Dacryocystectomy is the surgical removal of the lacrimal sac, the small pouch that collects tears before they drain into the nose. It is far less common than dacryocystorhinostomy (DCR), the standard operation that creates a new drainage channel between the sac and the nasal cavity, but it fills a distinct role for patients who are poor candidates for DCR or who have tumors of the lacrimal sac. The procedure essentially trades the possibility of restoring tear drainage for a simpler, lower-risk surgery that eliminates a source of chronic infection.
Why the Lacrimal Sac Would Need to Come Out
The most straightforward reason is a lacrimal sac tumor. When a mass inside or around the sac turns out to be malignant, removing the sac is part of the oncologic plan. A review in Ophthalmic Plastic & Reconstructive Surgery notes that malignant lacrimal sac tumors remain one of the classic indications for the procedure.1Ophthalmic Plastic & Reconstructive Surgery. Dacryocystectomy: Goals, Indications, Techniques and Complications Fortunately, lacrimal sac malignancies are rare. In a review of nearly 500 surgical specimens from a tertiary eye hospital, malignancy was suspected before surgery in only about 0.6% of cases, and none of the remaining specimens turned out to harbor an unsuspected cancer.2Canadian Journal of Ophthalmology. Is routine histopathological examination of dacryocystorhinostomy/dacryocystectomy specimens necessary? A tertiary eye hospital experience
Far more often, dacryocystectomy is performed for chronic dacryocystitis (a persistently infected lacrimal sac) in patients for whom a full DCR would carry excessive risk. A retrospective study of 25 non-tumor patients who underwent the procedure found that all had complete nasolacrimal duct obstruction along with dry eye and minimal tearing complaints. Nine of the 25 also had systemic medical problems that made them risky candidates for monitored sedation, and four had autoimmune conditions like ocular cicatricial pemphigoid, Crohn’s disease, or systemic lupus erythematosus that could cause nasal scarring and undermine a DCR.3PubMed. Dacryocystectomy: surgical indications and results in 25 patients
Who Typically Gets This Procedure Instead of a DCR
DCR is the gold standard for fixing a blocked tear duct because it restores drainage. Dacryocystectomy does not restore drainage at all; it simply removes the infected or diseased sac. That trade-off makes sense only when the patient either does not produce enough tears to make drainage matter or faces medical risks that outweigh the benefits of a more involved surgery.
The main groups include:
- Elderly patients: Adults over 70 or 80 are frequently selected for dacryocystectomy, particularly when they have multiple comorbidities that raise anesthetic or bleeding risk. A study focused on this population found that dacryocystectomy should be considered a primary procedure in individuals over 70 because of its lower risk profile.4PubMed. Dacryocystectomy as a treatment of chronic dacryocystitis in the elderly
- Patients on blood thinners: People taking anticoagulants or antiplatelet medications who cannot safely stop them are candidates, since DCR involves work near the nasal mucosa where bleeding can be problematic.5PubMed Central. Dacryocystitis: Is Dacryocystorhinostomy Always the Solution?
- Patients with dry eye: If the eyes are not producing much tear film in the first place, restoring the drainage pathway makes little practical difference. The sac just sits there harboring bacteria.
- People with systemic inflammatory or autoimmune diseases: Conditions like granulomatosis with polyangiitis (formerly Wegener’s) or lupus are associated with high DCR failure rates because they promote scarring in the nasal passage. Removing the sac avoids that problem entirely.6PubMed Central. Dacryocystitis: Is Dacryocystorhinostomy Always the Solution?
How the Surgery Is Performed
The traditional approach uses an external skin incision along the side of the nose, similar to the incision used for external DCR. The surgeon exposes the lacrimal fossa (the bony groove where the sac sits), carefully dissects the sac free from the surrounding bone and soft tissue, and removes it. The canaliculi, the tiny channels that carry tears from the inner corner of each eyelid into the sac, are either left alone or cauterized to prevent mucus reflux after surgery.
One refinement described in the Indian Journal of Ophthalmology involves injecting fibrin glue mixed with a blue dye directly into the lacrimal sac before dissection. The glue distends the sac, making it easier to separate from its periosteal and fascial attachments, while the dye stains the mucosal lining so the surgeon can see exactly where the sac tissue ends and surrounding tissue begins. This subfascial technique keeps the sac’s outer fascia intact and avoids disturbing the orbital fat behind it.7PubMed Central. Dacryocystectomy: A fibrin glue-assisted subfascial excision
An endoscopic endonasal approach has also been described, where the surgeon reaches the sac through the nose rather than through the skin. In one reported case of bilateral dacryocystectomy, the surgeon used an endoscope to access and remove both lacrimal sacs, then cauterized the common canaliculus on each side. The patient’s symptoms fully resolved.8PubMed. An endoscopic endonasal approach to dacryocystectomy The endonasal route avoids a visible skin scar, which matters to some patients, though it requires endoscopic skill and appropriate nasal anatomy.
