Obstruction of the nasolacrimal duct (commonly called “Rija”) is a very frequent cause of tearing. In addition to tearing, it also often leads to recurrent conjunctivitis, as the lacrimal sac acts as a reservoir for bacteria. Sometimes the lacrimal sac can dilate and produce a lump on the inner canthus, which, if infected, causes a lot of pain and signs of infection in the area.

Treatment of nasolacrimal duct obstruction in adults is always surgery. There is no medical treatment that cures the obstruction. The aim of surgery is not to re-drain the obstructed duct, but to create a new drainage route from the lacrimal sac to the nose. This surgery is called Dacryocystorhinostomy (DCR). Dacryocystorhinostomy eliminates both tearing and recurrent conjunctivitis.

There are 3 ways to perform Dacryocystorhinostomy: external, endonasal or transcanalicular laser.

DCR EXTERNAL

This is considered the “gold standard” surgery. It is performed through a small incision in the skin between the nose and the eye, generally more or less where the glasses rest. It is the one with the best rate of results, being between 90-95%. This means that only 5-10% of patients will have the communication that has been made closed again. It is the most versatile form and the one that best allows you to control any unforeseen event that may occur during surgery. It is performed under local anaesthesia and intravenous sedation so that the patient is at ease, and is performed on an outpatient basis, i.e. it does not require hospitalisation. The surgery and postoperative period are painless and recovery is quick, and the patient can return to normal life within a few days. The only drawback of external DCR is that there is a small risk of visible scarring. However, if certain precautions are followed at the time of incision placement and during surgery, only less than 3% of patients have a scar that they consider aesthetically unfavourable. In these cases, minor surgery can be performed on the scar to improve it.

DCR ENDONASAL

Instead of making a cut in the skin, it is done through the nose, with the use of the endoscope, so its main advantage is that it has no visible scar. It has a slightly lower success rate than external surgery, so it is slightly less effective. In addition, in many cases it needs to be done under general anaesthesia, as it is difficult to fully anaesthetise the nose to be able to work through it without pain for the patient.

TRANSCANALICULAR LASER DCR

It employs fine laser probe through the natural lacrimal pathway, making it the least invasive of all methods. Its advantage lies in the fact that it can be performed on patients with coagulation issues or those taking anticoagulants like warfarin. However, its major drawback is its low success rate, with a very high percentage of failures. As a result, it is recommended only in very exceptional cases.

Dr. Marco Sales generally recommends external Dacryocystorhinostomy as the first option, as it has the highest success rate, can be performed under local anaesthesia and without hospitalisation, and the likelihood of unfavourable scarring is very small.

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