The important aspect of functioning of eyes is lubrication. The tear film formed by secretions from the lacrimal glands present in the external orbit of each eye, protect the eye and wash it frequently, as the excess water drains into the nasal space. This explains why tears are generated when a person cries or sneezes or, is irritated by an allergen in the eye. However, if a patient sufferers from blurred vision, constant redness and burning in the eyes or, a drastic decrease in the lubrication of the eye, medical attention must be sought. This could be an underlying cause for eye infections. If the condition worsens, the palpable causes leading to blurred or double vision could be disorders in the eyelids and blockages in the lacrimal drainage system. The condition is known as Dacryocystitis. The sub specialty of ophthalmology that deals with treating extremely watering eyes and blockages in the lacrimal ducts, is lacrimal surgery.
The surgeons involved in lacrimal surgeries are included in a special training in ophthalmology that is initiated with performing oculoplastic correction procedures for eyelids like ectropion, entropion, Proptosis and eye lid retraction. Besides, these surgeons are involved in removal of tumourous growth in the eyelids and, treating eyes that have inwardly growing eye lashes. Essentially, patients that suffer from perpetually watering eyes are referred to oculoplastic surgeons. The treatment in the preliminary phase is not surgical. However in case of obstruction in the lacrimal drainage system, surgical treatment is engaged.
Lacrimal Surgery: Dacryocystorhinostomy (DCR)
In the initial phase of the treatment, a series of tests are conducted that includes lacrimal probing procedures. Once the diagnosis is complete, general anaesthesia is administered. The procedure is initiated by either making an external incision on the face or, by engaging an endoscopic approach in which the instrument is inserted nasally. In the external approach, a one inch incision is made between the eye and the nose. This procedure aims at bypassing the obstruction in the nasolacrimal duct so that the tears can drain directly from the lacrimal sac into the nasal cavity. A temporary tube is inserted to keep the nasal passage open through the procedure. Stents and sutures are used in performing the procedure. The incision is stitched back after the procedure. The stitches are removed within a week. This procedure largely cures the blockages in the nasolacrimal duct.
In the endoscopic approach, the nasal passage is cleared by administering decongestant to the patient. Following this, a gauze that is soaked with local anaesthesia is inserted through the nasal space, numbing the area of probing. An endoscope is inserted into the nasal space to evaluate the severity of the obstruction. If the obstruction is severe, the surgeon incises the mucous membrane to access the lacrimal sac. A vertical incision is made on the lacrimal sac after removing a small section of the lacrimal bone. This incision is aimed at draining the tears from the lacrimal sac into the nasolacrimal ducts. This is a one step procedure that does not cause any injury that could lead to external scars. Besides, it maintains the integrity of the lacrimal drainage system and takes lesser time than the external approach. Patients who feel pain are given pain killers like acetaminophen to alleviate discomfort during the procedure. For patients who have undergone DCR and for whom, the blockages have recurred again, Conjunctivodacryocystorhinostomy (CDCR) is performed. A pyrex glass tube is placed into the corner of the eye socket where the lacrimal ducts open into the nasal cavity directly. Oculoplastic surgeons performing DCR are required to be well trained in nasal endoscopic surgeries.
Other lacrimal surgery procedures include Punctoplasty and Probing. In Punctoplasty, the small orifices in the lower eyelids known as puncta are dilated by a dilator. This procedure is performed to improve the drainage of tears in patients who suffer from punctal stenosis. This is caused by narrowing of the lacrimal punctum that can later lead to obstruction in the lacrimal drainage system, thereby resulting in severe epiphora (extreme watering in the eyes). Punctoplasty is performed by administering local anaesthesia to the patient. Probe and tube procedure is performed by inserting a small tube into the lacrimal duct to dilate it. This dilation aids in clearing the blockage in the ducts. The tube is removed after 3 months. This is a simple procedure that does not call for incisions. It is very useful in clearing small obstructions in the lacrimal drainage system.
Apart from clearing blockages in the lacrimal drainage system, lacrimal surgeries are performed to improve the aesthetics of a person’s look. The surgery covers procedures that correct positions of the eyelids, alter the shape of the eyebrows and, even invigorate the periocular tissues in the eyelids. Surgeons involved in lacrimal surgeries often work closely with surgeons associated with specialties like oncology, ENT and dermatology. In cosmetic surgeries, oculoplastic surgeons operate with dermatological surgeons who aid in removal of periocular basal cells with techniques like Mohs’ micrographic surgery.
A great future awaits aspiring doctors who would want to specialise in oculoplastic surgeries. Dr. Debraj Shome, who is currently the Head of oculoplastic Surgery at multiple top hospitals in Mumbai, is one of the most well acclaimed oculoplastic surgeons in India. Besides, he has extensively researched on various aspects of oculoplastic surgeries.