DCR surgery should never be the first line of defense in epiphora treatment. In fact, it should never be the second or third, either. It should be dead last in the list. Only when every other method has been utilized exhaustively should such a drastic procedure be considered, and only then after the patient has been fully informed about the how a DCR is performed and what the risks are. Sparing details here is no different from flat-out lying. A lie by omission is still a lie. Lying to patients about the details of a medical procedure is about as unethical as it gets.
Because it’s difficult to know exactly what is causing the epiphora upon preliminary examination, especially considering it is usually a variety of factors, a number of initial treatments should be used. I barely received two of the following five treatment options. I was given unaggressive syringing early on, and then steroid eye drops. I supplemented this with over-the-counter antibiotic eye drops on my own, although my ophthalmologist didn’t think it was necessary.
Until you have tried everything in this list, don’t even begin to think about having a DCR performed. If your ophthalmologist isn’t willing to try all of these options first, get out of there! These are not unusual or new treatments. They are the status quo for many practices. And what’s more, they are proven effective by multiple studies and tons of clinical experience. If your doctor says otherwise, he or she is simply wrong.
1. Punctual Irrigation (Dilatation and Syringing)
Punctal dilation is very simple, and is done before syringing or on its own. The process consists of the application of anesthetic, then the insertion of a tapered instrument into the punctum. This will help to stretch it open slightly, potentially clearing any mucus plugs or simply expanding an unnaturally narrowed punctum. It will also allow a larger more defined opening for the insertion of a syringe.
A specialized syringe filled with saline is inserted into the punctum and led down the lacrimal duct. At this point, it may serve as a probe as well (discussed next). It is inserted until it hits the bone, and then retracted slightly. The plunger is then pushed with some force. At this point, any reflux of the fluid back into the eye is noted, indicating at least a partial blockage. The patient is then asked if he or she can feel or taste the saline in his or her nose. If not, then the blockage is usually deemed complete, or further diagnostics are performed. If the patient can feel or taste the saline, there may be no blockage or only partial blockage.
2. Therapeutic Probing
While probing is the status quo for congenital lacrimal obstruction in children, it is not regularly used on general lacrimal obstruction or stenosis in adults. The research and clinical experience, however, point to this as a viable treatment option that is currently under-utilized.
Probing may be used in conjunction with dilation and syringing, usually after dilation. This will allow for the most effective syringing possible, and thus a possible cure or at least temporary relief early on. It can actually serve as a diagnostic and therapeutic technique at the same time.
A small-gauge probe is inserted into the punctum and led into the canaliculus. If it stops hard against the bone, then there is not a complete obstruction, since it has successfully entered the lacrimal sac. If it stops ‘soft’, then there may be a blockage because it is stretching on the duct tissue rather than reaching the end firmly. If this happens, the probe is taken out and reinserted. If it reaches with a hard stop, successively larger probes may be used in order to widen the lacrimal duct and clear and partial obstructions. Syringing is then performed to provide additional clearance and to confirm the clearness of the duct.
‘Efficacy of probing as treatment of epiphora in adults with blocked nasolacrimal ducts’ (Link)
‘Probing in adults with confirmed nasolacrimal duct obstruction can be recommended as an initial treatment procedure because of its relatively good efficacy and high patient satisfaction without compromising subsequent surgical treatment if unsuccessful.’
Published in: British Journal of Ophthalmology, 1998
3. Antibiotics and Steroid Eye Drops
Steroid drops are used because they will reduce allergic inflammation, a common factor in epiphora. Topical steroids are commonly prescribed for allergic conditions. Anti-itch creams, for instance, are topical steroids. As inflammation and irritation decrease, the tear drainage system has an opportunity to correct itself.
Infection can also contribute to a blocked tear duct. In fact, it’s very common for an already blocked up eye to become infected, exacerbating the tearing. This is because the constant flushing of tears would usually help to keep the eye clean and healthy. But when they are stopped up, they stagnate and become a perfect environment to harbor infection. Antibiotics will help with this, and thus can help many epiphora sufferers.
Restasis, an immunomodulator, is also often used with the steroids. It works by decreasing swelling in the eye, thus allowing for more tear production. But wait—why would we want more tears to cure a watery eye? Well, it’s because dry eye is a common cause of epiphora. Confused? Well, it works like this: As the eye dries out, it causes irritation and swelling in and around the eye, followed by an increased chance of blockage and swelling in the drainage system, since it is not as well lubricated by tear production. In response to the irritation, the eye will want to produce more tears. Since the drainage system is impaired, the tears cannot be taken away quickly enough. Thus, we have a watery eye. By allowing for more consistency in tear production and eliminating periods of dryness and irritation, Restasis can help cure some instances of epiphora, and is often prescribed when steroids fail.
1. Dye Test
A few drops of dye are put into the watery eye to see if it drains down into the nose. If it does, then there is no blockage or a partial blockage. If none is seen in the nose and it drips down the cheek, the blockage is likely complete.
2. X-ray Examination (Macro Dacryocystography)
This x-ray examination involves a painless injection of dye into the punctum, which is then visible in the film. This simple and safe procedure allows doctors to determine the precise nature and location of the blockage.
3. Canalicular Endoscopy
In this procedure, a practitioner uses a microcanalicular endoscope to identify the location of the blockage and what is causing it. This device can take video inside the duct to allow a very precise diagnosis.
1. Balloon Dilatation (Dacryocystoplasty or DCP)
During this simple procedure, a balloon catheter, which looks like a small probe, is inserted into the punctum and into the canaliculus. Then it is inflated to enlarge the duct. At this point, it may be left in briefly or taken out right away. The procedure is sometimes done under a sedative, but general anesthesia is not used in most cases. It is a very quick, simple, safe, painless procedure with a very high success rate.
‘Non-surgical treatment of epiphora by balloon dacryocystoplasty—the technique’ (Link)
‘Dacryocystoplasty (DCP) was offered as an alternative to patients waiting for dacryocystorhinostomy (DCR) for epiphora. 31 procedures were undertaken with a technical success rate of 93% and a clinical improvement in 89% of these patients. It is concluded that DCP should be the technique of choice in the initial management of epiphora due to stenosis or occlusions of the nasolacrimal ducts before contemplating a DCR.’
Published in: British Journal of Radiology, 1995
2. Stenting (intubation)
Stenting is achieved through the insertion of a small tube into the canaliculus. This tube may be made of a variety of materials, but silicone is generally preferred. This tube will allow the flow of tears in a situation where narrowing or recurring blockage had previous disrupted flow. In some cases this stent is a permanent fixture, with in other it may be removed after a period of months. This is not a perfect solution and comes with its own risk, but it is reversible if necessary, unlike the DCR.
‘Nasolacrimal stent for epiphora caused by obstruction of the nasolacrimal duct’ (Link)
‘A 71-year-old patient with severe epiphora due to a subtotal obstruction of the nasolacrimal duct was initially treated with balloon dilatation. After failure of this procedure a nasolacrimal stent was placed under fluoroscopic control in an outpatient setting. After stenting there was complete resolution of the epiphora during a follow-up of six months. Outpatient treatment of complete nasolacrimal duct obstruction or obstruction after failure of balloon dilatation with a nasolacrimal stent appears to be a good alternative to surgery.’
Published in: Ned Tijdschr Geneeskd (a Dutch journal), 1997
(To see additional important studies, please read my updated blog post.)