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1. Unacceptable tearing, also known as epiphora caused by an obstruction the the tear outflow drainage system
2. Infections of the tear drain system
3. Tumors that form within the tear drain system.

The goal of surgery is to improve tear drainage through the tear drains that empty into the back of the nose.

Anatomy:

• Punctum- the tiny openings of the tear drain found in the upper and lower eyelid.
• Canaliculus--the delicate and tiny drains that lead to the lacrimal sac.
• Lacrimal sac--the sac that collects tears that have drained from the eye.
• Lacrimal duct--the duct that drains the contents of the lacrimal sac into the nose.

Common Tear Duct Procedures Include:

Dacryocystorhinostomy or DCR is a bypass surgery designed to directly connect the tear sac with the nose, effectively by-passing the obstructed portion of the tear drain. This is achieved by removing a small portion of the bone on the side of the nose and placing small stents in the the newly created tear drains into the nose. Typically a small incision is placed within the skin approximately midway between the corner of the eye and the bridge of the nose. In some rare cases it may be possible to avoid an external incision by using an endoscope or tiny telescope to perform the surgery entirely from the inside of the nose (Endoscopic DCR). With a traditional DCR success rates are up to 95% but with the endoscopic approach they are considerably lower. To qualify for an endoscopic DCR the patient must demonstrate normal nasal anatomy without a deviated septum.

Balloon dacryoplasty is a procedure by which a small inflatable balloon is introduced into a narrow tear drain and then inflated to dilate the narrowed portion of the tear drain. Often lacrimal stents are inserted into the drain at the time the duct is stretched open in order to promote continued dilation of the narrowed drainage system. These stents are left in place for a minimum of 3 months. During that time you may not notice a complete resolution of tearing. The long term success rates of this procedure are unknown and it is believed that this procedure may only be temporary. However, because it avoids a surgical scar and is relatively simple and risk free, it is preferred as an initial approach to dealing with a partially obstructed outflow system.

Conjunctivodacryorhinocystomy or C-DCR for short is a surgery in which tiny pyrex glass tubes known as Jones tubes, are placed through the inside corner of the eye down into the nasal cavity to serve as an artificial tear drain. This is the procedure of choice when diffuse damage to the tear duct and canaliculi are present. A surgical incision may be required to insert these tubes. The incision is placed half way between the inner corner of the eye and the bridge of the nose. These tubes are subject to migration and recurrent obstructions and may require periodic replacement, adjustment and cleaning.

Canaliculoplasty is designed to bypass an obstruction within the tiny canaliculi in the upper portion of the tear drain system. Such obstructions are notoriously difficult to resolve and surgical correction has a success rate of only about 50%. This procedure usually requires insertion of lacrimal stents that are left in place for a minimum of 6 months. During the time that the stents are in place you may continue to experience tearing.

Surgical Risks:

Tear duct surgery is relatively safe, but as with any invasive procedure, COMPLICATIONS ARE POSSIBLE! We have discussed the more common risks of surgery of this nature. A complete list of all foreseeable complications is listed below:

The risks of tear duct surgery include: Discomfort, Bruising and Swelling, Temporary Blurring of Vision, Numbness of the skin around the incision, Incomplete Eyelid Closure, Dry Eye or eye irritation, Nose Bleeds, Need for further surgery, Prominent scar, Vision change, Infection, Double vision, Failure to alleviate symptoms, Need to terminate surgery before completion, Permanent vision less (blindness), Death, coma and other rare risks not mentioned. In addition, no guarantees regarding surgical outcomes can be made.

Pre Operative Instructions:

Tear duct surgery is extremely delicate. There are several restrictions in place to ensure your safety and a good outcome. Failure to comply with any of the following will result in the cancellation of surgery (for your sake). NO exceptions.

Surgery Scheduling:

Most patients are assigned a date of surgery on their initial examination. If you have not yet been assigned a date of surgery, contact our office to schedule a date as soon as possible. To reach surgical scheduling call: 415- 482-6766. Occasionally we are forced to change a scheduled date for surgery, even at the last minute incases of emergency. We recognize that such last minute cancellations are stressful and extremely inconvenient and we will expedite rescheduling your surgery as soon as possible. The time of surgery is typically not available until after 2:00 pm the day before surgery. The number is call for arrival time is 415-444-2487.

Physical Examination:

State regulation requires a complete physical examination prior to surgery for any surgical procedure scheduled in the operating room. This examination must be performed within 30 days of surgery and must provide documentation that you are healthy and stable for the planned procedure.

If you live near San Rafael you can be scheduled for a physical with our POMS clinic. The POMS clinic is located in the Terra Linda Facility at 99 Montecillo Road in San Rafael.

If your live out of town your local physician can perform the examination. Because we use an electronic record, we will have access to the examination no matter in which Kaiser facility that your examination was performed. This physical examination must include a set of your latest vital signs, a complete history and physical documenting your heart and lung examination.

