Lacrimal Sac Surgery

Oculoplastic and lacrimal surgery is a sub-specialty of ophthalmology which focuses on disorders of the eyelids and tear-drainage system. Lacrimal Sac SurgeryIt has evolved as a distinct sub-specialty of ophthalmology gradually during the last three decades in the UK.   In the 1970s and 1980s, there were a number of ophthalmologists with an interest in oculoplastic and lacrimal surgery, but most common eyelid and lacrimal disorders and surgical procedures were considered to be within the remit of the general ophthalmologist.  

Today, the scene is somewhat different. Eyelid and lacrimal disorders are very common and minor disorders form a significant part of the workload of primary care ophthalmology in the community and hospital setting. However, eyelid and lacrimal disorders that do not respond to simple non-surgical measures increasingly tend to be referred to an oculoplastic and lacrimal service.
 
Oculoplastic and lacrimal surgery remains within the specialty training curriculum for ophthalmology and general ophthalmologists commonly undertake less complex oculoplastic procedures such as entropion and ectropion correction.   Ophthalmologists who specialise in this field commonly undertake additional training in advanced techniques following specialty training in ophthalmology and many work exclusively in the sub-specialty.  The heavy oculoplastic and lacrimal workload even in relatively small units often makes it impractical for them to maintain their skills in cataract surgery, for example.
 
The surgical repertoire of the oculoplastic and lacrimal surgeon includes correction of eyelid malpositions (eg entropion, ectropion, ptosis, lid retraction due to thyroid eye disease), treatment of ingrowing eyelashes, removal of tumours of the lids and surrounding tissues and reconstruction of these tissues following tumour excision or trauma.   Removal of the eye, once a relatively common operation performed by general ophthalmologists is now much rarer and is usually undertaken by oculoplastic surgeons, with implantation of a prosthesis in the socket wherever possible, to aid the subsequent fitting of an artificial eye. They may also undertake secondary reconstructive procedures on the socket following earlier removal of the eye. 
 
Excessive watering of the eye is an extremely common reason for referral to an oculoplastic and lacrimal surgeon.   Often the treatment is non-surgical , or involves correction of an eyelid malposition, but a proportion of these patients have an obstruction or increased resistance in the lacrimal drainage system.   Dacryocystorhinostomy (DCR) involves fashioning a connection between the lacrimal sac and the lateral wall of the nose, having made an opening through the thin lacrimal bone which normally separates them.   This may be done through a skin incision over the lacrimal sac, or via the nose (endoscopic DCR).   Endoscopic DCR requires the surgeon to be proficient with a nasal endoscope and it is sometimes necessary to correct abnormalities of the nasal septum or turbinate bones to gain access. The ophthalmologist must either acquire the necessary competencies in nasal surgery or obtain the help of an ENT surgeon.
 
Some oculoplastic and lacrimal surgeons undertake aesthetic or cosmetic surgery of the eyelids and periocular tissues. This field of surgery includes techniques to rejuvenate the appearance of the periocular tissues, procedures to alter the shape of the eyebrows and procedures to correct minor abnormalities of eyelid position that would not normally qualify for treatment under the NHS. Many of the techniques used in aesthetic surgery are similar to those used in other aspects of oculoplastic surgery. 
 
Oculoplastic and lacrimal surgeons often have close working links with related specialties such as dermatology, oncology, ENT and plastic surgery and may be part of a multi-disciplinary team for the management of specific conditions. For example, dermatological surgeons who remove periocular basal cell carcinomas using Mohs’ micrographic surgery often work in partnership with an oculoplastic surgeon who will undertake the subsequent reconstruction.