Blog

December 24, 2019

Lacrimal sac Surgery- ENDO DCR

Why is dacryocystorhinostomy done?

• Congenital problems(a person may be born with an underdeveloped tear duct system or defects
• Recurrent dacryocystitis (infection of the lacrimal sac)
• Canaliculitis (inflammation of the canaliculus, a short channel near the inner corner of the eyelids through which tears drain into the sac)
• Dacryolithiasis (inflammation due to formation of small stones in the tear duct system)
• Lacrimal system tumors
• Nasal pathology obstructing drainage
• Trauma
• Previous surgery 
• Unidentifiable causes 

What are the signs and symptoms of epiphora (watery eyes)?

One or both eyes can be affected with:

• Increased socially and personally unacceptable watering of eyes
• Pain
• Discharge of pus 
• Swelling in the inner corner of the eyes
• Inflammation or redness of the skin and eyelids 
• Crusting 
• Fever
• Ulceration of the eyes

What diagnostic tests do you need before dacryocystorhinostomy?

Your surgeon may administer one or more of the following diagnostic procedures:

• Dacryocystography
• CT scan 
• MRI
• Diagnostic nasal endoscopy 
• Metal probing and irrigation (with/without fluorescein dye irrigation) of the lacrimal drainage system

What is a dacryocystorhinostomy (DCR)?

A DCR is a type of surgery that is used to treat blocked tear ducts in adults. It creates a new passageway between the tear duct sac and the nose, bypassing the blockage and allowing tears to drain normally again. The operation usually takes about 1 hour. The operation is normally performed with the patient asleep (general anaesthetic), although, in very rare circumstances this may not be appropriate and the eye may be numbed using a local anaesthetic. This will be discussed with you prior to the surgery. There are two types of procedure that can be used.  The most suitable option for you will be discussed with you in the eye clinic when surgery is being offered and planned.

What happens during the dacryocystorhinostomy procedure?

• Surgery can be performed under local or general anesthesia.
• The surgical approach to the sac may be external or endoscopic through the nose. 
  • External approach is performed by ophthalmologists (eye surgeons). 
  • Endoscopic approach may be performed by ENT surgeons (otorhinolaryngologists) or ophthalmologists using rigid telescopes or microscope. 
  • A tube or stent may be inserted into the lacrimal apparatus to keep it open, maintain the drainage and prevent recurrence. 

Advantages of endoscopic approach

• Better aesthetic result with no external scars
• Allows a one-stage procedure to also correct associated nasal pathology
• Avoids injury to other structures and scarring
• Preserves function of eye muscles
• Surgery can be done even with an active infection of the lacrimal system
• Superior to external approach in revision surgery
• Less bloody and messy 
• Shorter operative time 
• Good success rate

Disadvantages of endoscopic approach

• Requires the surgeon to have specialized training in nasal endoscopic surgery.
• Endoscopic equipment is expensive; hence surgery cost may be higher

Why do I need A DCR?

Normally, the tears that wash over the eye drain away through a system that runs from the corner of the eye to the inside of the nose. If there is a blockage in this system the eye can start watering and you may be more prone to infections.

To unblock the area, warm compresses and massage may be tried first. Sometimes it is also possible to unblock the tear duct by probing it. This is called syringing and involves flushing salty water down the tear duct. If the tear duct is open then you will taste the salty water in your throat.

What are the complications or risks of a DCR?

The main complications after surgery are bleeding and infection. It is also possible to displace the tube, which is inserted to keep the duct open and you may experience some bruising around the area of the operation. A nosebleed may occur on the affected side. Usually this is a small amount and resolves within 48 hours. Excessive bleeding rarely occurs but if it does then a nasal pack may need to be used to stop the bleeding after the operation.

What happens before the operation?

In the outpatient clinic, your tear draining passages will be assessed by syringing salty water through the tear ducts to find out where, and how much of a blockage there is. Once you and your surgeon have agreed that you should have a DCR operation, then your name will be placed on the waiting list for the procedure.