In general patients undergoing any type of lacrimal surgery must be in good health and able to undergo general anesthesia. Blood pressure must be in good control and aspirin or blood thinning medications must be safely discontinued prior to the procedure. The patient must be free of coughs and colds and diabetics must be in good control of their disease. The patient must be able to lie flat on their backs for an extended period of time. Blood pressure that measures greater than 180 mmHg systolic (top number) or greater than 90 mmHg diastolic (lower number) in the pre-operative area will result in cancellation of your surgery, regardless of how well it may be controlled at home.

Pre –Anesthesia Assessment:

All patients having surgery in the Main Operating Room at Terra Linda must meet with the anesthesiologist prior to surgery. This is a separate consultation and is required for all patients undergoing surgery in the Main Operating Room at Terra Linda. This visit must be scheduled prior to surgery. If our staff has not arranged for a pre operative anesthesia consultation, please call 415-444-2607 to schedule. Leave a message on the voicemail if the nurses are unavailable and they will return your call. For this appointment you will go to the 3rdfloor of the San Rafael Kaiser Hospital at 99 Montecillo Road. Use Parking Lot D.

Laboratory Studies:

No specific lab tests are required for eyelid surgery; however the provider that performs your physical examination may order labs prior to surgery. Women of child-bearing age are required to have a blood or serum pregnancy test on the day of surgery.

EKG:

An EKG is required for all patients over age 60 and for all patients with a history of heart diease. This examination must be performed within one year of surgery. Abnormal studies may require additional evaluation. Our offices will notify you if you need an EKG and will assist you in scheduling this examination. Most times you can visit any facility to have this test performed and an appointment is not necessary.

Anesthesia:

Surgery performed in the operating room, is usually performed with general anesthesia. You will be completely asleep for the procedure and a breathing tube may be placed in your throat during surgery.

DO NOT EAT OR DRINK anything after midnight the evening before surgery. This includes chewing gum, mints, and smoking. The only exception is a sip of water with our prescription medications before surgery. Failure to comply will result in cancellation of surgery, without exception.

Tobacco and Alcohol Use:

Avoid smoking for 2 weeks before and after surgery (longer if skin grafting is used). Avoid alcohol for 2 days prior to surgery and one week afterwards.

Surgery Location:

Lacrimal surgery is scheduled in the main operating room located at the Kaiser San Rafael campus, also known as Terra Linda. The address for Kaiser is 99 Monticello Road. You can park in parking lot D.

To reach the facility take the Freitas Parkway exit off Highway 101. If you are coming from the North, go right off of 1010. If you are coming from the south, go to your left after exiting 101. Head west. Turn left on Las Gallinas to right at Nova Albion way. Take Nova Albion to Montecillo and turn right on Montecillo road. The medical Center is on the left.

Prescription Medications:

Unless specifically instructed, take all your routine medications up to and on the morning of your surgery. The most common exception is insulin and other diabetic medications. All diabetic patients should clarify with their primary care doctor exactly which medications to take on the morning of surgery.

A word about Blood Thinners:
All prescription or over-the-counter medications that increase the risk of bleeding must be avoided without exceptionprior to surgery near your eye. These medications include aspirin, non-steroidal anti-inflammatories, coagulants, antiplatelets and many common vitamins and herbal medications.

Did you know that even ONE TABLETofASPRINtaken within 2 weeks before surgery or 5 days after surgery, can result in severe bleeding that might result in permanent vision loss?

Avoid using any of these medications unless you are specifically instructed to continue using them by your doctor. Because most anti-inflammatories and pain relievers contain blood thinning agents, these medications should be avoided. The exceptionisTylenol(acetaminophen) For pain control, Tylenol is a safe alternative that can be taken at any time before surgery.

If you are taking warfarin (COUMADIN), HEPARIN or Lovenox, it is very important to discuss this with your doctor before surgery. Typically Coumadin must be discontinued for 5 days prior to surgery. Heparin and LOVENOX must be discontinued 24 hours prior to surgery. However, do not discontinue these medications before consulting your primary care provider or the pharmacists in the Warfarin clinic. Please, contact the warfarin clinic at 866-454-4917 for guidance.

