Dacryocystorhinostomy (Tear Duct Surgery)

What is dacryocystorhinostomy?

Dacryocystorhinostomy (DCR) is a procedure that reroutes your tear system drainage. It makes a new opening for tear fluid, and that opening lets tear fluid go from your tear sac directly into your nasal cavity (the open space inside your nose). Dacryocystorhinostomy (pronounced “DAK-re-oh-sis-to-RY-NOST-oh-me”) is also known as “tear duct surgery.”

Tear fluid is supposed to flow through special drainage ducts that drain into your nose, which is why excess tear production (like from irritation, allergies or crying) makes your nose stuffy and congested. When tear fluid can’t drain properly, it can lead to all sorts of issues. Some are just annoying, but others are more serious, like infections.

DCR surgery can treat conditions that are common, especially in children. But there are many reasons why adults (especially those over 65) might need this type of surgery, too.

How should I prepare for DCR?

Before you or your child undergo tear duct surgery, you’ll talk to a surgeon, either an ophthalmologist or otolaryngologist (ENT), who can do this procedure. In most cases, a surgeon from one of these specialties will team up with a surgeon from the other specialty. Some surgeons can do the entire surgery on their own, but that’s not as common.

Your surgeon(s) will explain DCR surgery to you and recommend certain tests to make sure you’re healthy enough for this surgery. They’ll also check for any issues that might affect your surgery or how you recover afterward.

Before your (or your child’s) surgery, you’ll also talk to an anesthesiologist. Tear duct surgery always involves anesthesia of some kind.

Once your surgeon clears you for this procedure, they’ll give you more specific instructions on the following:

• Medications. Your surgeon will tell you if you need to stop taking any medications before your surgery, including how and when to do this safely.
• Skin care before surgery. Your surgeon may have you use special soap to wash your face. You’ll use it before your surgery (usually the night before) to help reduce the risk of infections.
• Fasting. Your surgeon will give you specific instructions about when you (or your child) need to avoid eating or drinking before surgery. If your stomach isn’t empty, vomiting could lead to life-threatening aspiration pneumonia.

What happens during dacryocystorhinostomy?

At the very beginning of your DCR surgery, a nurse or other healthcare provider will insert an intravenous (IV) line into a vein somewhere on your body (usually your arm or hand). This line lets the anesthesiologist give you medications and fluids during your procedure.

Once your IV is in place, a surgeon or anesthesia provider will give you medications to make you fall asleep.

Your surgeon may approach the surgery one of two ways: from the outside (external) or inside (endonasal) of your nose.

External dacryocystorhinostomy

1. Your surgeon makes a small incision in the skin between your nose and eye.
2. They make a hole in the bone segment that separates the tear sac from the underlying nasal tissue.
3. They can insert tubing through this hole into the tear sac, threading the tube’s lower end so it drains into your nasal cavity. The tubing acts like a stent, or support frame, ensuring the passage from the tear sac to the nasal cavity stays open.
4. Once they secure the tubing and tissue in place, your surgeons can suture the skin incision closed. They may also leave foam packing inside to help prevent bleeding.

Endonasal dacryocystorhinostomy

1. With the help of nasal endoscopy, your surgeon makes an incision inside your nose. They use this incision to reach the bone that separates the nasal cavity and tear sac.
2. Once they reach the bone, they’ll create an opening in it.
3. They’ll make an opening in the tear sac on the outside of your nose.
4. Many surgeons will then thread tubing through the puncta in your eyelids and into the tear sac, pulling until it passes through the opening in the bone. They’ll secure the ends of the tubing in place.
5. Your surgeon may use a kind of foam packing to keep the tubing in place and reduce post-surgery bleeding.

How long does dacryocystorhinostomy take?

Tear duct surgery times vary slightly depending on which approach your surgeons use. For a first-time procedure, the external approach usually takes longer, around 45 minutes to 50 minutes. First-time endonasal approaches usually take about 30 minutes. But if this is a follow-up surgery, those times are usually shorter.

What are the benefits of dacryocystorhinostomy?

