A dacryocystectomy procedure refers to the complete surgical removal or destruction of the lacrimal sac. It is one of the ways to treat chronic dacryocystitis or lacrimal fistulae when a dacryocystorhinostomy (DCR) procedure is not possible. It is mainly conducted in two ways: an external approach through a skin incision and an endoscopic approach. The two main aims of a dacryocystectomy procedure are –
- To precisely excise the lacrimal sac with minimal concomitant damage to the surround tissues
- To completely excise the lacrimal sac and the nasolacrimal duct without leaving any lacrimal structures behind
Understanding the lacrimal drainage system
The lacrimal drainage system is made up of the puncta, canaliculi, lacrimal sac and the nasolacrimal duct.
- Puncta – These are the small orifices present at the beginning of the canalicular ducts and are known as puncta lacrimalia. Tears or lacrimal fluid produced by the lacrimal glands is collected by the puncta lacrimalia.
- Canaliculi – Ducts connecting the puncta lacrimalia to the lacrimal sac are known as the lacrimal canaliculi. The superior and inferior lacrimal canaliculi are the two types of canaliculi present in each eye.
- Lacrimal sac – This structure is found in the concavity produced by the lacrimal duct and the frontal process of the maxilla. It connects the lacrimal canaliculi, responsible for the collection of tears from the eye, to the nasolacrimal duct that performs the function of transmitting the fluid to the nasal cavity for drainage.
- Nasolacrimal duct – The tear duct, or nasolacrimal duct, acts as the connecting tube between the lacrimal sac and the nasal cavity.
When is a dacryocystectomy necessary?
- It may be a necessary procedure in the case of malignant tumours of the lacrimal sac. It may have significant implications on survival and quality of life
- It may be a necessity for patients with recurrent dacryocystitis with severe dry eyes
- Patients who have severe recurring dacryocystitis concurrent with other medical conditions that predispose nasal scarring such as Crohn’s disease and systematic lupus erythematosus may benefit from a dacryocystectomy
- It is indicated for frail, geriatric patients with dacryocystitis who have other cardiac or neurological problems
- It is necessary in the case of dacryocystitis in elderly patients with other ocular problems such as microbial keratitis, glaucoma or advanced cataract. In such cases, a dacryocystectomy may have impact on visual rehabilitation
- A dacryocystectomy may be necessary for patients who have recurrent dacryocystitis and have undergone multiple dacryocystorhinostomies with poor outcomes.
How is a dacryocystectomy carried out?
- Anaesthetic and adrenaline solution are injected into the area surround the lacrimal sac to be excised.
- An incision is made by the surgeon over the lacrimal sac, along the crease of skin. The incision is kept open with the help of sutures, a small retractor or two retractors. The surgical incision is extended inwards using blunt dissection through the muscle.
- The lacrimal sac is located and carefully dissected, with as much of the associated nasolacrimal duct being excised as far as possible. Any leakage of inflammatory, pus-like substances from the lacrimal sac is cleaned away and disinfected.
- The surgical incision is closed using sutures.
What are the complications associated with a dacryocystectomy?
It is unlikely that you will experience any post-operative complications from the dacryocystectomy procedure. In very rare cases, unintended injury to the angular vein may cause a copious amount of bleeding. However, this is fully avoidable if the surgical incision is made carefully not too close to the location of the angular vein. Other post-operative complications include breaking of the surgical sutures, known as wound dehiscence, infection of the surgical site, increased tearing, and recurring dacryocystitis in the remnant of the lacrimal sac. In some cases, a visible facial scar may remain. In exceedingly rare cases, there may be accidental damage to the surrounding orbital tissues resulting in orbital hemorrhage, hematomas, and potential visual loss.
Although several other surgical procedures such as dacryocystorhinostomy, conjunctivodacryocystorhinostomy have been developed for the treatment of lacrimal drainage disorders, a dacryocystectomy has a very specific set of uses and indications. It can be used as a treatment procedure in the case of lacrimal sac tumours as well as specific cases of recurring dacryocystitis in certain groups of patients.
Dacryocystectomy is a relatively simple and uncomplicated procedure but due to the fragile and sensitive nature of the eye, it must only be performed by an experienced oculoplastic surgeon.
Dr. Debraj Shome is a highly-experience oculoplastic surgeon with several accolades and awards to his name.