What causes tearing?
Tearing is possible in ones eye for several reasons. Consider the eye surface as a sink. There is a gland that sits under the eyebrow that pumps water to the eye. This is known as the lacrimal gland. I tell patients that this is a faucet. So why do we tear? We tear for the same reasons that our sink at home overflows. When a piece of sand, dust or dryness gets in the eye the eye become irritated and the faucet turns up the flow. When that happens, the sink can overflow. If I left my house this morning and turned the faucet on full blast, it is possible for the sink to overflow. Alternatively, the eye can tear if the drain is blocked. The lacrimal drain or duct is the drain of the eye surface. Like our drain at home it can become clogged and prevent water from coming down.
How does one test for the cause of tearing?
There are several steps for testing for the cause of tearing.As an oculoplastic surgeon we treat tearing and blocked tear ducts. These are the sequence of steps that we commonly do in our office.
First we examine the eyelids. We want to make sure that the eyelids are pumping water to the tear duct. In the patient below who has a stroke or bell’s palsy, one can see that the eyelid cannot pump the water to the entrance of the tear duct hole properly. As a result it flows down the side. If there is an eyelid problem, that would need to be fixed first.
The next step is a dye disappearance test. In this test we place yellow dye in the eye and see if it drains properly. After several minutes, the dye should drain away from the eye resulting in the eye returning to more of a white color. In the photo below, the patient has a blockage of the tear duct on the right side resulting in it being more yellow. It shows us preliminarily that there is a problem with blockage of the tear duct. Below this patient's right eye is still yellow whereas the left is white showing that the tears are not draining properly in the right eye.
After the dye disappearance, we look at the surface of the eye for irregularities and dryness. This is done with the slit lamp biomicroscope which looks at the surface of the eye. These problems such as dryness would cause the eye to tear as well and would be corrected.
Next, we irrigate the tear duct with a lacrimal irrigator. It is a small tube that is connected to water in a syringe. We squirt the water through the entrance of the tear duct to determine if there is a blockage. If there is no blockage, the water should go down the nose. If there is a blockage, the water would go back up over the eye. This tells us the tear duct is blocked. If the tear duct is blocked it needs to be opened with DCR or dacryocystorhinostomy. The picture below is magnifed several times because the tube is so small.
What is a dacryocystorhinostomy?
In a dacryocystorhinostomy (DCR), an incision is made near the inside corner of the eye or within the nose and a new opening is made to allow tears to drain from the eye into the nose. A flexible stent tube may be left in place for three months (sometimes longer) to keep the new drain open. This tube can be removed in the office. The goal of surgery is to eliminate tearing, discharge, and irritation, and reduce the risk of infection.
How will DCR surgery affect my vision or appearance?
A DCR will not directly affect your vision though many people see better after surgery because they no longer have tearing or discharge from the eye. If an incision has been made on your skin, a small scar will be created.
What are the major risks of DCR surgery?
Risks of DCR include but are not limited to bleeding, trouble with eye closure infection, and scarring. Anytime any procedure is done near the eye, there is a risk of vision loss. In addition, the new drainage channel may not stay open; this happens in less than 10% of all cases, and may require additional surgery to correct. There are additional costs if the surgery needs to be repeated or if revisions are required.
What are the alternatives?
You may decide to live with the tearing, discharge, and irritation that a blocked tear duct can cause. However, if you have had an infection, your surgeon will likely advise surgery to prevent future infections, since these can, in rare circumstances, lead to vision loss. If your tear duct is completely blocked, there is no other surgery, injection, or medicine available to treat this condition. If your tear duct is partially blocked, a balloon can be inflated and/or tubes placed to enlarge the duct and keep it open.
WHAT TYPE OF ANESTHESIA IS USED? WHAT ARE ITS MAJOR RISKS?
DCRs can be performed under sedation with local anesthesia (injections around the nose and eye), or under general anesthesia. Risks of anesthesia include but are not limited to damage to the eye and surrounding tissues and structures, loss of vision, breathing problems, and, in extremely rare circumstances, stroke or death.
How do I find someone to perform my DCR?
Oculoplastic surgeons perform DCRs and tear duct surgeries. They are accredited by ASOPRS. The American Society of Ophthalmic Plastic and Reconstructive Surgeons. In Denver, Dr Thiagarajah is an oculoplastic surgeon and member of ASOPRS. He performs these procedures routinely.