External Dacryocystorhinostomy (DCR)
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 drain into the superior and inferior puncta, located at the inner part of the upper and lower eyelids, and are carried by the superior and inferior canaliculi to the common canaliculus, then into the lacrimal sac. The lacrimal sac is a small pouch located next to the nose. The tears then drain into the nose (see diagram below). 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.
External Dacryocystorhinostomy (DCR)
Surgery can be performed to create a functioning tear drainage system where there is an obstruction to the tear duct causing a watery eye. An external dacryocystorhinostomy (abbreviated as external DCR), an operation performed for an obstruction in the nasolacrimal duct, is undertaken using a small incision on the side of the nose. The success rate of this procedure in our hands is better than 95%. 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 about 6 weeks in the clinic. This takes seconds to do.
This operation is usually performed under general anaesthesia in younger patients although it can be performed under local anaesthesia with intravenous sedation by an anaesthetist for older patients or for patient who are unfit for general anaesthesia.
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 external DCR?
Most complications of this surgery are amenable to successful treatment.
Complications from 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.
- Injury to the surface of the eyeball (a corneal abrasion) that causes persistent pain. If the pain lasts longer than a few hours after the operation, the surgeon must be informed. Such a problem is extremely rare in the hands of an oculoplastic surgeon. Such a problem is treated with antibiotic ointment. Sometimes a “bandage” contact lens needs to be used.
- 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.
- Scarring of the new tear drainage pathway. This can lead to failure of the procedure and the need for further surgery.
- strong>A stent prolapse. It is important to avoid rubbing the eye, blowing the nose or holding the nose when sneezing to prevent this. If the stent prolapses it will need to be replaced with an endoscope in clinic or it may need to be removed earlier than planned.
- A prominent or “bow string” skin scar. The incision is designed to try to minimize this risk.
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 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.
- 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.
- 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.
Conscious sedation, also known as “twilight anaesthesia”, is a type of anaesthesia which is preferred by many patients for most of my surgical procedures. It is a very comfortable and gentle type of anaesthesia which is far less invasive than the typical general anaesthesia but at the same time highly effective. It is also of advantage for very nervous or anxious patients undergoing quite minor procedures. Typically patients sleep most of the way through their procedure and have no or very little recollection of it at all. You are looked after throughout the procedure by a specialist consultant anaesthetist who has many years of experience of this type of anaesthesia, so that your surgeon can concentrate fully on your operation.
Shortly before moving to the operating room, a small tube (cannula) is placed into a vein in the back of your hand by the consultant anaesthetist and the anaesthetic drug is given through that. This is Propofol, a drug which is also used for general anaesthesia but, for conscious sedation, much lower doses are used. With conscious sedation there is no breathing tube or breathing machine, just a gentle flow of oxygen given through a plastic tube within a soft sponge protector inserted into one of your nostrils. Once the sedation has been commenced a local anaesthetic solution (a mixture of Marcaine and Lignocaine) is injected into the operative area to ensure a painless procedure. Typical side effects of general anaesthesia including a sore throat and nausea are avoided. Waking up takes only a few minutes at the completion of the surgery and is usually free of any “grogginess.” This type of anaesthesia has been used safely and successfully for our surgical procedures for over 20 years.