Endoscopic DacryocystorhinOSTOMY for Chronic Eye Watering

Introduction:

You might have seen many an aged person with constant watering of either one or both their eyes and wondered as to what they are ailing from.   They suffer from Chronic Dacryocystitis, an infection of the lacrimal sac caused by blockage of the duct which drains the tears of the eye into the nose or nasal cavity.  Modern endoscopic surgical techniques can easily and painlessly tackle this ailment which if left untreated can lead to repeated swelling and pain around the eyes due to recurrent infections.

What is the function of the lacrimal apparatus?

Tears are very essential to prevent the eyes from drying.  They are secreted by the lacrimal gland situated in the upper and lower eye lids.   The tears thus secreted moisten the eye and drains through the lacrimal apparatus into the nose.   A blockage along the course of the lacrimal apparatus causes watering of the eyes.   The lacrimal apparatus consists of lacrimal canaliculi, lacrimal sac and the nasolacrimal  duct.

What is Dacryocystitis?

Infection in the lacrimal sac is known as Dacryocystitis.  It may occur in:

a)      Infants, where there is improper formation of naso-lacrimal duct.

b)      B) Primary Dacryocystitis, due to the infection of the lacrimal sac caused by a block in the naso-lacrimal duct.   Due to the block there is no drainage of tears into the nose.   Hence tears get collected in the sac and soon start spilling out of the eyes.   This constant watering cause changes on the skin around the eyes.  If the blockage is not relieved by surgery, the tears that stagnate in the sac can get infected and result in severe pain and swelling around the eyes.   The only method of relieving this block is by surgery.   There is no role for conservative management to overcome this block.

What are the types of surgery to cure Dacryocystitis?

Surgery to relieve the block is of two types:

1)      Dacryocystectomy:  Here the lacrimal sac is removed completely.  Thus the chance of infection is not present.  But, because of discontinuity in the passage, the patient will continue to have watering of the eye.

2)      Dacryocystorhinostomy:  Here an alternate pathway is created between the lacrimal sac and the nose, thus bypassing the blocked naso-lacrimal duct.

What is traditional Dacryocystorhinostomy?

Traditionally the lacrimal sac was approached from outside, whether it is for excision of the sac or for creating an alternate pathway.   This involved making an external incision.  The operation is also bloody because the nose and the infected sac are richly supplied with blood vessels.  The external incision can also lead to an ugly scar, when healing takes place.

What is Endoscopic Dacryocystorhinostomy?

Unlike in the external approach where one has to go through the skin and ligament to reach the sac and then onto the nasal cavity, the endoscopic approach is direct.   The lacrimal sac is approached through the nasal cavity.  The surgery is generally performed under local anaesthesia. Using nasal endoscopes the lacrimal bone overlying the lacrimal sac is removed to gain access to the sac.  Smart equipment like the ‘Shark’ are used to make a bloodless incision of the overlying mucosa and the ‘microdebrider’ (used for endoscopic sinus surgery) has proved to be a valuable tool to excise the medial wall of the sac and make a permanent opening between the sac and the nasal cavity.  An eye surgeon assists in probing the sac and locating it.  Once the medial wall of the sac is excised the eye surgeon syringes the lacrimal apparatus through the lower canaliculi to clear any blood clots.  The duration of the surgery too is much shorter compared to the external approach.

What are the results of Endoscopic Dacryocystorhinostomy?

The results of the surgery too are excellent if performed properly.  Too small an opening carries the risk of re-closure of the opening in the sac.  Even failed external DCR operations performed earlier can be revised through the endoscopic approach.

Where does the endoscopic approach score over the traditional external approach?

The endoscopic approach to the sac is far superior to the external approach.  It is faster, bloodless and scar less.  It can be done in an outpatient setting under local anaesthesia, thus avoiding the risks of general anaesthesia in an older individual.  Better visualization of the structures and better equipment used for surgery ensures far superior results compared to the external approach.