Watery Eyes

AJGP Vol. 53, No. 11 Supplement, November 2024

Definitions and Classification

Epiphora

Definition: An overflow of tears onto the face, typically caused by dysfunction of the lacrimal drainage system or excessive tear production.
Distinction:
- True Epiphora: Represents the inability of tears to drain properly through the lacrimal drainage system.
- Pseudo-Epiphora (Reflex Tearing): Excess tear production due to ocular surface irritation, rather than an actual drainage problem.

Anatomy of the Lacrimal System

Components of the Lacrimal System

Lacrimal Gland: Located in the superolateral orbit, responsible for tear production.
- Secretion Stimuli:
  - Baseline Secretion: Continuous, helps in keeping the ocular surface moist.
  - Reflex Secretion: Triggered by sensory input via the trigeminal nerve (V1) or in response to emotions.
Tear Film Layers:
- Lipid Layer: Produced by Meibomian glands, prevents evaporation.
- Aqueous Layer: Secreted by lacrimal glands, provides nutrients.
- Mucin Layer: Produced by conjunctival goblet cells, aids tear adhesion to the cornea.
Lacrimal Drainage Pathway:
- Puncta: Upper and lower puncta drain tears from the ocular surface.
- Canaliculi: Upper and lower canaliculi join to form a common canaliculus, leading to the lacrimal sac.
- Lacrimal Sac and Nasolacrimal Duct: The lacrimal sac collects tears and drains them into the nasolacrimal duct, which opens into the inferior meatus of the nose.
- Valve of Hasner: Prevents backflow of nasal contents into the lacrimal drainage system.

Pathophysiology of a Watery Eye

Etiology of Epiphora

Overproduction of Tears:
- Reflex Hypersecretion:
  - Ocular Surface Irritation: Dry eye syndrome, conjunctivitis, corneal abrasions.
  - Inflammatory Causes: Allergic conjunctivitis, chemical exposure, infectious conjunctivitis.
Obstructed Drainage:
- Anatomical Obstructions:
  - Punctal Stenosis: Age-related narrowing or scarring, recurrent infections.
  - Canalicular Obstruction: Due to infection, trauma, inflammation.
  - Nasolacrimal Duct Obstruction (NLDO): Can be congenital or acquired.
- Functional Obstruction:
  - Lid Malposition:
    - Ectropion: Outward turning of the eyelid leading to exposure of the puncta.
    - Entropion: Inward turning causing irritation and subsequent reflex tearing.
  - Facial Nerve Palsy: Failure of the lacrimal pump mechanism due to orbicularis oculi paralysis.

Differential Diagnosis of Epiphora

Pediatric Population

Congenital Nasolacrimal Duct Obstruction (CNLDO): Most common cause in infants.
Congenital Glaucoma: Presents with epiphora, photophobia, and blepharospasm.
Ophthalmia Neonatorum: Neonatal conjunctivitis due to bacterial infection (e.g., Chlamydia, Gonorrhea).

Adult Population

Age-Related Changes:
- Ectropion/Entropion: Structural changes in elderly patients can cause malposition.
- Chronic Blepharitis: Chronic inflammation of eyelid margins, associated with Meibomian gland dysfunction.
Trauma or Surgery:
- Post-Surgical Complications: Nasolacrimal duct scarring, punctal obstruction.
- Facial Trauma: Fractures affecting the drainage system.
Sinonasal Disorders:
- Chronic Rhinosinusitis: Sinonasal inflammation can cause NLDO.
- Nasal Polyps or Masses: Direct compression or secondary inflammation.

Common Causes of Epiphora

Reflex Lacrimation:

Causes: Dry eye disease, blepharitis, foreign bodies, eyelid malposition.
Demographic: Typically affects older patients.
Management: Trial of lubricants and addressing the underlying irritative stimuli.

