Scarless Endoscopic Dacryocystorhinostomy (Blocked Tear Duct Surgery) - Information

Anh Q. Truong, MD

Bellevue ENT

1231 116th Avenue NE, Suite 915

Bellevue, WA 98004

Phone: (425) 454 - 3938

What are the indications for an endoscopic DCR (scarless block tear duct surgery)?

Epiphora (teary eye) related to nasolacrimal duct obstruction (blocked tear duct) can have a significant impact on quality of life and affect social interaction. Endoscopic dacryocystorhinostomy (DCR) offers a high cure rate of greater than 90% while avoiding a facial scar of a traditional external dacryocystorhinostomy. In general, the decision to proceed with surgery is one that the patient and ENT surgeon make together. Surgery is usually reserved for patients who are symptomatic and refractory to medical treatment. The endoscopic approach is indicated in patient who wishes to avoid an external scar.

Source: Kennedy et. al. Rhinology & Seely et. al. Anatomy & Physiology, 8th Ed.

What is an endoscopic dacryocystorhinostomy (DCR)?

An endoscopic dacryocystorhinostomy (DCR), or blocked tear duct surgery, is a minimally invasive outpatient surgical procedure that re-establishes the normal flow of tears from the eye into the nose. Using endoscopic instruments entirely through the nose, the thin lacrimal bone is removed and the lacrimal sac is open directly into the nose, thus bypassing the obstructed nasolacrimal duct. A small soft plastic tube is then inserted into the puncta and directed into the nose to stent the cystostomy (new conduit) open. This is usually left in place for about six weeks and can be removed in the clinic. Unlike the traditional external approach, the endoscopic approach does not require a skin incision, thus avoiding scar along the side of the nose. On rare occasions, there may be a concurrent deviated septum or nasal polyps which can limit the surgical exposure. In these cases, a septoplasty and/or nasal polypectomy may be performed at the same time.

Figure 2. Schematic of an endoscopic DCR. The thin lacrimal bone is removed.

Figure 3. The lacrimal sac is open into the nose and a temporary silastic stent is placed. Source: Kennedy et. al. Rhinology.

What should I expect before an endoscopic dacryocystorhinostomy (DCR)?

• DO NOT TAKE THE FOLLOWING MEDICATIONS FOR AT LEAST 14 DAYS PRIOR TO SURGERY: non-steroidal anti-inflammatories (NSAIDS) products including aspirin, ibuprofen, and naproxen. Avoid taking vitamin E (multivitamin is OK), gingko biloba, garlic (tablets), ginseng, and St. John’s wort. If you take the blood thinner Coumadin or Plavix, you must discuss this with your surgeon so the medication can be discontinued before surgery and restarted appropriately.

• If you smoke, you must stop smoking for at least three weeks prior to surgery, and at least four weeks after surgery. Smoking can contribute to scarring, poor healing, and failure of the operation. Your primary care physician can direct you to resources for smoking cessation.

• While our office will make every attempt to keep your primary care physician informed before and after your surgery, it is important that you personally inform him/her that you are planning to have sinus surgery. If you have underlying medical conditions, your primary care physician may help to clear you medically for surgery. Most of the necessary pre-operative testing will be performed at Bellevue ENT during your preoperative visit. This takes place approximately 1 week prior to your surgery if needed.

• Due to the frequently changing operating room schedule, the surgery center will usually call you one business day before your surgery date to inform you of your surgery time. You are usually expected to arrive two hours prior to your surgery to check in.

What should I expect during an endoscopic dacryocystorhinostomy?

Your surgical team will include your surgeon, an anesthesiologist, a scrub nurse, a circulating nurse, and additional supporting staffs dedicated to ensuring that your surgery is safe. An endoscopic dacryocystorhinostomy (DCR) is typically performed under general anesthesia and will usually last about 1.5 hours. The tear duct surgery is performed entirely through the nose using endoscopic instruments. The blood lost is minimal and no nasal packing is placed.

What should I expect after an endoscopic dacryocystorhinostomy?

• After your surgery, you will spend approximately 1.5 hours in the recovery area. Approximately 1 hour after you arrive in the recovery area, a family member or friend should be able to visit with you. You should not drive yourself home and you need to arrange for transportation prior to surgery.

• You can expect mild bleeding for 1 day after surgery. Pain can generally be controlled with over the counter Tylenol; however, narcotic (prescription) medication will be provided for additional control if needed. In the first few days, you may have some irritation to the corner of the eye similar to wearing a contact lens for the first time. The irritation will subside after 1-2 days.

• You will have return visits to the ENT clinic at approximately 1 and 6 weeks after surgery. At your first post-operative visit, the doctor will examine your sinuses with an endoscope and may clean your sinuses of dried blood. At your second visit, your doctor will remove the small lacrimal silastic stent. This can be performed without any anesthetic and does not cause discomfort. Please write down any questions you may have so that we can answer them at your appointment.

• You should plan on taking one week off from work and ideally have a half-day planned for your first day back.

• Please see the post-operative instructions for additional details.

What are the risks of a blocked tear duct surgery (dacryocystorhinostomy)?

As with any surgical procedure, endoscopic dacryocystorhinostomy (DCR) has associated risks. With meticulous planning and appropriate precautions, complications from an endoscopic dacryocystorhinostomy are very rare. Although the chance of a complication occurring is very small, it is important that you understand the potential complications and ask your surgeon about any concerns you may have. These risks may include:

• Recurrence of teary eyes: Endoscopic dacryocystorhinostomy is highly successful with a cure rate of 92-97%. Recurrent or persistent teary eyes may occur due to scarring or due to dysfunction of the “pumping” mechanism despite a widely open drainage system. Recurrence may necessitate revision surgery or placement of a permanent bypass tube.

• Orbital injury: Although exceedingly rare, bleeding in the orbital cavity (orbital hematoma) and injury to the lateral rectus muscle is can lead to vision change and/or vision loss. With appropriate precautions, these complications can be prevented.

• Other risks: Other uncommon risks of surgery include bloody nose; eye irritation; pain; and swelling or bruising of the area around the eye.

What restrictions will I have during the postoperative recovery period after blocked tear duct surgery?

• Do not blow your nose for 1 week following surgery. You may sniff back gently to clear your nose. Nasal irrigations can also help (see “post-operative patient instruction”).

• No strenuous activity for one week after surgery. This includes bending over to pick things up (bend at the knees, with your head up), straining, or lifting more than 20 lbs. Light walking and normal household activities are acceptable immediately after surgery. You may resume exercise at 50% intensity after one week, and full intensity at two weeks. You may drive the day after surgery if you are not requiring narcotic medication.

• Do not fly without your doctor’s clearance for 7 days after surgery.

Your surgeon is committed to providing you with the highest level of care in a comfortable and caring environment. We want you to have all of your questions answered and provide you with a complete understanding of your condition and treatment plan. Please feel free to ask questions about any aspect of your care. Learn more about blocked tear duct (nasolacrimal duct obstruction) and post-operative patient instructions.