Epiphora, also known as watery eyes, is a condition characterized by excessive tearing of the eye and constant overflow of tears onto the face. Epiphora can be an extremely bothersome problem. Many patients with the condition say it appears as if they are constantly crying. Incessant overflow of the tears onto the face can cause irritation and even breakdown of the eyelid skin. In addition, tearing can also cause distortion of the vision, oftentimes making driving difficult and even dangerous. It can additionally have a psychological impact, making people self conscious in public and at work.
CAUSES
Epiphora is due to a disruption in the balance between tear production and tear drainage. Common causes include:
Overproduction of Tears
Dry eyes with hypersecretion
Misdirected eyelashes (e.g., trichiasis, distichiasis)
Allergic/infective/irritative conjunctivitis
Corneal disease
Insufficient tear drainage
Blockage in the tear drainage system
Eyelid malposition (e.g., ectropion)
Lacrimal pump failure (in facial nerve palsy)
Epiphora can develop at any age. It can be congenital, i.e., occurring shortly after birth, or acquired in adulthood, particularly in patients over the age of 60 years. Symptoms may be present in one or both eyes.
DIAGNOSIS/EVALUATION
I frequently see patients with complaints of constant watery eyes in my practice. When evaluating a patient with epiphora, I closely examine the eye for signs of dryness and ocular surface disease, which may cause hypersecretion of tears. I additionally evaluate the face for signs of facial paralysis, the eyelids for evidence of malposition, the entire lacrimal system to rule out any blockage, and the nose for any evidence of intranasal causes.
Evaluation of the tear drainage system for blockage is performed with an in-office procedure where the lacrimal system is irrigated with a sterile water solution. If a blockage exists, the fluid will reflux back. A patent and open tear drainage system allows the fluid to drain into the nose.
This video demonstrates irrigation of a lacrimal system in a patient with a nasolacrimal duct obstruction:
TREATMENT
Treatment of epiphora depends on the cause. As an oculofacial plastic surgeon and an expert in the diseases of the eyelids and the lacrimal system, the most common causes of epiphora I see in my practice are eyelid malposition (e.g., ectropion), facial palsy (such as Bell's palsy), and blockage in the lacrimal (tear drainage) system.
The lacrimal system starts in the eyelids and ends in the nose. A blockage can occur anywhere along the lacrimal system. Narrowing or scarring of the puncta, the two small drain holes in the corner of the upper and lower eyelids, can be corrected with dilation of the punctum or with a simple surgical procedure called a punctoplasty. Blockage in the canaliculi requires surgical repair with placement of a silicone stent. An obstruction in the common canaliculus, which leads into the lacrimal sac, requires bypassing of the entire lacrimal system with a procedure called conjunctivo-dacryocystorhinostomy (CDCR) and placement of a glass (Jones) tube from the inner corner of the eye and into the nose. Obstruction in the bony portion of the tear drainage system, or the nasolacrimal duct, requires a surgical procedure called a dacryocystorhinostomy (DCR), which reroutes the tears from the lacrimal sac into the nose.
A nasolacrimal duct obstruction, if left untreated, can lead to infection of the lacrimal sac, a condition known as dacryocystitis. This infection can potentially spread to involve the eye socket, potentially compromising vision. It is therefore important to have symptoms of excessive tearing be evaluated by an oculofacial plastic surgeon.
Stay tuned for more posts about nasolacrimal duct obstruction and DCR for treatment of epiphora.
For more information about epiphora, excess tearing, and nasolacrimal duct obstruction, or to schedule a consultation, call us at 858.356.2647