Tear Duct Surgery (DCR or Dacryocystorhinostomy)
I have recommended DCR surgery because your tear duct on the affected side is either blocked or narrowed. Your tear duct problem may be the only problem that is causing your watery eye, but occasionally other problems, for example, sagging eyelids, can also contribute to your problem. Waiting for a longer period of time until you decide to have surgery does not normally make the operation more difficult. Occasionally, DCR surgery is necessary because of a tear duct infection (dacryocystitis); without surgery to clear a blockage, the problem is likely to recur. Likewise, other eye surgery, such as cataract surgery, cannot safely be performed in the presence of a blocked tear duct.
The purpose of the operation is to bypass the blocked tear duct, through the creation of a new drainage pathway for tears directly from the upper tear sac into the nasal cavity (nose).
DCR surgery is typically carried out under a general anaesthetic although in some circumstances I am happy to carry out the surgery under local anaesthetic with sedation. If you remain awake during the operation, some people are aware of pulling and pushing sensations, as well as some occasionally loud noises generated during the operation itself. The procedure typically takes about 60 minutes (per side), although it can be considerably less, depending on the thickness of the bone encountered between the tear duct and the nasal cavity. Whether you have a general anaesthetic or local anaesthetic / sedation, you are normally able to go home the same day, provided you will not be alone at home that night.
During the operation, the tear sac and upper duct are carefully dissected away from the underlying bone, which separates the tear system from the nasal cavity. This bone is then removed, taking care to preserve the underlying lining of the nasal cavity (nasal mucosa). Surgical openings in both the tear sac and nasal cavity are then sutured together to allow free drainage of tears directly into the nose. At this stage, silicone tubes are often placed into the tear system and down into the nose – these are typically left in place for around 6 weeks, although occasionally for much longer. The skin is then closed with sutures, before application of a dressing.
The operation can be done either from the outside through the skin (external DCR) or from the inside of the nose (endoscopic DCR, only done under general anaesthetic). Whichever technique I use, the basic principles outlined in the paragraph above still hold.
Aspirin / warfarin / clopidogrel drugs
If you are taking any of these drugs, I will have given you instructions about how to proceed at your consultation. If you start taking any of these medications between your consultation and surgery, or if this was not discussed at your consultation, it is vital that you contact my secretary prior to your operation going ahead. I will then advise you how to proceed. If you take non-steroidal anti-inflammatory drugs (e.g. ibuprofen, voltarol, etc.), it is preferable to avoid these prior to surgery, however, these are often necessary for other ailments and should not be stopped if you would otherwise be in pain.
After the operation
After waking from your anaesthetic, most people do not complain of much pain in the area. If you have discomfort, a pain reliever such as Paracetamol every 6 hours is recommended (but not aspirin - this can cause bleeding). It is normal to feel slightly tender in the region and also in the nose. Minor discharge (bloody) from the nose is normal and should settle spontaneously with conservative measures, including simply waiting, sitting upright, pinching the nose or even applying ice (wrapped in a cloth) to the area.
Please avoid hot drinks for a week after surgery, as the heat can lead to blood vessels dilating, perhaps initiating a nose bleed. If you sneeze, please do not occlude (block off) your nostrils during a sneeze – let the air out; such sudden rises in pressure can also trigger a nose bleed.
People rarely complain of minor irritation from the silicone tubes that are placed at the time of surgery. These tiny, nearly invisible tubes pass between the openings to the tear system in the inner corners of the upper and lower eyelids and are secured in the nose. Very rarely, they can ride up out of the tear system and irritate the eye – please do not pull on them, but they can safely be pushed back in again.
You will be given antibiotics during surgery and will also have antibiotic pills to take following surgery, as well as some ointment to carefully rub onto the incision site twice a day.
Please contact me immediately if you have any of the following symptoms:
§ Excessive pain
§ A nose bleed that fails to stop within half an hour of starting, or if it is particularly heavy
Likelihood of symptoms improving
Please do not judge the success of the operation in the first weeks after surgery, particularly if silicone tubes have been placed into your tear system. The silicone tubes temporarily obstruct the drainage of tears in many cases and thus you may have a watery eye until their removal.
The results of previous scientific studies suggest a success rate for the operation in excess of 90%, in terms of creating a successful opening between tear sac and nose. This is not always mirrored in an improvement in symptoms, although other surgery such as treating saggy eyelids will typically help if not.
Benefits and risks of surgery
The most obvious benefit is relief of your watery eye, although bear in mind you may need to wait 6 weeks after the operation for removal of the silicone tubes for this to occur.
You should be aware that there is a small risk of complications, either during or after the operation.
Some possible complications during the operation
§ Complications as a result of the anaesthetic itself. Your anaesthetist will visit you prior to surgery and discuss this with you.
§ Significant bleeding. In my hands, significant bleeding is uncommon but occasionally it may be necessary to pack the nose after surgery. In this case, upon waking you will be aware of some gauze in your nostril; this will be carefully removed later. Occasionally, I will request you to stay the night in hospital, particularly if you are to travel a long way home.
§ Damage to the base of the skull. This is an extremely uncommon complication (much less than 1%) and may result in leakage of cerebrospinal fluid (fluid that normally lines the brain) into the nose. As a result of this, infection (meningitis) has been reported and surgery would be required to correct this. I stress that this is extremely unlikely.
Some possible complications after the operation.
§ Allergy to the medication used.
§ Bleeding from the nose. It is not uncommon to have a minor nosebleed, however, approximately 1 in 100 people may need to return to hospital to have their nose packed after surgery; approximately 1 in 1000 may need a blood transfusion as a result of excessive bleeding.
§ Bruising is not uncommon, particularly if you are on aspirin. Although typically limited to around the surgical incision, it can occasionally track all the way down to the neck. If so, it will soon fade.
§ Infection is uncommon.
§ Local irritation from the silicone tubes protruding from the inner corners of the eyelids. This is uncommon, but please discuss with me should you have any concerns.
§ Scarring. The external DCR procedure will produce a scar, however, previous scientific studies suggest that 95% of people are happy with the minor scarring that occurs, particularly if they normally wear spectacles.
§ Failure of the operation. If this occurs, it will not be obvious until after removal of tubes at around the 6 week stage. Further surgery may be appropriate and I will discuss this with you.
What to expect at your follow-up visits
At one week, I will remove your sutures. At around 6 weeks, I will remove the silicone tubes from your nose and typically will perform nasal endoscopy (a look up the nose with an endoscope) to inspect the operation site, as well as to observe the free flow of a yellow dye from the eye into the nose, which helps confirm the success of the procedure.