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Dacryocystorhinostomy (DCR)


Unblocking the tear duct is called dacryocystorhinostomy (DCR) and is usually carried out under a general anaesthetic. In selected cases, when patients are unfit for general anaesthesia, it can be performed under local anaesthesia with intravenous sedation by an anaesthetist.


The surgery creates a new pathway between the lacrimal sac and the inside of the nose by removing a thin bone between them. Mr Malhotra may insert small silicone tubes temporarily to keep the new tear duct open while healing takes place. A DCR has traditionally been performed through a small skin incision at the side of the nose (external DCR). Nowadays, it is preferable to carry this out through the nose (endonasally).


DCR image 1
diagram courtesy of JL deSousa


DCR image 2

View of the inner lining of the nose during an endonasal DCR. The lacrimal sac has been opened to drain directly into the nose. Temporary tubes are also passed through this opening.

Endonasal DCR avoids a skin incision and the results are pretty much equal to external DCR. Mr Malhotra has designed specific pieces of equipment for this operation, the Malhotra endonasal DCR punch and the Malhotra endonasal nibbler.


watery eyes 1
The Malhotra endonasal DCR punch

watery eyes 3
The Malhotra endonasal nibbler

NICE information sheet on endoscopic DCR



Endonasal DCR may not be a suitable procedure if the obstruction is not in an appropriate location or there is a problem within the nose. Mr Malhotra carries out both external and endonasal DCRs and will recommend the best approach.


DCR removes the risk of an infection in the tear sac, known as dacryocystitis, This can develop when tears stagnate in the tear sac because of a blockage of the nasolacrimal duct. It is a painful condition that requires antibiotic tablets and sometimes injections and drainage of the tear sac. After DCR surgery, tears can no longer stagnate so the risk of infection of the sac is removed.


Septoplasty


If the nasal passage is too narrow to allow Mr Malhotra safely to carry out the procedure through an endonasal approach, he may carry out a small septoplasty to provide more space and access within your nasal passage.


A septoplasty straightens the partition between the two nasal passages (the nasal septum). Ideally, the septum should run down the centre of the nose. When it deviates into one of the cavities, it narrows that cavity and impedes airflow.


Because the deviation is a result of a cartilage and/or bone surplus, the procedure usually involves removing a portion of any of these tissues. Under general or local anesthesia, Mr Malhotra works through the nostrils, making an incision in the lining of the septum to reach the cartilage targeted in the operation.


Mr Malhotra takes care to preserve an L-shaped strut of cartilage of at least 1cm along the tip of the nose to maintain structural support and the overall shape and appearance of the nose. The procedure may increase your potential for a small nose bleed after surgery but only for the first day or so.


You are advised to carry out saline irrigations of the nasal passage and use an antibiotic ointment on the lining of the septum. You can blow your nose normally after a week.


Jones tube


This is an artificial tear duct made of Pyrex glass that remains in place permanently. This operation is usually performed under general anaesthesia, although it can be performed under local anaesthesia with intravenous sedation by an anaesthetist for patients unfit for general anaesthesia.


A Jones tube can be used when DCR surgery has failed and for patients who have a blockage of the duct between the eye socket and nose caused by scars, recurrent infections or ageing.


Unblocking the tear duct


A minor probing of the tear duct will usually fix matters if a baby is born with the condition and it does not heal itself without intervention. More specialist surgery may be needed if this is not successful.


Eyelid tightening


This can help when pump failure has taken place. The operation is usually performed under local anaesthetic.


Positioning the eyelid


For patients suffering from outward turning of the lower eyelid (ectropion).


Artificial tears


These prevent drying of the eyes that leads to excessive production of real tears. There are a variety of artificial tear preparations available. Some patients prefer one over another for their own reasons, so it is a good idea to try different preparations.


If the tears need to be used more frequently than four times a day it is better to choose a preparation that is free of preservatives. Mr Malhotra can advise which preparations to try and often carries out a lubricant trial when identifying the main cause for a watery eye.


Closing the openings of the tear drainage system


If artificial tears do not adequately relieve the discomfort of dry eyes, closing the openings of the tear drainage system can help to keep more moisture on the eye, making it feel less sore and gritty.


The closure can be performed temporarily, with the insertion of silicone plugs, or more permanently, with surgery. In either case, the procedure is carried out under local anaesthetic. In extreme cases, other eyelid procedures may be required to control the drying.


What to expect


  • You will normally be a day patient. After recovery time, you will be moved to a ward. Many people stay overnight but you may go home the same day if all is well.
  • You will generally be able to fly after two days but should check with your doctor.
  • Your eye may still be watery while the silicone tubes are in place — if you need to wipe your eye, do it towards your nose to avoid catching the tubes.
  • You should consider resting for two or three days but can drive and return to normal, gentle activities the next day, if necessary.
  • You should avoid blowing your nose for the first week after surgery.
  • At the first appointment, the tubes are checked and, with external DCRs, the stitches removed.
  • At the second, the drainage site is examined in the clinic and the silicone tubes are removed.

All procedures begin with a consultation. For full information about what to do before and after surgery, see Patient information.




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