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Dacryocystorhinostomy (DCR) – Lacrimal duct surgery

Dacryocystorhinostomy is surgery to treat a blocked tear duct. The procedure involves creating an opening in the lacrimal sac to the nasal cavity, bypassing the obstructed tear duct. The surgery is performed under general anesthesia, either through the bridge of the nose (external approach) or through the nasal cavity (endonasal procedure). This treatment can address chronic watery eyes, blocked tear ducts, and recurrent dacryocystitis. The main risk is bleeding, which is why nasal packing is left in your nostrils for 24 hours after the procedure.

What is a dacryocystorhinostomy?

  • Dacryocystorhinostomy (DCR) is a surgical procedure performed by ophthalmologists, oculoplastic surgeons, and ENT specialists.

  • The procedure involves creating a new pathway for the flow of your tears between your eyes and your nose.

  • This refers to the operation for a blocked tear duct. It can be performed externally through a skin incision at the inner corner of the nose, or internally, also known as endoscopic surgery, through the nose, leaving no visible scar. Both methods are equally effective.

Reminder about tear duct obstruction, also known as a “blocked tear duct”

  • Each of your eyelids has a lacrimal meatus, a small hole located on the inner edge of each eyelid. Blinking your eyes pushes tears into these meatus.

  • From there, the tears flow into the tear duct, the first part of which is thick: the lacrimal sac. This sac is located at the bridge of the nose, at the inner corner of the eye. The duct then descends and empties into your nasal cavity.

When to perform a DCR?

Dacryocystorhinostomy is indicated in cases of:

  • Chronic tearing and purulent discharge from the lacrimal meatus.

  • Recurrent dacryocystitis or chronic dacryocystitis.

  • Chronic obstruction of the lacrimal ducts.

  • In emergency situations involving antibiotic-resistant dacryocystitis.

Surgical techniques

External route – Incision in the skin

  • For external DCR, the oculoplastic surgeon creates a communication channel between the lacrimal sac and your nasal cavity.

  • To do this, he makes an incision on the bridge of the nose at the inner corner of the eye. The lacrimal sac is opened, then an opening is made in the bone below it.

  • The skin is then closed.

Endoscopic approach – Endonasal procedure

  • For endoscopic DCR, the surgeon follows the reverse path: starting from the sinuses and ending in the lacrimal sac.

  • The procedure is preferred by ENT specialists. The surgeon inserts a camera into the nose and positions it at the level of the bone and the lacrimal sac.

  • He cauterizes the nasal mucosa and then incises the bone using forceps inserted into the nostril. Once the bone is broken, the surgeon comes directly to the lacrimal sac, which he also opens.

Preparing for the operation

  • The pre-operative consultation is a crucial step. The surgeon will analyze the images provided by the dacryoscanner, confirming the obstruction and its cause.
    You will meet with the anesthesiologist. The operation is preferably performed under general anesthesia, but external DCR procedures can be performed under local anesthesia.

  • If you are taking antiplatelet or anticoagulant medication, it is best to stop taking it. However, this decision should only be made by the anesthesiologist, after consulting with your cardiologist.

  • You will need to fast on the day of the operation. Therefore, you must not eat, drink, or smoke for 6 hours before your arrival at the clinic.

The operation – The dacryocystorhinostomy

  • Ophthalmologists more readily perform external procedures, while ENT specialists prefer the endoscopic approach.

  • In all cases, the procedure takes place on an outpatient basis, so hospitalization only lasts a few hours, without an overnight stay in the hospital.

External dacryocystorhinostomy

  • The operation takes place under sterile conditions, under local or general anesthesia.

  • The surgeon makes an incision of less than 2 cm at the inner corner of the nose, at the level of your eye.

  • He will find the lacrimal sac and make a first incision, allowing the sac to be opened and unblocked.

  • An incision is then made at the bottom of the sac, which allows access to the nasal bones.

  • The bone is drilled using a suitable drill.

  • The lacrimal sac is fixed to the nasal mucosa using absorbable thread.

  • A suture is used to close the lacrimal sac and the skin.

  • The scar is minimal and very difficult to see after healing.

  • A wick is placed in the nose to prevent bleeding (epistaxis).

Endoscopic dacryocystorhinostomy

  • The internal procedure is performed under general anesthesia. The endonasal surgeon (most often an ENT specialist) uses an endoscope (camera) to navigate inside your nose.

  • Using forceps, he makes an opening in the bone that covers the lacrimal sac, in order to create a new passage between the lacrimal sac and your nose.

  • Once the opening is made, the healing is left natural; the hole will persist with a communication between the lacrimal sac and the nose.

  • In this case, there are no stitches or scars on the skin.

Convalescence after a DCR

  • The procedure is performed on an outpatient basis. You will therefore be able to return home the same day.
    The cauterizing gauze from the nose will be removed 24 to 48 hours after the operation, during a postoperative consultation.

  • Pain relief, anti-inflammatory and antibiotic treatment in the form of drops, tablets and nasal spray will need to be taken regularly.

  • Regular nasal irrigation with saline solution will be necessary to remove any crusts and clots that form. However, vigorous nose blowing is strongly discouraged.

  • Non-steroidal anti-inflammatory drugs in tablet form (such as Ibuprofen) are not recommended in the week following the procedure due to the risk of bleeding.

  • In the case of an external procedure, the stitches are removed 7 to 10 days after the procedure.

  • You will be able to return to work 7 to 10 days after the operation.

Risks and complications of DCR

The main risks and complications of dacryocystorhinostomy are:

  • Epistaxis – Postoperative nosebleed.

  • Cellulitis – Infection of the lacrimal sac and periocular tissues.

  • An unsightly skin scar.

  • Therapeutic failure due to abnormal scarring of the tissues between the sac and the sinus.

Surgical risks are also linked to an anesthetic risk, admittedly minor but present.

Sources:
https://eyewiki.org/Category:Articles
https://www.cahiers-ophtalmologie.fr/
https://snof.org/
https://couf.fr/

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