BLOCKED TEAR DUCT SURGERY -DACRYOCYSTORHINOSTOMY (DCR)

Tear duct surgery, also known as dacryocystorhinostomy (DCR), restores the flow of tears by creating a new drainage passage into the nose.

The procedure is highly effective and holds a success rate between 82-96%.

If you suffer from abnormal watery eyes (epiphora), you could have a blocked tear duct. This usually comes with frequent eye infections and sticky discharge.

THE NORMAL TEAR DUCT PATHWAY

Usually, tears wash away debris from the eye and are drained away into the nose using two ports (or ‘punctae’) located in the inner corner of the upper and lower eyelids.

Blinking pushes tears into these openings. From there, the tears empty into a short horizontal drainage canal (the canaliculus) that leads to a drainage sac located deep under the skin at the inner corner of the eye.

The lacrimal sac drains downwards (via the nasolacrimal duct), which goes deep around bony structures surrounding your nose and ends up into the nasal cavity itself.

Written by Dr Osama Bahsas Zaky
Updated on October 28, 2021

The Normal Tear Duct Pathway.

What is Dacryocystorhinostomy?

Causes and Symptoms of a Blocked Tear Duct.

Blocked Tear Duct in a Baby.

Am I Eligible for Surgery?

The Procedure.

DCR Through the Skin (External Surgery).

The Endoscopic Procedure.

What to Expect After Surgery?

Aftercare and Recovery.

Risks of Lacrimal Surgery.

Dacryocystorhinostomy Cost.

WHAT IS DACRYOCYSTORHINOSTOMY?

Tear duct surgery is a procedure that creates a new low-resistance pathway for tears to drain between your eyes and your nose. In doing so, any blockage of the nasolacrimal duct is completely bypassed.

DCR surgery essentially creates a short-cut beginning at the inner corner of the eye to let the tears drain directly into the nasal cavity. You need this surgery if your tear duct is blocked.

The procedure can be performed externally using a small incision in the skin, or endoscopically through the nose without leaving any scars.

The ‘rate success’ depends on the severity and location of the blockage, and in no case can it be fully guaranteed.

However, surgery for patients with significant mucus discharge, or watery eyes, reduces symptoms by 95%.

WHARE ARE THE CAUSES AND SYMPTOMS OF A BLOCKED TEAR DUCT?

In most cases, the cause of tear duct blockage is unknown. Nasolacrimal duct obstruction may be congenital or acquired.

Acquired obstructions may develop secondary to facial trauma, chronic allergies, toxicity from chemotherapy or topical medications, tumors, chronic sinus disease, or after sinonasal surgery.

Any irregularity, obstruction, or narrowing of the drainage ducts may lead to watering or crusting of your eyes, either under cold weather or on a regular basis.

A blocked tear duct in a baby could present with too much tearing at 6–8 months old.

Also, it could cause an infection of the sac itself and a painful lump in the inner corner of your eye, called dacryocystitis.

Blocked tear duct

HOW DO I KNOW IF MY BABY’S TEAR DUCT IS BLOCKED?

A blocked tear duct in a baby could present with too much tearing at 6–8 months old.

Frequently, narrowing of the nasolacrimal duct may lead to enlargement of the sac immediately above. This may cause mucous build-up, with repeated eye infections, smeary vision, and ‘gummy’ eyelids. Also, it could cause an infection of the sac itself and a painful lump in the inner corner of your eye, called dacryocystitis.

Am I Eligible for Blocked Tear Duct Surgery?

Not all patients with a blocked tear duct need DCR surgery. A thorough ocular and lacrimal examination are required to determine the true nature of the symptoms. There are several causes behind watery eyes, many of which do not involve blockage of the ducts.

Tests include gentle syringing of a small amount of saline water through the tear ducts to identify any blockage of the tear drainage system. The doctor also might do a dye test. Putting a special dye in the eye allows the doctor to evaluate the amount of tears and see if they’re draining properly.

You may have a blocked tear duct if most of the dye is on the surface of your eye after five minutes. Your eye doctor may first recommend less invasive blocked tear duct treatments. These include warm compresses (babies with congenital blockage), massages, and antibiotics.

Also, you could have a procedure to try to dilate the nasolacrimal duct. The ophthalmologist gently passes a probe (a thin metal instrument) through the tear duct to open the blockage. This may apply to babies, and it is performed under general anaesthesia.

Another treatment called balloon catheter dilation is usually effective for infants and toddlers or adults with partial blockage.

If your symptoms are persistent or severe, you may need DCR surgery, though. This is a more common treatment for blocked tear ducts in adults than for children.

HOW IS THE DCR PROCEDURE PERFORMED?

Surgery takes about one hour. It is generally performed under general anaesthesia (fully asleep) or under a local anaesthetic with intravenous sedation if needed.

Elderly patients, or those receiving general anaesthesia, should stay in hospital overnight. Otherwise, the patient is discharged from the hospital on the same day.

Your surgeon can decide between two different approaches. You should always discuss with your doctor which one would be best for you.

WHAT IS AN EXTERNAL DACRYOCYSTORHINOSTOMY (DCR THROUGH THE SKIN)?

The oculoplastic surgeon makes a small incision in the skin, under your eye, and next to your nose. Through this incision, your surgeon creates a channel inside the bone to connect the lacrimal sac (which lies under the skin in the inner corner of the eyelids) and the adjacent nasal space. The surgeon leaves a small tube (stent) in place to help keep the new tear duct open.

External DCR surgery is the most common procedure for blocked tear ducts and has a high success rate of over 90%.

WHAT IS AN ENDOSCOPIC DCR?

The sinus surgeon works together with the eye surgeon to go through the nasal passage under endoscopic vision. They locate the precise site of the blockage and open it up surgically.

