Dacryocystorhinostomy (DCR) is a curative surgery for epiphora and dacryocystitis caused by nasolacrimal duct obstruction, in which a window is created in the bone between the lacrimal sac and the nasal cavity to establish a new tear drainage pathway.
Tears collect in the lacrimal sac from the superior and inferior puncta via the canaliculi, and are drained into the nasal cavity through the nasolacrimal duct. When this pathway is obstructed at the level of the nasolacrimal duct, tears and secretions accumulate in the lacrimal sac, causing epiphora, discharge, and dacryocystitis. DCR surgically creates a new drainage route that bypasses the obstruction, providing a fundamental solution.
For nasolacrimal duct obstruction, lacrimal tube intubation is also available, but it only temporarily dilates and maintains patency of the obstructed site, with a high reocclusion rate after tube removal. In contrast, DCR creates a new anatomical drainage pathway, offering high curability. Success rates are reported to be 90–99% 2).
DCR has two main approaches: external and intranasal.
External DCR (percutaneous DCR) is a classic technique that reaches the lacrimal sac through a skin incision at the inner canthus (corner of the eye). It allows direct visualization and a large bony window, resulting in a high success rate. However, it requires a skin incision, which may leave a scar.
Intranasal DCR (endoscopic DCR) is a minimally invasive technique that approaches the lateral wall of the lacrimal sac from the nasal side under nasal endoscopy. It requires no skin incision and offers better cosmetic outcomes, but the bony window tends to be smaller, and some reports suggest slightly lower success rates 3, 4).
It is a surgery that creates a new drainage pathway for tears by opening a window in the bone between the lacrimal sac and the nasal cavity. It is a definitive treatment for epiphora and dacryocystitis caused by nasolacrimal duct obstruction, with a success rate of 90–99%. There are two approaches: external DCR (with skin incision) and intranasal DCR (through the nose). Unlike lacrimal tube intubation, it creates a new anatomical drainage pathway, offering a higher cure rate.
Dacryocystitis is an inflammatory disease caused by bacterial infection in the lacrimal sac due to impaired tear drainage, and is classified into acute and chronic types.
| Classification | Main Symptoms | Characteristics |
|---|---|---|
| Acute dacryocystitis | Redness, swelling, pain over lacrimal sac, epiphora, discharge | Plan DCR after inflammation subsides. Watch for progression to orbital cellulitis. |
| Chronic dacryocystitis | Epiphora, discharge, pus reflux on lacrimal sac compression | Difficult to cure with antibiotics alone; DCR is needed for definitive treatment. |
Acute dacryocystitis is a condition in which acute purulent inflammation spreads from the lacrimal sac to the surrounding tissues. The main symptoms are marked redness, swelling, and pain slightly below the inner corner of the eye (medial canthus), with severe pain upon touch. It may also be accompanied by high fever and general malaise. In severe cases, it can progress to orbital cellulitis (deep infection of the orbit), leading to proptosis, restricted eye movement, and decreased vision.
In the acute phase, systemic and topical antibiotics are used to reduce inflammation, and DCR is planned after inflammation subsides.
Chronic dacryocystitis is a condition in which waste products and mucus accumulate due to stenosis or obstruction of the lacrimal sac and nasolacrimal duct, leading to abnormal bacterial growth. The main symptoms are persistent tearing and discharge. Pressure on the lacrimal sac or lacrimal irrigation reveals reflux of pus from the punctum.
If refractory chronic conjunctivitis recurs, consider the possibility of underlying chronic dacryocystitis.
Most cases of nasolacrimal duct obstruction are idiopathic (age-related) with unknown cause, but infection, trauma, paranasal sinus disease, radiation exposure, and medications (including eye drops) can also be triggers. The most common site of obstruction is the entrance of the nasolacrimal duct.
The most common causative organism of dacryocystitis is Staphylococcus aureus, followed by Corynebacterium spp., Streptococcus pneumoniae, etc.7, 8)
Acquired nasolacrimal duct obstruction is more common in elderly women, and the anatomical narrowness of the nasolacrimal duct is thought to be related to female predominance2).
