KAISER PERMANENTE SAN RAFAEL MEDICAL CENTER
TEARING & LACRIMAL DRAINAGE SURGERY
DEPARTMENT OF OPHTHALMOLOGY
OCULOFACIAL PLASTIC & RECONSTRUCTIVE SURGERY
GREGG S. GAYRE, MD
BOARD CERTIFIED: AMERICAN BOARD OF OPHTHALMOLOGY
AMERICAN SOCIETY OF OPHTHALMIC PLASTIC & RECONSTRUCTIVE SURGERY

Why Patients Tear

Tears are made primarily by the lacrimal gland, which is anatomically located in the upper lateral aspect of the upper eyelid. With each blink, however, tears are drained from the eye through the tear drainage system, into the nose. There are normally two openings to the tear drainage system; one in the upper eyelid and one in the lower eyelid. These tiny drains are situated along the margin of the eyelid, closest to the nose, and are known as puncta. The puncta lead to tiny ducts known as canaliculi which lead to the lacrimal sac, situated just along the inside corner of the eye, on the side of the bridge of the nose. Tears are carried from the lacrimal sac down the nasolacrimal duct into the nose.

Epiphora, or excessive tearing, can occur as a result of excess tear secretion or as the result of a blockage in the lacrimal drainage system, which impairs normal tear channeling into the nose. Tearing can result if any portion of this drainage system becomes blocked, however, it is usually toward the bottom of the nasolacrimal duct that the majority of obstructions of this passageway occur.

In advanced cases infection may occur in a blocked tear drain. In nature, when a river flows freely, the river is healthy, the fish are healthy, and the water is clean. When it is blocked a "stagnant pond" can result. In the eye, this "stagnant pond" tends to accumulate debris and bacteria and is a constant or potential source of pus and other material. In such cases the infection can only be eradicated by restoration of flow by means of a bypass surgery to bypass the blockage and restore free flow into the nose.

Another common source of excess tear secretion is actually a dry eye. In patients with dry eyes, sensitive nerve endings in the cornea signal the lacrimal gland to produce tears. This reflex action may actually overwhelm the drainage system, leading to tearing. In such cases, the use of artificial tear products may actually diminish this reflex and decrease epiphora. The cause of most tear duct obstructions remains unknown. Occasionally, trauma, trauma, or sinus disease may lead to the obstruction of the tear drain system.

Finally, tearing may result from abnormal eyelid position. Out-turning eyelids, in-turning eyelids, and eyelids with weak muscle function may lead to tearing and require restoration of the normal eyelid anatomy in order to alleviate symptoms.

Symptoms of Excessive Tearing

Patients may complain socially unacceptable unilateral tearing from one or both eyes interfering with vision. They often complain of having to constantly have a tissue on hand to dab at the excess tears and the salt within the tears may actually corrode the metal frame of their glasses or cause chronic irritation of the skin.

When an individual develops tearing due to acquired obstruction of the nasolacrimal (tear) duct, a dacryocystorhinostomy, or DCR procedure is usually the treatment of choice. However, diagnosis of the condition must be made first, and this usually requires one or more in-office tests by the ophthalmologist. This may include a dye disappearance test, whereby fluorescent dye is placed on the eye surface, and the disappearance between the two eyes compared. A second test for obstruction of the nasolacrimal duct might include irrigation of the tear drainage pathways. This non-painful test is completed by placing a small, blunt irrigating syringe just inside the initial opening of the tear duct, and irrigating fluid (water or saline) through the tear drainage system. If the nasolacrimal duct is determined to be relatively or completely obstructed, a DCR procedure is often appropriate. Recurrent infection also may occur as a result of the stagnation. The dacryocystorhinostomy operation, which involves fistulization of the lacrimal sac into the nasal cavity, may alleviate the symptoms.

Indications for dacryocystorhinostomy

• Socially unacceptable epiphora caused by anatomic or functional lacrimal sac or nasolacrimal duct obstruction
• Chronic dacryocystitis with abscess formation within the tear sac and purulent drainage from the eye
• Inflammation of the skin overlying the lacrimal sac in the region of the medial canthus
• Dacryolith (stone) formation
• Lacrimal sac mass (both benign and malignant)

The DCR Procedure

Dacryocystorhinostomy is actually this bypass surgery to eliminate a portion of the nasolacrimal system that is diseased. If there is obstruction in the nasolacrimal system, this may be used to directly connect the tear drains into the nose. This is done by removing a small portion of the bone on the side of the nose and placing a small stent in the tear drains to allow drainage into the nose.