The ophthalmic plastic surgeon leaves a stent for a variable period (usually 6 – 12 weeks) while healing occurs and is then removed.

Advantages of the endonasal approach include the lack of a skin incision. This minimally invasive surgery is an ideal option for children, which usually lack skin creases that could help camouflage or disguise a scar.

There is evidence that endoscopic DCR surgery may be as effective as the external approach, although some report a lower success rate of 70%.

WHAT TO EXPECT AFTER DCR SURGERY?

In most external and endoscopic DCR procedures, you will be able to go home the same day. However, you should arrange for someone to drive you home after the procedure.

You will have a dressing over the eyes and under the nose. You can take them off gently the morning after the procedure. Carefully clean the area with cotton wool and boiled, cooled water. Do so gently, without rubbing vigorously. The wound should be kept uncovered and dry for the next few days.

Following surgery, it is normal to experience a bloody discharge (old clots) from the nose that empties into the back of the throat. Also, a small nose bleed may sometimes occur. This happens during the first hours and subsides over three to four days. Usually, the nose bleed is slight and settles quickly.

You could speed the process by applying an ice pack to the bridge of the nose and sitting forward. It is recommended to apply it for ten minutes every hour for the first 24-48hrs.

Heavy bleeding is not normal, though. It would need a nose packing or rarely another surgery. Also, there may be a little soreness and discomfort after the procedure, but over-the-counter painkillers should relieve this slight pain. However, aspirin/ ibuprofen (NSAIDs) should be avoided in the first week post-op because they can increase the chance of bleeding.

Also, expect some bruising after an external DCR. Swelling and bruising may involve the eyes, nose, and cheek area. It may take up to three weeks for the bruising to completely subside. It is usual to have watery eyes after lacrimal surgery until the swelling and inflammation settle and the tubes are removed.

HOW IS AFTERCARE AND RECOVERY FROM TEAR DUCT SURGERY?

After surgery, follow your doctor’s instructions about caring for your wounds. You may need to take antibiotics or use antibiotic eye drops several times a day to prevent infection. Your doctor might also instruct you on how to properly rinse the nasal cavity.

You may need other medications, such as steroids and nasal spray decongestants, to diminish inflammation and help with breathing.

If a stent (silicone ‘string’) was placed in the passage from the eye to the nose, it would be removed in six to eight weeks after surgery. In children, this is done in an outpatient hospital facility under general anaesthesia or sedation.

In the meantime, you should be careful with the stent. Although it is barely visible, it might stick out from the inner corner of the eye or the nose.

DO NOT PULL on the stent! If you dislodge it by accident, gently place it back if possible. If it causes you any irritation, call your doctor for advice and schedule an appointment if necessary.

We advise patients not to:

Do heavy lifting, or exercise yourself for at least ten days.
Avoid bending with your head below waist level (bowling and yoga) for two weeks.
Fly or swim for 2 − 3 weeks.
Drink hot beverages or eat spicy foods for 36 hours. These could cause the vessels in your nose to dilate, increasing the chances of bleeding.
Blow or pick your nose for two weeks.
Wear make-up or apply lotion to the incision site. Use only the prescribed ointment.

Patients should try to sleep with their heads elevated on an extra pillow if possible during the first days. The first follow-up appointment is scheduled one week after surgery to evaluate your eye-nose area and remove the stitches if present.

IS TEAR DUCT SURGERY RISKY?

With DCR surgery, the risk of complications is very low – and they can be managed quickly, such as bleeding and displacement of the tube.

With external DCR, the skin incision on the side of the nose typically settles very well and is not noticeable in most patients.

Infection after surgery is very uncommon, and all patients are given antibiotics during and after the procedure.

Rarely, the normal healing process in the nose can lead to the development of a fine membrane across the internal opening, with recurrence of symptoms (mainly watery eyes).

Over 50% of such patients respond to removing the membrane and reinsertion of the silicone’ stent’ in the nose under sedation or general anaesthesia.

How Much Does Tear Duct Surgery Cost?

Dacryocystorhinostomy cost depends on the technique performed. If you want to receive a quote, please, fill in the contact form. You can send us your recent medical reports, so we can offer you the solution that best suits your needs.

You can be sure that this information will always be treated with maximum confidentiality.

BEST TEAR DUCT SPECIALISTS IN SPAIN:

Doctor Ainhoa Martínez Grau

More information

Bachelor of Medicine and Surgery (University of Lleida, 1999) and specialist in Ophthalmology (2004). Fellowship of Oculoplasty at the Barraquer Ophthalmology Centre. External rotation with the prestigious oculoplastic specialist Doctor Guillermo Salcedo (Mexico City, 2005). She works in the Oculoplasty and Orbit Unit and the Ocular Motility and Binocular Vision Unit of the Barraquer Ophthalmology Centre.
Languages: Spanish, Catalan, English
Association number: 34.841

External links – Bibliography

Lacrimal gland pleomorphic adenoma: a review of 52 cases, 15-year experience. Clarós P, Lopez-Fortuny M, Clarós A. Acta Otolaryngol. 2019 Jan

Dacryocystorhinostomy: Evolution of endoscopic techniques after 498 cases.Trimarchi M, Giordano Resti A, Vinciguerra A, Danè G, Bussi M.Eur J Ophthalmol. 2020 Sep

External vs. endonasal dacryocystorhinostomy: has the current view changed? Savino G, Battendieri R, Traina S, Corbo G, Gari M.

The outcomes of 326 external dacryocystorhinostomy operations in children with dacryostenosis – 30-year experience of an oculoplastic surgeon. Ornek F, Acar DE, Acar U. Arq Bras Oftalmol. 2018

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