Blocked Tear Duct and DCR Surgery

Massage and probing in babies, external and endoscopic DCR surgery in adults — with Dr. Nejmi Öztürk, ophthalmologist and eye surgeon, at HG Hospital in Kahramanmaraş, Türkiye

What is a blocked tear duct?

A blocked tear duct means that the passage draining tears into the nose has narrowed or closed, so tears build up in the eye. Tears pass through tiny openings (puncta) at the inner corner of the eyelids, travel through fine channels (canaliculi) into the tear sac and flow into the nose through the nasolacrimal duct (tear duct). When this passage is blocked, tears overflow; this is called epiphora (watery eye).

Congenital blocked tear duct in babies

In babies, the blockage is caused by a thin membrane at the end of the duct, where it opens into the nose, that has not yet opened at birth; it is seen in about 5–20 percent of newborns. Symptoms begin in the weeks after birth: constant watering, yellow crusts on the lashes, eyelids stuck together in the morning. The white of the eye usually does not turn red; this helps to distinguish it from conjunctivitis (pink eye). The great majority of these blockages (close to 90 percent) open on their own or with massage by the age of one.

Acquired blocked tear duct in adults

In adults, the blockage usually develops as the part of the duct that runs through the bone narrows over the years; the cause cannot always be found, and it is more common in women past middle age. Nose and sinus disease, fractures of the facial bones, previous nasal surgery, long-term use of eye drops and, rarely, tumours can also block the duct.

Infection of the tear sac (dacryocystitis)

Dacryocystitis is an infection of the tear sac that develops when the tears trapped behind the blocked duct become infected with microbes. A painful, red, swollen area forms between the inner corner of the eye and the nose; sometimes there is fever. It requires antibiotic treatment; if an abscess forms, it is drained. In patients with repeated infections, surgery to relieve the blockage is recommended to prevent new attacks.

What are the symptoms? Who is DCR surgery suitable for?

Constant watering, sticky discharge and swelling at the inner corner of the eye are the main symptoms of a blocked tear duct.

• Watering that gets worse in wind, in the cold and while reading
• Yellow-white crusts on the lashes, eyelids stuck together in the morning
• Cloudy or pus-like discharge when the inner corner of the eye is pressed
• Swelling, redness and pain at the inner corner (tear sac infection)
• Frequently recurring conjunctivitis

DCR surgery is suitable for adults in whom the blockage has been confirmed by the syringing test and who have watering or tear sac infections. In babies, probing is considered for blockages that have not opened with massage by the age of one.

Who is it not suitable for?

• Babies under one year: Because the chance of the duct opening on its own is high, massage and observation are recommended initially.
• People with an acute tear sac infection (abscess): Surgery is planned after the infection has been settled with antibiotics.
• People whose watering has another cause: DCR does not help watering due to dry eye, eyelid laxity or blepharitis; the underlying cause is treated.
• People whose blockage is at the level of the punctum or canaliculus: A different surgical plan is required.
• People who cannot stop their blood-thinning medication, and those with a marked deviated septum or nasal polyps: Surgery is planned in consultation with the relevant physicians.

Which examinations and tests are done?

The diagnosis is usually made on the same day with an eye examination and a syringing (irrigation) test.

• Slit-lamp examination: The tear openings, eyelid position, eye surface and lash line are examined.
• Dye disappearance test: A drop of dye is placed in the eye and it is checked whether it drains away within a few minutes; this is the test most often used in babies.
• Syringing (lacrimal irrigation): Saline is passed through the tear opening with a fine cannula. If the saline reaches the nose, the passage is open; if it comes back, there is a blockage, and where the fluid comes back shows the level of the blockage.
• Nasal examination: Septal deviation, polyps and the condition of the nasal lining are assessed; this is important in patients planned for endoscopic DCR.
• Imaging: Rarely needed; a computed tomography (CT) scan may be requested if a tumour is suspected or there is a history of fracture.

How is the procedure done?

Massage and probing in babies

1. Massage: With clean hands, use your index finger to press with moderate firmness over the tear sac at the inner corner of the eye, stroking downwards along the side of the nose 5–10 times; do this 2–3 times a day. The pressure helps the membrane at the end of the duct to open.
2. Cleaning the crusts and drops when needed: Crusts are wiped away with boiled and cooled water. If the discharge is infected, the doctor may prescribe antibiotic drops for a short time; drops do not open the blockage.
3. Probing: Performed in babies whose blockage has not cleared by the age of one. Under brief general anaesthesia, a thin, blunt-tipped probe is passed through the tear opening into the duct to open the membrane; the procedure takes about 10–15 minutes and the baby goes home the same day.
4. In babies whose duct blocks again: Probing can be repeated, a thin silicone tube can be placed in the duct, or the duct can be widened with a balloon.

DCR (dacryocystorhinostomy) surgery in adults

DCR (dacryocystorhinostomy) is an operation that creates a new passage between the tear sac and the nasal cavity, bypassing the blocked duct. It is performed by two methods: external (through a skin incision) and endoscopic (through the nose).

1. Preparation: Blood-thinning medicines are adjusted with the approval of the physician who prescribed them. The operation is done under local anaesthesia with sedation or under general anaesthesia; the choice is made together, according to your condition and your preference.
2. External DCR: A skin incision of about 1–1.5 cm is made between the inner corner of the eye and the nose. A small window is opened in the thin bone between the sac and the nose; the lining of the sac and the lining of the nose are stitched together to form the new passage.
3. Endoscopic DCR: A thin camera (endoscope) is passed through the nostril; no skin incision is made. The same bony window is opened from inside the nose; if there is a deviated septum, it can be corrected in the same session.
4. Silicone tube: To stop the new passage closing while it heals, a thin silicone tube running from the tear openings into the nose is placed; it is visible as a small loop at the inner corner.
5. Duration and discharge: The operation takes about 45–60 minutes. Patients are usually discharged the same day or the next morning.