In this procedure, the tear drainage pathways are reconnected to the inside of the nose. A small incision is usually placed approximately midway between the corner of the eye and the bridge of the nose. The lacrimal sac is located, incised, and then connected to the nasal mucosa creating a new tear drainage pathway. Tiny plastic tubes (stents) are then placed in the newly created tear drainage pathway for a few months to prevent scarring of the tear drainage ducts, which might otherwise result in failure of the surgery. The tubes can usually be removed in the office with little if any discomfort or need for anesthesia.

Endocscopic DCR

In some cases it may be preferable for the patient to avoid any external scars. In such cases the surgical approach may employ rigid telescopes or microscopes to perform the entire procedure through the nose. With this technique, surgical success rates are lower (70% as compared to the 95% success of an external DCR). In addition, the patient must have relatively normal nasal anatomy without enlarged sinus cavities or a deviated septum.

The Balloon (Non-Incisional) DCR

A balloon DCR is similar to the incisional DCR in objective, although the procedure is completed without an incision. The surgeon advances tiny tubing through the blocked tear duct, utilizing an inflatable balloon to help create a new tear drainage pathway into the nose. The inflatable balloon is the same type of balloon used in coronary (heart) artery angioplasty procedures. The long term success rates for this procedure are unknown and is believed to be temporary. In each of these procedures it is necessary to place a temporary stent in the newly opened tear drain in order to ensure longterm success. The stent is small a causes no symptoms. It is usually left in place for six months. Removal of the tubing causes little if any discomfort and is typically performed in the office without the need for anesthesia. A larger, red rubber tube is also in your nose. This passes into the new drainage opening we made during surgery. This red tube will fall out by itself about 3 weeks after surgery.

Surgical Risks

As with any surgical procedure, complications are possible. Significant surgical complications are minimal, but may occur. The most dreaded complication of any surgery is a complication to your overall health (including death). Such complications are exceedingly rare and, in fact, your health is at greater risk from a motor vehicle accident on the way to or from surgery than from the actual procedure itself.

Additionally, when surgery is performed around the eyes, vision loss is possible. However, in the hands of an experienced surgeon, visual loss is exceedingly rare.

Excessive and prolonged bleed can occur after a DCR. In anticipation of surgery, it is very important to minimize your risk of bleeding. The eyelids and nasal cavity have a very rich blood supply and excessive bleeding may result in excessive bruising and swelling, nose bleeds, need to abort the surgical procedure, failure of the procedure and in rare instances, permanent vision loss.

You will find an attached list of over-the-counter, prescription, and alternative medications that increase the risk of bleeding. In addition, it is very important to inform you doctor of any history of bleeding or clotting disorders.

With any surgical procedure, a surgical scar in the skin is produced. The surgical wounds in tear drain surgery are minimal and barely noticeable. Where possible, these procedures are performed through a skin incision across the lower eyelid hidden in the eyelid crease, or within other natural folds of wrinkles. After the initial redness at the incision site resolves, scarring is minimal and not visible to the untrained eye. Occasionally, surgical scarring may result in an abnormally prominent scar or an asymmetric eyelid crease. For the vast majority of patients, these prominent scars or asymmetrical eyelid creases will resolve without need for further surgery. In rare instances, further surgical intervention will be required to treat abnormal scarring.

Infection is also a potential complication of any surgical procedure. Fortunately, infection after tear drain is also very rare. You will be given an antibiotic ointment to apply to the incision site 4 times daily as well as a drop to use in the eye four times daily for two weeks after surgery. Occasionally, oral antibiotics are prescribed for prolonged surgical procedures or for patients with increased risk of infection.

Occasionally scar tissue may occur within the nose near the site of surgery. In most cases, this is asymptomatic, but occasionally such scarring may result in recurrent tearing or obstruction of the air passage way. If such symptoms occur, they may require surgical correction.

External DCR has a 95% success rate. As with any surgery, no guarantees can be made regarding outcome. For those 5% of patients who do not respond, a repeat DCR may be necessary. Often times it is possible to repeat surgery without having to create another external incision.

Because tear drain surgery requires either IV or general anesthesia, it is necessary that patients avoid eating or drinking after midnight on the morning of the procedure. Failure to comply may result in the cancellation of your surgery. Despite this warning it is important that you continue to take your regular medications with a small sip of clear fluids unless otherwise instructed by your doctor or nurse. If you have a condition that requires antibiotics before any invasive procedure, be sure to let your physician know, so that a prescription antibiotic can be provided in advance.

