Ophthalmology – Epiphora

Epiphora, or excessive tearing, represents an imbalance between tear production and tear drainage. Tears are produced primarily by the lacrimal and accessory lacrimal glands and normally drain through the puncta, canaliculi, lacrimal sac, and nasolacrimal duct into the nose. Epiphora therefore develops either because of excessive tear production, usually from ocular surface irritation, or because of impaired tear drainage.

Epiphora can occur at any age but has a bimodal distribution, being particularly common in infancy and later adulthood. In infants, the most frequent cause is congenital nasolacrimal duct obstruction, occurring in approximately 5% of infants. About 90% resolve spontaneously by 1 year of age. In adults, tearing is common and frequently results from dry eye with reflex tearing, particularly in women after menopause.

Normally, aqueous tears mix with lipid secretions from the meibomian glands and mucins to form a stable tear film. Blinking distributes this tear film and generates a pumping action that moves tears through the lacrimal drainage system. Disruption at any point can produce epiphora. Congenital nasolacrimal duct obstruction results from incomplete canalization of the nasolacrimal duct during embryologic development.

In adults, an unstable tear film or dry eye disease can irritate the ocular surface and paradoxically stimulate excessive reflex tearing. Blepharitis and meibomian gland dysfunction may contribute. Other causes of reflex tearing include trichiasis, entropion, corneal foreign bodies, keratitis, uveitis, and conjunctivitis. Lower eyelid laxity or ectropion can impair the normal lacrimal pump. Acquired obstruction can occur anywhere along the drainage system because of infection, inflammation, trauma, or medication-related stenosis, including that caused by certain chemotherapeutic agents.

Common associated conditions include blepharitis, dry eye, trichiasis, entropion, ectropion, nasolacrimal drainage obstruction, ocular surface inflammation, and foreign bodies.

Diagnosis

Infants with congenital nasolacrimal duct obstruction typically develop persistent unilateral or bilateral tearing shortly after birth. Crusting and discharge around the eyelashes are common, particularly after sleep, and symptoms may become worse during nasal congestion.

Adults with dry eye typically describe intermittent tearing with a gradual onset. Symptoms may worsen during activities that reduce blinking, such as reading, computer use, watching television, and driving, as well as in cold or windy environments. In contrast, patients with a dysfunctional tear pump or an anatomic drainage obstruction generally experience more constant tearing. A history of dacryocystitis, ocular infection, trauma, or previous surgery may suggest an acquired obstruction.

Physical examination should assess the quality and quantity of the tear film, eyelid position and laxity, punctal position, eyelashes, and ocular surface. The examiner should specifically look for trichiasis, entropion, ectropion, conjunctivitis, keratitis, foreign bodies, and signs of dry eye. The puncta, canaliculi, lacrimal sac, and nasolacrimal duct should also be evaluated. Palpation of the lacrimal sac is particularly important when distal obstruction is suspected.

The fluorescein dye disappearance test provides a simple assessment of tear drainage. Fluorescein is placed in the conjunctival cul-de-sac and evaluated after approximately 5 minutes. Normally, most dye disappears as tears drain through the lacrimal system. Persistence or increasing height of the fluorescein-stained tear meniscus suggests impaired drainage.

The Schirmer test can evaluate aqueous tear production. When performed with topical anesthesia to assess basal secretion, less than approximately 5 mm of wetting in 5 minutes suggests aqueous tear deficiency, 5–10 mm is borderline, and greater than 10 mm is generally considered normal.

Additional testing depends on the suspected cause. Patients with dry mouth or systemic rheumatologic symptoms may require evaluation for Sjögren syndrome. Lacrimal irrigation can identify obstruction in teenagers and adults. Dacryocystography may help distinguish mechanical obstruction from tear-pump dysfunction, while lacrimal scintigraphy can assess functional drainage. CT imaging may be appropriate when a dacryocele, nasolacrimal cyst, lacrimal sac tumor, or another structural lesion is suspected.

Moderate or severe dry eye may produce punctate staining of the exposed cornea and conjunctiva. A distended lacrimal sac that produces purulent material through the puncta when compressed strongly suggests chronic dacryocystitis associated with nasolacrimal duct obstruction.

The differential diagnosis varies with age and presentation. Chronic tearing in children includes congenital nasolacrimal duct obstruction, congenital glaucoma, and epiblepharon, while acute tearing may result from conjunctivitis, keratitis, or a foreign body. Chronic adult causes include dry eye, acquired nasolacrimal duct obstruction, ectropion, entropion, trichiasis, and previous facial nerve palsy. Acute adult causes include conjunctivitis, keratitis, uveitis, foreign bodies, and acute facial nerve palsy. Importantly, infantile glaucoma should not be overlooked in a persistently tearing infant.

Treatment

Treatment is directed at the underlying cause rather than tearing itself. Infants with congenital nasolacrimal duct obstruction are usually managed initially with observation and lacrimal sac massage. Topical antibiotic ointment, such as erythromycin, may be used when significant mucopurulent discharge or crusting is present, although antibiotics do not correct the underlying obstruction.

Adults with dry-eye-related reflex tearing are generally treated initially with artificial tears and management of associated blepharitis or meibomian gland dysfunction. More persistent inflammatory dry eye may require treatments such as topical anti-inflammatory therapy. Foreign bodies, trichiasis, bacterial conjunctivitis, keratitis, and other identifiable causes should be treated specifically.

Procedural treatment depends on the anatomical abnormality. Punctal stenosis may require punctoplasty, while persistent congenital nasolacrimal obstruction may require probing and irrigation, lacrimal intubation, or balloon dacryoplasty. More severe obstruction may require dacryocystorhinostomy (DCR) or, in selected cases, conjunctivodacryocystorhinostomy. Adults with nasolacrimal obstruction may similarly require punctoplasty, probing with stenting, balloon dacryoplasty, or DCR. When eyelid malposition or pump failure is responsible, entropion repair, ectropion repair, or horizontal eyelid tightening may be necessary.

Follow-up and Prognosis

Infants with uncomplicated congenital nasolacrimal duct obstruction can generally be observed during the first year of life, because most cases resolve spontaneously. Persistent obstruction beyond this period may require procedural intervention. Acute dacryocystitis, particularly in an infant, requires prompt ophthalmologic assessment.

Adults are followed according to the underlying cause and severity. Dry eye and blepharitis frequently produce chronic or intermittent symptoms, whereas anatomical obstruction or eyelid malposition may require surgery followed by postoperative monitoring.

Parents should be instructed in the correct technique for nasolacrimal sac massage when treating congenital obstruction. Adults with blepharitis may benefit from regular eyelid hygiene and warm compresses.

The prognosis is excellent in most pediatric cases. Adult prognosis depends on the etiology. Dry eye and blepharitis may cause recurrent symptoms, whereas patients with significant nasolacrimal duct obstruction generally have a good outcome following appropriate DCR surgery.