Chronic dacryocystitis is difficult to cure with prolonged antibiotic administration alone; relieving the lacrimal duct obstruction is the definitive treatment. Complications of chronic dacryocystitis include corneal ulcers and endophthalmitis after intraocular surgery. To reduce the risk of infection during intraocular surgery, it is important to cure dacryocystitis before surgery.
The success rate of lacrimal tube insertion (endoscopic lacrimal intubation) is 70–87% at one year after tube removal, with a residual risk of long-term recurrence1). In contrast, DCR is highly curative and shows superior long-term outcomes compared to lacrimal tube insertion, making it the first choice for definitive treatment of chronic dacryocystitis.
Evaluate the condition of the lacrimal pathway in detail before surgery.
Lacrimal sac compression test (Crigler method): Compress the lacrimal sac area below the medial canthus and check for reflux of pus or mucus from the punctum. If reflux is observed, dacryocystitis is almost certain.
Lacrimal irrigation test: Inject saline through the punctum and evaluate the patency and the nature of reflux (pus, mucus, tears). If there is no irrigation and pus reflux is observed, dacryocystitis with nasolacrimal duct obstruction can be diagnosed.
Lacrimal endoscopy: Insert an endoscope through the punctum to directly observe the lumen of the canaliculi, lacrimal sac, and nasolacrimal duct. It allows detailed evaluation of sac enlargement, inflammatory findings, and obstruction sites, and is useful for preoperative assessment 1).
Preoperative CT: Check the shape of the orbit, lacrimal sac fossa, nasal cavity, and the presence of sinusitis. Preoperative understanding of the width of the lacrimal sac fossa for bone window creation, nasal septum position, and nasal polyps enables safe surgical planning.
The main indication is long-standing epiphora and discharge with the patient’s desire for surgery. In acute dacryocystitis, first perform incision and drainage, intravenous antibiotics, and oral medication to reduce inflammation, then plan surgery after inflammation subsides. Surgery with residual acute inflammation is not recommended due to increased risk of bleeding and infection.
For chronic dacryocystitis, antibiotics should not be continued indefinitely; DCR, a curative surgery, should be actively considered.
Choice between tube intubation and DCR: Lacrimal tube intubation (under lacrimal endoscopy) has the advantage of being minimally invasive and can be performed as an outpatient procedure, chosen based on the patient’s general condition and surgeon’s experience. However, DCR is superior in terms of radical cure.
Performing intraocular surgery in the presence of chronic dacryocystitis carries a risk of bacteria from the lacrimal sac entering the eye and causing endophthalmitis. If intraocular surgery such as cataract surgery is planned, it is recommended to cure dacryocystitis with DCR beforehand. After confirming normalization of the lacrimal pathway, intraocular surgery can be performed with standard risk management.
| Step | Procedure | Key Points |
|---|---|---|
| 1. Anesthesia | General anesthesia (local anesthesia also possible) | Prepare for risk of blood dripping into the larynx during bleeding |
| 2. Preoperative intranasal treatment | Bosmin® + 2% Xylocaine® mixed 1:1 | Essential to minimize bleeding |
| 3. Skin incision | Incision along the anterior lacrimal crest (using a round knife) | From the upper edge of the medial canthal tendon to the entrance of the nasolacrimal duct |
| 4. Osteotomy | Approximately 1×1 cm bone window in the lacrimal sac fossa | Using chisel + hammer or electric drill |
| 5. Mucosal flap suturing | H-shaped incision → two-flap suturing | No significant difference in outcomes with flapless technique |
| 6. Stent placement | Tube + pod + Beskitchin® placement | Removal: Beskitchin at 1 week, pod at 1 month, tube at 2 months |
General anesthesia is standard. Endotracheal intubation is recommended for safety because blood may flow into the larynx during heavy bleeding, or the patient may become agitated due to vibration during bone window creation. Surgery under local anesthesia is possible in patients at high risk for general anesthesia.
