DCR Surgery and Lacrimal Intubation

Patient information document for patients undergoing lacrimal surgery.

This includes the following procedures:

• External dachryocystorhinostomy (DCR)
• Endo-nasal DCR
• Lester Jones tube insertion

INSTRUCTIONS

This is an informed-consent document that has been prepared to help you understand the procedures mentioned above and their risks. It is important that you read this information carefully and completely.

Section A provides a brief outline of the procedures. Section B outlines the risks associated with lacrimal surgery and before and after care. The surgical plan is individually tailored for every patient and your physician will discuss your individual needs.

SECTION A

Dacryocystorhinostomy or DCR is a procedure that creates a bypass when the tear drainage system is blocked. Lacrimal intubation (stenting) can help overcome a partial obstruction (stenosis) of the naso-lacrimal duct. Lester Jones tube insertion indicated when all other measures have failed.

TEAR DRAINAGE

With every blink, the eyelids spread tears evenly across the eye to keep it moist; the remaining tears are then pumped into the nose via the tear drainage system. If this tear duct is blocked, the tears spill over your eyelids on to your cheeks. Stagnant tears can also result in repeated infections.

FEATURES OF BLOCKED TEAR DUCT

Excessive watering is the most common symptom but recurrent conjunctivitis or a painful swelling (mucocoele) in the inner aspect of the eyelid can also occur. A careful history and examination help exclude other causes of a watery eye. The location and severity of the obstruction can be determined by passing a fine probe into the tear drainage system. This procedure is performed in clinic. Anesthetic drops are used so that this is not too uncomfortable. Occasionally additional imaging studies may be needed.

ANATOMY

The tear drain starts at two tiny openings called punctum that are located in the inner aspect of both the upper and lower lids. The punctum is connected to the tear sac by very fine tubes called canaliculus. The tear sac is located in the inner corner of the eye next to the nose. A bony canal called the nasolacrimal duct drains the tears from the sac into the nasal cavity.

TREATMENT OPTIONS

When the more common causes of a watery eye have been ruled out and a blocked tear duct has been confirmed, your surgeon will discuss the various options. Depending on the severity, precise area of the obstruction and nasal anatomy the surgery can either be carried out from inside the nose using an endoscope (endonasal DCR) or via a small skin incision (external DCR). A new tear drain is created to by-pass the obstruction that opens directly into the nose. A fine silicone stent is temporarily inserted into the new tear drain (for 8 to 12 weeks) to keep it open during the healing process.

• DCR surgery is performed under general anesthesia but can also be performed under local anesthesia with sedation in patients that are not suitable for general anesthesia. Most patients go home the same day and are advised to use antibiotic drops and ointment for a week after surgery.
• Lacrimal intubation for narrowed tear ducts is performed under general anesthesia and the stents are left in place for 12 weeks.
• Lester Jones tubes are special glass tubes that are permanently placed in the inner corner of the eye when the obstruction cannot be overcome by any other means.

SECTION B

RISK AND COMPLICATIONS

• Bleeding – Most patients experience minor bleeding from the nose for the first few days after surgery. When there is more than a trickle of bleeding, leaning forward and pinching the nostrils will stop the bleeding in almost all patients. In the extremely rare case of severe persistent bleeding, please go to the nearest emergency department.
• Bruising and swelling - Minor bruising and swelling can be expected on the side of the nose (external DCR) that settles within two weeks.
• Scar - The small skin scar for patients undergoing external DCR usually fades within six months.
• Chronic pain - Chronic pain may occur very infrequently after surgery.
• Infection - Infection is very rare after surgery. Should an infection occur, additional treatment including antibiotics might be necessary.
• Additional surgery – Watery eye symptoms occur due to many causes and occasionally the symptoms may not resolve completely following surgery. In some patients, additional surgery may be recommended by your doctor.

WHAT ARE THE PREPARATIONS FOR SURGERY?

