Tears are constantly produced to lubricate and clean the eye. This fluid is collected and drained by the lacrimal apparatus, flowing across the eye and into the nasal cavity via the nasolacrimal duct. When the duct becomes partially or completely blocked, tears cannot drain normally—a condition called nasolacrimal duct obstruction (NLDO). This results in excessive tearing (epiphora), which is uncomfortable, blurs vision, and increases the risk of eye and tear sac infections.
Understanding Lacrimal System Blockages
In adults, the most frequent cause of lacrimal system blockages is age-related narrowing (involutional stenosis), seen more often in women. Other acquired causes include chronic inflammation or infection in the eyes or nose, leading to scar tissue formation and duct narrowing. Trauma to the face or nose can also disrupt the tear drainage system, causing an obstruction. Patients typically report persistent tearing (epiphora) as the main symptom, often accompanied by a gooey discharge on the eyelids. A more concerning symptom is dacryocystitis, a painful infection of the lacrimal sac, appearing as swelling and redness near the inner corner of the eye. These chronic symptoms indicate that tear duct surgery is required.
The Goal of Dacryocystorhinostomy
Dacryocystorhinostomy (DCR) is the surgical procedure designed to treat this obstruction. The purpose of DCR is to entirely bypass the blocked portion of the nasolacrimal duct and create a new, direct drainage pathway for tears. The obstruction typically occurs in the bony canal, preventing tears from traveling from the lacrimal sac into the nose.
The surgeon addresses this by creating a new opening (an osteotomy) in the bone separating the lacrimal sac from the nasal cavity. This opening allows the lacrimal sac to connect directly to the nasal mucosa, rerouting tears into the nose above the original blocked duct. By establishing this fistula, tears can once again drain internally, relieving chronic tearing and infection.
During the procedure, the surgeon creates flaps from the lining of the lacrimal sac and the nasal mucosa, which are stitched together to ensure the new channel remains open. This process, called marsupialization, helps promote healing and prevents scarring that could close the new passageway. To secure the patency of this new drainage route, a small, soft silicone tube or stent is often temporarily placed through the new opening. This stent runs from the eyelid puncta, through the new connection, and into the nose, acting as a scaffold during the initial healing phase. It remains in place for several weeks to a few months before being removed in an outpatient setting. The DCR success rate ranges from 90% to 95%, measured by the resolution of the patient’s tearing symptoms.
Surgical Methods and Techniques
Dacryocystorhinostomy is performed using two distinct methodologies: the External DCR and the Endoscopic Endonasal DCR. The traditional External DCR involves making a small incision (10 to 20 millimeters long) near the inner corner of the eye. This approach offers the surgeon direct visual access to the lacrimal sac and surrounding bony structures, which is advantageous in complicated cases. Although often cited as the gold standard due to high success rates, the external approach leaves a small, permanent facial scar.
A more modern alternative is the Endoscopic Endonasal DCR, which avoids any external skin incision. In this minimally invasive technique, the surgeon operates entirely through the nostril using an endoscope and specialized instruments to create the new drainage pathway. The endonasal method results in a quicker recovery time and eliminates the risk of a visible facial scar. While technically more demanding, its success rates have become comparable to the external technique, often exceeding 90%. The choice depends on the patient’s anatomy, the surgeon’s expertise, and the complexity of the obstruction.
Recovery and Long-Term Care
Following DCR, patients generally return home the same day. Temporary side effects include bruising and swelling around the eye and nose, especially with the external approach. Patients are advised to use prescribed antibiotic eye drops and, in some cases, nasal decongestants or steroid sprays to manage inflammation and prevent infection.
A crucial post-operative instruction is to avoid blowing the nose for at least one week, as the force can disrupt the surgical site or dislodge the stent. Strenuous activity or heavy lifting is restricted for 7 to 10 days to minimize the risk of bleeding. If a silicone stent was placed, it is usually removed by the surgeon during a follow-up visit, typically a few weeks to several months after the initial surgery.
Long-term success is monitored through follow-up appointments to ensure the new passage remains open and tearing symptoms have resolved. While rare, potential complications include persistent nosebleeds, failure of the new channel requiring revision surgery, or recurrence of tearing. Most patients see significant symptom improvement within the first few weeks, though the bony opening takes several weeks to fully heal.