Nasolacrimal Duct Surgery

What is Dacryocystorhinostomy (DCR)?

This is an operation to create a new tear-drainage passage between your eye and your nose when the existing one has become blocked. If the normal drainage passage becomes blocked or narrowed, you may develop a watery eye or repeated eye infections.

How do tears normally drain away?

Tears are produced continuously and, when you blink, they are drawn into two small openings in the inner corner of your eyelids. Each opening is known as a punctum, with one in the upper and one in the lower eyelid. They lead into small tubes known as the canaliculi, which in turn drain into the lacrimal sac. This sac lies between the corner of your eye and your nose and has a duct at the bottom, the nasolacrimal duct, which drains into your nose.

Why do the passages become blocked?

The normal system does not have much spare capacity (which is why we ‘cry’), and the narrow drainage channel becomes even narrower with age, especially if you have had disease of the nose or sinuses.

What happens when I come to the ophthalmology clinic?

You will first be seen by an optometrist, who will take your history, check your vision and measure the pressure in your eye. Your eye will then be examined by a surgeon. This may involve tests such as syringing water through your tear ducts to see whether there is a blockage. Once we have discussed your options and you have decided to go ahead with the operation, we will arrange a date and ask you to attend a pre-operative assessment clinic. There you may have some routine tests to check your general health, including blood tests and an electrocardiogram (ECG). You will be advised to stop taking any medicines containing aspirin or ibuprofen two weeks before the operation. If you have been prescribed these, or any anticoagulants (blood-thinning drugs such as warfarin), please discuss this with your GP or your anticoagulation clinic.

What does surgery involve?

During DCR, your tear-drainage passages are opened so that the tears can drain into the nose. There are two approaches to DCR surgery: external DCR and endoscopic endonasal DCR, often referred to as EndoDCR. They are similar operations with similar success rates.

1. External DCR

The operation is performed through a 10-15mm incision in the side of your nose. This heals very quickly and, in most people, is rarely visible once healing is complete. You will have sutures (stitches), which are usually removed seven to ten days later. As part of the procedure, small polythene rods are positioned internally to make sure the newly created passage stays open during the healing phase. These rods are removed after four to six weeks.

2. Endoscopic DCR

Endoscopic DCR is a minimally invasive procedure to unblock the tear ducts. The operation is very similar to external DCR, except that there is no cut through the skin and no scar afterwards. Access is through your nose, using a small, thin camera (an endoscope). As with all DCR surgery, small rods are placed internally in the newly created passage, and these are removed after four to six weeks.

3. Removal of rods

The rods will be trimmed on the ward before you leave. They will later be removed at your next clinic appointment. They are tied inside your nose, and occasionally a loop can protrude from the inner corner of your eyelids. If this happens, the soft polythene rods can gently be pushed back into place.

What are the surgery aftercare instructions?

After your operation, try to have a quiet evening at home and avoid strenuous exercise for a week. You are advised not to drive, drink alcohol or take sedative drugs for 24 hours. If your eye pad was not removed at the ophthalmology clinic, gently remove it at home in the morning and wash as normal, taking care to dab rather than rub the operation site. If you have had external DCR, it is advisable to keep the skin wound dry and uncovered. After endoscopic DCR, your doctor will usually ask you to douche (wash out) your nose with a saline spray for several weeks.

After the operation, you may notice some blood-stained oozing from your nose. This usually stops within a few hours. If there is bleeding, apply an ice pack to the bridge of your nose (on the opposite side to the dressing) and wipe away any blood with a paper tissue. If the bleeding is severe or continues for more than half an hour, seek medical advice immediately from Athens EyeCare Clinic or your nearest accident and emergency department.

If you experience pain, which is unusual, you can take paracetamol or codeine. You must not take aspirin or ibuprofen for two weeks, as these could cause bleeding. It is normal to have a watery eye for some weeks after surgery, until the swelling and inflammation settle and the rods are removed.

Is there anything else I should not do after the surgery?

Hot food and drinks should be avoided for up to 24 hours after the operation, as they can trigger post-operative bleeding. You may wipe your nose or sniff to clear it, but you must not blow your nose for seven to 10 days. If you sneeze, try to keep your mouth open.

What are the main complications following a DCR?

• Bleeding: A nosebleed can occur up to 10 days after surgery. This happens to about one in 50 patients. In most cases the bleeding will stop by itself, but if it continues or is very heavy you should attend the accident and emergency department at your nearest hospital.
• Infection: This is a rare but possible complication. When you leave the hospital, you will be given drops to use during the day to prevent infection. Scar formation is also possible: in the case of external DCR, the incision on the side of the nose is usually small.
• Blockage: Rarely, scar tissue can form internally, blocking the drainage passage again and requiring a further operation. Occasionally this may require the surgical insertion of a small pyrex tube known as a Jones tube, which stays permanently in the tear duct.

What is the follow-up treatment?

After external DCR surgery, you will be given a clinic appointment for one or two weeks after the operation. The stitch in your skin will be removed by a nurse, and the silicone rods may be removed from inside your nose at the same visit, or at a later appointment, by a nurse or a doctor (usually between four and six weeks). The nurse or doctor will then discharge you from hospital. If you have had an EndoDCR, you will be seen after six weeks for removal of the tube, and then again after six months for a final check. You only need to contact us if you experience any problems.