Definition and Overview
Also referred to as DCR, dacryocystorhinostomy is a surgical procedure that aims to correct the flow of tears from the eyes to the nose by creating another passageway toward the latter. This is performed when the nasolacrimal duct is narrowed or blocked.
The two common techniques used in DCR are external and powered endonasal DCR, which uses an endoscope, a long narrow scope that can be easily inserted into the nasal cavity. It is equipped with a light to provide excellent visuals of the target site and its surrounding tissues as well as camera so a live feed guides the surgeon throughout surgery.
Who Should Undergo and Expected Results
DCR is recommended for people diagnosed with nasolacrimal duct obstruction (NLDO), which can be caused by a congenital defect or an underlying condition. Cases due to congenital defect affect at least 5% of newborns, although they tend to occur more often among children with cleft and Down syndromes. The condition can also be due to exposure to certain drugs or chemicals, recurrent nasal allergies and infections, inflammation of the sinuses, and trauma to the face.
Tears, which are regularly produced by the eyes for moisture and protection, flow through openings found on the corner of the eyelids to the lacrimal sac and the nasolacrimal duct. If the duct is blocked, the person becomes more prone to epiphora (excessive tearing), eye infection, and mucus discharge. Pain, blurry vision, and crusting may also be experienced.
The success rate of a DCR is very high. At least 95% of the cases are corrected properly. Although some believe that external DCR is better than endoscopic technique, most studies point to basically the same success rate.
How Does the Procedure Work?
Since the blockage can involve two major organs, the eyes and nose, the patient may have to see an ophthalmologist and ENT specialist or otolaryngologist. These specialists can work together to diagnose the problem affecting the nasolacrimal duct by conducting a series of tests. The eye doctor, for example, can measure the level of pressure surrounding the eyes while the ENT specialist can look for any blockage through the nasal cavity.
As part of the pre-operative care, patients taking certain medications like blood thinners are advised to stop taking them at least a few days or a week before the surgery to minimise surgical complications. Imaging exams are also performed to locate the blockage and plan the procedure. The surgeon will consider both techniques and weigh their benefits and disadvantages as well as consider the patient’s unique circumstances to make a well-informed decision.
During the procedure, general anaesthesia is administered. Local anesthesia is also possible, but it’s usually complemented with sedation. In an external DCR, an incision of about 15 millimeters is made on the side of the nose near the eyes to access the lacrimal sac. A bone may be removed so the sac can be connected to the nose and allow the tears to drain, bypassing the obstructed duct. To keep the new channel open, a stent, rod, or tube is inserted. It is trimmed before the patient leaves and removed after a month.
In a powered endonasal DCR, the process is almost similar. The major difference is that there’s no need for an incision, which means absolutely no scarring. An endoscope travels through the nasal cavity to access the lacrimal sac and creates a new passage for the tears. Rods can also be inserted in the same manner.
This procedure can be done in an outpatient setting and can be completed in around an hour. However, the doctor may advise the patient to stay overnight for close monitoring.
Possible Risks and Complications
Aside from the discomfort, the patient can also experience pain and sometimes bleeding of the nose following a powered endonasal DCR or external surgery. The latter can be controlled through a cold compress. Other possible complications are infection and persistent tearing, which indicates the procedure was not successful and thus, must be repeated.
Marcet MM, Kuk AK, Phelps PO. Evidence-based review of surgical practices in endoscopic endonasaldacryocystorhinostomy for primary acquired nasolacrimal duct obstruction and other new indications. CurrOpinOphthalmol. 2014 Sep. 25(5):443-8.
Jung SK, Kim YC, Cho WK, Paik JS, Yang SW. Surgical outcomes of endoscopic dacryocystorhinostomy: analysis of 1083 consecutive cases. Can J Ophthalmol. 2015 Dec. 50 (6):466-70
Kiroglu AF, Cankaya H, Yuca K, Kiris M. Endoscopic dacryocystorhinostomy with a T-type ventilation tube. J Otolaryngol. 2007 Jun. 36(3):164-7.