Dacryocystorhinostomy (DCR)

This leaflet has been produced to provide information for patients requiring surgery for a blocked tear duct.

Why do my eyes water?

Tears are produced by the tear gland which lies in your eye socket, under the outer corner of the upper lid. Tears lubricate the surface of your eye and drain away via a tiny opening (punctum) on the inner corner of each eyelid. Each punctum leads into a very fine drainage channel (canaliculus). The upper lid canaliculi and lower lid canaliculi join to form a short common channel (common canaliculus) which drains into the tear sac. From the tear sac the tears drain into the tear duct (nasolacrimal duct) which runs in a bony canal in the side of the nose, then opens into the bottom of your nose (see diagram 1) and the tears ultimately trickle into your throat, without you being aware of it. There is a delicate balance between the amount of tears produced and the amount that drains. Upsetting the balance can either lead to a dry eye or a watery eye. A watery eye is often (not always) due to blockage of the tear duct, which not only causes watering but can also result in excessive sticky discharge due to stagnation of tears and collection of mucus in the tear sac, which spills back into the eye.

What is dacryocystorhinostomy (DCR)?

Dacryocystorhinostomy (DCR) is an operation which bypasses the blocked tear duct and provides an alternative route to drain the tears from your eye into your nose (see diagram 2). This bypass channel is created by removing a small piece of bone from the side wall of the nose and connecting the tear sac directly to the nasal cavity either through a skin incision (external DCR), or by looking up your nose with a small telescopic instrument (endoscopic DCR). There are pros and cons to both methods.

External DCR surgery?

A small incision is made on the side of your nose to gain access to the tear sac. A small piece of bone is removed from the side of your nose to expose the inner lining of the nose. The tear sac is opened, and an opening is also made in the inner lining of the nose. The tear sac is stitched to the inner lining of your nose allowing direct passage of tears from the tear sac into your nose, bypassing the blocked tear duct. A tiny silicone stent (also referred to as ‘tubes’) is used to keep the bypass channel open while the tissues heal. The skin wound is closed with very fine stitches. The whole operation takes about 60 to 90 minutes. Most patients prefer to have a general anaesthetic (be put to sleep) but the operation can be performed under local anaesthetic (where you are awake and given injections to numb the side of your nose and inner corner of your eye). The stitches are removed seven to ten days after surgery and the small scar that results is usually imperceptible within three months. The stent is normally removed about six weeks after the operation in a simple out-patient procedure which involves cutting the loop of the stent in the inner corner of the eye and retrieving the stent from inside the nose after spraying the nose with local anaesthetic. The silicone ‘tubes’ are barely noticeable in the inner corner of the eyelids and rarely irritate. Whilst the stent is in place you may experience a slight overflow of tears, which should improve once it is removed.

Overall 90-95% of patients have a successful outcome with external DCR.

Endoscopic DCR

In this operation, which is also called endonasal DCR, the connection between the tear sac and the nose is made while the surgeon is looking up your nose with a small telescopic instrument called an endoscope. A small piece of bone is removed between the tear sac and your nose in much the same way as in an external DCR. However, the opening is slightly smaller than that of external DCR and there are no internal or skin stitches. Therefore, the operation is slightly quicker. As with an external DCR, a temporary silicone stent is used and left in place for about six weeks to prevent the bypass channel closing.

The success rates of external and endoscopic DCR are similar. Overall about 85-90% of patients have a successful outcome with endoscopic DCR.

What type of anaesthetic is used?

Most patients prefer to have a general anaesthetic (be put to sleep) but the operation can be performed under local anaesthetic with a numbing spray in your nose and an injection in the inner corner of your eye and the skin on the side of your nose. If you have a local anaesthetic you should not feel any discomfort during the surgery but may hear a crunching sound as the bone is removed. Do not be afraid, as this is quite normal.

What are the risks/complications of DCR surgery?

• You can expect slight swelling and bruising of the eyelids, which usually resolves in a fortnight.
• There is a small risk of infection with any surgery, but this rarely happens after a DCR.
• It is normal to have slight bleeding from your nose after surgery; this usually settles in a few days.
• A severe nosebleed is a rare event which can happen up to ten days after the operation. This is more likely to happen in patients with infection, uncontrolled high blood pressure or those on blood thinning agents (e.g. aspirin, clopidogrel, warfarin, apixaban or rivaroxaban). We may ask you to stop your blood-thinning pills before surgery. However, you should consult your GP and/or cardiologist before stopping your medication, to confirm that it is safe to do so.
• The surgery can fail in a minority of patients, usually because scar tissue forms inside the nose and blocks the bypass channel. This may require further surgery to revise the bypass channel, or even insertion of a small pyrex tube known as a Lester Jones tube to bypass the entire tear duct system.
• The scar on the side of your nose usually fades and only 3% of patients notice it after three months.
• Rarely, the stent may irritate or “cheese-wire” towards the inner corner of the eye.
• The loop of the stent can occasionally protrude outwards in the inner corner of the eye where it passes from one eyelid to the other. If this happens do not tug on it but seek attention because the stent might need to be repositioned.
• The fine silicone stent may protrude from the nostril if it is cut too long inside the nose. If this happens do not tug on it but seek attention because it may need to be trimmed.
• The stent may break and spontaneously work its way out of your nostril. Do not panic if this happens and there is no need to seek attention if it comes out completely.

What happens after the surgery?

The operated eye is usually covered with a dressing overnight to minimize swelling and bruising. If both eyes are operated on, only one eye will be covered and the other side will have a small dressing over the skin wound. Depending on your general health you may be able to go home the same evening or you may be kept in overnight. Before you go home you will be given some antibiotic drops, ointment and/or tablets, instructions for dressing removal and a follow-up appointment for the eye clinic.

What do I need to do at home?

You can take paracetamol or codeine but avoid aspirin or ibuprofen for pain relief. You can clean the wound gently with cooled, boiled water and cotton wool. You can wash your hair and face but pat the wounds dry carefully. To reduce the risk of severe bleeding, avoid hot drinks for the first 24 hours, avoid blowing your nose for the first ten days and avoid vigorous physical activity or swimming for a fortnight. Remaining upright as much as possible, sleeping on several pillows and using icepacks will also help to reduce excessive swelling and bleeding. If you have a severe nosebleed pinch your nose firmly, keep your head up and cool your nose with an ice pack. If the bleeding continues contact the emergency eye clinic or the emergency department at your local hospital. Your nose may need to be packed to stop it bleeding.

Contacts and further information

Please contact the theatre bookings team in the Eye Department on 01223 274863 if you have any queries regarding your appointment for surgery. For urgent post-operative concerns please contact the Emergency Eye Service on 01223 217778.