Indications for External Dacryocystorhinostomy (DCR) Surgery
External DCR is indicated for patients with nasolacrimal duct obstruction (NLDO) who present with epiphora (tearing) and/or recurrent dacryocystitis that significantly impairs quality of life.
Primary Indications
Acquired Nasolacrimal Duct Obstruction
- Complete or partial NLDO causing symptomatic epiphora that interferes with daily activities and quality of life 1, 2
- Diagnosis confirmed by irrigation of the nasolacrimal drainage system showing obstruction 1
- Postsac obstructions respond particularly well, with 80% long-term success rates at 3 years 2
Recurrent or Chronic Dacryocystitis
- Patients with previous episodes of acute dacryocystitis have excellent surgical outcomes, with 94.4% success rates 3
- Presence of purulent secretions with sac swelling is a strong predictor of surgical success and correlates significantly with postoperative patency 4
- Glaucoma patients with NLDO have significantly higher risk of developing dacryocystitis and should be considered for earlier surgical intervention 3
Diagnostic Confirmation Required
Clinical Assessment
- Symptomatic epiphora with or without mucopurulent discharge 5
- Lacrimal sac distension or swelling 4
- Patent system to irrigation should be established postoperatively in >90% of cases 5
Imaging Considerations
- When purulent secretions are present with epiphora, X-ray examination (dacryocystography) is redundant and may be avoided 4
- When epiphora is isolated without purulent discharge, imaging must be performed to localize the obstruction and assess lacrimal sac morphology 4
- Lacrimal scintigraphy can differentiate presac versus postsac delays, which affects prognosis 2
Important Prognostic Factors
Favorable Indicators
- Postsac obstructions achieve 91% subjective success at short-term follow-up and 80% at 3 years 2
- Presence of purulent secretions significantly correlates with success (p<0.001) 4
- Previous dacryocystitis does not negatively impact outcomes 3
Less Favorable Indicators
- Presac delays have significantly worse outcomes, with only 47% success at 3 years versus 80% for postsac obstructions (p=0.04) 2
- Isolated epiphora without infection may indicate presac pathology requiring different surgical approach 4
Expected Outcomes
- Objective success (patent system on irrigation): 90-95% 1, 5
- Subjective success (resolution of symptoms): 84-92% initially, declining to 70% at 3 years overall 2, 5
- Patient satisfaction: 97% rate cosmetic outcome as good to excellent; 100% would recommend the procedure 5
Common Pitfalls to Avoid
- Do not proceed with external DCR for presac obstructions without considering alternative approaches, as these have significantly lower success rates 2
- Left-sided obstructions are more common in patients with previous dacryocystitis (48.3% versus 31.7%, p=0.031) 3
- Avoid unnecessary imaging when purulent secretions are present, as clinical diagnosis is sufficient 4