(See the Introduction from the homepage if you haven’t read it yet.)
The protocol for evaluating and treating epiphora in Australia is dangerously flawed. Let me prove it to you. In many cases when a patient is referred to an ophthalmologist/oculoplastic surgeon, they will have a syringe test performed. A syringe test works by injecting a saline solution into the tear sac through the puncta (the tear drainage holes) in the corners of your eyes. If you cannot feel any solution in your throat and if there is regurgitation of solution back out of the puncta in your eyelids, you are deemed to have a blockage. Then, in short order, you are recommended to have DCR surgery.
The above scenario is unfortunately common. There is no attempt at probing or examining exactly where the block is with a macro-dacryocystogram. Nor is there any mention of non-surgical interventions. It seems most surgeons using this approach argue there’s no use locating the block. They believe surgery is the only sensible solution. And on paper, DCR does look very good. It’s cost effective, it requires relatively few follow-up visits, it’s not extremely complicated, and it has a high ‘success’ rate. I put success in quotes there because I think that in the case of DCR, we have to re-examine our definition of success. Yes, there may not be a problem with watery eye anymore—but at what cost?
I also acknowledge there are brilliant and conservative ophthalmologist/oculoplastic surgeons who believe in surgery as the last resort. They meticulously examine the lacrimal system with probing, X-rays, etc., and first place the patient on the least invasive therapy, such as steroid/antibiotic drops. If those things fail, they’ll attempt other non-surgical approaches. Surgery is applied only as the very last resort and only when the patient is fully informed whether living with epiphora is better than possible complications of DCR. It is my honest, informed, and well-considered opinion that the practices of these responsible doctors should become the status quo.
My Epiphora Treatment & Complications
In the start of this ordeal, I had bothersome (though not unbearable) epiphora in my left eye. I would have a stray tear or two roll down my cheek at random points throughout the day. Although it wasn’t terrible, I know that these things can become out of control if not dealt with as soon as possible. So I went to visit my general practitioner, and was referred to an ophthalmologist.
At the ophthalmologist, I had both of my eyes syringed, and the doctor deemed them to have significant blockages in both eyes. I didn’t think he syringed them hard enough because there was not much pressure. Regardless, he immediately referred me to an oculoplastic surgeon, who had a three-month long waiting list. I had to move interstate during this time, and decided to let my watery eye be for a while to see if there would be any improvement with time. While I usually trust my doctors, I wasn’t feeling confident in my first ophthalmologist’s assessment. My right eye hadn’t even been bothering me much at all, yet he found it to be significantly blocked. Something didn’t add up there for me.
A few months after my first syringe test, I consulted another ophthalmologist who syringed just the left eye. Again, I felt little to no pressure, and I was sure he didn’t push hard enough to clear it out. You see, when performed correctly the syringe test is also a therapeutic treatment. It can clear an obstruction or widen a narrowed tear duct when the syringe is used as a probe and when saline is injected with sufficient force. This time, I was recommended FML (Fluorometholone) steroid eye drops four times a day. That’s the only treatment I was given, and was advised to see him again in three months time if the epiphora persisted.
It continued watering despite the steroid drops, and three months later I returned (now six month since I originally sought treatment). I was given the same FML prescription, with instructions to come back in another three months. During these three months, I learnt how to drain the tear sac myself and noticed mucus emerging. Upon my own suspicions, I used some antibiotic drops from the local pharmacy and actually noticed a decrease in the watering.
On my next visit to the same ophthalmologist, I told him about the antibiotic drops—which he generally dismissed. He kept me on FML drops and advised me to return in another three months. It was winter at the time and the watering was not improving much. After a full year since I had originally visited my GP, I returned for a third visit and finally was referred to an oculoplastic surgeon—again.
This time I decided I should see the surgeon. I wasn’t thinking that I would get the surgery, but I wanted to have someone else look at it anyway. It had been going on so long without improvement that I knew something needed to be done, and I wanted to hear my options from a specialist.
The oculoplastic surgeon syringed both eyes and, indeed, the left eye refluxed the solution and I didn’t feel anything in the throat. The syringing was far more thorough and forceful than the previous two ophthalmologists. The first ophthalmologist syringed the right eye and I did not feel it in the throat, whereas the oculoplastic surgeon actually syringed it with more force and I felt it go into my throat fully.
