Lacrimal (tear duct) Surgery

There are often multiple reasons, which fall into 2 categories:
1. The eye is overproducing tears
2. The tears are not draining properly

Most tears evaporate from the surface of the eye.
The excess tears flow into the nose via small drainage holes in the eyelids (puncta), into the lacrimal sac then into the nose via the nasolacrimal duct.
The passages of the nasolacrimal system are very narrow and small changes can cause blockage.
Tears will well up in the eye and spill onto the cheek or the eye becomes sticky.
Some people develop a painless swelling of the tear sac or secondary infections.

Dacryocystorhinostomy (DCR) surgery creates a new pathway between the tear sac and nose to bypass the tear duct blockage.
There are 2 techniques:
1. Surgery is performed via the inside of the nose (endoscopic DCR)
2. Surgery is performed via a small skin incision on the side of the nose (external DCR)

DCR surgery is successful in 90-95% of cases where there is a clear nasolacrimal blockage.
The success rate is lower if there is no clear blockage demonstrated on syringing or imaging or if there are additional blockages in the lacrimal system.
There is no difference in success rate between the endoscopic or external approach.

Most cases are performed as a day case procedure, usually under general anaesthesia
It is possible to have surgery local anaesthesia and twilight sedation in some cases.
In some patients, small silicone tubes (stents) are placed through the newly formed passage.
The stents are usually removed after 4 to 6 weeks.
The eye is not padded after endoscopic DCR.
Driving can be resumed after 24 hours and patients can return to their normal routine after several days.
A period of 5 to 7 days off work is recommended.
There may be some bruising around the eye, lasting a week.
Vigorous exercise is resumed after 1 to 2 weeks.
Nose blowing is avoided for 1 week then allowed gently for 4 weeks.
Routine postoperative appointments are 1 week and 1 month after surgery.

Most people are helped by DCR surgery but there are potential risks.
There may only be partial improvement of watering under certain conditions.
Uncommonly the watering is not improved or can return weeks or months after surgery.
The new tear duct opening can close due to scarring inside the nose.
Repeat or revision surgery can be considered to reopen the scar and remains effective in helping most patients.
The lacrimal tubing can cause irritation to the eye before it is removed after several weeks.
Sometimes the tubing can spontaneously prolapse or fall out.
There is a small risk of infection (sinusitis).
Some patients will feel a brief puff of air (air reflux) passing onto the eye. This may be noticeable in about 20% of patients. This is due to the new passage created which allows air to travel back up the tear ducts. It is not harmful to the eye and usually improves over time.

There are no drops or medication that can treat tear duct obstruction.
Sometimes nasolacrimal syringing can improve symptoms for a limited time.
Watering does not damage the eye but can blur the vision and be irritating.
Infection can result from a tear duct blockage. In these patients, surgery is recommended as infections can become recurrent.