What Happens to Tearing Afterward
This is the question that matters most to patients considering the surgery. Removing the lacrimal sac eliminates the reservoir where tears collect before draining into the nose, so you might expect tearing to get worse. In practice, the picture is more nuanced. Many patients selected for dacryocystectomy have dry eye or reduced tear production, so they don’t generate the volume of tears that would cause troublesome overflow.
A study measuring tearing before and after surgery found that average subjective improvement was about 87%, with postoperative tearing scores dropping significantly compared to preoperative levels.9PubMed Central. Is dacryocystectomy effective in reducing epiphora? That sounds counterintuitive, but the explanation is that many of these patients were tearing not because their drainage was merely blocked but because the chronically infected sac was actively producing discharge and triggering reflex tearing. Removing the infection source reduced tearing overall.
Still, not everyone ends up tear-free. In the elderly cohort studied, about three-quarters reported improvement, but roughly a quarter continued to experience some tearing after surgery. Of those, about half were later treated successfully with lacrimal stent intubation.10PubMed. Dacryocystectomy as a treatment of chronic dacryocystitis in the elderly Another study found that about a third of patients reported some persistent tearing in the month after surgery, though it had markedly diminished by six months.11The Open Ophthalmology Journal. Dacryocystectomy with Lacrimal Silicone Intubation in Challenging Patients Affected by Recurrent Dacryocystitis and Epiphora: Expanding Minimally Invasive Approach Indications
The takeaway is that dacryocystectomy reliably solves the infection and usually reduces tearing, but it does not guarantee a completely dry eye. The patients who do best tend to be those who were not producing many tears to begin with.
When Things Go Wrong
Dacryocystectomy is considered a simpler and lower-risk operation than DCR, but it is not without potential complications. The most clinically relevant problem is incomplete excision of the sac. If remnants of the sac lining are left behind, they can form a “pseudosac” or a diverticulum that continues to harbor infection and keeps the patient symptomatic.12Indian Journal of Ophthalmology. Cyanoacrylate lacrimal system occlusion after failed Sac surgery Techniques like the fibrin glue injection described earlier are designed in part to reduce this risk by making the sac boundaries clearer during dissection.
Other risks include bleeding, wound infection, and scarring around the medial canthal area (the inner corner of the eye). Since the lacrimal sac sits close to the medial canthal tendon, which anchors the eyelids, damage during dissection can lead to subtle changes in eyelid position, though this is uncommon with careful technique.
Preoperative Imaging and Planning
For straightforward chronic dacryocystitis in an elderly patient, clinical examination and syringing of the tear duct may be all the workup needed. In more complex situations, especially after facial trauma, imaging plays a bigger role. CT-dacryocystography, which combines a CT scan with contrast injected into the tear drainage system, can map out the anatomy and show exactly where obstruction has occurred. A study on traumatic lacrimal duct obstruction found that CT-dacryocystography helped surgeons decide among endoscopic DCR, external DCR, and dacryocystectomy based on what the imaging revealed about local anatomy and the nature of the blockage.13PubMed. Computed Tomography – Dacryocystography Guided Management of Traumatic Secondary Acquired Lacrimal Duct Obstruction: SALDO Update Study (SUP) – Paper V
When there is any suspicion of a mass in the lacrimal sac, imaging becomes essential before surgery. Although unsuspected malignancies found incidentally in surgical specimens are extremely rare, preoperative imaging can change the surgical plan. A patient thought to need a simple DCR might be redirected to dacryocystectomy if imaging suggests a tumor, since the surgical goals shift from restoring drainage to achieving clear margins around the mass.
What the Pathologist Finds in the Removed Sac
Sending the excised sac to the pathology lab is routine, and the vast majority of specimens show nothing more than chronic inflammation consistent with longstanding infection. The tertiary-hospital review mentioned earlier examined nearly 500 specimens from both DCR and dacryocystectomy procedures. Among specimens where malignancy was not already suspected, about 3.4% had an unexpected tissue diagnosis: oncocytomas (benign glandular tumors) in seven cases, dacryoliths (tear duct stones) in seven, and granulomas in three.14Canadian Journal of Ophthalmology. Is routine histopathological examination of dacryocystorhinostomy/dacryocystectomy specimens necessary? A tertiary eye hospital experience None turned out to be malignant. Whether routine histopathology is strictly necessary for every specimen is debated, but most surgeons still send the tissue because the occasional surprise finding can matter.