So I finally received a thorough syringing for the first time after five visits to eye doctors over the course of a year. If I had received such a forceful syringing at the beginning of the epiphora, maybe it could have been flushed out from the start. We’ll never know. But once the oculoplastic surgeon deemed that I had a blockage in the left tear duct, he immediately drew a diagram for an external DCR. I was horrified about the concept of him cutting through bone and the extent and theory of the surgery. I absolutely refused.
This surgeon then offered the endoscopic approach to DCR, but he insisted that it’s not as successful and that he would need an assistant in the room with him, which would cost more money. He was insistent that the external DCR was the best solution. I asked him to attempt probing the nasolacrimal duct (a non-surgical alternative), but he told me that he doesn’t use the procedure, nor does he know anyone else who uses it. When I told him that I’d search for someone, he told his secretary to book me in anyway for surgery.
I left his office with not much hope. I was very wary of the idea of any surgery, let alone one as extreme as bone removal with external DCR in such a fine-tuned area of the body. But who would attempt probing on me?
* * *
Weeks later, a friend claimed she had her tear ducts unblocked by a top oculoplastic surgeon. I rung his office asking for probing, not surgery. They said that he could unblock the tear ducts. So I had a consult with him and he did the routine syringing, then went onto a spiel about endoscopic DCR (recall the last doctor pushed the external DCR)—that it’s ‘the best way’. He completely dismissed the idea that the nasolacrimal duct could be opened. I told him I did not want surgery, and he said that I’d just have to ‘live with it’, then.
By this stage, I was really getting sick of the tearing, which had increased, and wanted relief. I reluctantly booked in for the surgery. That is a decision I wish every day that I could undo.
The surgeon did not mention that endoscopic DCR involved drilling through bone—a concept that I found entirely unacceptable. I thought endoscopic DCR was less invasive than the external approach and believed that bone removal was not part of the procedure. If I had known, I would have refused. I certainly did not want bone removed from my nasal area just for a bothersome watery eye. It’s something the surgeon should emphasize—not exclude—during the preoperative consultation. Yes, the watery eye was uncomfortable, but bone removal wouldn’t have been worth it for me. I’d imagine many others would agree.
Complicating the Matter
Possible complications are a huge deciding factor for those considering a non-essential surgery. It’s a matter of carefully weighing the odds and the risk/reward ratio. We all understand that there are no guarantees in life, and everything has risks, but we at least want to know the odds and worst-case scenarios. Prior to the surgery, I was only given the following as complications:
- Reaction to drugs
- 10% restenosis
This small number of complications gave me the impression of a very safe procedure, which was important to me. Notice the complications are based on the very short term. I was not issued with an information booklet on the procedure (they are available for responsible surgeons to issue to patients). I’ve since seen an information leaflet about the surgery, and it certainly outlined more complications than what my surgeon gave me.
Immediately after the surgery I bled profusely through the nose for many hours. I also had a complication with my heart rate and blood pressure rising and had to stay overnight in hospital.
For the few weeks after surgery I found the silicone tubing very annoying and irritating, but that was to be expected. Overall I was not feeling good, but was still hopeful that when everything healed and settled I would be cured. Unfortunately, the real problems set in when the silicone tubing was removed after five weeks.
I now suffer from severe dry eye, and I believe it’s due to the following:
- There is significant air regurgitation through the corner of my left eye when I talk and breathe. This is not acceptable! Apparently air regurgitation upon blowing the nose is a common complication of DCR surgery, but it’s occurring all the time with me, and is very unpleasant to live with. The air regurgitation blows on my eyeball, contributing to severe dryness. I was not advised about this common permanent side effect during the initial consultation.
- The puncta (holes in the eyelid they place the silicone tubes through) are very dilated after the tube removal. This seems to have caused an increase in tear drainage, thus tears are being removed from the eye too quickly. The dilated puncta are also irritating my eyeball. Apparently, during the operation, they ‘snip’ the puncta to make them larger. Again, shouldn’t we be told about this part of the procedure?
- The hole in the nasal bone may be too large (apparently, it’s 9mm by 5mm).
The dry eye has induced a yellowish white inflammation on inner side of my eye near the iris, and I’m developing sty growths on the eyelid. Both are very irritable along with the dry eye pain. None of these were a problem before the DCR surgery. Before the surgery I just had a watery eye with some low-grade infection. I’d just wipe the occasional tear that dripped over my cheek. There was no pain or irritation involved, and it was much easier to live with than what I have now.
A dry eye is far more dangerous and uncomfortable than a watery eye. The presence of a dry eye leads to keratoconjunctivitis sicca, a condition that causes breakdown of the cornea and eventually possible blindness.
