Revisional Surgery for Failed Nasolacrimal Duct Obstruction Treatment

Scarring (fibrosis): The most common cause. The new passage narrows or closes as scar tissue forms during healing.

An inadequate bony window: An opening in the bone that is too small or poorly positioned. If it does not include the whole sac, tears continue to pool in the lower part.

A missed canalicular obstruction: If the real problem lies in the canaliculi, creating a new passage between the sac and the nose does not resolve the watering.

Nasal problems: Septal deviation, enlarged turbinates, polyps and adhesions covering the new opening.

Infection: Post-operative inflammation disturbs healing and accelerates narrowing.

Chronic inflammation: Persistent inflammation and granulation tissue in the sac.

Altered anatomy: Changed anatomy in patients who have had trauma or previous nasal surgery.

Tumours or masses: Uncommon, but they should be considered in repeated failure.

Problems with the silicone tube: Early extrusion or displacement.

Watering (epiphora) that never settles after surgery, or improves for a time and then returns.

Continuing discharge and crusting.

Swelling reappearing beside the bridge of the nose.

Recurrent eye and lacrimal sac infections.

Pain or tenderness at the nasal bridge.

Purulent material returning through the punctum when the sac is pressed.

Detailed examination: Lid position, patency of the puncta, the tear meniscus, the sac area and the ocular surface.

Syringing and probing: These establish the level of the obstruction, distinguishing canalicular blockage, blockage at the level of the sac, and closure of the newly created opening.

Nasal endoscopy: The most important investigation. It shows directly where the previous opening lies, whether it is patent, and what adhesions or granulation tissue surround it.

Imaging: Dacryocystography maps the drainage system. CT is requested where there is a history of trauma, suspicion of a mass or complex anatomy.

The previous operation note: Which technique was used, whether a tube was placed and when it was removed all shape the plan directly.

Ocular surface assessment: If the watering is reflex in origin, caused by dry eye or lid malposition, further duct surgery will not solve it.

Revision DCR: The passage is recreated. The bony window is enlarged, scar tissue is cleared and the sac lining is brought back into contact with the nasal lining.

External approach: Often preferred in revision because it gives direct control of the anatomy, and the bony window can be enlarged in a controlled way.

Endoscopic approach: Leaves no skin incision. Where the problem is adhesions, granulation tissue or a narrowed opening inside the nose, that area is addressed directly.

Silicone tube intubation: Frequently used in revision so that the new passage does not close early. The tube is removed after a few months.

Balloon dacryoplasty: Where the passage is patent but narrow, it can be dilated with a balloon catheter.

Conjunctivodacryocystorhinostomy (CDCR): Where the canaliculi cannot be used, a glass Jones tube is placed between the eye and the nose to direct tears straight into the nasal cavity. The tube needs regular review.

Additional nasal procedures: Septal deviation or turbinate enlargement obstructing the opening is corrected in the same session.

Measures to limit scarring: In selected cases, adjunctive methods may be used to reduce re-narrowing of the new passage.

Medical support: Antibiotic and anti-inflammatory drops support surgery where there is infection or inflammation. On their own they do not relieve the obstruction.

The new opening has closed: Revision DCR enlarging the bony window, with a silicone tube.

The opening is patent but narrow, with granulation tissue: Endoscopic clearance and, if needed, balloon dilation.

There is canalicular obstruction: Intubation or CDCR, depending on the state of the canaliculi.

There is nasal narrowing and adhesion: A nasal procedure in the same session.

The watering is reflex in origin: Ocular surface and lid treatment rather than duct surgery.

Light blood-stained discharge from the nose is usual in the first days. The head is kept elevated on pillows.

Nose blowing is not allowed in the first week, and the mouth should be kept open when sneezing.

Antibiotic and anti-inflammatory eye drops are used regularly for the period advised.

Any nasal spray prescribed should not be skipped; keeping the nasal lining moist helps the new passage stay open.

Hot steam, saunas, swimming pools and heavy lifting are restricted in the early weeks.

If a silicone tube was placed, it is usually removed in clinic within a few months. A mild foreign-body sensation while it is in place is common.

Follow-up after revision is more frequent than after a first operation. Granulation or adhesion found early can be dealt with in clinic; advanced narrowing requires further surgery.

Seek advice without delay for increasing pain and swelling, uncontrolled nosebleed, fever or reduced vision.

The level of the obstruction should be clearly established before surgery.

The nasal anatomy should be assessed and, where necessary, corrected in the same session.

The bony window should be wide enough to include the whole sac.

Drop and spray treatment after surgery should be completed as prescribed.

Follow-up appointments should not be missed; problems found early are easily dealt with.

Actions that raise pressure, such as nose blowing and straining, should be avoided.