Medications to stop prior to surgery:

Vitamins :

• Vitamin E
• Chondroitn
• Fish Oil (Omega Fatty Acids)
• Glucosamine

Hold these vitamins for 14 days prior to surgery

Herbals:

• Dong quai
• Ginseng
• Ephedra
• Garlic
• Green Tea
• Feverfew
• Ginkgo Biloba
• Tumeric
• Ginger

Hold these herbals for 14 days prior to surgery

AntiPlatelet Drugs:

• Agrylin (Anagrelide)
• Cilostazol (PLETAL)
• Clopidogrel (PLAVIX)
• Dipyridamole (AGGRENOX or PERSANTINE)
• Ticlopidine (TICLID)
• Pentoxyphylline (TRENTAL)

Hold these antiplatelet drugs for 7 days prior to surgery

Non Steroidal Anti-Inflammatories:

• Ibuprofen (MOTRIN, ADVIL, MIDOL, NUPRIN)
• Naproxin (NAPROSIN, ALEVE ANAPROX)
• Celecoxib (CELEBREX)
• Diclofenac (VOLTAREN, CATAFLAM, ARTHROTEC)
• Diflunisal (DOLOBID)
• Etodaolac (LODINE)
• Fenoprofen (ANSAID)
• Ibuprofen (MOTRIN, ADVIL, MIDOL, NUPRIN)
• Indomethacin (INDOCIN)
• Ketoprofen (ORUDIS, ORUVAIL)
• Ketorolac (TORADOL)
• Meloxicam (PONSTEL)
• Nabumetone (RELAFEN)
• Naproxen (NAPROXYN, ALEVE, ANAPROX)
• Oxaprozin (DAYPRO)
• Piroxicam (FLEDANE)
• Pletal (CILOSTAZOL)
• Rofecoxib (VIOXX)
• Sulindac (CLINORIL)
• Tolmetrin (TOECTIN)
• Valdecoxib (BEXTRA)

Hold these non-steroidals for 7 days prior to surgery

Aspirin Products (including "Baby Aspirin"):

• BAYER
• EXCEDRIN
• BUFFERIN
• ANACIN
• ALKA-SELTZER

HOLD ALL ASPIRIN FOR 14 DAYS PRIOR TO SURGERY

Anti-Coagulants:

• Enoxaparin (LOVANOX)
• Heparin
• Warfarin (Coumadin)

HOLD THESE MEDICATIONS AS INSTRUCTED BY WARFARIN CLINIC

Accompanying Adult:

You must have a responsible adult available to take you home after surgery. Traveling alone or on a bus or in a cab is not accepted. Your driver may be available for you by phone if they cannot wait for you during the procedure. Most patients who require assistance after surgery usually rely on a family member or friend on the afternoon and evening of surgery only. Extended assistance is usually unnecessary.

Clothing and Make-up:

Avoid make-up on the day of surgery. Avoid any nail polish on finger or toenails. Do not wear your contact lenses on the day of surgery. Preferably, wear a loose button-down shirt with easy access to your arms. Please remove all jewelry before surgery. Also remove hearing aids and dentures prior to surgery in the operating room.

Recovery:

Post-operative healing time varies from patient to patient and depends on the procedure that you are having. Most patients have some mild to moderate bruising or swelling, especially in a surgical incision is required. If you are concerned about your appearance you may require one to two weeks out of work to allow the expected bruising and swelling to resolve.

After your procedure you should refrain from strenuous activities for a minimum of one week. This includes absolutely no cardiovascular activity such as hiking, climbing, running or swimming for one to two weeks. No lifting over ten pounds, no exertion.

Whenever possible dissolving sutures will be used that will not require removal. If an incision is required to treat your condition then you will develop a scar at the surgery site.

Most scarring will resolve, but may take between 6 months and one year. Vision changes and eye irritation including redness, foreign body sensation and tearing are common in the first few days after surgery. Over the counter artificial tear drops used every one to two hours are helpful to alleviate most instances of blurry vision or ocular discomfort. You should not purchase or change your glasses prescription for about one month after surgery. Scheduling travel plans or important events within 4 weeks of surgery is not recommended.

Most patients undergoing tear duct surgery usually require a minimum of 1 to two post-operative visits in San Rafael. Occasionally more visits are necessary. If lacrimal stents are placed they may be left in place for 3 months to one year before removal. Most of the time stents can be removed in the office. In children, it may be necessary to return to the operating room to remove the stents.

Occasionally these stents may dislodge from the inner corner of the eye. Should this happen do not pull or cut these stents. This can result in pain and permanent damage to the tear drain system. Instead tape the dislodged stent to the bridge of the nose and contact your physician for proper removal or re-insertion.

If you are undergoing a DCR then a second, larger red rubber tube may be inserted in your nose at the time of surgery. This stent may cause a sensation of nasal congestion and may actually make tearing worse while it is in place. It is designed to fall out of the nose on its own within 2 weeks. If not it will be removed on your first follow up visit.

Please Remember:

Do not eat or drink anything after midnight on the night before surgery.

Non Diabetics: Take your usual morning medications with a small sip of water.
Attention Diabetics: Take your normal medications except for your diabetic medications on the morning of surgery unless instructed by your doctor. Your blood sugar will be tested on arrival to surgery.
Do not wear any make-up or jewelry on the morning of surgery
Stop all Aspirin 2 weeks in advance; stop other blood thinning agents 7 days in advance or as directed.
Arrange for transportation home from surgery. You may not drive a vehicle or take a bus home.