Tear duct obstruction in adults

TEAR DUCT OBSTRUCTION IN ADULTS

Tear duct obstruction in adults is a clogging of the duct through which tears are excreted (blocked tear ducts). After bathing the eye, tears normally flow through fine ducts into the nose.

Normal tear production does not manifest itself in the nose, but in cases of crying, excessive laughter or irritation of the eyes, the formation of large amounts of tears is reflected in nasal obstruction or “blocked nose”.

SYMPTOMS OF TEAR DUCT OBSTRUCTION

The main symptom is the fall of tears down the cheek, which is more pronounced in cold and windy weather. When the duct becomes completely blocked, tears accumulate in the lacrimal sac and become infected. As a result, the patient has discharge in the morning and is more prone to conjunctivitis. If infected tears accumulate under pressure, acute dacryocystitis can occur, an infection of the lacrimal sac that causes severe pain and must be treated with antibiotics.

People with allergies or who have suffered acute viral conjunctivitis may have obstruction of the lacrimal puncta or canaliculi, which are the fine ducts that carry tears to the lacrimal sac. When they become blocked, intense tearing occurs but without secretions or infection.

CAUSES OF TEAR DUCT OBSTRUCTION

The most usual location of the obstruction is the nasolacrimal canal, a duct through which tears pass before reaching the nose. This duct is lined by mucosa. The first phenomenon that occurs at this level is inflammation, which produces a partial obstruction of the passage of tears when the weather is windy or cold. If the problem persists, the amount of accumulated tears gradually increases and may make it difficult to read through them, or they may fall heavily on the cheeks.

Some people start experiencing this problem after a trauma or blow to the nose or face, and it usually stems from a fracture that affects the canal. There are other causes that can produce obstructions, but they are less frequent. Most patients present with this problem with no known cause.

When there is a sudden onset of the symptom, particularly if it occurs after severe conjunctivitis, it may result from a blockage in the canaliculi. These are small ducts that carry tears inside the eyelids to the lacrimal sac.

TREATMENT

Tear duct obstructions in adults are solved surgically. It is not possible to treat this problem in the long term way with non-surgical procedures. The three currently existing methods, which have proven to be the most effective, are:

DCR or dacryocystorhinostomy
CDCR or Jones procedure
Unblocking of lacrimal punctal with microsurgery

The choice of the type of treatment depends on the exact site of the obstruction. In most cases, a diagnosis can be made based on the medical history and a complete examination in the office. First, colored drops are placed to determine if there really is an obstruction. If there is, tear irrigation is generally performed using a cannula specially developed for this purpose, which makes it possible to pass saline solution through the tear duct in a non-traumatic way and to assess the degree and the location of the obstruction.

This procedure does not constitute a treatment since it does not unblock the tear ducts, and should not be repeated to avoid damaging them. In some cases, further tests are required.

DCR OR DACRYOCYSTORHINOSTOMY

This surgery creates a by-pass of the tear duct, forming a new communication to the nose. It can be performed under local anesthesia and sedation to achieve a total absence of pain, without the risks of general anesthesia. Dr. Devoto published a scientific paper based on 99 consecutive DCR surgeries where he demonstrated that blood loss is minimal and intraoperative comfort very high. (Devoto MH, Kersten RC. Dacriocistorrinostomía con anestesia local. Arch. Oftalmol. de Bs. As.1998, 73:-199-203.)

THERE ARE THREE ALTERNATIVES, WITH DIFFERENT SUCCESS RATES:

The external approach, performed under local anesthesia and sedation, has a success rate of over 95 % in restoring tear evacuation. It is performed through a small incision measuring approximately 10 mm, which is almost invisible in most people.
Patients who do not want the incision can opt for the endoscopic approach, which is 95 % successful. It requires general anesthesia and has a very rapid recovery due to the complete absence of bruising and external signs of the procedure. Endoscopic dacryocystorhinostomy (endoscopic DCR)
Finally, interest has been shown in the operation performed with laser. At present, its success rate does not exceed 60 %.

In general, patients are advised to undergo this surgery, in any of its variants, to avoid the risk of infection of the lacrimal sac or dacryocystitis.

MICDCR OR JONES PROCEDURE (MINIMALLY INVASIVE CONJUNCTIVAL RHINOSTOMY) – DEVOTO, M.H., F.P. BERNARDINI, AND C. DE CONCILIIS

It is performed in those cases in which there is a canalicular obstruction that cannot be resolved. It involves the placement of a special thin glass tube that connects the lacrimal lake with the nose.

Dr. Devoto published in the United States an innovative technique to perform this surgery in a minimally invasive way, without making incisions in the skin. The success of this procedure is very high and the chances of reoperation have decreased to 5 %.

UNBLOCKING OF LACRIMAL PUNCTA WITH MICROSURGERY

This procedure is intended for the surgical opening of the lacrimal puncta, when they are obstructed. It is a minimally invasive microsurgery, since local anesthesia is used on an outpatient basis. It has a success rate of 80 %. In the most severe cases, it is necessary to insert a Silastic tube, which is placed inside the tear duct and keeps it open during healing.

Is external DCR a traumatic operation?

No, not at all. By using intravenous sedatives, it is possible to perform this surgery without any pain or discomfort under local anesthesia. This has the advantage of minimal risk and no discomfort during the operation.

Does DCR cause bleeding?

It is very important to prepare adequately for this procedure, which means discontinuing aspirin and other medications that may affect coagulation.
Clotting time is monitored as part of the pre-surgery tests.
With these measures, the amount of bleeding during surgery is minimal. In fact, we have published a scientific paper that studied this issue in 99 consecutive surgeries, proving that there is minimal bleeding thanks to these measures and some technical details. Intraoperative discomfort was evaluated in this same study and 100 % of the patients said that they would undergo the same surgery again.

Does the incision used in the external approach leave a very visible scar?

The incision used in this procedure measures 10 mm. We have also studied this issue in a paper that was published in the scientific journal Ophthalmic Plastic and Reconstructive Surgery, in the United States. In this paper, we showed that 91 % of the patients have a scar that they cannot see or is minimal. Again, 100 % of patients in the study expressed satisfaction with the final appearance of the incision.