DCR surgery restores tear fluid drainage so you don’t have excess tear fluid in or around your eyes. This makes it easier to see and may reduce your chance of infection.

Both approaches to DCR surgery have an extremely high success rate. For external DCR surgery, the success rate is between 85% and 99%. For endonasal DCR surgery, it’s between 91% and 96%.

What are the risks or complications of this surgery?

There are a few risks that are common across all types of surgery. Those risks are:

• Pain
• Bleeding
• Infections

With DCR surgery, there are a few more complications or side effects that are specific to this type of procedure. Those include:

• Scar formation or tissue shifts and changes that affect the new drainage route
• Stenting or tubing slipping out of place
• Wound reopening or skin scarring (external method only)
• Bone-related healing and closure issues (endonasal method only)

A rare — but serious — complication of DCR is a condition called cerebrospinal fluid (CSF) leak. This may feel like fluid running down the back of your throat or a constant runny nose. If this happens, you’ll need to have another surgery to patch the leak with fat taken from your abdomen.

Other factors can affect which side effects or complications you’re likely to experience. Your surgeon(s) are the best source of information about what you can and should expect.

What happens after dacryocystorhinostomy?

Tear duct surgery is usually an outpatient procedure, so it’s common for people to go home the same day as their surgery. If you received general anesthesia for the surgery, your surgeon(s) and other providers will want to monitor you for a short time after you wake up. That monitoring period is to watch for any signs of complications from anesthesia or the surgery itself.

It’s also common for your surgeon(s) to prescribe pain medications, antibiotics, anti-inflammatory medications, decongestants or other medications. It’s very important that you take your medications exactly as prescribed.

Your surgical team will want to see you within a week after your surgery. This is to check your incisions and remove any gauze or packing they placed to prevent bleeding. What happens over the coming weeks to come can vary slightly, depending on the approach.

External DCR surgery

A week after your surgery, you’ll see your surgeon for removal of your stitches. Around this time, your surgeon may adjust certain medication dosages or let you finish them. But you may need to keep taking other medications for another week or two. Your surgeon will determine the right time to remove the stenting tubes (if necessary).

Endonasal DCR surgery

About a week after your surgery, you’ll have your first follow-up visit. During that visit, your surgeon(s) will prescribe a saline wash to use in your nose. It’s important to use this exactly as prescribed (don’t substitute other products for the prescribed wash).

You’ll have additional follow-up visits with your surgeon(s) to ensure everything in your nose heals properly. They may also remove the stenting tubes during one of the visits.

What is the recovery time from dacryocystorhinostomy?

The recovery time for tear duct surgery is similar across both the external and endonasal approaches. Both take several weeks at least to fully heal. That’s because both involve making an opening in your bone, and the edges of those openings will need to heal. In some cases, it might take up to a few months.

While you recover, it’s important to remember that there are certain things you shouldn’t do. One of the most important things to avoid is blowing your nose. Doing that can reopen wounds and move tissue or stenting tubes out of place. You’ll need to avoid blowing your nose for at least a week after surgery. Your surgeon can tell you about any other activities you should avoid and how long you’ll need to avoid them.

When should I call my healthcare provider?

You should call your surgeon or eye care specialist if you notice any changes in tear drainage on the side you had surgery on. You should also call them if you notice any changes that could be symptoms of an infection, like:

• Fever
• Swelling or warmth around the surgery site
• Bleeding or oozing from the wound (after external DCR surgery) or nosebleeds (after endonasal DCR surgery) that don’t stop

What are the alternatives to DCR?

There are several alternative approaches that your provider might recommend instead of DCR. They include:

• Observation. If your symptoms are merely an annoyance, you may choose not to treat your nasolacrimal duct obstruction.
• Medical therapy. In some cases, your doctor may offer nonsurgical options to treat your nasolacrimal duct obstruction, like antibiotic-steroid drops.
• Tubes. Another surgical option your doctor may offer is to place tubes in your natural tear drainage system. Those tubes will stay in place for three to six months to see if that helps your symptoms.
• Conjunctivodacryocystorhinostomy (CDCR). This is usually the final option for people with nasolacrimal duct obstruction where DCR wasn’t helpful.