Eye Surgery Associates

Most of your tears are produced in the lacrimal gland and are vital for the health of your eyes. Blinking aids in spreading the tear film over the eye and assists in draining the tears into two small ducts (lacrimal puncta) in the corner of the eye. The tears collect in the lacrimal sac, which then drain into the nose.

A watering eye can be the result of producing too many tears or a disruption of their drainage, which causes overflow.

There are many reasons for each of these and a thorough examination by an ophthalmologist is required to determine the exact cause.

Some of the problems can be:

• a foreign body or ulcer in the eye
• a floppy and loose lower eyelid
• blockage of the lacrimal ducts between the eye and the nose

What is nasolacrimal duct obstruction?

Nasolacrimal duct obstruction (NLDO) refers to a specific blockage of the passage of tears from the lacrimal sac to the nose. There can also be a number of causes for this but often it is due to a progressive narrowing of the duct, perhaps due to chronic inflammation and swelling of the tissues that line the duct. Sometimes patients may experience other symptoms, which can include a chronic sticky eye or even an infection in the lacrimal sac, also called dacryocystitis.

If following an examination this is found to be the cause, then you may want to consider lacrimal duct bypass surgery as a solution to the eye-watering problem.

Lacrimal duct bypass surgery

This surgery, also called a dacrocystorhinostomy (DCR), is most commonly done for nasolacrimal duct obstruction (NLDO). By removing a small piece of bone lying between the lacrimal sac and the nose the blocked duct can be bypassed. In most cases (more than 90%) this will relieve eye-watering symptoms or problems caused by an obstruction.

Are there other alternatives?

For the problem of NLDO there are no other effective treatments. For most patients it is a question of how significant the eye-watering problem is for them, and how it is affecting their lives and day-to-day activities. By not having surgery the overflow of tears generally does not lead to serious eye problems. There is a small risk of an infection of the lacrimal sac and overlying skin (dacryocystitis) and if this occurs a DCR is recommended to prevent further episodes.

What does the surgery involve?

There are two techniques both with excellent success rates.

One is called the external DCR and is via a small skin incision (about 1.5 cm) on the side of the nose. The small scar generally fades after 3 to 6 months.

The other technique is an endonasal DCR, which involves using a special camera and operating via the nose. An endonasal approach means no skin incision is made.

The shape and anatomy of your nose will determine which technique is best for you and will offer the greatest chance of success.

Both procedures can be done as a day surgery and usually under local anaesthetic with sedation. General anaesthetic may be suggested in certain situations.

After the anaesthetist has administered relaxing medication, local anaesthetic is injected into the skin around the lacrimal sac area. The nose on the side to be operated on is gently packed with small pieces of gauze, which is important to prevent bleeding during the operation, but these are removed during the procedure.

At the end of the operation a small silicone tube remains in the corner of the eye and sits in the nose. This assists in establishing the new bypass connection and is generally left for 4 to 6 weeks. It is rarely noted by the patient and easily removed in the clinic at a follow-up appointment without further surgery.

What are the risks?

There are a small group of patients in whom the surgery is unsuccessful, generally less than 5%. This rate can vary depending on how severe the NLDO is. If the blockage is initially only partial the success rate can be less.

Nose bleeding can also uncommonly occur either following the procedure or rarely up to one week later. Infection following the surgery is very uncommon.

Damage to your eye or vision is extremely rare as the surgery occurs next to and within the nose.

Complications from the anaesthesia, such as allergic reactions, breathing or heart problems are also extremely rare.

What happens after the surgery?

You will be given a list of instructions, which will outline what to do following the surgery. You should plan to have at least one week's rest. Follow-up appointments are generally at one week and one month. There is minimal pain and discomfort following the surgery, which usually responds very well to simple oral analgesia.

Please note that eye watering may still continue while the small silicone tubes are in the nose, until removed at around one month.

Following DCR surgery some patients will notice 'air' blowing on the eye when blowing their nose, which is normal and confirms that the bypass surgery has been successful.

If you or your family have any other questions regarding the surgery please take the opportunity to ask them.