Dacryocystorhinostomy (Tear Duct Surgery)

Introduction

Dacryocystorhinostomy (DCR) is a surgical procedure designed to treat blocked tear ducts, also known as nasolacrimal duct obstruction. This condition can result in excessive tearing (epiphora), recurrent eye infections, and inflammation. DCR aims to create a new pathway for tears to drain from the eyes into the nose, bypassing the blocked duct.

History and Development

The concept of dacryocystorhinostomy dates back to the early 20th century. Over the years, the procedure has evolved significantly, with advancements in surgical techniques and technologies enhancing its safety and efficacy. Initially performed as an external surgery, DCR now includes minimally invasive endoscopic approaches, which offer numerous benefits, including reduced scarring and quicker recovery times.

Indications for DCR

Dacryocystorhinostomy is recommended for patients experiencing:

• Chronic tearing due to nasolacrimal duct obstruction
• Recurrent dacryocystitis (infections of the tear sac)
• Mucocele or pyocele formation (cystic swellings due to mucus or pus accumulation)
• Failed conservative treatments, such as probing and irrigation

Types of DCR

There are two primary types of dacryocystorhinostomy:

External DCR

This traditional approach involves making a small incision on the side of the nose, near the corner of the eye. The surgeon then creates a new opening between the lacrimal sac (tear sac) and the nasal cavity. Although effective, external DCR may leave a visible scar and requires a longer recovery period.

Endoscopic DCR

In this minimally invasive technique, the surgeon uses a nasal endoscope to access the tear sac through the nasal cavity. No external incision is necessary, resulting in a scar-free appearance and faster recovery. Endoscopic DCR is increasingly preferred due to its less invasive nature and high success rates.

The Surgical Procedure

Preoperative Preparation

Prior to the surgery, patients undergo a thorough evaluation, including a detailed medical history, physical examination, and imaging studies (such as dacryocystography or CT scans) to confirm the diagnosis and plan the procedure. Patients are advised to stop taking blood-thinning medications and refrain from eating or drinking for a specified period before the surgery.

The Operation

DCR is typically performed under local anesthesia with sedation or general anesthesia, depending on the patient’s preference and the surgeon’s recommendation. The surgical steps include:

• Administering anesthesia to ensure patient comfort during the procedure
• Accessing the tear sac either externally or endoscopically
• Creating a new pathway between the tear sac and the nasal cavity
• Inserting a silicone stent to keep the new passage open during healing
• Closing the incision (for external DCR) or ensuring proper placement of the endoscopic instruments

The entire procedure typically takes about 1 to 2 hours, and patients can usually go home the same day.

Postoperative Care and Recovery

After the surgery, patients receive detailed instructions for postoperative care, which may include:

• Using prescribed antibiotic and anti-inflammatory eye drops to prevent infection and reduce inflammation
• Avoiding strenuous activities and heavy lifting for several weeks
• Keeping the surgical site clean and dry
• Attending follow-up appointments to monitor healing and remove the stent (usually after a few weeks to several months)

Most patients experience significant improvement in symptoms within a few weeks, with complete recovery typically occurring within 4 to 6 weeks.

Benefits of DCR

Dacryocystorhinostomy offers several benefits, including:

• Relief from chronic tearing and its associated discomfort
• Reduction in recurrent eye infections and inflammation
• Improvement in quality of life and daily activities

Endoscopic DCR, in particular, provides additional advantages such as minimal scarring, faster recovery, and reduced postoperative complications.

Potential Risks and Complications

As with any surgical procedure, DCR carries certain risks and potential complications, including:

• Infection at the surgical site
• Bleeding or hematoma formation
• Scarring (primarily with external DCR)
• Failure of the new tear drainage pathway to remain open
• Adverse reactions to anesthesia

However, these risks are relatively rare, and the vast majority of patients experience successful outcomes.

Nursing Care of a Patient with Dacryocystorhinostomy (Tear Duct Surgery)

Dacryocystorhinostomy (DCR) is a surgical procedure performed to create a new tear drainage pathway between the lacrimal sac and the nasal cavity, bypassing an obstructed nasolacrimal duct. This surgery can be done externally or endoscopically, with the latter offering benefits like minimal scarring and quicker recovery. Effective nursing care is essential for optimizing patient outcomes and minimizing complications.

