CDCR & Lester Jones Tube Surgery
Conjunctivo-dacryocystorhinostomy (CDCR) + Lester Jones tube
This operation is performed for patients who have a watery eye due to a complete blockage of the canaliculi e.g. following trauma. The operation is very similar to a DCR but instead of a removable silicone stent, a tiny pyrex tube is placed between the inner corner of the eye and the nose. Unlike a stent this remains in place indefinitely. This is prone to problems in some patients e.g. foreign body reactions. On the whole, however, these tubes are very well tolerated in patients of all ages as long as the patient is able to comply with simple daily cleaning. This simply involves cleaning any mucus from around the tube morning and evening using a moistened cotton bud and instilling simple watery artificial tears (Hypromellose drops) twice a day and sniffing while occluding the opposite nostril. The tube is not usually visible to others.
This surgery is most often performed endoscopically (using a small surgical telescope with the surgery visible on a TV screen in the operating theatre) avoiding the need for an external incision and a visible scar. Occasionally there is insufficient space within the nose to accommodate the tube e.g. due to a deviation of the nasal septum which divides the nose into 2 separate cavities. If the septum is deviated a nasal septoplasty is performed, also endoscopically.
What happens before lacrimal drainage surgery?
You will visit the clinic to have a consultation with your surgeon. 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 we 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 55.
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. You must check with your GP first to ensure that it is safe for you to do so. If you can, try to stop smoking at least six to eight weeks prior to surgery.
Your vision in each eye is measured. Your eyes are examined carefully with a slit-lamp (special ophthalmic microscope) and the back of the eye (called the retina) is examined as well as the eyelids and nose. The positioning of the eyelids is noted.
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 required additional treatment. This is referred to as nasal endoscopy. You should check with your insurance company that the additional cost of these clinical tests is covered.
Occasionally a dacryocystogram (a special form of X-ray examination of the tear drainage pathway) or lacrimal scintigraphy (a test utilizing a radiolabelled tracer) is required to assist in the assessment and diagnosis of your condition. If these additional investigations are required, arrangements will be made for these to be undertaken at a local hospital.
The procedure most appropriate to your individual case 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.
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.
The risks and potential complications of surgery should be considered but these need to be kept in perspective. Complications in the hands of a trained and experienced oculoplastic surgeon are very rare and all precautions are taken to minimize any risks.
What are the possible complications of an endoscopic CDCR + Lester Jones tube?
Most complications of this surgery are amenable to successful treatment.
Complications from this type of tear drainage surgery include:
- Blurred or double vision, lasting mainly for a few hours, and sometimes up to a day or two after surgery. This may occur for several reasons – ointment put in the eyes immediately after the operation, local anaesthetic used in the operation. If blurring persists for longer than 48 hours, it is important to inform your surgeon.
- Bleeding from the nose. This usually subsides spontaneously but very rarely the bleeding may need to be stopped in the operating theatre.
- Infection. An infection following this surgery is very rare and would be treated with antibiotics.
- A prolapse or extrusion of the tube. If the tube prolapses or is lost it will need to be replaced with an endoscope in theatre.
- A foreign body granuloma. This appears as a pink fleshy lump around the tube. It may respond to topical steroid drops or it may need to be removed with minor surgery in theatre.
- Migration of the tube into the nose. This necessitates further surgery in theatre.
- Irritation of the eye with inflammation. This is rare but will necessitate removal and replacement of the tube.
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. You can then write to us or email us requesting further information if required.
- If you have had general anaesthesia
- You will awaken in the recovery room in the theatre.
- You will be returned to the ward usually after a period of up to 30 minutes in
- You may go to the bathroom with assistance.
- Your usual medications may be continued. Resume aspirin, blood thinners, and arthritis medications 72 hours after surgery unless otherwise instructed.
- 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.
- You will be given instructions on how to perform nasal douching using Sinurinse (see below) which you should commence 1-2 days after your surgery. You should use Sinurinse in the future to manage any nasal stuffiness e.g. if you experience hay fever or a cold.
- You will be given a nasal spray to be used 4 times a day for 14 days postoperatively (Beconase).
- You may experience nasal stuffiness but this will gradually improve with the regular use of Sinurinse. Avoid blowing your nose or rubbing your eye.
- Clean any mucus from around the tube morning and evening using a moistened cotton tip applicator and instil Hypromellose drops twice a day and sniff while occluding the opposite nostril. Do not use thicker more viscous drops.
- If the following occur notify the hospital:
- Sudden severe bleeding from the nose which does not stop
- Pain and redness of the wound
Arrangements will then be made for you to be seen as soon as possible.
In order for the internal nasal 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
- Rinse out your nose four times a day using NeilMed Sinurinse starting the day after surgery.
You can order the Neilmed Sinurinse 100 refill mixture sachets and the sinurinse kit from our clinic Face & Eye in Manchester or online from the clinic’s online shop at (www.faceandeyeshop.co.uk) so that this is available to you prior to your elective surgery.
This frequent nasal douching is essential to the success of your surgery. Please follow the instructions provided with the Sinurinse kit.
A patient with a Lester Jones tube. This is just visible in the inner aspect of the eyelids: