Dacryocystorhinostomy

What is Dacryocystorhinostomy?

Dacryocystorhinostomy (DCR) is a surgery that helps tears drain from the eyes into the nose more easily by creating a new passage into the nose. This can help fix problems with the natural pathway for tears, known as the lacrimal system. DCR can be performed in two ways: externally (through the skin) or internally (through the nose).

Blocked tear ducts can make tears spill down the face, a condition known as epiphora. Depending upon the exact cause and location of the blockage, various surgical procedures can clear the obstruction. However, usually, the definitive treatment involves one type of DCR.

The idea of DCR harks back to the 12th century. A doctor named Muhamad Ibn Aslam Al Ghafiqi described how to create a new drainage route for tears in his book “The Right Guide to Ophthalmology.” Al Ghafiqi would create a hole from the corner of the eye into the nose, which would then form a new tear drainage route as the hole healed. Despite how little was known about the workings of the tear drainage system back then, these fundamental principles are still used today.

The modern version of the DCR procedure was first described in the 20th century by Addeo Toti, an Italian ear, nose, and throat professor. His technique exposed the drainage sac of tears via a skin cut. He then cut out the inner wall of the sac, the neighboring bone, and the surrounding tissue. Finally, he pushed the side wall of the sac towards the nasal opening to create the new tear draining route.

There have been significant improvements to the original technique. For example, techniques now aim to prevent scarring and ensure correct pressure by suturing the nasal tissue to the tear sac or removing a part of the bone structure inside the nose to create larger openings.

The endonasal (through the nose) DCR method was first suggested in 1893, but significant improvements in this technique came with rigid nasal endoscopes, which helped doctors see inside the nose during surgery. This method of DCR is now widely recommended for blocked tear duct treatments.

Over the years, nasal endoscopes, lasers, and power tools have helped to further refine the endonasal DCR surgery, leading to more successful outcomes. Patient preference has also leaned towards endonasal DCR surgery more recently because it avoids having to make a skin cut.

Research shows that the success rate of endonasal DCR surgery approaches that of external DCR if adequate bone removal and correct placement of the new tear drainage route are achieved. Recent studies suggest that these endonasal techniques can be used safely and effectively in different patient populations, including children and those with certain facial syndromes.

However, regardless of the method used, the key to successful DCR surgery lies in understanding the precise anatomy of the tear drainage system. This system includes the tear puncta (tiny holes where tears drain into), the canaliculus (the tubes that take tears to the tear sac), the nasolacrimal sac (where tears are stored), and the nasal cavity (where tears drain out). It’s also important to know the structure of the nose and the neighboring bone structures to ensure safe and effective surgery.

What Causes Dacryocystorhinostomy?

Nasolacrimal duct obstruction, or the blockage of the tear duct, can happen due to several reasons.

If it happens at birth (Congenital Nasolacrimal Duct Obstruction or CNLDO), it’s often because a layer of tissue is blocking the duct. Sometimes, it might be because the duct is squeezed by bone.

If it happens later in life (Primary Acquired Nasolacrimal Duct Obstruction or PANDO), it’s usually because the tear duct has hardened over time.

Secondary Acquired Nasolacrimal Duct Obstruction (SANDO) can happen due to several more complex reasons:

Infections caused by bacteria like Staphylococcus, Streptococcus, and Actinomyces are common, but it can also result from fungal, viral, or parasitic infections.

Inflammation-related conditions like Sarcoidosis, Wegener granulomatosis, allergies, ocular problems, and reactions to certain medications or treatments can also lead to the obstruction. Physical or chemical burns and diseases like Pemphigoid disease and Stevens-Johnson disease are other potential causes.

Tumors related to the lacrimal sac or nearby soft tissues can also cause blockages. This includes cancers like lymphoma, papilloma, squamous cell carcinoma, melanoma, and others like basal cell carcinoma, adenoid cystic carcinoma, lymphoma, and leukemia. Spread of cancers from other body parts like breast, melanoma, or prostate to the tear duct can also result in blockage.

Physical trauma to the midface, surgical accidents, or mechanical factors like surrounding fluid-filled cysts or stones within the tear system can also result in nasolacrimal duct obstruction.

Risk Factors and Frequency for Dacryocystorhinostomy

Nasolacrimal duct obstruction, which can be either acquired or present from birth (congenital), is a common condition. The acquired type is slightly more common in females.

• The estimated incidence of acquired nasolacrimal duct obstruction is 20.24 per 100,000 people.
• Congenital nasolacrimal duct obstruction affects 5% to 20% of newborns, with an average of 6% affected. However, most of these issues resolve on their own by the time the child is 12 months old.
• Nasolacrimal duct obstruction is responsible for 31.8% of cases of chronic tear overflow (epiphora).
• All cases of tear overflow due to obstruction in the tear passage is caused by this condition.
• Dacryocystitis, an infection of the tear sac, occurs in 1 in every 3884 live births.
• Acquired nasolacrimal duct obstruction is more often seen in Whites as compared to African Americans.
• There is no scientific evidence suggesting that the use of eye make-up can cause nasolacrimal duct obstruction.

Signs and Symptoms of Dacryocystorhinostomy

Nasolacrimal duct obstruction or blockage can lead to a condition called epiphora, which is characterized by excessive tearing or overflow of tears. This can occur due to issues in either the tear-production part of the eye or the tear-drainage system. It often comes along with different symptoms like a sticky discharge from the eyes or a mucous-filled pocket in the tear sac called a mucocele. Experiencing pain in the area closest to the nose is also common, especially if the tear sac is inflamed. To diagnose this condition, your eye doctor will take a thorough medical history and perform extensive eye and nose exams.

There are several important details your doctor may need to determine the cause of your excessive tearing. These may include the characteristics of the tearing such as:

• Which eye is affected (laterality)
• Duration of the symptom
• Variation throughout the day
• Variation depending on whether you’re indoors or outside
• Location on the eye where the tears overflow
• Consequences (like previous inflammation of the tear sac, repeated antibiotic use, frequent doctor visits or skin irritation due to the excess tears)
• In children: Has the excessive tearing been present since birth, and has there been any improvement?

Your doctor will also need information about your medical history, including:

• Past surgeries on the nose or sinuses
• Past facial injuries or fractures
• Prior conditions like rhinitis or rhinosinusitis
• General health status
• Current medications, especially anticoagulants

For children, the doctor will also need information about the birth and if the child was premature, as well as any other medical issues or syndromes. Previous treatments for the excessive tearing and other eye conditions like dry eyes or Meibomian gland dysfunction, or past eye surgeries also need to be discussed. In addition, the doctor will check for any swelling of the tear sac or mucocele, and the location of the swelling in relation to the eye’s medial canthal tendon (the tendon near the nose).

Testing for Dacryocystorhinostomy

The Jones 1 and Jones 2 tests are commonly carried out to check for blockages in the nasolacrimal system, which carries tears from the corners of your eyes into your nose. The Jones 2 test in particular is very effective for pinpointing where the blockage is. In rare cases, another test called a dacryocystogram might be necessary if signs point towards fistulas, injury done by medical intervention, or potential lacrimal sac tumors.

Before moving forward with the procedure, a careful assessment is undertaken to rule out other potential causes for excessive tearing, such as dry eyes, reflexive tearing, eyelid positioning, and narrowing of the punctum, which is the eye’s tear duct. The eyelids, the location and size of the punctum, as well as any signs of punctum absence or abnormalities are all checked. It’s especially critical to perform this examination in children. The health of the eye’s surface is also checked, along with tear film quality and the time it takes for the tear film to break up.

A test called the fluorescein dye disappearance test, designed to measure the flow of tears, is usually performed. Additionally, the region around the nasolacrimal sac is inspected for any swelling that may indicate an obstruction.

Sometimes, a process known as diagnostic irrigation of the lacrimal system is undertaken. In this procedure, the inner lining of the eye – conjunctiva – is numbed, and saline solution is injected to check how well it passes through the lower punctum. The whole process is performed very carefully and methodically to avoid causing any harm.

Nasoendoscopic examination is included in the preoperative assessment. This is essential when performing surgeries through the nasal route. Eyedrops that cause the mucous lining inside the nose to shrink are used, and a thin, flexible tube with a camera attached is inserted into the nose to check for any abnormalities that might interfere with the surgery.

In the case of young patients, most of the above tests may not be feasible. In such cases, a thorough discussion with the caregiver usually provides a likely diagnosis. Apart from that, the health of the eyelids, the level of tears in the eyes, and possibly, a fluorescein dye disappearance test is carried out if deemed feasible.

Before deciding on the surgery, the doctor has to carefully weigh the benefits of an External DCR (external approach) and an Endoscopic DCR (nasal approach). The choice might depend on the patient’s particular situation and the expertise of the surgeon.

Some factors to consider when choosing an external DCR procedure might be the patient’s general health, if the patient has had previous facial fractures or unusual anatomy, if anesthesia is required, and if the patient has experienced proximal or mid canalicular closing, this technique allows for a retrograde intubation.

On the other hand, an endoscopic DCR is usually the preferred choice because of its high success rate, faster recovery, and fewer necessary postoperative follow-up visits. However, if the patient had a previous medial canthal region radiotherapy, it might reduce the ability to heal in this region.

All these factors should be carefully kept in mind, as improper or unnecessary surgeries could lead to complications.

Treatment Options for Dacryocystorhinostomy

Vasoconstriction, or the narrowing of blood vessels, is critical in managing any bleeding that occurs during endoscopic DCR, a procedure for treating tear duct problems. There are several steps to minimize blood loss during operation:

1. Properly prepare the nose, no matter whether local or general anesthesia is used.

2. Place the patient in an inclined position.

3. If the patient is under general anesthesia, maintain their blood pressure at a slightly lower level.

4. Tranexamic acid may be given to help control bleeding, but needs to be used carefully in patients with kidney problems or recent blood clot issues.

5. If the DCR procedure is performed under local anesthesia, slower and gentler techniques are encouraged to reduce bleeding.

For an external DCR:

1. The face and nose are cleansed with a surgical preparation. A solution containing chlorhexidine is typically used.

2. When the patient is under general anesthesia, the tube facilitating breathing needs to be covered, yet access to the nose should be maintained.

3. One dose of a broad-spectrum antibiotic is given before making the skin incision.

The procedure includes various steps including incisions and gentle dissections which need to be done with care to avoid any injuries or post-operative complications.

In endoscopic DCR, similar preparation steps are followed. The surgeon then uses an endoscope (a tube with a light and camera) and conducts the procedure in the nose. An important note is to ensure good anesthesia and control of bleeding.

In cases of pediatric DCR, where the procedure is carried out on children, it’s important to note that most cases of congenital nasal duct obstruction resolve by the time the child turns one. However, for cases where surgery is needed, the anesthesia and surgical technique must be adapted to the child’s size and medical needs. Pediatric endoscopic DCR should only be performed by surgeons with expertise in adult endoscopic DCR.

Regarding the use of lacrimal intubation in DCR: This procedure involves inserting stents, or small tubes, into the tear duct system. This is thought to prevent the closure of the internal ostium, or the opening of the tear duct, and keep the soft opening between the sac and nasal cavity open during DCR healing. There are two types of stents: monocanalicular, which only requires one open canaliculus, and bicanalicular, which requires both.

No definitive guidelines exist for the use of canalicular intubation in DCR, and the choice often depends on the surgeon’s preference and the specific patient situation. The timing for removal of the stents also varies, from weeks to months after the procedure. Potential complications could arise from lacrimal stents, such as discomfort in the ocular surface, or the stent might get stuck.

