There is one in the upper and lower eyelid. They lead into small tubes known as the canaliculi, which in turn drain into the lacrimal or tear sac. This lies between the corner of your eye and your nose and has a duct at the bottom, which drains into your nose, the nasolacrimal duct.
If the nasolacrimal duct blocks the eye becomes watery, and sometimes sticky. Some people develop a painless swelling of the tear sac at the inner corner of the eye and a few get repeated painful infections, like a boil or abscess. Your doctor will examine you to see if your watering is due to a problem in the tear drainage system.
This will include syringing water through the tear ducts to see whether there is a blockage. The surgery creates a new pathway between the tear sac and the inside of the nose by removing a small piece of bone between them and bypassing the blocked nasolacrimal duct. This operation is called a dacryocystorhinostomy or DCR for short. The surgery is done through an endonasal approach avoiding a skin incision and is performed through the nose using an endoscope.
If the nasal passage is too narrow a procedure to straighten the nasal septum septoplasty may also be done. In a few patients small soft silicon tubes are placed in the tear canals to keep the passages open while healing takes place. This means 1 in 10 people may not improve after surgery. The operation takes about 30 minutes and is usually performed under a general anaesthetic where you are asleep, or under local anaesthetic with intravenous sedation to make you sleepy so you do not feel any discomfort.
You will usually have the surgery as a day patient and go home the same day. Although the great majority of patients will have surgery as a day patient, some may elect to stay in hospital overnight. This will usually be for social reasons such as if you live alone. Professor Selva will discuss this with you as necessary at the consultation prior to surgery.
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. Apply the ice packs over the bridge of the nose, changing the packs every 10 — 15 minutes or so, with ice-free intervals of 5 — 10 minutes to allow the skin to warm again. Although in most cases the bleeding will stop spontaneously, if it continues for more than half an hour,or is very heavy, you should attend the Accident and Emergency Department at your nearest hospital, where nasal packing may be required.
In the first instance, at home you should sit upright and you should apply ice packs as above. The degree of swelling over the inner corner of the eyelids after surgery can vary markedly, some reporting little or none, and others experiencing some swelling and bruising which takes up to a week to settle the latter being unusual.
Often, patients take the health food remedy called Arnica in tablet form , and although there are few established studies on its use, it does seem to reduce the swelling oedema in some patients after surgery. In the unlikely event that the oedema is marked, cold compresses over the bridge of the nose in the form of ice packs twice or thrice daily can also help. The incision on the side of the nose typically settles very well, becoming visually insignificant in time in most patients.
Infection after DCR surgery is very uncommon, and all patients are given antibiotics during the surgery, with tablets after the surgery in those with infection preoperatively, or where both sides are operated on at the same time. All patients are also given antibiotic eye drops as a precautionary measure for 2 weeks after the surgery. Rarely, the normal healing reaction in the nose can lead to the formation of a fine membrane across the internal opening, with recurrence of the original watering symptoms.
In other patients and especially if there has been previous trauma, or disease of the inner eyelids , the surgery described above is inadequate to allow tears to drain into the nose.
The first review occurs weeks after surgery, when the skin stitch is removed and the eye examined. At the second clinic visit a month later the silicone stent is removed and no further routine review is necessary in most cases. However, a further appointment can easily be arranged if any further ocular or lacrimal symptoms occur. The success rate depends very much on the nature of the underlying causes of watering.
These points are discussed in detail with every patient before any proposed operation. DCR surgery is becoming like any other oculoplastic operation that it can be done under a local anaesthetic with sedation as a day case and the recovery is quite rapid.
The most common complications that the patient can expect in the first few days are bruising around the eye and some bleeding or oozing from the nose.
After the tubes have been removed, I will then see the lacrimal patient once more when I check the inside of the nose again with the endoscope, making sure that the ostium where the tear duct is now draining is healthy and that I can see tears emerging from the side wall of the nose.
I put in a drop of fluorescein onto the surface of the eye, as a coloured tear as it lightens up the tears and makes them much easier to see as a yellow colour in the nose. I can calculate the transit from putting them on the surface of the eye to emerging in the nose and would expect this to be between one second and possibly three to four seconds on occasion.
Once I know that everything is fine and you are at least six weeks after surgery, then we do have the choice of discharging you. The surgeon makes a small incision in the skin, in the area under your eye and next to your nose. Through this incision, your surgeon creates a small opening in the bone beneath. This opening then connects your lacrimal sac and your nasal cavity.
The surgeon leaves a small tube there to help keep the new tear duct open. During an endoscopic DCR, the sinus surgeon works together with the eye surgeon to bypass the tear duct by creating a new opening directly from the lacrimal sac to your nasal cavity. Going through the nasal passage under endoscopic vision, the sinus surgeon creates an opening in the bone that overlies the lacrimal sac.
A connection is then created between the lacrimal sac and your nasal cavity. The ophthalmic plastic surgeon usually places a small tube there to help keep the new tear duct open.
The procedure is done to relieve the symptoms of a blocked tear duct. These include excessive eye watering or crusting around your eye.
If the duct is infected, you might have the following symptoms:. Not everyone who has a blocked tear duct needs a DCR. This is a much more common treatment for adults than for children.
Your health care provider might first recommend less invasive treatments. These may include warm compresses, massage, and antibiotics for an infection. Or the provider might advise having a procedure to try to dilate the nasolacrimal duct. If your symptoms are severe, however, you may need a DCR. Depending on the cause of your blocked tear duct, you may need another treatment.
For example, you might need a different kind of surgery if a tumor blocks your duct. You and your health care provider may need to discuss what type of DCR will be best for you. Sometimes, providers perform the procedure externally.
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