasal approach avoided the need for a facial incision, a postoperative orbital infection developed in one patient who almost lost her eye, prompting Mosher to abandon the procedure in favor of a combined external-intranasal approach. In his words, “Where light is possible it is folly to work in the dark. The best surgery is done by sight.” For the next 70 years, DCRs were performed almost exclusively in an external manner through a medial canthal incision, and largely by ophthalmologists.

With the advent of small-diameter, high-resolution nasal endoscopes for sinus surgery in the mid-1980s, a renewed interest developed in the possibility of accessing orbital pathology through the nose. Otolaryngologists found themselves routinely operating in the vicinity of the lacrimal sac as they cleared disease from adjacent ethmoid air cells under excellent visualization. While doing so, the potential to readily access the medial orbital structures via a transnasal approach became readily apparent, and early reports in the literature supported the concept.

In 1989, I was approached by Daniel Townsend, an ophthalmologist at Massachusetts Eye and Ear Infirmary, who had recently performed an external DCR on a 52 year-old woman, only to have her troublesome tearing return 3 months later. When I examined the patient in the office with a nasal endoscope, a dense scar band could be seen overlying the region of the lacrimal sac along the lateral nasal wall. She appeared to be an ideal candidate to revisit Mosher’s intranasal DCR approach, this time with the necessary “light” and visualization to perform a safe and effective surgery.

The trip to the operating room proved to be a fruitful one. The ophthalmologist passed lacrimal probes through the canaliculi to localize the obstructed lacrimal sac while I resected the scar tissue and made a wide opening around the probes into the sac. The patient tolerated the 90-minute procedure well, and her epiphora has not returned in more than 30 years.

The early success of endoscopic DCR led to its relatively rapid adoption by other surgeons at our hospital and across the country. The benefits of avoiding a facial incision and reducing patient morbidity offered by endoscopic DCR were obvious. However, not so obvious at the time were the subtleties of patient selection and surgical technique that affected clinical outcome.

One such example was the use of surgical lasers, which were quite popular at the time, for the performance of endoscopic DCR. Although laser fibers could be passed through either the tear duct or nose to remove bone overlying the lacrimal sac, their use led to postoperative scar formation and restenosis. Laser endoscopic DCR had a success rate of 78% compared with a rate of more than 90% for conventional DCR. Because of these early setbacks, endoscopic DCR lost favor among many ophthalmologists who continued to perform conventional external DCR. Nevertheless, with increasing clinical experience, the performance of endoscopic DCR was refined and its adoption grew worldwide. Numerous reports over the past decade have described the safety and efficacy of this technique with results comparable to those of external DCR.