What to expect: With local anaesthesia there may be brief burning during the injection and a feeling of pressure and pulling during the operation; pain is usually mild and is controlled with painkillers over the following days.

Where do tears go, and where do they get blocked?

The path tears take from the openings at the lid margin to the nose, and the procedures used when it is blocked.

1. The normal pathAfter washing the surface of the eye, tears are collected through two small openings at the lid margin, pass through fine channels into the tear sac and drain through the duct that opens into the nose.
2. BlockageWhen the path is blocked at any point, tears cannot drain; constant watering, sticky discharge and infection of the tear sac may occur.
3. Probing in babiesIn a congenital blockage, the duct is opened with a thin probe. Because the blockage opens by itself with massage and waiting in most babies, the timing is decided together with the doctor.
4. DCR in adultsIf the duct is permanently blocked, a new passage is created between the tear sac and the nasal cavity. The procedure can be done from the outside or endoscopically through the nose.

What is recovery like?

Return to daily life after DCR usually takes 1–2 weeks; the result is assessed after the silicone tube has been removed.

Day 1

Slight blood-stained discharge from the nose and watering of the eye are normal. Do not blow your nose; rest with your head raised and use the prescribed drops and nasal spray regularly. With the external method there may be swelling and bruising around the incision.

Week 1

The skin stitches are removed about 7 days after surgery. During this time avoid heavy lifting, bending forward, hot baths and blowing your nose; keep your mouth open when you sneeze. Return to desk work is usually possible within 3–5 days.

Month 1 and beyond

Swelling and bruising settle in 2–3 weeks; the external incision scar fades over the months. The silicone tube is usually removed in a few seconds at a check-up 1–3 months later, and syringing confirms that the passage is open. Check-ups are at week 1, at month 1 and when the tube is removed; for patients coming from the outlying districts, check-up days are combined so that the number of journeys is kept to a minimum.

What are the risks and limitations?

DCR surgery relieves watering in the great majority of patients; nevertheless, like any operation, it has risks and limitations.

• Bleeding: Nosebleed is the most common problem; it is usually mild and stops within a few days. Nasal packing is rarely needed.
• Re-blockage (recurrence): The newly opened passage may narrow while it heals. Success rates of about 85–95 percent are reported in the literature; in other words, in 5–15 out of every 100 patients watering may continue and a second procedure (revision) may be needed.
• Infection and skin scar: Infection is rare; with the external method the scar fades over time in most patients.
• Problems related to the silicone tube: The tube may slip or cause irritation; in that case it is removed early.
• Watering that partly continues: If there are additional causes such as dry eye or eyelid laxity, the watering may not disappear completely.

The result cannot be promised in advance; the expected benefit and the risks are explained to you individually at the examination.

Alternatives and comparison

The choice of treatment depends on the level of the blockage, the patient’s age and the severity of the complaint.

Method	Who it is for	Anaesthesia	What to know
Massage and observation	Babies under 1 year	None	Most open on their own
Probing	Babies over 1 year whose duct has not opened with massage	Brief general anaesthesia	10–15 minutes; success decreases with age
Silicone tube / balloon dilation	Re-blockage after probing	General or local	The tube stays in place for 3–6 months
External DCR	Complete blockage in adults, tear sac infection	Local + sedation, or general	Small skin scar
Endoscopic DCR	Complete blockage in adults; those who do not want a scar; recurrent cases	General or local	No skin incision; a deviated septum can be corrected in the same session

If eyelid laxity or an outward-turning eyelid is contributing to the watering, eyelid surgery may be needed. If the watering is a reflex to dry eye, treatment of dry eye takes priority; if it is due to inflammation of the lash line, blepharitis is treated before anything else.

This treatment in Kahramanmaraş

The diagnosis of a blocked tear duct, probing in babies, and external and endoscopic DCR surgery in adults are carried out by Dr. Nejmi Öztürk at HG Hospital in Kahramanmaraş, Türkiye. Dr. Öztürk has a study on endoscopic revision in recurrent DCR cases published in a peer-reviewed journal (MN Oftalmoloji, 2012).

HG Hospital is a private hospital contracted with the Turkish social security institution (SGK); patients with valid SGK coverage may use it, although a private-hospital co-payment may apply. DCR surgery and probing are generally covered by SGK. Patients without SGK coverage, such as international patients and visitors from abroad, pay privately or through their private or travel health insurance; the hospital checks coverage before treatment. Fee information is given by the hospital after the examination, and insurance coverage is clarified at the consultation.

Patients from Elbistan, Afşin, Göksun, Ekinözü and Nurhak come to HG Hospital in Kahramanmaraş for the examination and surgery; Dr. Öztürk does not see patients in Elbistan. For travel planning, see the patients from Elbistan and the surrounding area page.

Frequently asked questions

Sources

• Turkish Ophthalmological Society — todnet.org
• American Academy of Ophthalmology (AAO) — aao.org
• National Eye Institute (NEI) — nei.nih.gov

Related pages

• Droopy eyelid and blepharoplasty
• Dry eye
• Blepharitis (inflammation of the eyelid margin)
• Strabismus and lazy eye

This page is for information only; diagnosis and treatment decisions are made after an examination. The results of any surgical or interventional procedure may vary from person to person. You are advised to obtain detailed advice from your physician before any procedure.