Dacryocystorhinostomy (DCR)

Vijay Ramakrishnan, MD
Todd Kingdom, MD

Introduction
Dacryocystorhinostomy (DCR) is a procedure performed for the treatment of tearing (epiphora) due to blockage of the nasolacrimal duct. Tears originate in the lacrimal gland, located at the upper outer margin of the eye. As tears cross the eye with each blink, they are directed into small openings in the eyelids called puncta. From this point, tears travel through a pathway known as the canalicular system into the lacrimal sac. The lacrimal sac is located between the eye and the nose, and funnels tears into the nasal cavity through the nasolacrimal duct (Figure 1). As this is quite a long path for tears to travel, there can be many causes of excessive tearing. Blockage of the nasolacrimal duct is one common cause, and can be treated by creating a direct opening from the lacrimal sac into the nasal cavity in a procedure known as DCR. The evaluation and management of tearing may involve both an ophthalmologist and an otolaryngologist.
 
Fig 1. Tears originating from the lacrimal gland cross over the eye into the canalicular system on their way to the nasal cavity.
Fig 1. Tears originating from the lacrimal gland cross over the eye into the canalicular system on their way to the nasal cavity.
 
Indications
DCR is indicated in the treatment of tearing due to nasolacrimal duct obstruction. Blockage of this duct can be due to trauma, prior surgery, tumor, or inflammatory medical conditions, but most commonly occurs without an identifiable cause. To determine if this is truly the problem area in a patient with tearing, a number of tests may be performed. A physical examination is performed by the physician, and is often followed by probing and irrigation of the canalicular system (Figure 2). Placement of dye in the tears may be observed and timed for clearance. This evaluation is easily done and well-tolerated in the office setting.  
 
 
Fig 2. Probing and irrigation is commonly performed in the evaluation of tearing.

Procedure
Surgery is often performed under general anesthesia, but may be performed under local anesthesia according to patient or surgeon preference. DCR can be achieved from an external approach or from an endoscopic approach. The goal of the procedure is to bypass the obstructed nasolacrimal duct and allow for tear drainage into the nose directly from the lacrimal sac. External DCR approaches the lacrimal sac through a small incision between the eye and the nose. The lacrimal sac is identified and opened into the nasal cavity. To maintain the opening, the surgeon may use sutures or stents  (Figure 3).
 
Fig 3. If used, a stent is placed through the puncta into the nose.

Endoscopic DCR accomplishes the same goal, but is performed through the nose with the use of telescopes and small instruments. This approach to DCR is now commonly performed because it avoids a facial scar, and is generally associated with less pain. The location of the lacrimal sac is known based on extensive anatomic study. Bone is removed from the area over the lacrimal sac and the sac is opened into the nose (Figure 4). Some surgeons prefer to use stents for some time postoperatively to maintain the opening. 
 

Fig 4. Intraoperative endoscopic view of the opening created from the lacrimal sac into the nose (circled), after irrigation with fluorescein dye. The common internal punctum is located at the asterisk.

Risks
In the endoscopic approach, pain is minimal and can be controlled with acetaminophen or mild prescription pain medications. Infection is uncommon, but many surgeons prefer to administer antibiotics after surgery. Bleeding should be minimal, but rarely can be significant. Scarring within the nose may occur, leading to blockage of the opening and recurrence of tearing. Although extremely rare, the major risk of the procedure is bleeding within the orbital cavity (orbital hematoma) or injury to an eye muscle, which may cause double vision or vision loss. Scar and temporary bruising will occur with external procedures, although these should be relatively minor. If your surgeon prefers to keep a stent in place afterwards, prolapse (movement or extrusion) may occur, which requires stent adjustment or removal.
 
Benefits
DCR is a fairly simple outpatient procedure. Overall success rates exceed 90%, although in particular cases the likelihood of success may be lower. The risks and side effects of the procedure are relatively low, and can potentially lead to a long-lasting relief of bothersome tearing.
 
Summary
Although there are many causes of tearing, some patients are excellent candidates for DCR. A proper evaluation must take place to determine the likelihood of success with this surgery. As an outpatient procedure, DCR presents a nice option for patients with bothersome tearing due to obstruction of the nasolacrimal duct. Surgeons will have their own preferences in particular aspects of the procedure—external or endoscopic, use of stents, size of opening created, postoperative visit schedule—but the ultimate goals and success rates are quite similar. 
 
 

Revised 4/2012
©American Rhinologic Society