External Dacryocystorhinostomy (External DCR)

Dacryocystorhinostomy (DCR)
A dacryocystorhinostomy (often abbreviated as “DCR”) is an operation that is performed for the management of a watering eye (epiphora) caused by an obstruction in the nasolacrimal duct. An “external DCR” is performed via a small incision on the side of the nose. The success rate of the surgery in the hands of suitably trained and experienced oculoplastic surgeon is approximately 80-85%. In the event of a failure the surgery can be repeated or revised. During the surgery, the lining of the lacrimal sac is attached to the inner lining of the nose (the nasal mucosa) to create a new passageway for the tears. A fine silicone tube (a stent) is usually placed at surgery to maintain an opening in the tear drainage system. This is removed after a few weeks using an endoscope in the clinic. This is quick and simple to perform.

silicone stent
An example of a silicone stent


This operation is usually performed under general anaesthesia although it can be performed under local anaesthesia with intravenous sedation by an anaesthetist (“twilight anaesthesia”) for patients unfit for general anaesthesia. It can be performed either as a day case procedure or with an overnight stay in hospital.

What happens before lacrimal drainage surgery?
You will visit the hospital a few days/weeks before the date of your surgery, to have a preoperative consultation with your surgeon. You will be asked questions about your current and past health, and about any allergies you may have, medications you are taking (including over the counter products e.g. aspirin, indomethacin or vitamin supplements), previous surgery, and whether you smoke. You may also be required to have a physical examination of your heart and lungs to make sure it is safe for you to have an anaesthetic. You may need to have some routine laboratory tests, such as urinalysis (tests of your urine), chest x- rays, or complete blood cell counts to ensure that you are not anaemic. These should reveal potential problems that might complicate the surgery if not detected and treated early. No testing may be necessary if you are in good health and younger than 55 years of age.

Please answer all questions completely and honestly as they are asked only for your own well being, so that your surgery can be planned as carefully as possible. If you are unsure of the names of any medications, bring them with you. You will be told whether or not to stop any medications at this preoperative clinic visit. For example, if you are taking aspirin-containing medicines or anticoagulants, they may need to be temporarily withdrawn for two weeks before the procedure. It is important to check with your GP that it is safe for you to do so. If you can, try to stop smoking at least six to eight weeks prior to surgery.

Your eyes are examined carefully. Your vision in each eye is measured, and the eyelids and nose are examined. The positioning of the eyelids is noted. A "sac washout" or syringing of the tear drainage pathway is often performed using a fine blunt lacrimal cannula and some sterile saline solution. This is performed to determine whether or not there is a blockage of the tear drainage pathway. If there is a blockage this also provides important information about the precise location of the blockage and whether the blockage causing a watery eye is partial or complete. Your nose will be examined with an endoscope to ensure that you have no nasal abnormalities.

What should I expect at the hospital?
The procedure most appropriate to your individual case will be explained to you and you will then be asked to sign a consent form saying that you understand the procedure and that you have been told about any possible complications. Very rare complications will be described, as well as any more common ones, so try to keep things in perspective. If you have any questions or worries, make sure they are answered, before you sign the consent form. You are quite free to go away and consider the options before committing yourself to any surgery.

What are the risks of lacrimal drainage surgery?
No operation is free from risk. There are small risks associated with general anaesthesia common to all operations. The main risks of this type of surgery are bleeding, and infection, but such problems are very rarely encountered. All precautions are taken before, during and after surgery to reduce the risk of bleeding.

Before surgery

  1. Discontinue the use of aspirin and products containing aspirin for three weeks before your scheduled surgery unless instructed otherwise. This may include a number of arthritis medications. If you have any queries about your medications please check with your G.P. If you take anticoagulants e.g. Warfarin you must inform us. You should ensure that you do not have hypertension prior to surgery by having your blood pressure checked at your GP surgery. If you have hypertension you should ensure that this is well controlled prior to surgery.
  2. If your operation is planned to be done under a general anaesthetic (when you will be asleep), you may have some blood tests done and an ECG (heart tracing) prior to surgery. Please bring all your tablets/medications in their original, labelled bottles. Also provide information on any known allergies.
  3. Unless specific arrangements have been made to do your surgery on a day case basis, you will be admitted to hospital on the day of surgery. You will be discharged the day after surgery unless there are any post-operative problems e.g. a nose bleed, requiring you to stay longer. This is very rare indeed.
  4. It is important that you follow all instructions about food and drink prior to surgery. A patient undergoing a general anaesthetic or having sedation (“twilight anaesthesia”) must not eat or drink for a minimum period of 6 hours before the operation.

After Surgery

  1. If you have had general anaesthesia a) You will awaken in the recovery room in the theatre. b) You will be returned to the ward usually after a period of up to 30 minutes in
  2. You may go to the bathroom with assistance.
  3. Your usual medications may be continued. Resume aspirin, blood thinners, and arthritis medications 72 hours after surgery unless otherwise instructed.
  4. You may have a compressive dressing over your eye and wound. You may have a nasal tampon in your nostril overnight to reduce the risk of bleeding. This will be gently soaked with saline and removed 1- 2 hours after surgery by a nurse in the recovery area or on the ward. You should anticipate some minor intermittent nose bleeding at home which will take 3-4 days to settle down. Avoid any activity which can provoke a nose bleed e.g. lifting heavy weights, straining.
  5. You may have difficulty wearing your glasses for a short period after surgery because of the position of the skin wound.
  6. You may experience nasal stuffiness but this will gradually improve. Avoid blowing your nose or rubbing your eye
  7. Apply antibiotic ointment three times a day to the wound for 2 weeks after soaking the wound with cooled boiled water and cotton wool. Wash your hands thoroughly first.
  8. The stitches used to close the wound are absorbable and will drop out in 3-4 weeks or they can be removed easily.
  9. If the silicone stent comes out as a loop in the inner corner of the eye, simply tape it to the side of the nose and report this to the hospital during normal working hours - this is not an emergency problem. DO NOT CUT IT OR PULL IT.
  10. The scar can be flattened and made less prominent by firm massage performed along the scar with the forefinger and a small amount of Lacrilube ointment for 3 minutes 2-3 times a day - this can be bought across the counter at the chemist and replaces the antibiotic ointment after 2 weeks (external DCR). The massage should commence after 2 weeks and continue for up to 12 weeks after surgery.
  11. If the following occur notify the hospital:
    a) Sudden severe bleeding from the nose which does not stop
    b) Pain and redness of the wound

Arrangements will then be made for you to be seen as soon as possible.
Consultants who undertake private surgery:

Saj Ataullah
Anne Cook
Brian Leatherbarrow
Ahmed Sadiq