Prior to surgery, it is important that you secure a ride to and from the surgical center. Even if you do not receive a sedative your vision after surgery will be blurry, and your doctor does not recommend that you drive. It is also advised that you do not to rely on a taxi or public transportation in case you should require urgent medical attention in the immediate post-operative period. Failure to secure travel arrangements with a family member or friend may result in the cancellation of your surgery. Most patients who require assistance after surgery, usually rely on a family member or friend on the afternoon and evening of surgery. Extended assistance is usually unnecessary. If you are making arrangements for assistance, typically this is necessary for only the first evening following surgery.

In most cases dissolvable sutures are utilized to close your surgical incisions. These sutures are delicate. Avoid manipulating or rubbing your incision sites. As the sutures dissolve, itching and a slight increase in redness may occur. This is normal. Over the counter Benadryl® and ice may help with itching. Please avoid using home remedies or other over- the-counter remedies as they may cause an abnormal reaction in the delicate eyelid skin.

You will be asked not to bend over and not to blow your nose for 2 weeks after surgery. Tearing may temporarily worsen post-operatively, but should improve with time. After surgery ice packs are applied and are utilized for the first 48 hours after surgery in order to minimize swelling. Specialized ice packs are available at the pharmacy; however they are often expensive and function poorly. Many patients prefer to use a package of frozen peas as they easily conform to the curves of the face. Alternatively, bath cloths, soaked in an ice bath function well. Swelling is best minimized by applying ice for 20 minute intervals followed by 20 minutes without ice, then repeating. Cold compresses should be used at a minimum of 15 minutes out of the hour, every hour, while awake.

It will be important that you try to sleep with your head elevated on 2 pillows for 4 days.

Post-operative healing time varies from patient to patient. It is advisable not to schedule travel plans or important events within four weeks of surgery. This will allow adequate time to heal. For most, swelling and bruising resolves within two weeks. It is not uncommon however, for patients to appreciate a subtle, mild change in their vision.

Most patients undergoing eyelid surgery require post-operative visits at two weeks, and six months following surgery. Occasionally more visits are necessary.

If you’ve been troubled or embarrassed by tears running down your face, you may want to consider one of the latest DCR procedures. These advanced procedures performed by experienced surgeons offer tremendous potential to effectively and permanently resolve your tearing, in some cases without even so much as an incision! I hope that you have found this information helpful and I would appreciate your feedback on how to improve this guide so that it will be helpful to future patients.

Frequently Asked Questions:

What are the risks of tear drain surgery?
Bleeding for several days after surgery; wound infection; persistent tearing; nose-bleeds; CSF-leaks; nasal scarring; persistent swelling of the eyelid, prominent scarring; ETC.

Will my scar be noticeable after surgery?
The scar is less than ½ inch long and in most cases is placed in a natural skin fold near the area of the nose where your glasses rest. Most patients report that they cannot see the area of incision within a month after the wound is healed.

How do I know if my vision or health is affected by my tearing?
The degree of excess tearing that causes a disruption in your normal life-style varies from patient-to-patient. Only you (not the physician) can determine when your symptoms are severe enough to warrant surgery. Any patient with a history of tear duct infection or patients with symptoms consistent with a tear duct tumor are recommended to undergo surgery.

What are the symptoms that my eyes are dry and require lubrication?
Tearing, foreign body sensation, redness and blurred vision are common features of dry eye.

How long will the surgery take?
Surgery itself takes only about an hour. However, the pre-operative evaluation requires up to 30 minutes and patients that receive sedation may require up to 2 hours observation in the post-op holding area.

Will my surgery be covered by my insurance?
Yes. Tear duct obstruction by-pass surgery is a covered benefit.

I am a diabetic, are there special precautions?
As a rule, diabetics heal more slowly and have a higher risk of complications. It is important to have your blood sugar under tight control prior to surgery. Additionally, it is very important that you discuss with your physician and nurse, how to take your normal a.m. dose of insulin or oral glucose control medications. In most instances, your doctor will recommend avoiding taking oral glucose control medications and short acting insulin on the morning of surgery. Please confirm this with your doctor or nurse.

Should I take my regular medications on the morning of surgery?
Despite the rule of no eating or drinking after midnight on the morning of surgery, In most instances it is important to take your regular prescribed medications on the morning of surgery with a sip of clear fluid. Failure to do so could result in cancellation of your surgery.

What number should I call in case of emergency?
(415) 444-0111 and explain that you have recently had eyelid surgery and need to speak to Dr. Gayre or the eye specialist covering his “on-call” patients.