Tearing or epiphora is a relatively common problem and represents one of the symptoms most often reported by patients attending an ophthalmology practice. Epiphora can be a very uncomfortable problem for the patient as it leads to continual drying of the tears to prevent them from spilling over the cheek, as well as causing blurred vision. Some patients find this embarrassing and even run away from social gatherings for this reason.

The normal tear duct

The normal drainage route for tears originates in the inner canthus of the palpebral fissure, near the nose. From there, two small tubes called tear ducts start. These originate in the upper and lower eyelids, and drain into the lacrimal sac, a structure located in close relation to the nostrils and sinuses. The tear sac drains directly into the nose through the tear duct. Under normal conditions, the volume of tears is imperceptible in the nose since they are reabsorbed helped by the continuous passage of air. When we cry, however, the increased volume of tears is perceived as nasal mucus.

How tearing works

What are the causes of tearing?

There are many causes of tearing, so the key to successful treatment is based on a thorough initial examination by an ophthalmologist specializing in the tear duct. A simple way to understand this is to classify epiphora into those caused by abnormalities in the tear drainage system and those caused by excessive tear production. The lacrimal system can be altered anywhere from the beginning of the canaliculi to the tear duct. Sometimes the system is permeable to exploration but does not drain tears adequately; this is called functional epiphora, since it is the function and not the structure of the tear duct that is altered. Newborns can sometimes have a low obstruction of the tear duct. This is usually due to an immaturity of the system that in most cases is solved spontaneously before the year of age. In adults, the most common condition of the lacrimal system occurs at the level of the tear duct. For unknown reasons, the duct narrows with age and may close completely. This occurs most often in women over the age of 50. Stenosis of the tear duct, in addition to tearing, makes the tear sac more prone to infection. This is called dacryocystitis and is characterized by pain, redness and sometimes abscess in the area of the tear sac.

lacrimal blockage
Patient with a tear sac abscess due to an untreated tear obstruction

When the patient with tears has a normal tear duct, we must look for other causes. It is important in this case to carefully explore the eye surface, as any problem at this level causes irritation and reflects increased tearing. One of the most common eye surface problems that can occur as an epiphora is dry eye. Dry eye is a very common condition in which there is a deficit in tear production, either in quantity or quality. As contradictory as it sounds, dry eye can cause tearing. When the eye surface is not adequately protected by the tear film, irritation of the tear film occurs, causing great discomfort to the patient and at the same time causing the main tear gland to overact momentarily to protect the eye surface. This increased reflex tearing does not adequately protect the eye, since the main tear gland mainly produces the aqueous volume of the tear film, but the minute components that cause the tear to form a film and remain on the eye surface are missing. Therefore on many occasions the patient refers to these reflex tearing bursts as ‘wet eye’ or as epiphora falling down the cheek. The treatment of these types of tears is aimed at solving or improving the process that causes irritation of the eye surface.

Treatment of tear duct obstructions

Obstruction of the tear duct can only be treated surgically and is called dacryocystorhinostomy (DCR). This means creating a new pathway for tears from the tear sac to the nose, avoiding the blocked tear duct. It is an outpatient surgery that in the vast majority of cases is performed under local anesthesia with sedation. The classic approach in RCD is done through an incision of approximately 1 cm in the skin of the internal canthus. Through it, the tear sac and the nose are accessed, creating the new pathway. External RCD is the most effective technique although it has the disadvantage of a small scar and a somewhat slower recovery than endoscopic techniques. In many cases the scar becomes imperceptible. The endoscopic approach through the nose obtains results very similar to external surgery with the advantage of being a shorter surgery, without scars and with a faster recovery. Whenever possible due to the patient’s nasal anatomy, we recommend the endoscopic approach. In both approaches a small silicone probe is placed through the new tear duct that we have created in order to keep the duct open during the healing process. The normal healing process would tend to close the new pathway, so the probe acts as a ‘stent’, keeping it open. This tube is removed between 6 and 10 weeks after surgery and can be done in the office as it is not painful.

Endonasal RCD intervention in a patient
Endonasal image of an endonasal RCD patient showing a new duct created by surgery and the silicone probe passing through it

The post-operative period after RCD surgery

Undergoing RCD surgery, especially if it is endoscopic, is not going to be a major brake on your daily activity. We recommend rest for the first 1-2 days after surgery. After that, if the patient is well, he can go back to work. It’s not a painful post-op. Usually if the surgery is performed on a Thursday or Friday, the patient can return to work the following Monday. We do recommend not making vigorous physical efforts for a week. In addition, the patient should avoid blowing his or her nose during the first week. The first post-operative visit is made a week after the operation. If an external approach has been made, the stitches are removed at this visit. The second visit will be to remove the probe.

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