Dr Tom Cunneen
MBBS(Hons) MMed FRANZCO
Ophthalmic Surgeon, Sir Charles Gairdner Hospital
Watery eye is a common presentation that varies from constant debilitating epiphora to intermittent, wet-feeling eyes.
Ordinarily, tears are swept across the eye by lid closure and the slight lateral to medial slant of the lower lid. The tears are then pumped through the canaliculi, into the lacrimal sac and finally down the nasolacrimal duct to emerge in the inferior part of the lateral nose, under the inferior turbinate. While there is still debate about the precise nature of this ‘lacrimal pump,’ what is clear is that reasonable tone in the eyelids is important for the efficient movement of tears.
Epiphora results when the capacity of the drainage system to clear tears is overwhelmed by the amount of tears produced. As such, epiphora can be caused by increased tear production, decreased tear clearance or a combination of the two.
The assessment of patients with epiphora begins with a focused history. Constant, severe watering points to an obstruction somewhere in the tear drainage pathway. Intermittent watering in the setting of ocular irritation is more likely to respond to conservative measures.
As well as a general history, I ask specifically about sinus and rhinitis symptoms such as nasal obstruction and facial pressure or fullness. Facial trauma alters the surgical anatomy of the nasolacrimal system. A rare but serious symptom is bloody epiphora which is associated with lacrimal sac tumours.
Clinical examination begins with inspection. Both ectropion and entropion will cause watering. If there is an ectropion, look for any skin lesions that are rolling the eyelid out (Figure 1). The laxity of the lower eyelid is subjectively assessed by distracting the eyelid away from the globe, medially and laterally.
Figure 1. A basal cell carcinoma of the left lower lid causing a medial ectropion
I examine the patient under the slitlamp with a drop of fluorescein in each eye. I assess the tear film height and symmetry, the punctal size and position, corneal and conjunctival staining, tear film break up time and any tarsal papillae consistent with allergic eye disease. Significant conjunctivochalasis occasionally lies over the inferior puncta.
Special tests I perform routinely include the dye disappearance test (DDT) and lacrimal syringing.
The DDT involves placing a drop of 2% fluorescein in the eye and assessing the patient five minutes later. At five minutes, if there is any more than a tiny slither of fluorescein, the test is positive. This is a specific but not particularly sensitive test for outflow obstruction.1
I then syringe the lacrimal system. I use 26 gauge cannula on a 3 ml syringe. The canaliculus classically has a 2 mm vertical component and an 8 mm horizontal component. It is important to have the eyelid stretched laterally and to follow this path with the cannula to avoid damaging this sensitive structure. Syringing tells me whether the lacrimal system is completely obstructed and gives some information on where the obstruction is. However, this is not a physiologic test and patients with functional nasolacrimal duct obstruction (NLDO) often still have epiphora despite a patent syringing.
The management of epiphora depends on the underlying cause. Commonly, simple treatments for ocular surface irritation such as warm compresses, artificial tears and anti-allergy drops will relieve the epiphora sufficiently. Punctal stenosis can be treated effectively in the outpatient setting with punctoplasty.2 Significant conjunctivochalasis can be resected.
In a patient with complete NLDO, the treatment is a dacryocystorhinostomy (DCR) which involves anastomosing the lacrimal sac to the nasal mucosa by removing the bone of the anterio-medial orbit. This can be done either externally or endonasally. Both techniques have advantages and disadvantages as described in Table 1.3
Table 1. External and endonasal DCR3
Dacryocystitis is a serious complication of NLDO and presents with painful swelling of the lacrimal sac. This often requires intravenous antibiotics to resolve followed by a DCR procedure. It is important to note that dacryocystitis causes a mass below the medial canthal tendon. If there is swelling above this structure, then a tumour needs to be excluded with imaging (Figure 2).
Figure 2. A mass above the medial canthal tendon caused by a squamous cell carcinoma
Lacrimal pump failure requires tightening of the lower eyelid. This can be performed with either a lateral tarsal strip procedure or sutured canthoplasty (Figures 3A and 3B). This procedure can be combined with a punctoplasty or a DCR procedure.
Figures 3A and 3B. Pre-operative (left) and post-operative (right) images following bilateral lower lid tightening procedures to treat epiphora
Canaliculitis is a rare but often missed cause of epiphora.4 Be aware of the patient with chronic, unilateral discharge and epiphora. Look for an erythematous, pouting punctum with granules able to be expressed with compression. This condition requires dilation of the punctum with or without canaliculotomy, expression of the granules and topical antibiotic drops.
Canalicular obstruction is the most challenging condition to treat. This occurs in the setting of inflammation to the canaliculus such as infection, chemotherapeutic agents, allergy, radiation or chronic drop use. If there is sufficient length of patent canaliculus, this can be anastomosed to the lacrimal sac during an external DCR. If there is little proximal patent canaliculus, then various options are available including retrograde intubation of the canaliculus or Jones tube insertion.
The Jones tube is a glass tube which runs directly from the medial conjunctiva to the nose. These require significant maintenance and not infrequently block or become loose; however, they are the current technique of choice when other surgical options have been exhausted. A recently-described technique involves using botox to the lacrimal gland. This has been used for some time in patients with aberrant regeneration of the 7th nerve causing gustatory lacrimation; however, there are recent reports of this technique being used for complete outflow obstruction, not amenable to surgery.5
1. Kashkouli MB, et al. Fluorescein dye disappearance test: a reliable test in assessment of success after dacryocystorhinostomy procedure. Ophthal Plast Reconstr Surg 2015; 31: 4: 296-299.
2. Caesar RH, McNab AA. A brief history of punctoplasty: the 3-snip revisited. Eye (Lond) 2005; 19: 1: 16-18.
3. Huang J, et al. Systematic review and meta-analysis on outcomes for endoscopic versus external dacryocystorhinostomy. Orbit 2014; 33: 2: 81-90.
4. Freedman JR, Markert MS, Cohen AJ. Primary and secondary lacrimal canaliculitis: a review of literature. Surv Ophthalmol 2011; 56: 4: 336-347.
5. Ziahosseini K, Al-Abbadi Z, Malhotra R. Botulinum toxin injection for the treatment of epiphora in lacrimal outflow obstruction. Eye (Lond) 2015; 29: 5: 656-661.