Preoperative Care

Patient Assessment

• Conduct a thorough assessment of the patient’s medical history, including any allergies and previous reactions to anesthesia.
• Evaluate the patient’s current medications, including anticoagulants, which may need to be discontinued before surgery.
• Assess the patient’s understanding of the procedure and provide education to address any concerns or misconceptions.

Preparation

• Ensure that the patient has adhered to preoperative instructions, including fasting protocols if required.
• Administer preoperative medications as prescribed, such as antibiotics or sedatives.
• Assist the patient in removing any makeup, contact lenses, or jewelry prior to the procedure.

Postoperative Care

Monitoring and Assessment

• Closely monitor vital signs, including blood pressure, heart rate, and respiratory rate, ensuring they remain stable.
• Observe the surgical site for signs of infection, bleeding, or hematoma formation.
• Assess the patient’s level of pain and administer analgesics as prescribed.

Patient Education

• Instruct the patient on proper wound care, emphasizing the importance of keeping the surgical site clean and dry.
• Provide guidelines on activity restrictions, such as avoiding strenuous activities and heavy lifting.
• Educate the patient on recognizing signs of complications, including infection, excessive bleeding, or adverse reactions to medications.

Pain Management

• Administer prescribed pain medications and monitor their effectiveness.
• Encourage the use of non-pharmacological pain relief methods, such as applying cold compresses to reduce swelling.

Follow-Up Care

Ongoing Monitoring

• Schedule follow-up appointments to monitor the patient’s healing progress and address any concerns.
• Ensure that the new tear drainage pathway remains open and functioning properly.
• Continue to assess for any late-onset complications and provide appropriate interventions.

Support and Resources

• Provide information on support groups or counseling services if the patient experiences anxiety or emotional distress related to the surgery.
• Offer resources for additional information on Dacryocystorhinostomy and postoperative care.

REFERENCES

1. Ali MJ. Primary External Dacryocystorhinostomy. In: Ali MJ, ed. Principles and Practice of Lacrimal Surgery. Springer. 2018:189-195.
2. Ali MJ, Naik MN, Honavar SG. External dacryocystorhinostomy: Tips and tricks. Oman J Ophthalmol. 2012 Sep;5(3):191-5. doi: 10.4103/0974-620X.106106. PMID: 23440476; PMCID: PMC3574519.
3. American College of Ophthalmology EyeWiki. Multiple Dacryocystorhinostomy. https://eyewiki.aao.org/Dacryocystorhinostomy pages reviewed.
4. Bourdeu K, Bayes J, Eappen S. Anesthesia for Ophthalmic Surgery. In: Longnecker DE, Mackey SC, Newman MF, Sandberg WS, Zapol WM, eds. Anesthesiology. 3rd ed. McGraw-Hill Education; 2017.
5. Gupta N. Surgical Technique of Endoscopic Dacryocystorhinostomy. In: Gupta N, ed. Endoscopic Dacryocystorhinostomy. Springer. 2020:89-105.
6. Ullrich K, Malhotra R, Patel BC. Dacryocystorhinostomy. 2023 Aug 7. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan–. PMID: 32496731.
7. Hurwitz JJ, Olver JM, Dutton JJ. The Lacrimal Drainage System. In: Yanoff M and Juker JS, eds. Ophthalmology. 6th ed. Elsevier. 2023:1266-1271.
8. Kshirsagar RS, Vu PQ, Liang J. Endoscopic versus external dacryocystorhinostomy: temporal and regional trends in the United States Medicare population. https://pubmed.ncbi.nlm.nih.gov/30712428/). Orbit. 2019 Feb;38(6):453-460.
9. Muscatello L, Giudice M, Spriano G, Tondini L. Endoscopic dacryocystorhinostomy: personal experience. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2639884/. Acta Otorhinolaryngol Ital. 2005 Aug;25(4):209-213.
10. Sobel RK, Aakalu VK, Wladis EJ, Bilyk JR, Yen MT, Mawn LA. A Comparison of Endonasal Dacryocystorhinostomy and External Dacryocystorhinostomy: A Report by the American Academy of Ophthalmology (https://pubmed.ncbi.nlm.nih.gov/31358391/). Ophthalmology. 2019 Nov;126(11):1580-1585. Accessed 1/12/2025.
11. StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. Multiple Dacryocystorhinostomy (https://www.ncbi.nlm.nih.gov/books/NBK557851/) pages reviewed. Accessed via the U.S. Library of Medicine 1/12/2025.

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