Tear duct opening using endoscopic approach
What are the reasons of excessive tearing?
One of the most common complaints of eye problems – Excessive tearing. Excessive tearing may be caused by a number of reasons. The main reasons are as follows:
1. Activity disorder of meibomian glands in the eyelids (due to hormonal changes or age) and, as a result, abnormal and ineffective lacrimal fluid secretion. In this case, a reflex increasing the tears secretion is transmitted to the lacrimal gland and leading to excessive lacrimation (reflex tearing).
2. Incorrect lower eyelid position, resulting in forcing of tears to the drainage hole;
3. Tear drainage problem. Narrowing or blockage of the drainage tubes in the lacrimal sac can lead to rupture or even development of infectious inflammation characterized by painful swelling in the inner corner of the eye.
What should be checked in case of excessive tearing?
In order to find out the cause of excessive tearing, a comprehensive ophthalmologic examination should be carried out, including examination of the eyelids and cornea, as well as tear duct irrigation. When flushing the tear ducts, the doctor uses a syringe filled with saline and attached to a tube that is very thin and not sharp. The doctor inserts the end of the tube into the tear duct opening at the eyelid corner and drains the liquid from the syringe. If the tear duct is not blocked, the patient will feel a salty fluid in the nose or throat. If the tear duct is blocked, the fluid will not go to the nose or throat. Blockage location in the tear duct can usually be found during the tear duct irrigation.
Where exactly is the tear duct blocked
The most common place for tear duct blockage in adults is the transition from the lacrimal sac to the nose (obstruction of the nasolacrimal canal); in this case, treatment consists of creating a surgical bypass of the blocked part.
In children, the situation is different, and in most cases the blockage can be cleared by flushing the tear ducts or inserting a silicone tube for the tear ducts dilation. Bypass surgery is performed only when simpler means of the tear ducts opening are not effective. Endoscopic surgeries for the tear ducts opening are performed on children as well if necessary.
What is tear duct bypass surgery?
During the operation, it is necessary to create a bypass between the lacrimal sac and the nose by making a small hole in the thin bone between them (fig. 1A). In the course of this procedure, the lacrimal sac is opened and connected to the nasal mucosa. That way, the lacrimal fluid penetrates through the outer lacrimal opening of the eyelid directly into the nose, bypassing the blocked area.
Where exactly the surgical incision is made?
This procedure is usually performed with a skin incision in the inner corner of the eye adjacent to the nose bridge (external dacryocystorhinostomy, DCR), but today, thanks to the development of endoscopic techniques and a general preference for less invasive techniques, the same procedure is performed through the nose using an endoscope (endonasal dacryocystorhinostomy, DCR). With this method, the surgical incision is not made from the outside, but from the inside, on the nasal mucosa.
What are the advantages of the endonasal endoscopic approach?
The main advantages of this method are the absence of a skin incision (and, accordingly, a scar on the face), and the absence of damage to other subcutaneous tissues, such as the circular muscle of the eye and the medial canthal tendon, as in external DCR. These tissues are involved in the process of pumping tears into the lacrimal sac (“lacrimal pump”), and their damage may disrupt this process. Another advantage is that, thanks to the endoscopic approach, nasal pathologies that may interfere with the procedure success can be identified and treated during the same surgical procedure. Recovery after endoscopic procedure is easier and faster than after surgery procedure with external access.
Another important advantage of the endoscopic method is the treatment of acute infection of the lacrimal sac. Traditionally, this condition is first treated with antibiotics, and only after a few weeks can external DCR be performed. Unlike external DCR, endoscopic DCR can be performed even in the acute phase (for example, with abscess drainage into the nasal cavity); this not only provides excellent results and quick healing, but also helps to avoid long-term antibiotic treatment and to reduce the number of hospitalization days before surgery in severe cases and recurrent infections.
Side effects of surgical procedure for eliminating tear duct obstruction
The main side effect is nose bleed after surgery. After the procedure, the glued gauze pad will absorb the blood from the nose. This bleeding is usually mild. It subsides within a few hours after surgery and stops completely within two to three days. Therefore, we recommend avoiding hot drinks for the first two days after surgery, and we also advise you not to blow out your nose for the first two weeks after surgery. It is recommended to use a simple saline spray to absorb nasal discharge.
Surgical procedure for eliminating tear duct obstruction – chances for success
The results of endonasal DCR are now comparable to the results of external DCR and sometimes even surpass them. This surgical procedure is successful in approximately 90% of cases. For the last several years in Rabin Medical Center we opt for endoscopic procedures for most patients, and our surgical results are excellent.