Is DCR surgery painful?

• The surgery is performed under local or general anesthesia, hence there is no pain during the surgery.
• Pain during the postoperative period may be present. The degree may vary based on the patient’s pain tolerance. 
• The pain can be managed by oral or injectable pain killers.

How long is the recovery from DCR surgery?

• It is normal to have watery eyes until the swelling and inflammation settles, which may take around two weeks. 
• Swelling and bruising can involve eyes, nose and cheek and may take two to three weeks to resolve. 
• Follow-up in the clinic is necessary to monitor healing and cleaning. 
• Maintenance of hygiene using prescribed medication and saline washes promotes faster healing.  
• Most patients return to all their preoperative activities after two weeks, including swimming, exercise and sports. 
• The tube would be removed after two to six months, during which it may cause mild discomfort or pain, usually without any more serious post-procedure issues. 

What are the complications of DCR surgery?

• Bleeding through the nose
• Swelling
• Bruising
• Infection
• Adhesions in the nose
• Persistent watering due to scarring
• Sump syndrome: Tears and mucus accumulate in the sac and discharge into the eye

Pre-operative assessment

Before the surgery you will need to attend for a pre-operative assessment.  At this visit you will be asked questions about your general health, some blood tests will be taken and a recording heartbeat (sometimes referred to as an Electrocardiogram – ECG) are performed to ensure your general health is good enough to undergo the surgery.

At this visit you will be given a suitable date for your operation.

How do I prepare for the operation?

Please read the information leaflet carefully. Share the information it contains with your partner and family (if you wish) so that they can be of help and support.  There may be information they need to know, especially if they are taking care of you following this examination.

Medication

We need to know what tablets and medicines you are currently taking also if you are sensitive to any substances.  At the pre-operative assessment you will be advised on what pre-operative preparations you need to make such as altering medications.

If you are on warfarin or aspirin tablets it is important that you inform your surgeon, as these can lead to bleeding during or after the operation. You should stop your aspirin one week before surgery but the need to stop your warfarin will be discussed with you at pre-operative assessment.

Admission to hospital

You will generally be admitted to hospital on the day of your surgery, although in some circumstances you may need to be admitted the day before. This will be discussed with you.

What happens afterwards?

Immediately after the operation there may be a little discomfort, some spots of blood from the nose and some facial bruising at the site of the operation (this would be expected to resolve within 2 – 4 weeks). Occasionally, a pressure bandage will be placed over the site of the operation to reduce the bruising. This will be removed before you go home. Usually you can go home the day after surgery.

After care

In order to prevent infection you will be prescribed eye drops or ointment for two weeks and possibly antibiotic tablets to take for 5 – 7 days. Some patients are also prescribed a nasal steroid spray twice a day.

The first clinic appointment is 7 – 10 days after surgery to remove the stitches if they have been used. The second appointment will be 6 – 8 weeks after surgery to remove the tubes in the outpatient department. A final check is usually made six months after surgery when you will be discharged from our care if all is well.

If you do develop bleeding from the nose that will not stop, do not dab the nose but hold the end of the nose tightly. If bleeding carries on then attend your nearest casualty department immediately, also contact Ward 35 to let us know that you are having a problem on telephone number (01482) 604346 (24 hours).

Is there anything that I should avoid after the operation?

Important points to follow

Please remember the following points:

• During the first week after surgery you may get a little bleeding from your nose. In order to minimise this, you are advised to sit up rather than lie down and to sleep with extra pillows at night. You must not blow or pick your nose for one week after your operation. After that you are encouraged to blow your nose to clear the blood clots. If you need to sneeze, you are advised to do this with your mouth open.
• Avoid taking aspirin for at least ten days after surgery.
• For discomfort use a painkiller that you would normally take for a headache.
• Also avoid exercise especially swimming for two weeks after surgery.
• Air travel is not advisable for at least seven days after surgery.
• Do not wear make up for two weeks after surgery.
• Avoid homeopathic medicines that promote fast healing.