What is the appropriate postoperative follow‑up schedule and management after dacryocystorhinostomy (DCR)?

Postoperative Follow-Up After Dacryocystorhinostomy (DCR)

Following DCR surgery, patients should be seen within the first week postoperatively to assess for infection and wound healing, with subsequent visits at 3-4 weeks for tube removal (if placed) and evaluation of ostium patency, followed by a final assessment at 3 months to confirm long-term success. 1

Initial Postoperative Visit (Within 1 Week)

The first postoperative examination is critical for identifying early complications:

• Check for signs of infection or inflammation, including wound assessment for external DCR or intranasal examination for endonasal approaches 2, 3
• Evaluate for postoperative bleeding, which occurs in approximately 1-4% of cases and may require nasal packing 3
• Assess nasal cavity patency and examine for early adhesion formation between the ostium and nasal septum 3
• Initiate nasal saline irrigations 2-3 times daily to improve mucociliary clearance and prevent crusting 1, 4

Common Early Complications to Monitor

Postoperative infection after external DCR is uncommon (approximately 1.2%), and when it occurs, typically presents as superficial wound infection manageable with oral antibiotics 2. Intraoperative and immediate postoperative bleeding ranges from minor (60%) to severe (12%), though severe bleeding requiring intervention is rare 3.

Intermediate Follow-Up (3-4 Weeks)

This visit focuses on tube management and ostium assessment:

• Remove silicone intubation tubes if placed, typically at 3-4 weeks postoperatively (average 3.7 weeks in successful cases) 5
• Perform nasal endoscopy to evaluate the nasolacrimal fistula and assess for granulation tissue or early stenosis 6
• Test lacrimal patency by syringing the lacrimal apparatus to confirm flow through the newly created ostium 6
• Continue nasal saline irrigations to maintain ostium patency 1

Final Assessment (3 Months)

The 3-month visit establishes long-term surgical success:

• Assess symptom resolution, specifically relief from epiphora and dacryocystitis 5, 6
• Perform nasal endoscopy to evaluate ostium patency and identify late complications 6, 3
• Test lacrimal patency by irrigation to confirm sustained drainage 6
• Document surgical outcome, as 92-95% of patients should have complete relief from symptoms at this timepoint 5, 6

Late Complications Requiring Extended Follow-Up

Distal stenosis from progressive healing closure of the ostium occurs in approximately 7% of cases and typically manifests within the first 3 months 3. Adhesions between the ostium and nasal septum (0.6%) and sump syndrome (1.2%) are less common but require identification during this period 3. Secondary canalicular stenosis is rare (0.6%) but represents a distinct failure mechanism requiring different management 3.

Postoperative Medical Management

Topical antibiotic-steroid combinations (such as dexamethasone 0.1% with neomycin and polymyxin B) should be prescribed three times daily for 1 week postoperatively 2. Routine systemic antibiotic prophylaxis is not justified given the low infection rate (1.2%), with a number needed to treat of 104 to prevent one infection 2.

Nasal saline irrigations remain the cornerstone of postoperative care and should be continued for several weeks to optimize mucociliary clearance and prevent ostium closure 1, 4.

Key Pitfalls to Avoid

• Do not delay the first postoperative visit beyond 1 week, as early infections and bleeding complications require prompt identification 2, 3
• Avoid removing silicone tubes too early (before 3 weeks), as premature removal may compromise ostium patency 5
• Do not use topical nasal decongestants, which can worsen mucosal dryness and impair healing 4
• Ensure adequate follow-up through 3 months to identify late stenosis, as 7% of failures result from progressive ostium closure that develops over weeks to months 3

The overall success rate for DCR is 92-95% when appropriate postoperative management and follow-up are maintained 5, 6. Patient satisfaction is exceptionally high, with 97% rating cosmetic outcomes as good to excellent and 100% willing to recommend the procedure to others 5.