I have to apply artificial tears very frequently—every 15-20 minute—to keep the eyeball moist, as well a thick ointment before bed. Despite the artificial tears, I still feel burning and pain from it, especially with air conditioning and outside wind. I often wake in the middle of the night in pain and having to apply more drops.
It’s very difficult to live with. I find it frustrating carrying artificial tears wherever I go. In the hot weather the artificial tears get hot and burn my eye on application. Again, before the operation, none of this was a problem.
Frequent application of artificial tears is enough to drive anyone insane, especially during work. It has prevented me from pursing my career to the extent I would like to. I’m simply not able to spend so much time at the computer or meet for lengthy consultations. I’d have to reapply them three or four times during a one-hour consultation, which would be distracting both to my clients and myself. Thus, it has become a burden not just physically and emotionally, but financially as well.
Other complications I’m experiencing:
- Upper left eyelid pain (where tubes were placed), especially when using the computer.
- The left eye tires more quickly than the right.
- The left upper eyelid and upper canaliculus occasionally twitches. This never occurred before the operation.
- Involuntary nerve twitches in the inner corner of my left eye.
- The inner corner of the left eye (where you would massage the tear sac) puffs in and out as I breathe and talk. There is also a constant feeling of pressure there.
- Gritty feeling around eyeball near the eyelids (due to dry eye).
- Pain at surgical site. (I’ve investigated, and it’s not unusual to experience pain up to ten months after surgery!)
- Frequent headaches, which were not present before the DCR.
I cannot use a computer for very long due to the eyestrain and headaches. This has seriously affected my work, which involves lengthy computer use. Again, this wasn’t a problem before the DCR surgery.
Since having the DCR surgery I’ve noticed my left eye appears smaller. It’s since been noticed and confirmed by a medical practitioner. It’s not the eyeball that’s smaller, but a drooping upper eyelid (giving the appearance of a smaller eye), which, in fact, has occurred in other people whom have had DCR surgery. The difference is clear in the following image:
This is a less physically serious complication than the painful dry eye, but it is still psychologically unnerving. It’s a problem that I wasn’t told about, and that would have affected my decision about the surgery.
Please see my blog post for a full list of possible complications resulting from a DCR.
How It Feels and the Impact on My Wellbeing
The eye and nose are very sensitive parts of the body. Any change means a permanent awareness of discomfort or altered, unsettling sensation. This is why it should be left alone unless it’s absolutely vital.
I am constantly aware of air gushing in and out of the corner of my eye when I breathe and talk. It feels like someone blowing up a balloon then releasing it. It’s a pumping action that I’ve found very disturbing to live with. The only time I get relief from it is when I hold my breath!
It’s automatically assumed that patients won’t mind the ‘eyelid flutter’ upon blowing their nose after DCR, so they are often not told about it. How dare surgeons assume what we’ll feel comfortable with! I don’t like it at all, and certainly do not appreciate feeling my eye breathe when I do.
When I kneel down to pick something up, I can feel the difference and the tears rolling down the nasal cavity. It’s an eerie sensation.
The air regurgitation and pain from the dry eye has caused me significant emotional distress, especially because of the following:
- Knowing I was better before the surgery
- Knowing there were less invasive procedures available
- Knowing I wasn’t fully informed about the surgical procedure
- Knowing they cut through my bone when I was against it
- Frequently having to apply artificial tears
- Knowing these problems are permanent
- Constant awareness of the altered sensation between my left and right eye
All of these things have blended to cause a severe depression. I have not been able to work and have had to receive counselling, all because of DCR surgery. All because of a little eye watering.
Lack of Information During Consultation
I’m still confused as to why so many doctors in this field do not regard this surgery as the absolute last resort for epiphora. There is a lot of research that the non-surgical techniques work. They may not have the high success rate of DCR, but they are much safer, quicker and more economical.
Two oculoplastic surgeons could clearly see how opposed and terrified I was about surgery. Still, they dismissed my feelings and pushed the surgery. Neither of them mentioned there were non-surgical treatments that existed. I trusted them, and where did it get me? What can they do for me now? As it turns out—not much.