Nasolacrimal Duct Obstruction (NLDO):

Symptoms: True tearing epiphora lasting for at least three months. It can be unilateral or bilateral, with a usually normal examination.
First-line Management: Lubricants and warm compress.
Surgical Management: Considered if symptoms persist, with surgery aiming to correct the underlying cause of obstruction and maintain duct patency to prevent complications like mucocoeles or dacryocystitis.
Referral: If symptoms significantly impact daily activities.

Facial Palsy:

Mechanism: Can cause both true epiphora (due to lacrimal pump failure) and reflex lacrimation (due to drying of the ocular surface).
Management:
- Lubrication for the eye.
- Identification and reversal of any underlying cause of facial nerve dysfunction.
- For permanent paralysis: Surgical corrections such as tarsorrhaphy, gold weight insertion, or other surgical facial reanimation procedures.

Eyelid Malposition:

Cause: Malposition can lead to reflex lacrimation due to ocular surface drying and corneal injury.
Management:
- Initial management with lubrication.
- Forms of malposition, including entropion, ectropion, excessive eyelid laxity, or Floppy Eyelid Syndrome, respond well to surgical correction.
- Referral to oculoplastics service for surgical consideration.

Assessment of a Watery Eye

`History Taking`

Onset and Duration:
- Acute: Suggestive of infection or trauma.
- Chronic: Typically related to anatomical obstruction or functional issues.
Laterality:
- Unilateral: More suggestive of localized obstruction or pathology.
- Bilateral: Could indicate systemic conditions or generalized ocular surface disease.
Associated Symptoms:
- Discharge: Mucoid, purulent (infection); clear (allergic or irritation).
- Pain and Redness: Suggestive of an inflammatory cause like conjunctivitis or keratitis.
- Visual Changes: Blurred vision or diplopia—possible intraocular involvement.
- Systemic Symptoms: History of sinonasal symptoms, autoimmune diseases, or trauma.

`Physical Examination`

External Inspection:
- Facial Symmetry: Look for facial nerve palsy.
- Eyelid Position and Function: Ectropion, entropion, lid laxity.
- Punctal Examination: Evaluate for stenosis, location, and integrity.
Slit Lamp Examination:
- Conjunctiva and Cornea: Look for signs of inflammation, foreign bodies, keratitis.
- Fluorescein Dye Testing:
  - Tear Breakup Time (TBUT): Assess evaporative component of dry eye.
  - Dye Disappearance Test: Excess dye after 5 minutes suggests drainage dysfunction.
Nasolacrimal Duct Probing (if needed in infants): Helps evaluate the presence of an obstruction.

`Sinonasal Examination`

Nasal Septum and Turbinates:
- Deviated Septum: Can obstruct nasolacrimal duct drainage.
- Polyps or Masses: Suggest a possible compression or obstruction.
Anterior Rhinoscopy: Visual inspection with an otoscope.
Flexible Nasoendoscopy: Consider referral to ENT for thorough sinonasal examination.

Investigations for Epiphora

`Imaging Studies`

Indications: When NLDO or other anatomical abnormalities are suspected.
Modalities:
- CT Scan: To evaluate traumatic injury, sinonasal causes, or mass lesions.
- MRI: Occasionally indicated for soft tissue evaluation or in cases of neoplastic suspicion.
- Dacryocystography: Radiographic imaging using contrast to visualize the nasolacrimal duct.

`Laboratory Tests`

Conjunctival Swabs: In cases of infectious conjunctivitis.
Inflammatory Markers:
- Rarely indicated unless systemic inflammatory disease or vasculitis is suspected.

Management Strategies for Watery Eye

General Principle: Initiate symptomatic treatment in primary care while awaiting definitive diagnosis. Treatment depends on suspected etiology.

Ocular Surface Disease (e.g., Dry Eye Disease):

Initiate preservative-free lubricants (four times daily).
Consider chloramphenicol ointment for more severe cases.
Refer to an optometrist for ongoing management due to the complexity of dry eye disease.

