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Ophthalmology – Epiphora
Epiphora, commonly referred to as excessive tearing, results from an imbalance between tear production and tear drainage. Tears are produced by the lacrimal glands and normally drain through the nasolacrimal system into the nose. Any disruption in this balance—either overproduction due to irritation or impaired drainage due to obstruction—can lead to tearing.
Epidemiologically, epiphora shows a bimodal distribution, occurring most often in infants and older adults. In infants, the most common cause is congenital nasolacrimal duct obstruction, affecting about 5% of newborns, with 90% resolving spontaneously by age 1. In adults, tearing is frequently due to dry eye syndrome, particularly in postmenopausal women, where ocular surface irritation leads to reflex tearing.
The pathophysiology involves disruption of the normal tear film dynamics. Tears consist of aqueous, lipid, and mucin layers that maintain ocular surface health. Blinking helps pump tears into the drainage system. In infants, incomplete canalization of the nasolacrimal duct leads to obstruction. In adults, dry eye or tear film instability causes irritation and reflex tearing. Other contributors include blepharitis (affecting lipid layer), decreased tear production, eyelid malposition (e.g., ectropion), or obstruction from inflammation, trauma, or infection.
Etiologically, epiphora can be broadly divided into overproduction and outflow obstruction. Overproduction is usually secondary to ocular surface irritation, such as from trichiasis, entropion, keratitis, uveitis, conjunctivitis, or foreign bodies. Outflow obstruction may occur anywhere along the lacrimal drainage pathway due to infection (dacryocystitis), inflammation, trauma, or medication-induced stenosis. Poor tear pump function from eyelid laxity or facial nerve palsy may also contribute.
Clinically, infants present with constant tearing shortly after birth, often accompanied by crusting of eyelashes, especially after sleep, and symptoms may worsen with nasal congestion. Adults with dry eye typically report intermittent tearing, worsened by activities that reduce blinking (e.g., reading, screen use, driving) or environmental factors like wind and cold air. In contrast, patients with obstruction often have constant tearing and may have a history of infection or trauma.
Physical examination includes assessment of the tear film quality and quantity, eyelid position (looking for entropion, ectropion, or misdirected lashes), and ocular surface for signs of dry eye or inflammation. Evaluation of the lacrimal drainage system includes inspection of the puncta, canaliculi, and lacrimal sac, with palpation to check for reflux of discharge suggestive of obstruction or infection.
Diagnostic testing may include the fluorescein dye disappearance test, where persistence of dye suggests impaired drainage. Schirmer testing evaluates tear production, with less than 5 mm of wetting in 5 minutes indicating dry eye. Additional studies such as dacryocystography or lacrimal scintigraphy can help differentiate obstruction from pump failure. Imaging (CT scan) may be used if structural abnormalities, cysts, or tumors are suspected. Lacrimal irrigation in-office is a useful diagnostic tool in older children and adults.
The differential diagnosis varies by age. In children, causes include congenital nasolacrimal duct obstruction, congenital glaucoma, and epiblepharon. In adults, common causes include dry eye, nasolacrimal duct obstruction, eyelid malposition, trichiasis, and facial nerve palsy, while acute causes include conjunctivitis, keratitis, uveitis, or foreign body.
Management depends on the underlying cause. In infants, conservative treatment includes topical antibiotic ointment for discharge and lacrimal sac massage, which can help open the duct. Most cases resolve spontaneously. In adults with dry eye, artificial tears are first-line, with second-line options including topical cyclosporine or short-term steroids for inflammation. Acute causes require treatment of the underlying condition, such as antibiotics for infection or removal of a foreign body.
Procedural interventions include punctal occlusion for dry eye, punctoplasty for stenosis, and probing and irrigation for congenital obstruction. Surgical options such as dacryocystorhinostomy (DCR) are used for persistent nasolacrimal duct obstruction. Eyelid malpositions may require entropion or ectropion repair.
Follow-up varies by age and severity. Infants are typically observed during the first year, with surgery considered if symptoms persist beyond age 1. Adults are managed based on cause, with surgical follow-up as needed. Prognosis is excellent in pediatric cases, while in adults it depends on the underlying etiology—patients with obstruction often do well after surgery, whereas those with chronic dry eye may have ongoing intermittent symptoms.