Mix Bosmin® (adrenaline) and 2% Xylocaine® (lidocaine) in a 1:1 ratio, soak gauze, and insert it into the nasal mucosa at the bone window site using nasal forceps. Adequate preoperative intranasal treatment is essential to minimize intraoperative bleeding from the nasal mucosa and is an important step affecting surgical outcomes.
Draw a skin incision line along the anterior lacrimal crest from the upper edge of the medial canthal tendon to the entrance of the nasolacrimal duct, and make the incision with a round blade (scalpel). Accurate incision placement is important because it affects access to the bone window and the visibility of postoperative scars.
Create a bone window of approximately 1×1 cm in the lacrimal fossa (the bony depression between the anterior and posterior lacrimal crests). Use a flat chisel or round chisel with a hammer, or an electric drill. Since the size of the bone window directly affects the success of DCR, it is desirable to make it as large as possible.
An H-shaped incision is made in the lacrimal sac and nasal mucosa to create mucosal flaps for suturing. In principle, the anterior and posterior two flaps are sutured. However, it has been reported that there is no significant difference in surgical outcomes even with a technique that excises the nasal mucosa and lacrimal sac as much as possible without creating flaps.
A silicone tube and a silicone pod for retinal detachment are placed in the bony window. The use of Beschitin® (chitin-based hemostatic agent) is useful for maintaining the bony window space and hemostasis. The silicone pod is sutured at its cranial side to the medial canthal tendon.
| Material | Removal timing | Notes |
|---|---|---|
| Beschitin® | 1 week postoperatively | For maintaining bony window space and hemostasis |
| Silicone pod | 1 month postoperatively | Removed via the nose |
| Silicone tube | 2 months postoperatively | Removed between the puncta |
External DCR (Percutaneous DCR)
Approach: Skin incision at the inner canthus
Bone window size: Approximately 1×1 cm (can be made large)
Re-obstruction rate: Stable results at 10% or less
Cosmesis: May leave a skin scar
Indications: Standard nasolacrimal duct obstruction, cases with complex nasal anatomy
Endonasal DCR (Endoscopic DCR)
Approach: Via the nasal cavity under nasal endoscopy
Bone window size: Tends to be slightly smaller than external DCR
Re-obstruction rate: Some reports suggest slightly inferior results 3, 4)
Cosmesis: No skin incision, no scar
Indications: Cases where cosmesis is important, cases where external DCR is difficult
Endonasal DCR is a surgical technique that approaches the lateral wall of the lacrimal sac from the nasal cavity using a nasal endoscope. It requires no skin incision and offers superior cosmetic outcomes. A challenge is that the bone window tends to be smaller than in external DCR, and some reports indicate slightly inferior results 4); however, increasing reports suggest that with surgeon proficiency, outcomes comparable to external DCR can be achieved 3). The introduction of powered instruments (powered endonasal DCR) has improved the precision of bone resection under endoscopic guidance 5).
For acute dacryocystitis, first perform incision and drainage and administer antibiotics (intravenous or oral) to reduce inflammation. After confirming resolution of inflammation, plan and perform DCR. DCR during the acute inflammatory phase should be avoided due to increased bleeding risk and infection risk.
External DCR allows for a larger bony window and shows stable results with a reocclusion rate of less than 10%. Endoscopic DCR has no skin scar and is cosmetically superior, but some reports indicate a smaller bony window and slightly inferior outcomes 3, 4). The choice is made by comprehensively considering nasal structure, presence of sinusitis, cosmetic preferences, and surgeon experience. In recent years, improvements in endoscopic techniques have been improving the outcomes of endoscopic DCR.
After surgery, antibiotic eye drops and oral antibiotics are prescribed to prevent infection. Lifestyle guidance is given to avoid irritation of the nasal mucosa. Stents are removed sequentially in the outpatient clinic according to the removal schedule (Besikitin® 1 week, silicone pod 1 month, silicone tube 2 months).
After tube removal, periodic lacrimal irrigation tests are performed to confirm the patency of the bony window.
