Purpose

External dacryocystorhinostomy (DCR) is a widely performed and effective surgical technique for the management of nasolacrimal duct obstruction. Although generally safe, rare intraoperative complications may occur, particularly in anatomically challenging patients.
Here, we report a case of intraoperative discovery and retrieval of a broken Kerrison punch tip embedded intranasally during external DCR in a young male patient with dense bony anatomy.

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Methods

We report the case of a young male patient who underwent external DCR and developed a rare intraoperative complication: the tip of a Kerrison punch broke off during osteotomy and became lodged in the nasal cavity. While proceeding with the osteotomy, it was noted that the patient’s bones were relatively thick and dense, which is typical in younger male patients. A small Kerrison punch was initially used to remove the lacrimal bone; however, the tip of the instrument broke off during the procedure. Subsequently, a larger Kerrison punch was used to remove the lacrimal bone.
The intraoperative bone window measured 2×1 cm. Before creating the nasal mucosal flap, a 4×1 mm broken instrument tip was detected between the ethmoid bone and the outer surface of the nasal mucosa with the aid of suction.

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Results

The metallic fragment was identified intraoperatively and successfully retrieved with forceps. This case underscores the importance of recognizing patient-specific anatomic factors, the mechanical limitations of surgical instruments in dense bony structures, and the potential value of tactile feedback and preoperative imaging in preventing such events. Surgical video footage and intraoperative images are provided to illustrate the complication and its resolution.

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Conclusion

To our knowledge, this is the first case report documenting punch breakage and intraoperative retrieval of a metallic foreign body during external DCR. Ultimately, understanding patient-specific anatomic variability, adopting safer osteotomy methods, and recognizing tool limitations may help reduce rare but impactful complications in routine oculoplastic surgery.

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Additional Authors

First name	Last name	Base Hospital / Institution
Emirhan	Ozkul	Sancaktepe Prof. Dr. Ilhan Varank Education and Research Hospital
Hatice	Tekcan	Haydarpasa Numune Education and Research Hospital

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