Muhammad Sharjeel, et al
Unlike congenital nasolacrimal duct obstruction in
which lacrimal probing and syringing has a high
success rate, acquired nasolacrimal duct obstruction in
adults gets minimal benefit from probing and
syringing in terms of treatment3. Most of the patients
need surgical intervention to overcome the
obstruction4.
acute infection, having history of previous DCR and
those not willing to participate in the study or refusing
surgery under local anesthesia were excluded from our
study. All the patients were adults from 18-60 years
old. Patients participating in our study were divided in
two groups. First 25 patients booked for DCR surgery
were allocated to group A, next 25 patients during
study period were allotted to group B.
External Dacryocystorhinostomy (DCR) was
introduced in 1904 by a French Ophthalmologist,
AdeoToti5. Since then different ophthalmologists have
developed various techniques for this procedure.
External DCR remains the most commonly performed
surgery for this purpose and is considered a gold
standard technique6. Success rate of external DCR is
upto 91% as compared to 63 – 75% for endonasal
DCR7.
All the patients had complete ophthalmic
examination before surgery. General physical health of
the patients was also assessed in terms of hypertension
and diabetes. Those having uncontrolled hypertension
and poor glycemic control were excluded from our
study.
Patients in group A underwent DCR under local
anesthesia i.e. 5 ml anesthetic formulation made by 2.5
ml of 2% Bupivacaine and 2.5 ml of commercially
available 2% xylocaine, with 1:200,000 adrenaline
(0.005 mg/ml); whereas those in group B had their
surgery done under local anesthesia with 2.5 ml of 2%
Bupivacaine, 2.4 ml of 2% Xylocaine and 0.1 ml of
1:50,000 adrenaline (0.02 mg/ml). Injection of local
anesthetic was given at three points; Supratrochlear
block, infra-trochlear block and 10 mm from medical
canthus. No sedative or Intra muscular analgesics were
used in any case.
External DCR is not performed routinely in
private sector hospitals. This procedure is mostly
performed in public sector hospitals. To deal with
large number of patients with complaint of epiphora
presenting to public sector hospitals, it is often
required to perform this procedure in local anesthesia
(LA). There are certain drawbacks of performing this
procedure in LA8. The most problematic per-operative
complication during external DCR is bleeding from
the highly vascular nasolacrimal apparatus, which
prolongs the surgical time and reduces patient comfort.
Another troublesome complication during the surgery
is ineffective analgesia. To overcome these
complications various techniques have been employed
like use of a vasoconstrictive agents e.g. adrenaline,
raising the head end of the table, good nasal packing or
using cautery9. Use of adrenaline along with the local
anesthetic has beneficial effects in terms of reduced
per-operative bleeding and more concentration of the
local anesthetic at the place of interest10.
Except for the concentration and formulation of
local anesthesia, there was no difference in the surgical
technique in both groups and all surgeries were
performed by the same surgeon. Per-operative pain,
bleeding and effectiveness of anesthesia were noted in
both the groups and were compared. Scoring of Pain,
bleeding and anesthesia effectiveness was done using
the scoring table shown below (table 1). Pain was
assessed on a numeric scale by asking the patient
during the procedure and postoperatively. Per-
operative bleeding was scored on the basis of number
of gauze packs (one gauze pack contain 10 gauze
pieces) used during procedure. Effectiveness of
anesthesia was measured in terms of number of doses
required during the surgery. Data was recorded in
excel spreadsheets and analyzed using SPSS version
20. Descriptive statistics were used to describe the
data. Means of pain score, bleeding score and
anesthesia effectiveness score for both groups were
compared.
In this study we intend to compare two different
concentrations of adrenaline used along with local
anesthetic, in terms of their beneficial outcomes in the
form of reduced pain, per-operative bleeding and
effectiveness of anesthesia.
MATERIAL AND METHODS
This study started after approval from the ethical
committee of DHQ Hospital Dera Ismail Khan. 50
patients presenting to the outpatient ophthalmology
department who were diagnosed as cases of primary
nasolacrimal duct obstruction were selected. Patients
suffering from any kind of cardiovascular disease,
RESULTS
In group A, 21 (84%) patients were females and 4
(16%) were males. In group B 20 (80%) patients were
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Pakistan Journal of Ophthalmology, 2020, Vol. 36 (3): 287-291