• Do not take Ibuprofen or other non-steroidal anti-inflammatory tablets* for two weeks before your procedure. These medications thin the blood, interfere with normal blood clotting and increase the risk of bleeding and bruising. Instead, use medications containing paracetamol. If you are taking any other medication to improve your circulation or thin the blood (for example: Aspirin, Warfarin, Clopidogrel or Plavix), please inform your surgeon.
• Discontinue smoking for 2 weeks before and after surgery. Smoking constricts small blood vessels and can delay the healing process.
• Drink plenty of water to help flush toxins from your body.
• Stop taking all Herbal remedies 2 weeks prior to surgery.
• Continue any other prescription medication as before.
• Arrange for someone to take you home and to assist you for 24 hours after surgery.

WHAT SHOULD I EXPECT AFTER SURGERY?

Most patients go home the same day. Very occasionally the eyes are bandaged overnight. Have someone drive you home after surgery and help you at home for 1-2 days. Follow a balanced diet. Decreased activity may promote constipation, so you may want to add more raw fruit to your diet, and be sure to increase fluid intake.

Wound Care

A small pad may be placed in front of the nostril overnight as some patients experience minor bleeding from the nose after surgery. If you’ve had an external DCR, there may also be a small dressing on the skin. The dressing and the pad are removed the next day. Clean the incision area daily with sterile wipes and warm water. Instil drops and apply ointment as advised. A nasal spray may be prescribed if necessary. Special silicone tubes are inserted in to the tear duct during surgery. You may see the top end of the tube near the inner corner of the eye and occasionally you may feel the tube moving inside the nose: this is to be expected and nothing to worry about.

If Lester Jones tubes (permanent glass tubes) are inserted, the top end of the tube will be visible in the inner corner of the eye and you may occasionally feel air blowing through these tubes.

Swelling and Bruising

The side of the nose and eyelids will be swollen and bruised (external DCR), the tear film may be bloody and the eyes might be more red than usual. Keep your head elevated for 2 or 3 days following surgery and apply cold compresses or small ice packs to help reduce swelling. Wrap these in a thin, clean flannel or cloth, so as not to harm your skin. You can also use refrigerated gel masks from pharmacy. Apply this for 20 minutes per hour for the first 3 days (waking hours). Maximum swelling and bruising tend to occur in the first 2-3 days and resolves over 10 - 15 days, although this varies from person to person.

Bleeding

Minimal bleeding from the nose may be present for up to 48 hours after surgery. In the rare case that the bleeding is severe and persistent, please go to the nearest ED.

Discomfort

Your eyes might feel tight, sore and gritty for a few days. You may experience excessive tearing, sensitivity to bright lights, or temporary changes in your sight such as blurred vision.

Pain

You may experience a dull ache for up to 24 hours after surgery. This should settle with simple analgesics like paracetamol. Your doctor will prescribe stronger pain medication if needed. If you experience severe persistent pain that does not respond to medication, please call the clinic or go to ED if necessary.

Showering

You may shower on the day following surgery.

Salah

You should offer salah sitting on a chair and avoid bending from the hip (rukuh & sajdah) for one week.

Sleeping

Sleep with your head on 2 pillows at least 1 week.

Work

You may feel well enough to return to work after a few days (depending on the individual procedure).

Activity & Sports

Light physical activity such as walking is encouraged from day one as it aids in recovery and prevents blood clots. Keeping in mind that everyone heals at a different rate, you may start golf after about 10 days, gym after 2 weeks, tennis and swimming after 3 weeks.

Contact Lenses

Contact lenses may be worn earliest 3 weeks after surgery (or when comfortable).

Removal of stitches

The stitches will be removed 7 to 10 days after surgery (external DCR).

Removal of DCR tubes

These tubes are removed 8-12 weeks after surgery based on the type and complexity of procedure. This is done in clinic after spraying some local anaesthetic in the nose.

Make-up

You may begin wearing make-up after removal of stitches (usually 7 days after surgery).

Driving

Do not drive whilst on strong pain medication (narcotic) or while applying ointment into the eye. Most patients can start driving 3 to 5 days after surgery but you are the best judge of when it is safe for you to do this.

Smoking and dietary supplements

Do not smoke, as smoking delays healing and increases the risk of complications. Dietary supplements such as vitamins, garlic, ginseng can be re-started one day after surgery.

Recovery

Although you should be up and about following the procedure, plan on taking it easy for the first week after surgery. You should be able to read and watch television from the day after surgery, though your vision may be blurred due to the ointment. Most visible signs of the surgery should fade within three weeks (depends on procedure).