I was never told bone would be removed or my puncta would be snipped and dilated. That alone would be enough for me to absolutely refuse the surgery. It seems obvious to me that if the puncta were dilated, then it would alter the tear flow system and possibly cause irritation. Not to mention that bone removal is a truly extreme invasion and alteration of the body. It is even possible, though rare, to have leakage of CSF (cerebrospinal fluid). Note the conclusion of a study published in Ophthalmologica in 1991, titled ‘Anatomical consideration for dacryocystorhinostomy’:
‘It is obvious that, if a posterior nasal window is enlarged more than 3 mm above the medial palpebral tendon, a bony opening will be formed in the anterior cranial fossa floor in these 6 cases, resulting in cerebrospinal fluid leakage. In conclusion, DCR should be done without severing the medial palpebral tendon to make a bony nasal window under the tendon.’
In fact, one oculoplastic surgeon actually told me he doesn’t tell his patients he removes bone because it scares them away. That says it all. We have the right to know exactly what an operation involves, and it is the responsibility of our doctors to inform us so that we can consent or not consent based on the reality of the situation.
I was never told a large gaping hole would be made in my nose of 9mm by 5mm! This allows air to flow directly from the nose to the eye. It’s no wonder I feel air gushing in and out of my eye when I breathe and talk.
It stands that I was much better before DCR surgery. My eye was normal with just some watering and minor infection that could have been controlled with antibiotics. I didn’t need to carry artificial tears around and there was no pain at all. I would do anything to revert back to how I was.
Inappropriate Medical Treatment
I believe the very first ophthalmologist I saw should not have referred me on without giving me a treatment plan. I would have had to wait three months to book an appointment with the oculoplastic surgeon. Three months where I could have been using FML drops, antibiotics, heat packs, and so on, very early in the development of watery eye. Unfortunately, I was left without treatment and simply hoped it would clear up on it’s own.
The second ophthalmologist only gave me FML drops to use. He did not mention anything about massaging or using heat packs. I also do not think he syringed the tear sac properly. Then, despite the drops being prescribed and re-prescribed for almost a year, the watering got worse.
When I eventually consulted two oculoplastic surgeons, neither was interested in non-surgical intervention, such as probing or balloon dilatation. At the time I didn’t know about stenting or balloon dilatation, which according to studies can work very well—without the complications of DCR. I believe my concerns against surgery fell on deaf ears and I was given endoscopic DCR as the only choice.
My only desire was to attempt to have my nasolacrimal duct opened with non-surgical interventions. I very much wanted to feel that block being pushed through, either with probing, balloon dilation or stenting. Indeed, stenting now sounds the most promising from the three options. If the stent gets occluded, it can simply be removed and you’d still have a patent tear duct. Indeed, it could have worked for many years without any complications.
So why did I sign up for the surgery if I didn’t want it? Basically, after hearing more than one top oculoplastic surgeon emphatically tell me that there is no other way, then having them explain how ‘simple’ and ‘safe’ DCR is—I think I made the choice most anyone would. I followed what I thought was sound, thoroughly considered professional advice. If we can’t trust our doctors, whom can we trust?
If you have a blocked tear duct, I urge you to persist till you find someone who will do what you want. Don’t be pressured into something that doesn’t feel right by pushy doctors. Make sure you get all of the available information on a procedure before committing to it, even if that means going home to research and ‘think it over’. This is not an emergency procedure. Don’t let anyone rush you.
Non-Surgical Approaches to Adult Epiphora
There are studies to prove stenting can work up to 60% of the time in adults with epiphora. Stenting is an office procedure that takes only minutes to perform and opens the natural tear duct. Surgery works 90% of the time. My argument is this: why risk all the complications of surgery for a mere 30% increase in success rate? Not to mention the permanent change to anatomical structure, altered sensation, possible life long discomfort, pain, and unknown long-term complications of bone removal. And let’s not forget that the operation may fail, too.
It simply doesn’t make sense. In fact, it’s ridiculous—but they continue to push DCR as primary treatment. Just because my eye doesn’t water anymore, does that really make my surgery a success? Not in my view. But when they generate these statistics, I am considered a success—as are all of the other unsatisfied ‘cured’ customers.
I think the British Journal of Ophthalmology put it best in a short article for the September 2002 issue, titled ‘Dacryocystorhinostomy for partial nasolacrimal obstruction’:
‘The importance of giving a thorough trial to less invasive treatments such as forced syringing, stents, balloon dacryoplasty, and silicone intubation before undertaking a DCR in such cases has not been adequately emphasised. It is true that variable results have been reported with these techniques, but there are studies which show success rates as high as 73.3% with antegrade balloon dilatation combined with silicone intubation even in cases of complete nasolacrimal obstruction over a 1 year follow up.’