What else can Dacryocystorhinostomy be?

• Severe problems related to sarcoidosis (a disease affecting lungs, skin and other body parts)
• Blepharitis in adults (a common eye condition causing inflamed eyelids)
• Alacrima (a medical condition where tears are decreased or absent)
• Bacterial conjunctivitis (a common eye infection also known as pink eye caused by bacteria)
• Basal cell carcinoma (a type of skin cancer)
• Canaliculitis (an infection of the tear duct)
• Chalazion (an inflammation of a small oil gland in the eyelid)
• Conjunctival melanoma (a rare eye cancer)
• Dermoid cyst (a type of benign growth consisting of skin cells)
• Episcleritis (an inflammation of the white part of the eye)

What to expect with Dacryocystorhinostomy

Possible Complications When Diagnosed with Dacryocystorhinostomy

All types of DCR (Dacryocystorhinostomy) surgical procedures, which help to restore the flow of tears, come with certain risks. These include but are not limited to:

• Bleeding
• Infection
• Complications from silicone stent usage
• Potential lack of improvement in tearing symptoms
• Cerebrospinal fluid (CSF) leak, which is a rare but serious complication

Using careful, non-twisting movements while removing bone during the procedure can help reduce the occurrence of CSF leaks.

External DCR, a type of DCR surgery that involves making a skin incision, has its own specific risks:

• Scarring at the incision site, which can be noticeable or cosmetically significant in a subset of patients
• Injury to the facial nerve, which can lead to issues with eye muscle function, such as difficulty closing the eye (lagophthalmos). This issue typically resolves over time, but can occasionally be permanent.

Endoscopic DCR, a type of DCR surgery that is performed through the nose, also introduces specific risks:

• Damage to the nasal lining, which can lead to the formation of abnormal tissue connections (adhesions)
• Protrusion of orbital fat
• Injury to the medial rectus muscle, a rare complication which only occurs if the location of the tear sac isn’t clear to the operating surgeon and the bone is removed improperly

Recovery from Dacryocystorhinostomy

After a surgical operation, it’s common for patients to experience mild nosebleeding, which typically stops within 12 to 24 hours. However, if the nosebleeding becomes more severe, immediate medical steps like applying pressure to the nose for at least 10 minutes can be used to control it. If necessary, the inside of the nose can be packed with gauze or a special nosebleed pack. Ongoing nosebleeds might require another visit to the operating room.

For procedures like external DCR, it’s important to keep the surgical wound dry and the sterile skin closures intact to prevent infection. The patient should avoid hot drinks for the first 48 hours after the operation as they can increase the likelihood of nosebleeds. They should also avoid blowing their nose in the first week and sneeze with their mouth open to protect the surgical site.

Once nose bleeding has stopped (usually after the first day), the patient can start using a steroid-based nasal spray, like fluticasone, twice a day for a month. There’s typically no need for topical or oral antibiotics. If any stitches were placed on the skin during surgery, these can be removed after 7 to 10 days. If silicone intubation was used during surgery, the tubes can be removed 3 to 4 weeks after the operation, although some surgeons prefer to remove them three months post-surgery.

Preventing Dacryocystorhinostomy

Before going into surgery, it’s important for patients to stop taking blood-thinning medications about 7 to 10 days in advance. This is something that should be discussed between the doctor and the patient.

The patient should also be informed about the surgical method to be used. This can be explained using visual aids like handouts or videos, making it easier to understand.

Additionally, doctors should talk about the success and failure rates of the chosen surgical procedure with their patients. It’s also useful to discuss how the surgeon’s experience can influence the outcome.

After the operation, the patient must know how to take care of their wound. This includes instructions on cleaning and dressing the wound to reduce the risk of infection.

Lastly, patients are advised not to blow their nose for a week after surgery. This is to ensure proper healing and prevent complications.