Bleeding may occur during or after surgery. Intraoperative nasal mucosal bleeding can be minimized with preoperative nasal treatment (Bosmin® + Xylocaine®). If postoperative epistaxis occurs, apply pressure for hemostasis.
Reocclusion is reported to be less than 10% with external DCR. The main causes are granulation tissue formation, scar contraction, and narrowing of the bony window. In some cases, topical steroid administration during follow-up may be effective 10).
Skin scar is a complication specific to external DCR, and a linear scar may remain at the inner canthus. Proper skin suturing and postoperative management can make it less noticeable. Endoscopic DCR does not cause skin scars.
Canalicular injury rarely occurs during skin incision or instrument manipulation. If the canaliculus is damaged, repair surgery may be necessary.
Meningitis may very rarely occur if the dura mater is damaged during creation of the bony window.
Complications of untreated chronic dacryocystitis: If intraocular surgery (e.g., cataract surgery) is performed in the presence of chronic dacryocystitis, the risk of endophthalmitis and corneal ulcer increases. Preoperative cure of dacryocystitis by DCR is key to improving the safety of intraocular surgery.
The reocclusion rate with external DCR is low, below 10%. The main causes of reocclusion are granulation tissue formation and scar contraction at the bony window. Postoperative stent placement (tube for 2 months, pod for 1 month) and appropriate follow-up are important to prevent reocclusion. In case of reocclusion, consider reoperation (revisional DCR) or treatment under dacryoendoscopy.
The tear drainage pathway runs from the superior and inferior puncta → canaliculi (vertical part 2 mm, horizontal part 8 mm) → common canaliculus → lacrimal sac (approximately 12 mm long) → nasolacrimal duct (approximately 12 mm long) → inferior meatus. The lacrimal sac sits in the bony lacrimal fossa (between the anterior and posterior lacrimal crests). In DCR, the bone of the lacrimal fossa is removed to create an anastomosis with the nasal cavity.
The most common mechanism of nasolacrimal duct obstruction is scarring and luminal narrowing due to chronic mucosal inflammation. The most frequent site of obstruction is the entrance of the nasolacrimal duct, and age-related mucosal atrophy and fibrosis are considered the main triggers.
When obstruction occurs, tears and secretions accumulate in the lacrimal sac proximal to the blockage. Bacteria such as Staphylococcus aureus and Corynebacterium overgrow, leading to dacryocystitis. Persistent chronic inflammation causes thickening and fibrosis of the lacrimal sac mucosa, worsening the obstruction in a vicious cycle.
DCR bypasses the obstructed nasolacrimal duct and creates a direct drainage pathway between the lacrimal sac and the nasal cavity. A new drainage route is formed by mucosal anastomosis through the bony window. A larger bony window reduces the risk of reocclusion, and the ability to create a larger window with external DCR directly contributes to its high success rate.
Intraoperative topical application of mitomycin C (MMC) to prevent reocclusion has been reported to potentially reduce scar formation around the bony window by suppressing fibroblast proliferation. Systematic reviews have not established a statistically significant effect for MMC administration 10), and its standard use is currently limited.
The introduction of powered instruments (powered endonasal DCR) and precise mucosal treatment using a microdebrider have improved the size of the bony window in the endonasal approach, leading to better outcomes5). Data from RCTs directly comparing the outcomes of external and endoscopic DCR have accumulated, showing no significant difference in primary success rates6).
Traumatic/iatrogenic nasolacrimal duct obstruction differs in pathophysiology from common age-related obstruction, with the main cause being obstruction due to fractures or postoperative scarring. In these cases, more extensive bone resection and assessment of the nasal mucosal condition are important.
CDCR (conjunctivodacryocystorhinostomy) is an option for cases with canalicular obstruction (canalicular obstruction + dacryocystitis), where a Jones tube (glass tube) is placed from the conjunctival sac into the nasal cavity to establish a tear drainage pathway1).
Dacryocyst transposition (conjunctivodacryocystostomy) is described as a new surgical technique in which the lacrimal sac is rotated forward and anastomosed to the conjunctival sac9).