I was denied procedures that very well could have provided a perfectly functioning eye, no complications, no difference between eyes, no pain, no bone removal, and so on. It’s okay with the surgeons to cut us up with DCR, but for them the complications are all statistics and theoretical possibilities. For us, these complications are real, and we may carry them for the rest of our lives. Don’t we deserve a choice?
Believe it or not, DCR has been used for over one hundred years. It’s an old technique they’ve refined, but the theory remains the same. Surely, in this day and age there are less traumatic methods to treat a blocked tear duct. In reality, drilling through bone and slaughtering the lacrimal sac open and forcing it to join the nasal mucosa sounds barbaric and extreme for a simple watery eye.
If dry eye doesn’t occur, then there is still a disturbance in balance between both eyes. That’s why I firmly believe the natural nasolacrimal duct should be unblocked with all the methods available. If they haven’t worked, then at least there was an attempt. Furthermore, who is necessarily looking for a complete cure? Some people (like myself) were only looking for a reduction in tear flow. A moderate improvement is better than surgical complications. It’s argued by many surgeons that these alternatives do not work in the long term. But who necessarily wants that? Maybe a short relief from watering is enough. Ten months of relief is very good in my opinion. You can always go back for a repeat or try a different alternative.
It’s up to you. It depends on how you feel about what happens to your body. Some people don’t care if bone is drilled out and are willing to risk complications. As long as it’s a long-term cure for watery eye, it doesn’t bother them. But many, many others would disagree. Shouldn’t we all be treated on our own terms?
Two weeks after my endoscopic DCR surgery, I discovered there was stenting available. And yes—surgeons available in Australia who will probe and use stenting on adults. Knowing I could have prevented the surgery is demoralising. Why didn’t I discover this before the surgery? Because I was pushed and bullied into the surgery by being told no other options exist and being given the sales spin on DCR. I believe this is not only unfair—it’s unethical, even immoral. It is, without a doubt, entirely unacceptable.
See my blog post for more information on DCR alternatives.
Challenge for Surgeons
What to do when DCR goes wrong? Shouldn’t we have an option to ask for it to be reversed, especially if not given enough detail of the operative procedure and complications? Has anyone ever totally reversed DCR surgery before? Have you ever closed the hole in the nasal mucosa? What was the result?
I’ve sent my request via email to countless eye/lacrimal surgeons around the world. Not surprisingly, most have ignored my email. It seems surgeons can be quite dismissive when it comes to a patient who’s had complications—as if they don’t want to deal with damaged goods.
How could you do the following?
- Replace the bone that was cut out
- Detach the lacrimal sac from the nasal mucosa and close it up again
- Close the hole in the nasal mucosa
- Decrease the size of the puncta
For my air regurgitation and dry eye, I was given the following ideas (none are particularly appealing to me):
- Punctal plugs or permanently closing the puncta
- Replace the silicone tubing back into the canaliculi and through into the nose
- Rough up the nasal mucosa to cover the hole
- A donor piece of skin to cover the hole in the nasal mucosa
Firstly, punctal plugs can migrate and fall into the lacrimal sac, requiring an operation for removal. They can also cause infection and scarring. Also, they would take me back to square one with the watering. Now, square one doesn’t sound too bad to me right now, but at what risk? The puncta are natural openings for tear drainage, what are the long-term repercussions of closing them? Again, there’s been too much altering of the body.
The silicone tubing placed back into the canaliculi (as is done during DCR) is not appropriate because it’s very irritating on the eyeball. In fact, I couldn’t wait to get it out. There’s also a risk of corneal abrasion, scarring, and infection of the canaliculus with long-term use. Furthermore, I still feel the upper canaliculus. It’s painful and twitches from having had the tubing in it for five weeks.
Help make a change to this protocol by raising awareness of alternatives and insisting that you are treated according to your own level of comfort. We have to hold these doctors accountable and let them know that pressuring wary patients into potentially dangerous surgeries is entirely unacceptable.
If you have a story to tell related to DCR, please speak up! Contact me with your experiences. If you’d like, I can even share your story on this site, anonymously if you’d prefer. It’s so important that we do not remain quiet about this. The medical community needs to hear us and change this protocol. Irresponsible surgeons need to be held accountable. We are not just customers—we are patients, helpless and trusting.
We need to live in a world where we can trust our doctors to have our best interests in mind, who will listen to our concerns and wishes and take them seriously. Help me make that more of a reality.
NEW UPDATE: Want to know how I’m doing five years later? Visit this page and find out.