Endoscopic Surgery for the Treatment of Blocked Tear Ducts

Constant watery eyes due to blocked tear ducts not only make it difficult to get through normal activities and everyday life, but can as well be the cause of a variety of other eye-related diseases and disorders.

Thanks to a modern surgical treatment known as endoscopic dacryocystorhinostomy (endoscopic DCR), treatment of blocked tear ducts can now be carried out much more effectively, with a very high success rate. And patients can return to their normal lives much more quickly.


When Tear Drainage Systems Malfunction

Tears are produced by the lacrimal glands located behind and inside the eyelids in order to lubricate the ocular surface and reduce friction when blinking. Tears also help to wash out any foreign matter that might cause eye irritation.

Tears drain from the eyes through two openings called the puncta, located in the inner corners (inner canthus) of the upper and lower eyelids. From the puncta, tears drain into the lacrimal sac. And from the lacrimal sac, tears flow down through the nasolacrimal duct and empty into the nose and throat.

Sometimes, the tear drainage system (lacrimal drainage system) may malfunction for a number of reasons, for example, congenital nasolacrimal duct obstruction, which is a blockage in the tear duct valve from birth; anatomical abnormalities in various parts of the tear drainage system; infection or inflammation of the tear drainage system; viral infection; chronic conjunctivitis; and overuse of eye drops and/or drug allergies, although, in many cases, the cause is unknown. It has also been found that the risk of blocked tear ducts increases with age.

Patients with blocked tear ducts will experience excessively watery eyes to the point that they will need to constantly wipe their eyes. As a result, contaminants often remain in the eyes, and the trapped bacteria can lead to infections, which cause abscesses and discharge. This also creates the risk of a bacterial infection spreading into the eyes and the tissue surrounding the eye sockets, as well as a wide variety of other diseases, such as chronic conjunctivitis, keratitis, and blepharitis (chronic inflammation of the eyelids) – which can cause eyelashes to grow abnormally or fall out, and is a constant source of itchiness and irritation.

Treatment Using Endoscopic Surgery (Endoscopic Dacryocystorhinostomy)

Although treatment for blocked tear ducts can be carried out through an external dacryocystorhinostomy, commonly known as the traditional surgery, it does involve an incision on the side of the nose. The surgeon must cut through the skin and muscle at the inner aspect of the lower eyelid to perform an osteotomy (removal of bone) of about 1.5 cm in order to create a new passage way between the lacrimal sac and the nose. However, this results in permanent scarring and a longer recovery time.

Ophthalmologists, therefore, will generally recommend the newer surgical technology which, in addition to leaving no visible scarring, also allows patients to heal and recover much more quickly. This type of surgery employs the use of a microscopic camera known as an endoscope and other instruments which are inserted through the nasal opening to the tear duct system. Surgery can then be performed to create a pathway for drainage from the eye to the inside of the nose. This method uses flap suturing techniques to create a new, direct and permanent passage way between the lacrimal sac and the nose. This new route bypasses the duct that empties into the nose (nasolacrimal duct), which is the most common site of blockage, and allows tears to drain directly into the nasal cavity. A silicone stent is then inserted and can be left in the nasal vestibule, to be removed approximately four weeks later.

An endoscopic dacryocystorhinostomy (endoscopic DCR) procedure must only be carried out by an ophthalmologist who has received specialized training, called oculoplastic specialist, and has a high level of experience.

Before and After Endoscopic Surgery

In order to be sure that a patient’s watery eye symptoms are indeed due to blocked tear ducts, the ophthalmologist will carry out a diagnosis using a technique known as lacrimal irrigation, which includes the following steps:

  • Topical anesthetic is administered to the patient’s eye.
  • The doctor dilates the puncta.
  • Irrigation (flushing sterile liquid through the duct and into the nose) is then carried out to ensure the duct is open and that any blockage has been removed.

In cases where the patient’s lacrimal system is functioning normally, the sterile fluid will pass freely through to the nose. The patient will have a salty or bitter taste in the back of their throat. If, however, the patient’s tear duct is restricted or blocked, the liquid will be unable to drain down freely or may flow slower than normal, and there will be regurgitation of the liquid through the punctum.

This method, in addition to confirming the cause of the condition, can also help to determine the location of the blockage, indicating whether the blockage is in the nasolacrimal duct, the puncta, or the lacrimal sac. It can also help to identify the degree of the blockage as well.

After endoscopic DCR surgery (which should take approximately 45 minutes to 1 hour), the patient is recommended to stay in the hospital overnight in order to sleep off the effects of the anesthesia. Some patients may experience a slight swelling or bruising and may feel as if they have a cold for about 3-5 days. Doctors will usually prescribe antibiotic medication to be taken for approximately one week following surgery, along with eye drops and nasal spray to help cleanse the eyes and nose. They can be self-administered at home and are required to be used for about one month following surgery. An eye patch is not required for the patient to wear at home.

By Dr . Nattawut Wanumkarng , Ophthalmologist specializing in Oculoplastic and Reconstructive Surgery, Eye Center, Bumrungrad Hospital

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