Epiphora, commonly referred to as excessive tearing, results from an imbalance between tear production and tear drainage. Tears are produced by the lacrimal glands and normally drain through the nasolacrimal system into the nose. Any disruption in this balance—either overproduction due to irritation or impaired drainage due to obstruction—can lead to tearing.
Epidemiologically, epiphora shows a bimodal distribution, occurring most often in infants and older adults. In infants, the most common cause is congenital nasolacrimal duct obstruction, affecting about 5% of newborns, with 90% resolving spontaneously by age 1. In adults, tearing is frequently due to dry eye syndrome, particularly in postmenopausal women, where ocular surface irritation leads to reflex tearing.
The pathophysiology involves disruption of the normal tear film dynamics. Tears consist of aqueous, lipid, and mucin layers that maintain ocular surface health. Blinking helps pump tears into the drainage system. In infants, incomplete canalization of the nasolacrimal duct leads to obstruction. In adults, dry eye or tear film instability causes irritation and reflex tearing. Other contributors include blepharitis (affecting lipid layer), decreased tear production, eyelid malposition (e.g., ectropion), or obstruction from inflammation, trauma, or infection.
Etiologically, epiphora can be broadly divided into overproduction and outflow obstruction. Overproduction is usually secondary to ocular surface irritation, such as from trichiasis, entropion, keratitis, uveitis, conjunctivitis, or foreign bodies. Outflow obstruction may occur anywhere along the lacrimal drainage pathway due to infection (dacryocystitis), inflammation, trauma, or medication-induced stenosis. Poor tear pump function from eyelid laxity or facial nerve palsy may also contribute.
Clinically, infants present with constant tearing shortly after birth, often accompanied by crusting of eyelashes, especially after sleep, and symptoms may worsen with nasal congestion. Adults with dry eye typically report intermittent tearing, worsened by activities that reduce blinking (e.g., reading, screen use, driving) or environmental factors like wind and cold air. In contrast, patients with obstruction often have constant tearing and may have a history of infection or trauma.
Physical examination includes assessment of the tear film quality and quantity, eyelid position (looking for entropion, ectropion, or misdirected lashes), and ocular surface for signs of dry eye or inflammation. Evaluation of the lacrimal drainage system includes inspection of the puncta, canaliculi, and lacrimal sac, with palpation to check for reflux of discharge suggestive of obstruction or infection.
Diagnostic testing may include the fluorescein dye disappearance test, where persistence of dye suggests impaired drainage. Schirmer testing evaluates tear production, with less than 5 mm of wetting in 5 minutes indicating dry eye. Additional studies such as dacryocystography or lacrimal scintigraphy can help differentiate obstruction from pump failure. Imaging (CT scan) may be used if structural abnormalities, cysts, or tumors are suspected. Lacrimal irrigation in-office is a useful diagnostic tool in older children and adults.
The differential diagnosis varies by age. In children, causes include congenital nasolacrimal duct obstruction, congenital glaucoma, and epiblepharon. In adults, common causes include dry eye, nasolacrimal duct obstruction, eyelid malposition, trichiasis, and facial nerve palsy, while acute causes include conjunctivitis, keratitis, uveitis, or foreign body.
Management depends on the underlying cause. In infants, conservative treatment includes topical antibiotic ointment for discharge and lacrimal sac massage, which can help open the duct. Most cases resolve spontaneously. In adults with dry eye, artificial tears are first-line, with second-line options including topical cyclosporine or short-term steroids for inflammation. Acute causes require treatment of the underlying condition, such as antibiotics for infection or removal of a foreign body.
Procedural interventions include punctal occlusion for dry eye, punctoplasty for stenosis, and probing and irrigation for congenital obstruction. Surgical options such as dacryocystorhinostomy (DCR) are used for persistent nasolacrimal duct obstruction. Eyelid malpositions may require entropion or ectropion repair.
Follow-up varies by age and severity. Infants are typically observed during the first year, with surgery considered if symptoms persist beyond age 1. Adults are managed based on cause, with surgical follow-up as needed. Prognosis is excellent in pediatric cases, while in adults it depends on the underlying etiology—patients with obstruction often do well after surgery, whereas those with chronic dry eye may have ongoing intermittent symptoms.
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