| Summary: | This video presents the trauma to the lacrimal sac. The nasolacrimal duct (NLD) includes severe lacerations of the lacrimal sac and Le Fort II and Le Fort III type nasoethmoid fractures 1,2,3,4 following high impact blunt trauma. Since the upper lacrimal pathway is protected by the medial canthal ligament and lacrimal obstruction usually occurs in the bony nasolacrimal canal2. It further adds to the difficulty if it involves a lacrimal sac with its entrapment in the fractured segment. Management of traumatic lacrimal drainage pathway obstruction remains challenging, unlike primarily acquired NLD obstruction. The anatomy of the bony lacrimal fossa and NLD is altered with a lot of scarring, and the surgery carries an increased risk of failure2. Some studies prefer external DCR and Dacryocystectomy in cases where flap formation is complex. They discourage endoscopic, endonasal, or laser DCR in posttraumatic NLD obstruction due to the loss of bony anatomical landmarks after trauma and subsequent surgery2. The current video describes that a successful endoscopic DCR is possible even in the most complex posttraumatic obstructions of the lacrimal pathway. A step-wise approach to these cases with a careful reading of the preoperative DCG and complete marsupialization of the portion of the sac above the common canaliculus gives an excellent long-term outcome. The patient had a fractured frontal process of the maxilla with its posteromedial impaction into the ethmoids. The sac was lacerated and divided into fragments. Preoperative CT DCG provided valuable information. CT DCG showed a breach in the bone covering the superior part of the sac that allowed prolapse of skin and muscle with the prominent segment of the fundus of the sac hidden under it. All aspects of the sac were exposed and marsupialized. Intraoperative assessment and Preoperative CT/CT DCG helped in achieving an excellent outcome in these complex cases.
|
|---|