What is a dacryocystorhinostomy (DCR)?
DCR surgery is performed to treat a watery, sticky eye caused by narrowing or blockage of the tear drainage system, which run from the inner corner of the eye into the tear sac and then down into the nose. This is the reason why the nose runs when someone cries. Under general anaesthetic day case (home the same day), a new passage is made between the tear sac and the nose and this bypasses any blockage below the tear sac and allows tears to drain normally again. A tube is normally inserted for at least a month to keep the tear duct from scarring up again. The tube is usually not noticeable by the patient. It is usually removed by blowing the nose, but sometimes a camera up the nose is needed.
There are two ways of performing the surgery:
• Externally – through a 1cm incision on the side of the nose where glasses rest.
• Endoscopically – from within the nostril.
The external method takes about an hour leaves a small and usually imperceptible scar that is often hidden behind glasses. It is more useful than endoscopic in certain circumstances. The endoscopic method is usually faster to perform. If clinically indicated, the surgeon will take a biopsy of the tissue inside the tear duct.
Who needs DCR surgery?
A narrowing in the tear duct may also lead to enlargement of the lacrimal sac and a lump in the inner corner of the eye. This may cause a build-up of mucus in the sac, which may either discharge back onto the eye (causing smeary vision, ‘gummy’ eyelids, or repeated eye infections), or it may result in an infection of the lacrimal sac itself (a condition referred to as dacrocystitis).
Having a watery eye may also blur your vision especially when reading or cause embarrassment.
What are the considerations before having a DCR?
If it is essential for you to take blood thinning tablets such as warfarin, surgery may not be advisable. Medications either containing, or being similar to aspirin, need to be stopped 2 weeks before surgery. If a patient has been prescribed these or any other blood-thinning drugs, your GP or Hospital Doctor (or anti-coagulation clinic) will need to be contacted to determine if it is safe to discontinue these medications prior to surgery to reduce the risk of bruising and a post-operative nose bleed, which, although rare, can be severe. Paracetamol and Codeine do not affect bleeding and can be taken before and after this surgery. All general anaesthesia carry risks depending on whether there are other health problems.
What is the success rate of a DCR?
The success of lacrimal surgery depends on the severity and position of the blockage, and in no case can this be guaranteed. Nevertheless, surgery for patients troubled with infections or significant mucus discharge has a very high success rate (reduction of symptoms in at least 95%). Among those with watering only, an operation carries a lower success rate (approximately 85%) even if surgery is successful in creating this channel. This is because there are often other causes for an overproduction of tears which the tear drainage channel cannot cope with.
What happens after the operation?
Written instructions will be provided for you. The key aftercare aspects are to minimise infection, bleeding/bruising, swelling and discomfort. You should not drive yourself home. Clean the eyelids gently with cooled, boiled water. If your eye feels sore when the anaesthetic wears off, take paracetamol. Avoid aspirin as this will encourage bleeding. Normally, the discomfort will settle within a few days. Ice packs (such as frozen peas wrapped in a clean towel) will reduce pain and swelling, and sleeping with more pillows to keep the head elevated will help.
You may start driving and working again as long as your vision is clear and you are not light-sensitive. Most forms of light exercise and a normal work pattern may be resumed within a few days of surgery. Keep the eyelids dry until all scabs have fallen off. Eyelid makeup can be worn once any scabs fall off.
If you have severe pain, not relieved by simple painkillers, please contact Mr Lin on his mobile as provided.
To minimise risk of post-operative bleeding, we ask that you:
- Avoid hot drinks or food for 2 days
- Sleep with more pillows to keep your head elevated for 2 days
- Do not blow your nose for 2 weeks
- Avoid heavy lifting for 4 weeks
Often there is some bleeding from the nose. Usually there is only a little trickle from the nostril or down the back of the throat. This usually settles after a few hours, and may be helped with application of an ice pack to the bridge of the nose and sitting forward. If there is bleeding at the end of the operation the surgeon may pack the nostril. The pack is removed the next day.
You will be given eye drops to use in the eye. You will be given a nasal spray to loosen crusts inside your nose. Please ask for a certificate for work if you need one.
Many patients continue to have a watery eye for some weeks after surgery until the swelling and inflammation settles, and the silicone stent in the nose is removed. Although the skin incision heals over a few weeks, internal (unseen) swelling and healing may take many months to settle, and thus some occasional watering can persist for several months after surgery. Usually no more visits are required unless you still have problems.
What problems can occur after the operation?
Mr Lin performs many hundreds of eyelid and tear duct operations each year and will draw on his expertise to minimise the risk of problems.
- Displacement of the tube. Usually this does not happen, unless you blow your nose hard or fiddle with the tube at the corner of your eye. It is possible to replace it.
- Bruising and swelling is normal. These changes will settle after a few weeks, and will take longer to resolve in patients with blood thinners.
- Bleeding after the operation is usually slight and stops within a short time. If bleeding continues you should contact the hospital in case further treatment is required. In a small percentage of patients require admitting to the hopsital overnight for observation.
- A post-operative infection may rarely develop in the lids when they would become tender, red and more swollen and the wound may open and discharge. If this happens then you should contact the hospital as antibiotic tablets may be needed to help correct this and allow the lids to heal.
- The incision site is usually difficult to see after a few months. You may improve the appearance of any scarring by massaging the area with ointment e.g. Vaseline or silicon gel.
- Incomplete eyelid closure. The eye may not close fully especially at night. There is a risk of the front surface of the eye becoming dry and uncomfortable. Drops and ointment will help. This usually resolves after a few months.
- Further surgery:
In a few rarer circumstances, the surgery described above is inadequate to allow tears to drain into the nose. In this situation, the only way to drain the tears is to insert a small, smooth, glass drain (known as a “Lester Jones tube”) through the inner corner of the eyelids to the nose (without any further skin incision) under a general anaesthetic. This tube remains permanently in place, although it can move slightly with blinking. This requires the daily instillation of drops twice a day followed by sniffing while occluding the opposite nostril to keep the tube clear.