Blepharitis or Meibomian Gland Dysfunction:

Recommend warm compresses, gentle eyelid massage, and lid hygiene.
Use a cotton bud or pad dipped in dilute baby shampoo to cleanse the lid and lash line twice daily.

Rhinosinusitis or Allergy:

Start intranasal topical corticosteroids.
Add oral antihistamine or use a combined corticosteroid-antihistamine spray for allergy symptoms.

Referral to Specialist:

Refer to an otolaryngologist if sinonasal symptoms are present.
Ophthalmologist referral may also be needed for further evaluation.

Surgical Management

Eyelid Malposition:
- Ectropion/Entropion Repair: Surgical correction by tightening or repositioning the eyelid.
Nasolacrimal Duct Obstruction:
- Dacryocystorhinostomy (DCR):
  - External DCR: Creates a bypass from the lacrimal sac to the nasal cavity.
  - Endoscopic DCR: Performed intranasally with the help of an ENT surgeon.
- Canaliculoplasty: For proximal canalicular obstruction or stenosis.
Facial Palsy:
- Gold Weight Implantation: Implanting a small gold weight in the upper eyelid to assist with closure.
- Tarsorrhaphy: Suturing part of the eyelid together to narrow the palpebral fissure and protect the cornea.

Special Considerations in Paediatric Population

Ophthalmia Neonatorum (Neonatal Conjunctivitis):

Due to the potentially sight- and life-threatening complications of chlamydia or gonorrhoea, neonates under one month should be urgently discussed with an ophthalmology service for review.

`Congenital Nasolacrimal Duct Obstruction`

Presentation:
- Persistent tearing
- discharge
- matting of the eyelashes
Most commonly resolves spontaneously by the age of one year.
Initial Management:
- Lacrimal sac massage
- ensure good hygiene.
Referral Indications:
- Persistent symptoms beyond 12 months of age, presence of red flags (buphthalmos, corneal clouding).
Probing and Syringing: Typically considered if obstruction persists beyond 12-18 months of age, performed under general anesthesia.

`Paediatric Glaucoma`

Signs:
- Buphthalmos (enlarged globe)
- corneal haze
- photophobia
- tearing
Referral: Immediate referral to a pediatric ophthalmologist for surgical intervention to prevent vision loss.

Complications and Referral Guidelines

`Complications of Epiphora`

Infection: Chronic stagnation of tears can lead to dacryocystitis, presenting as swelling, pain, and erythema over the lacrimal sac.
Conjunctivitis: Chronic tearing may predispose to secondary bacterial infections.
Visual Impairment: Continuous tearing may cause blurred vision and interference with activities of daily living.

`Referral Indications`

Ophthalmologist:
- Persistent Epiphora: Especially with red-eye, pain, or vision loss.
- Suspected Congenital Glaucoma: Requires immediate evaluation.
- Dacryocystitis: Swelling and pain over lacrimal sac require urgent assessment.
ENT Specialist:
- Sinonasal Pathology: If sinonasal obstruction or mass is suspected.
- Surgical DCR: When nasolacrimal duct obstruction is confirmed.

Prognosis and Patient Counselling

General Prognosis

Congenital NLDO: Excellent prognosis with spontaneous resolution or after probing.
Adult Epiphora: Generally depends on the cause; surgical interventions such as DCR have high success rates.

Patient Education and Counseling

Reassurance: In cases like congenital NLDO, educate parents about the high likelihood of spontaneous resolution.
Importance of Compliance: Lid hygiene, warm compresses, and massage techniques need compliance for effective management.
Surgical Considerations: Discuss potential risks and benefits of surgical intervention, such as DCR, to manage expectations.

Conclusion

The management of a watery eye (epiphora) involves a structured and thorough approach, beginning with history taking and examination to differentiate between excessive production and impaired drainage. Treatment is guided by the underlying etiology and ranges from conservative methods, such as lubrication and massage, to more invasive procedures like dacryocystorhinostomy for cases involving obstructed drainage.