TREATMENT OF TEARING
I. Congenital Nasolacrimal Duct Obstruction
In babies, the initial treatment involves massaging the area around the affected lacrimal sac to force the tears down the duct, and to push open the membrane causing the obstruction. This works in about 90% of cases. If the symptoms do not resolve by 9 months of age, a small office-based procedure is necessary to open the membrane in the nose. After 1 year of age, the membrane can only be opened in the operating room using an endoscope under general anesthesia. The advantage of using an endoscope to directly visualize Hasner’s valve is the high success rate of the procedure and the decreased risk of complications. This outpatient procedure takes less than 15 min.
In the rare instance where the bony nasolacrimal duct is absent (congenital malformation), a bypass procedure that directly connects the lacrimal sac with the nose can be done endoscopically (eDCR) around 4 years of age. This reestablishes the missing anatomy and is usually permanent.
II. Acquired (Adult) Tear Duct Blockage
There are different treatments for adults depending on the location of the blockage:
Punctoplasty
When the opening of the tear duct (punctum) is blocked, a small office-based procedure called punctoplasty is performed to open it. It takes about 5 minutes and is done under local anesthesia. There is no downtime and the patient can resume normal activities immediately after. Although the success of the procedure is high and immediate, failure to treat the underlying inflammation (dry eyes, allergies etc) can lead to recurrence of punctal stenosis and tearing.
Intubation (Stenting)
An upper obstruction in one or both tear ducts located inside the eyelid (canaliculus) can usually be resolved with placement of a small silicone tube (lacrimal stent) in the natural canal, for a couple of months. This is done in the operating room under general anesthesia and takes about 20 minutes. The patient can go home immediately after and resume normal activities the next day. The patient needs to use anti-inflammatory eyedrops and nasal spray for a couple of weeks. The tube is removed in the office through a painless procedure. Intubation is rarely used by itself today since better techniques are available, but in certain situations (cancer treatments) they can be quite effective.
A severe upper canalicular obstruction at the level of the eyelids can be solved by placing a rigid glass tube, called the Jones tube, in the inner corner of the eye. This will directly drain the tears into the nose. The permanent tube is generally well tolerated and does not cause discomfort. Rarely, the tube can get blocked by scar tissue or fall out. If this happens, an additional procedure to replace it will be required. Surgery is done under general anesthesia and takes about 20 minutes. The patient can go home soon after. Using an endoscopic technique, this procedure does not require a skin incision and recovery is quick, although the patient cannot blow the nose for 2 weeks.
A lower obstruction in the nasolacrimal duct can be resolved with an endoscopic dacryocystorhinostomy (eDCR). This is the only effective long-term treatment with a success rate of over 95%. The eDCR is done under general anesthesia or MAC sedation using an endoscope through the nose. A new communication between the lacrimal sac and the nose is made that allows tears to drain. A silicone stent is usually placed for 6 weeks and removed in the office. This outpatient surgery takes about 20 min and the patient goes home 30-60 minutes after (as soon as full recovery from the anesthesia is obtained).
Patients prefer the endoscopic DCR to the external DCR (older technique) because no skin incision is necessary, the recovery time is shorter and there is less postoperative discomfort.
Whenever the eye watering (tearing) is the result of an eyelid pathology, functional eyelid surgery needs to be performed in order to correct the abnormal eyelid position. Ectropion, entropion, eyelid laxity and eyelid retraction can all result in reflex tearing and functional NLDO from lacrimal pump failure.
Eyelid surgery is typically performed at the same time with lacrimal duct surgery or as a standalone procedure if the tear duct is anatomically normal. Most cases require horizontal tightening of the eyelid and repositioning of the lacrimal punctum. Sometimes a vertical eyelid lift is necessary to correct the eyelid retraction.
The recovery from both lacrimal and eyelid surgery is relatively quick. The advantage of performing both the tear duct and the eyelid surgery at the same setting is having only one recovery. Minimal bruising can be seen for a couple of weeks, if eyelid surgery is performed (there is no bruising when only lacrimal surgery is performed). Antibiotic ointment is applied on the incisions 3 times a day for 3 weeks. Stitches dissolve themselves. It is essential to stop all anti-inflammatory medication such as Aspirin, Ibuprofen, Advil, Naproxen, Diclofenac etc. and all vitamins and supplements 2 weeks prior to surgery with the accord of the primary care physician to avoid unnecessary bruising.
An upper obstruction in one or both tear ducts located inside the eyelid (canaliculus) can usually be resolved with placement of a small silicone tube (lacrimal stent) in the natural canal, for a couple of months. This is done in the operating room under general anesthesia and takes about 20 minutes. The patient can go home immediately after and resume normal activities the next day. The patient needs to use anti-inflammatory eyedrops and nasal spray for a couple of weeks. The tube is removed in the office through a painless procedure. Intubation is rarely used by itself today since better techniques are available, but in certain situations (cancer treatments) they can be quite effective.
Jones Tube
A severe upper canalicular obstruction at the level of the eyelids can be solved by placing a rigid glass tube, called the Jones tube, in the inner corner of the eye. This will directly drain the tears into the nose. The permanent tube is generally well tolerated and does not cause discomfort. Rarely, the tube can get blocked by scar tissue or fall out. If this happens, an additional procedure to replace it will be required. Surgery is done under general anesthesia and takes about 20 minutes. The patient can go home soon after. Using an endoscopic technique, this procedure does not require a skin incision and recovery is quick, although the patient cannot blow the nose for 2 weeks.
Endoscopic Dacryocystorhinostomy (eDCR)
A lower obstruction in the nasolacrimal duct can be resolved with an endoscopic dacryocystorhinostomy (eDCR). This is the only effective long-term treatment with a success rate of over 95%. The eDCR is done under general anesthesia or MAC sedation using an endoscope through the nose. A new communication between the lacrimal sac and the nose is made that allows tears to drain. A silicone stent is usually placed for 6 weeks and removed in the office. This outpatient surgery takes about 20 min and the patient goes home 30-60 minutes after (as soon as full recovery from the anesthesia is obtained).
Patients prefer the endoscopic DCR to the external DCR (older technique) because no skin incision is necessary, the recovery time is shorter and there is less postoperative discomfort.
Eyelid Problems
Whenever the eye watering (tearing) is the result of an eyelid pathology, functional eyelid surgery needs to be performed in order to correct the abnormal eyelid position. Ectropion, entropion, eyelid laxity and eyelid retraction can all result in reflex tearing and functional NLDO from lacrimal pump failure.
Eyelid surgery is typically performed at the same time with lacrimal duct surgery or as a standalone procedure if the tear duct is anatomically normal. Most cases require horizontal tightening of the eyelid and repositioning of the lacrimal punctum. Sometimes a vertical eyelid lift is necessary to correct the eyelid retraction.
Recovery
The recovery from both lacrimal and eyelid surgery is relatively quick. The advantage of performing both the tear duct and the eyelid surgery at the same setting is having only one recovery. Minimal bruising can be seen for a couple of weeks, if eyelid surgery is performed (there is no bruising when only lacrimal surgery is performed). Antibiotic ointment is applied on the incisions 3 times a day for 3 weeks. Stitches dissolve themselves. It is essential to stop all anti-inflammatory medication such as Aspirin, Ibuprofen, Advil, Naproxen, Diclofenac etc. and all vitamins and supplements 2 weeks prior to surgery with the accord of the primary care physician to avoid unnecessary bruising.