Endoscopic dacryocystorhinostomy

Endoscopic dacryocystorhinostomy (DCR) is used to treat patients diagnosed with lacrimal sac or nasolacrimal duct obstruction (NLDO). This can be caused by chronic stenosis of the nasolacrimal duct and can be congenital or acquired. NLDO is common but is not a serious condition. The external DCR is standard treatment.  Endoscopic DCR is a minimally invasive procedure performed by ophthalmologists and otorhinolaryngologists to unblock tear ducts and correct other causes of decreased patency of the nasal passages. Presenting symptoms include excessive epiphora (tearing) and dacryocystitis (infection). Usually, cases have been refractory to conventional treatment such as warm compresses, massage and probing the nasal passage. If NLDO is left untreated, these symptoms persist and may cause embarrassment for the patient.

Watering Eyes

Excessive tearing or the bothersome problem of tears overflowing down the cheek is called epiphora (watering eye or watery eye). This can have many different causes. A careful clinical examination is performed to determine the underlying cause. Treatment will depend on the cause e.g. if the lower eyelid is sagging away from the eye (ectropion) and causing watery eye, the treatment will be surgery designed to reposition the eyelid. Epiphora (watery eye) commonly develops from abnormalities in the lacrimal drainage system from scarring due to injury, recurrent infection, the ageing process, or from unknown causes. Surgery is required to improve a watery eye which is caused by blockages in the tear drainage system. Paradoxically a dry eye can lead to tearing. Glands in the eyelids (the Meibomian glands) secrete an oily material which lines the tear film covering the cornea, the clear and extremely sensitive window at the front of the eye. The oily secretion retards the evaporation of the tear film in between blinks. If these glands do not function properly (e.g. in blepharitis), the tear film evaporates quickly leaving the sensitive cornea exposed. The tear glands then produce an excessive volume of tears as a reflex which overwhelms the tear drainage system (as in emotional crying). This often leads to confusion with patients failing to understand why they have been prescribed artificial tears to improve their symptoms!

The Lacrimal (Tear) System

The lacrimal gland, situated in the outer portion of the upper eyelid (see diagram below), produces the tears which drain downward and inward across the eye. Blinking of the lids helps to spread the tears to lubricate and protect the eyes. The tears normally drain from the corner of the eye close to the nose, via tiny puncta into the very fine lacrimal drainage channels (canaliculi). The tears go into the lacrimal sac, then down the nasolacrimal duct which lies in a bony canal, then opens into your nose. You are not aware of the tears draining into your nose and these go down into the throat. A blockage at the lower end of the nasolacrimal duct is the most common cause of a tear drainage outflow problem leading to a watery eye. The tear drainage pathway The most common cause of watering eyes is a blocked nasolacrimal duct. Surgery to overcome this blockage is called “dacryocystorhinostomy” or DCR. In order to confirm the site of the obstruction causing the watering, lacrimal syringing and gentle probing is done. The aim of this operation is to relieve a watery, sticky eye caused by blockage of the tear duct (nasolacrimal duct) situated between the tear sac (lacrimal sac) at the corner of the eye and the tear outflow passage into the back of the nose. DCR consists of creating a direct connection between the tear sac into the nose, bypassing the blockage and allowing tears to drain normally again. Usually some soft silicone tubes are placed, which are removed about two months after surgery. There are two methods of doing this:

1. Externally (from the outside, via a short skin incision)
2. Internally (from inside the nose: endonasal endoscopic)

General procedure before lacrimal drainage surgery

You will visit the clinic to have a consultation with me. You will be asked questions about your current and past health e.g. whether or not you have previously suffered a fractured nose or had any surgery by an ENT surgeon, and I will need to know about any allergies you may have, medications you are taking (including over the counter products e.g. aspirin, indomethacin or vitamin supplements), previous surgery, and whether you smoke. You may also be required to have a physical examination of your heart and lungs by your GP or by my anaesthetist at the clinic to make sure it is safe for you to have an anaesthetic. You may need to have some routine laboratory tests, such as urinalysis (tests of your urine), chest x- rays, or complete blood cell counts. These should reveal potential problems that might complicate the surgery if not detected and treated early. No testing may be necessary if you are in good health and younger than age 45. Please answer all questions completely and honestly as they are asked only for your own well-being, so that your surgery can be planned as carefully as possible. If you are unsure of the names of any medications, bring them with you. You will be told whether or not to stop any medications at this preoperative clinic visit. For example, if you are taking aspirin-containing medicines or anticoagulants, they may need to be temporarily withdrawn or reduced in dose for two weeks before the procedure. If you can, try to stop smoking at least six to eight weeks prior to surgery. A “sac washout” or syringing of the tear drainage pathway is often performed using a fine blunt lacrimal cannula and some sterile saline solution. This is performed to determine whether or not there is a blockage of the tear drainage pathway and if one is present, whereabouts in the system is this located. This is not in itself a treatment – merely a diagnostic test. If there is a blockage this also provides important information about the precise location of the blockage and whether the blockage causing a watery eye is partial or complete. Your nose will be examined with an endoscope (a small straight thin telescope) to ensure that you have no nasal abnormalities e.g. a deviated nasal septum, which may require additional treatment. This is referred to as nasal endoscopy. The procedure will be explained to you and you will then be asked to sign a consent form saying that you understand the procedure and that you have been told about any possible complications. Very rare complications will be described, as well as any more common ones, so try to keep things in perspective. If you have any questions or worries, make sure they are answered, before you sign the consent form. You are quite free to go away and consider the options before committing yourself to any surgery.