Restoring Tear Drainage After the Sac Has Been Removed
One of the inherent limitations of dacryocystectomy is that it burns a bridge. Once the sac is gone, a standard DCR is no longer possible because there is no sac to connect to the nasal cavity. If a patient’s tearing becomes problematic later, or if the original medical issues that led to dacryocystectomy resolve, the options narrow considerably.
Lacrimal bypass surgery, which places a glass or silicone tube from the inner corner of the eye directly into the nasal cavity, is one possibility. This approach is indicated when the sac is absent, destroyed, or has been previously excised.15PubMed. A Brief History of Lacrimal Bypass Techniques Another approach that has been described is a modified canaliculorhinostomy, in which the remaining canalicular tissue is connected directly to the nasal cavity, bypassing where the sac used to be. In a small series of 15 patients who underwent this modified procedure after prior dacryocystectomy, the success rate was about 93%, with almost all patients achieving a patent, functioning drainage pathway.16PubMed Central. Reestablishing Lacrimal Drainage by Canaliculorhinostomy after Dacryocystectomy: A Viable Option in Symptomatic Patients These reconstructive options exist, but they are technically more demanding than a first-line DCR would have been, which is part of why dacryocystectomy is reserved for patients who genuinely cannot or do not need to have drainage preserved.
The Scar Question
For patients who undergo external dacryocystectomy, the skin incision is typically placed in the same location as an external DCR incision, along the side of the nose near the inner corner of the eye. How visible the resulting scar is depends on the incision design, the closure technique, and the individual patient’s healing.
A study comparing incision approaches for external DCR, which shares the same general surgical access, found that a subciliary incision (placed in the natural crease below the lower eyelid) produced much better cosmetic results than a conventional vertical incision along the nose. Only 5% of patients with a subciliary incision rated their scar as cosmetically significant, compared to 50% in the vertical incision group.17PubMed Central. The cosmetic outcome of external dacryocystorhinostomy scar and factors affecting it The type of suture material also played a role, though the difference did not reach statistical significance in that study. A broader literature review confirmed that minimal-incision approaches and sutureless skin closures, tailored to the patient’s skin type, tend to produce the best aesthetic results.18PubMed Central. Minimizing Post-Operative Scars in External Dacryocystorhinostomy: A Literature Review
For patients for whom scarring is a major concern, the endoscopic endonasal approach eliminates the external incision entirely. The trade-off is that it requires specific surgical expertise and may not be available everywhere.
Dacryocystectomy in Children
The procedure is exceedingly rare in pediatric patients. In a review of 142 children who underwent major lacrimal surgery, 160 procedures were dacryocystorhinostomies and only one was a dacryocystectomy.19PubMed Central. Lacrimal surgery in children Children with blocked tear ducts almost always receive probing, silicone intubation, or DCR, because preserving and restoring drainage is the goal in a young person who will live with the result for decades. Dacryocystectomy in a child would come into play only under exceptional circumstances, such as a lacrimal sac tumor or a situation where the sac itself is destroyed by disease.
How Surgeons Decide Between DCR and Dacryocystectomy
The decision framework is less about which procedure is “better” and more about which makes sense for a particular patient’s combination of age, systemic health, tear production, and disease pathology. A younger, otherwise healthy patient with a blocked tear duct and normally functioning tear glands will almost always get a DCR. An 85-year-old on warfarin with dry eyes and recurrent infections of the lacrimal sac is a textbook candidate for dacryocystectomy. The gray zone falls in between, such as a 65-year-old with moderate dry eye and a history of autoimmune disease, where the surgeon weighs the realistic chance of a successful DCR against the simplicity and safety of sac removal.
Imaging, clinical examination, and an honest conversation about what matters to the patient all factor in. Some patients care most about eliminating the recurrent swelling and discharge at the inner corner of the eye and are perfectly content to dab away the occasional tear. Others prioritize having a functioning drainage system and are willing to accept the higher complexity and risk of a DCR or, if the sac has already been removed, a secondary reconstructive procedure. The evidence is clear that dacryocystectomy resolves the infection reliably and reduces tearing for most patients, but it does so by removing infrastructure that is difficult to rebuild later. That irreversibility is the single most important thing for a patient to understand before consenting to the surgery.