Watery Eye

 
 
 

"On Tuesday I had the little lacrimal tube removed by Dr Khan following my recent DCR.  I just want to tell you how successful it was & how thankful I am to you.  I have been miserable for years suffering a watery eye.  It has spoiled many occasions.  I am elated with the results & almost afraid to think that it will be permanent.  I haven’t had to wipe my eye once since Tuesday!  Out of habit I keep wanting to and have to stop myself.  I will save a fortune on tissues!  Even today, Mid Summer’s Day!!!, wet & windy, the only water on my face was the rain!

Thank you so much & wishing you continued success in the wonderful work you do." Ms L McG  

Dublin


Epiphora, or watery eye, is due to overflow of tears. It may be caused by a variety of ocular disorders, which can result in acute or chronic epiphora.


Acute epiphora is caused by irritative diseases of the ocular surface and resolves with the treatment of the disorder.


Chronic epiphora, on the other hand, is usually due to long-standing disorders and can cause epiphora with excessive tears sometimes streaming down the patient’s face.

The main causes of epiphora are hypersecretion (over production of tears)of tears and outflow failure


Causes of hypersecretion (over production of tears) include:

* Eyelid diseases like blepharitis, mebomian cysts and

      molluscum contagiosum.

* Eyelid malposition like ectropion, entropion and lid retraction.

* Eyelid weakness secondary to facial-nerve weakness.

* Other causes include trichiasis (misdirected lashes), corneal foreign bodies,

      conjunctival concretions, corneal abrasion or infections, ocular

      surface diseases and dry eye syndromes.


Causes of outflow failure  (obstruction in the tear drainage system) Include:


* Congenital punctual or canalicular atresia (upper tear duct blockage)

* Acquired punctual and canalicular malposition/ blockage, trauma, infections

    (herpes zoster, simplex, adenovirus, actinomyces), pharmacological agents.

* Nasolacrimal duct obstruction (blockage of the lower/nasal part of

             tear duct opening) secondary to congenital causes, trauma,

     neoplasm, nasal polyps, allergic rhinitis, chronic atrophic,

     inflammatory or destructive conditions in the nose and nasal surgery. 


Initial management is directed towards treating the identifiable causes.

History should help identify the problem, establish the severity and the possible

etiology.


The conditions leading to hypersecretion (over production) of tears can be treated and

eyelid malpositions can be corrected surgically.


A common cause of hypersecretion is dry eye, which also causes symptoms

of grittiness, foreign body sensation and burning, tired and itchy eyes.


This can be diagnosed simply by examining the tear film break-up time

and the corneal surface.


Diagnosis can be aided by measurement of tear production and treatment

is lubricant drops and, in some cases, punctal plugs.


In facial palsy, epiphora is a result of lid malposition, corneal exposure

and lacrimal (tear) pump failure due to orbicularis weakness (outermost muscle of the eyelid).

For idiopathic facial palsy, initially lubricants may suffice until recovery takes place.

In severe and longstanding facial palsy, surgical corrections like tarsorrhaphy,

gold weight insertion in the upper lid, lower lid shortening and augmentation

and dacryocystorhinostomy for lacrimal pump failure is considered.


If the cause of epiphora is outflow failure, punctal stenosis or atresia must be ruled

out.


Lacrimal (tear duct)syringing gives valuable information regarding the upper lacrimal system. 


Dacryoscintillography is carried out in patients patent to syringing and can help

differentiate between hypersecretion, pump failure and partial outflow blocks.

This test does not provide detailed anatomical information provided by contrast

dacryocstogram (DCG), but it offers valuable functional information.


DCG, even though rarely performed, can provide valuable information regarding

nasolacrimal obstruction, failed lacrimal surgery, trauma, sac tumors/stones,

previous reconstructive surgery and adnexal problems.

CT-DCG is far more superior than DCG alone as it can demonstrate the

relationship between the lacrimal system and surrounding bone and soft

tissues.


The treatment of nasolacrimal obstruction varies depending on the severity of the

epiphora; patient may decide not to have any treatment.


Treatment options include syringing and probing in children, intubation

of the nasolacrimal system or DCR ( surgery involving formation of a new tear duct)

which may be carried out through external or endonasal (through the nose) approach.


DCR involves fistulisation of the lacrimal sac into the nasal cavity and

bypassing nasolacrimal obstruction.


External DCR has 95 per cent or more success rate.

Endonasal DCR on the other hand tries to mimic external DCR but without

the disadvantages of a scar and orbicularis and medial canthal tendon disruption.


The success rate with the current technique is as high as 95 per cent but the

disadvantages are the limitations due to nasal anatomical variation and

pathology.


Written for and published in Irish medical times 28th March 2008

Rizwana I. Khan,

MBBS, FRCSI, MRCOphth,

Consultant Ophthalmic Surgeon

Hermitage Medical Clinic and

Blackrock Clinic.