Dacryocystorhinostomy (DCR)

Surgery can be performed to create a functioning tear drainage system where there is an obstruction causing a watery eye. A dacryocystorhinostomy (abbreviated as DCR), an operation performed for an obstruction in the nasolacrimal duct, is performed through the nose with the use of an endoscope (endoscopic DCR). Though the surgery can be performed through a small incision on the side of the nose (external DCR) the use of an endoscope is preferable as it avoids the need for a skin incision and so does not leave a visible scar. The success rate Endo DCR in our hands is better than 90%. In the event of a failure the surgery can be repeated. During the surgery, the lining of the lacrimal sac is attached to the inner lining of the nose (the nasal mucosa) to create a new passageway for the tears. A fine silicone tube (a stent) is usually placed at surgery to maintain an opening in the tear drainage system. This is removed after a few weeks – months in the clinic. An example of a sili The endoscopic approach cannot be used for patients who have a blockage in the common canaliculus or the canaliculi. This requires an external incision or the placement of a Lester Jones tube. If the surgery has failed in spite of a re-operation the symptoms may instead be overcome with the use of a Lester Jones tube (see below). It is very rare not to be able to overcome the problem of a watery eye due to a blockage of the tear drainage pathway for a patient. This operation is usually performed under general anaesthesia although it can be performed under local anaesthesia with intravenous sedation by an anaesthetist for patients unfit for general anaesthesia.

Instructions before the surgery

1. Discontinue the use of aspirin and products containing aspirin for three weeks before your scheduled surgery unless instructed otherwise. This may include a number of arthritis medications. If you have any queries about your medications please contact us. If you take anticoagulants e.g. Warfarin you must inform us. You should ensure that you do not have hypertension prior to surgery by having your blood pressure checked at your GP surgery. If you have hypertension you should ensure that this is well controlled prior to surgery.
2. If your operation is planned to be done under a general anaesthetic (when you will be asleep), you may have some blood tests done and an ECG (heart tracing) prior to surgery. Please bring all your tablets/medications in their original, labelled bottles. Also provide information on any known allergies.
3. Unless specific arrangements have been made to do your surgery on a day case basis, you will be admitted to hospital on the day of surgery. You will be discharged the day after surgery unless there are any post-operative problems e.g. a nose bleed, requiring you to stay longer.
4. It is important that you follow all instructions about food and drink prior to surgery. A patient undergoing a general anaesthetic must not eat or drink for a minimum period of 6 hours before the operation.

Instructions after the Surgery

1. If you have had general anaesthesia a) You will awaken in the recovery room in the theatre. b) You will be returned to the ward usually after a period of up to 30 minutes in
2. You may go to the bathroom with assistance.
3. Your usual medications may be continued. Resume aspirin, blood thinners, and arthritis medications 72 hours after surgery unless otherwise instructed.
4. You may have a compressive dressing over your eye and wound overnight external DCR only). You may have a nasal tampon in your nostril overnight to reduce the risk of bleeding. This will be gently soaked with saline the morning after surgery by a nurse on the ward. The nurse will gently remove your nasal tampon and will keep you on the ward for at least 2 hours to ensure that you have no significant nose bleeding. You should anticipate some minor intermittent nose bleeding at home which will take 3-4 days to settle down. Avoid any activity which can provoke a nose bleed e.g. lifting heavy weights, straining.
5. You may have difficulty wearing your glasses for a short period after surgery because of the position of the wound (external DCR only).
6. You may experience nasal stuffiness but this will gradually improve. Avoid blowing your nose or rubbing your eye
7. Apply antibiotic ointment three times a day to the wound for 2 weeks after soaking the wound with cooled boiled water and cotton wool (external DCR only). Wash your hands thoroughly first.
8. The stitches used to close the wound are absorbable and will drop out in 3-4 weeks (external DCR only) or they can be removed easily.
9. If the silicone stent comes out as a loop in the inner corner of the eye, simply tape it to the side of the nose and report this to the hospital during normal working hours – this is not an emergency problem. DO NOT CUT IT OR PULL IT.
10. If your surgery has been performed endoscopically you will be given instructions on how to perform nasal douching (see below) which you should commence 2 days after your surgery. You will be given 2 nasal sprays to be used twice a day for 5-7 days postoperatively (Beconase and Otrivine).

If the following occur notify the hospital: a) Sudden severe bleeding from the nose which does not stop b) Pain and redness of the wound

Arrangements will then be made for you to be seen as soon as possible.

Instructions for patients following 1 week after endoscopic DCR surgery

1. During the first week after surgery you may get a little bleeding from your nose. In order to minimize this, you are advised to sit up rather than lie down, and to sleep with extra pillows at night. You must not blow your nose for one week immediately after your operation. After that you are encouraged to blow your nose to clear clots.
2. You will be prescribed eye drops for three to four weeks and possible antibiotic tablets to take for 5 to 7 days.
3. Some patients are also prescribed a nasal steroid spray.
4. Please avoid aspirin for at least 10 days after surgery – take paracetamol or codeine-based tablets for mild discomfort or ache.
5. Avoid exercise and especially swimming for 2 weeks after surgery.
6. Do not apply makeup for the first 2 weeks after surgery.
7. You may fly from 7 days after surgery.
8. Avoid homeopathic medicines which promote fast healing.
9. In order for the wound to heal well and to prevent infection, please follow these instructions:

• Do not remove any dried blood from your nose by inserting tissues, handkerchiefs, or fingers into your nostril
• Do not attempt to turn/twist/manipulate in any way the ends of the stent tube placed in the nostril.