What Is Dacryocystorhinostomy (DCR ) surgery?

What is dacryocystorhinostomy surgery?

Dacryocystorhinostomy (DCR) is a surgical procedure that involves restoration of the normal flow of tears through the tear ducts to the nose and alleviates the excessive tearing. 

Abnormal watering of eyes (epiphora) occurs because of an obstruction of the tear drainage system (tear ducts), either due to structural problems or infection. This impairs normal tear drainage into the nose. Regular infection may also occur because of the stagnation of tears.

Dacryocystorhinostomy (DCR) is a surgical procedure that involves restoration of the normal flow of tears through the tear ducts to the nose and alleviates the excessive tearing. 

The surgical approach may be external or endoscopic through the nose. 

The success rate ranges from 82-96%.

What is the anatomy of the tear ducts?

The eyes consist of a system of glands and ducts (called the lacrimal system) which produces tears to keep eyes from drying out, to clean them and to protect them against infections. 

Tear-producing (lacrimal) glands secrete the watery part of tears. These glands are located behind the upper eyelids. The tears drain out of the eyes through two openings (puncta, or lacrimal ducts), located on the upper and lower inner corner of the lids.

Why is dacryocystorhinostomy done?

• Congenital problems (a person may be born with an underdeveloped tear duct system or defects
• Recurrent dacryocystitis (infection of the lacrimal sac)
• Canaliculitis (inflammation of the canaliculus, a short channel near the inner corner of the eyelids through which tears drain into the sac)
• Dacryolithiasis (inflammation due to formation of small stones in the tear duct system)
• Lacrimal system tumors
• Nasal pathology obstructing drainage
• Trauma
• Previous surgery 
• Unidentifiable causes 

What are the signs and symptoms of epiphora (watery eyes)?

One or both eyes can be affected with:

• Increased socially and personally unacceptable watering of eyes
• Pain
• Discharge of pus 
• Swelling in the inner corner of the eyes
• Inflammation or redness of the skin and eyelids 
• Crusting 
• Fever
• Ulceration of the eyes 

When should dacryocystorhinostomy be avoided?

People with the following problems should not have this surgery:

• Conditions associated with dry eyes (Sjogren’s syndrome)
• Bleeding disorders
• Systemic diseases 

What diagnostic tests do you need before dacryocystorhinostomy?

Your surgeon may administer one or more of the following diagnostic procedures:

• Dacryocystography
• CT scan 
• MRI
• Diagnostic nasal endoscopy 
• Metal probing and irrigation (with/without fluorescein dye irrigation) of the lacrimal drainage system

What happens during the dacryocystorhinostomy procedure?

• Surgery can be performed under local or general anesthesia.
• The surgical approach to the sac may be external or endoscopic through the nose. 
  • External approach is performed by ophthalmologists (eye surgeons). 
  • Endoscopic approach may be performed by ENT surgeons (otorhinolaryngologists) or ophthalmologists using rigid telescopes or microscope. 
  • A tube or stent may be inserted into the lacrimal apparatus to keep it open, maintain the drainage and prevent recurrence. 

Advantages of endoscopic approach

• Better aesthetic result with no external scars
• Allows a one-stage procedure to also correct associated nasal pathology
• Avoids injury to other structures and scarring
• Preserves function of eye muscles
• Surgery can be done even with an active infection of the lacrimal system
• Superior to external approach in revision surgery
• Less bloody and messy 
• Shorter operative time 
• Good success rate

Disadvantages of endoscopic approach

• Requires the surgeon to have specialized training in nasal endoscopic surgery.
• Endoscopic equipment is expensive; hence surgery cost may be higher.

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What happens after the DCR procedure?

• Pain killers and antibiotics may be administered.
• In the endoscopic approach, the nose may be packed with gauze or tampon and dressed for 24-48 hours, during which patient would have to resort to mouth breathing.
• Dressing may be applied over the operated area in external approach.
• Advised to rest with head elevated above the feet for 48 hours.
• Patient can be discharged from the hospital after 24-48 hours 
• Minimal watering of eyes, swelling and bruising.  
• Patient can resume normal activities following discharge. 
• It is advised to stay indoors for around a week to avoid exposure to pollution or infection.
• Avoid forcefully blowing the nose, spicy food/drinks, swimming, exercise, sports, lifting heavy objects, yoga, bending for long, eye makeup or over the counter creams and lotions for 2 weeks.
• Surgeon would prescribe eye drops/ointment and saline wash 2 to 3 times a day for around 2 weeks. 
• Follow up with the surgeon may be required after 7-10 days during which the nose may be cleaned. Follow-up may be required again after 2-6 months to remove the tube.

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Is DCR surgery painful?

• The surgery is performed under local or general anesthesia, hence there is no pain during the surgery.
• Pain during the postoperative period may be present. The degree may vary based on the patient’s pain tolerance. 
• The pain can be managed by oral or injectable pain killers.

How long is the recovery from DCR surgery?

• It is normal to have watery eyes until the swelling and inflammation settles, which may take around two weeks. 
• Swelling and bruising can involve eyes, nose and cheek and may take two to three weeks to resolve. 
• Follow-up in the clinic is necessary to monitor healing and cleaning. 
• Maintenance of hygiene using prescribed medication and saline washes promotes faster healing.  
• Most patients return to all their preoperative activities after two weeks, including swimming, exercise and sports. 
• The tube would be removed after two to six months, during which it may cause mild discomfort or pain, usually without any more serious post-procedure issues. 

What are the complications of DCR surgery?

• Bleeding through the nose
• Swelling
• Bruising
• Infection
• Adhesions in the nose
• Persistent watering due to scarring
• Sump syndrome: Tears and mucus accumulate in the sac and discharge into the eye