Dacryocystorhinostomy

Tears are produced from lacrymal glands located on our upper eyelids. From here, they are spread all over the surface of our eyes. Our eyelids contain small openings to drain tears that cover them. When we blink, the tears are pushed into these openings. From these openings, some tears drain through a small tube into a larger area called the lacrimal sac (present in the inside of the nose). From the lacrimal sac, they are emptied into the nasal cavity via a tear duct. Your body reabsorbs tears from your nose.

However, when a tear duct is blocked, it causes excessive discharge or tearing from the eye. This can also lead to infection in the duct. Dacryocystorhinostomy (DCR) is used to treat tear duct blockage usually by forming a new tear drain between the eyes and nose. It can be performed in two ways:

• External DCR: In this surgery, a small opening is made at the side of the nose to expose the tear sac.
• Endoscopic DCR: A device called a telescope is used to look inside the nose and locate the area of blockage. That duct is then opened through surgery.

Dacryocystorhinostomy is needed to relieve you from the symptoms of a blocked tear duct. The symptoms include:

• Excessive watery eyes 
• Crusting around your eyes 
• Eye irritation 
• Mucous discharge 
• Swelling or tenderness around your eye

The surgery is indicated in conditions such as:

• Swelling of the skin overlying the lacrimal sac
• Excessive tearing that is socially unacceptable or interferes with vision
• Dacryolith formation (accumulation of a hard solid mass within the lacrimal drainage system)
• Non-cancerous lacrimal sac mass
• Chronic dacryocystitis (a condition that causes inflammation of the lacrimal sacs due to chronic obstruction of the duct)
• Nasal polyps (a painless non-cancerous growth on the nasal lining)
• Trauma to the nose 
• Conjunctivitis (infection or inflammation of the white part of the eyeball)

Dacryocystorhinostomy is contraindicated in people with the following conditions:

• Dry eye syndrome
• Bleeding dyscrasias (a disorder of the blood)

The following preparation is required before the surgery:

Diagnostic tests: 

• You may need an eye check-up before the surgery. This includes syringing water through the tear duct to check for blockages. 
• A telescopic examination to check inside your nose. 
• Routine tests like a blood test, electrocardiogram (ECG), computed tomography (CT) scan or magnetic resonance imaging (MRI) of the nasal passage.

Medications:

• You will be asked if you are taking any medicines. 
• Inform your healthcare practitioner if you are allergic or sensitive to any medicine.
• You may need to stop aspirin or ibuprofen (if you are taking them) two weeks before the surgery. 
• Inform your doctor if you are on blood-thinning medicines like warfarin.

Diet:

• Fasting after midnight the night before the surgery is needed.

Consent form:

• You will be given a consent form before the surgery. By signing this form, you are permitting the healthcare practitioner to conduct this surgery.

Stop smoking before the surgery to reduce the risk of complications. You may need someone to take you home after the surgery. Read more: Effects of smoking on health

The following steps are performed in this surgery:

• You will be awake during the surgery. A packing material with anaesthesia will be placed inside your nose to prevent pain during the surgery. 
• Medicine will also be placed inside the packing material to prevent bleeding during the surgery. 
• You will require an injection to numb the operating area.

For an external DCR procedure:

• The doctor will make a 10 to 15 mm incision on the side of your nose.
• He/she will access the tissue below the incision and make a small hole in the bone underneath.
• This creates a new pathway to drain the tears from the lacrimal sac to the nose.
• Next, the doctor will insert a small tube to ensure that the new drainage pathway remains open during the healing process. 
• Finally, he/she will close the incision using sutures or stitches. 

The procedure for an endoscopic DCR remains same as that of an external DCR; however:

• No cut will be made at the side of the nose. 
• An endoscope will be used to access the blockage through the nose.

The process may take around one hour, and the tube to maintain the pathway will be trimmed before you leave. You may get it removed after four to six weeks. You may experience some spotting, discomfort and facial bruising immediately after the surgery. This will go away after two to four weeks. Usually, patients are sent home on the same day of this surgery. Your nose will be re-filled with the packaging material to avoid the risk of bleeding.

After the surgery, you may experience watery eyes until the tubes are removed and swelling settles. You should take the following care at home:

• If an eye pad placed on the surgical site is not removed before returning home, then the doctor may ask you to gently remove it the next morning, wash the site normally and dab the site dry instead of rubbing.
• In case of external DCR, keep your wound dry and uncovered. 
• If you had endoscopic DCR, your healthcare practitioner will ask you to wash out your nose using a special nasal spray for several weeks. 
• If you still have bleeding, place an ice pack over the nose on the opposite side of the surgical site. 
• You may take painkillers like paracetamol or codeine if you have pain.
• You may need antibiotics to prevent infection.

You should avoid the following after the surgery:

• Picking or blowing your nose for a week
• Sneezing, (you can sneeze with your mouth open)
• Homoeopathic medicines that promote fast healing
• Makeup for two weeks
• Strenuous exercise, especially swimming, for the next two weeks 
• Medicines like aspirin for at least 10 days
• Air travel for at least seven days
• Hot drinks or foods for 24 hours as it can cause bleeding
• Driving
• Drinking alcohol or taking sedatives (medicines that make you relax) for 24 hours

Although the success rate of the endoscopic DCR (70%) is less than the external DCR (90%), it has the following advantages:

• Minimally invasive
• Leaves no scar later

When to see the doctor?

Call your doctor if you have:

• Bleeding that continues for more than half an hour
• Increasing swelling or pain
• Fever

The possible risks associated with this surgery are as follow:

• Prominent facial scar
• Excess bleeding 
• Failure of the surgery 
• Displacement of the tube 
• Infection 
• Abnormally fused tissue in the nose

For an external DCR, a follow-up visit is required to remove the stitch. This is typically done after one or two weeks of the surgery. The tube may also be removed or in the next follow-up (occurring between four and six weeks). You can have a follow-up meeting after six weeks to remove the tube in an endoscopic DCR. Later, you can check with your doctor after six months for a final check-up.

Disclaimer: The above information is provided purely from an educational point of view and is in no way a substitute for medical advice by a qualified doctor.