DCR...external or endoscopicby Dr Chris Thiagarajah on 05/28/12
I have been asked by several patients and people desiring second opinions about DCR surgery and whether an external (skin) approach or endoscopic (nose) approach is better. I am trained to do both and thought it would be a good discussion for this month.
A DCR (Dacryocystorhinostomy) is a tear duct procedure that is done to stop tearing in patients who have a blocked tear duct. The main purpose of the procedure is to open the tear duct and this can be done one of two ways: through the skin or through the nose. Both are done as an outpatient and both take about 30 minutes to do.
The approach through the skin is done through an incision that is approximately 1-1.5 cm in length through the tear trough crease. Most people have a crease that is adjacent to the nose and eyelid. A recent study showed that the incision site heals imperceptibly in most patients. There are several advantages to this technique. One, the success rate is higher. Most data show a success rate upwards of 90%. Also, It is easier to see in the procedure where one is looking at an open space as opposed to through the nose. Two, if cancer is causing the blockage, the surgeon can easily see it and send it to biopsy.
The approach through the nose has a main advantage of no incision in the skin. Since it is done through the nose there are no cuts on the skin made. There are several disadvantages to the endoscopic approach. First, it is not as easy to see as well in the nose endoscopically and cancer can be missed. Second the success rate is lower (around 80-85%).
So who should get which procedure? I offer both to patients and let them decide. Natural tear duct blockage tends to occur in the older population. Younger patients with tear duct blockage are less common and are at more risk for cancer or a growth. Interestingly it is the younger patients who are more concerned about the incision from an external DCR. I try to counsel patients both ways to see which is the one they want to do. It is a personal decision. I generally like to give the patients the facts and let them choose. The exception is if I am very concerned about cancer in the tear duct and then I recommend an external approach.
Once however someone has an endoscopic DCR and if the surgery fails (remember the success rate is only 80-85%), I recommend an external approach. I can see better the second time around and if there is a cancer growing I can easily catch it.
I hope this is helpful and allows patients to understand more about which approach is used for tear duct surgery.