The document discusses epiphora, which is excessive tearing or watering of the eyes, describing the various causes including abnormalities of the puncta, canaliculi, lacrimal sac, or nasolacrimal duct. Evaluation methods such as syringing, dye tests, and imaging are covered. Surgical treatments for different obstructions include punctal dilation, intubation, dacryocystorhinostomy, and silicone stent placement.

1. EPIPHORA
BY Dr. Lakshmi.K.S
Moderator- DR. Rajani.K

2. • Introduction to watering eye
• Causes op epiphora and their
management
• Clinical evaluation of watering eye
• Management of traumatic disruption of
lacrimal apparatus
• DCR- types and techniques

3. Introduction
The watering eye- characterized by overflow
of tears from the conjunctival sac. Can be
due to
• Hyperlacrimation (excessive secretion of
tears)
• Epiphora (obstruction to the outflow of
normally secreted tears)

4. Hyperlacrimation
1. Primary hyperlacrimation- direct
stimulation of lacrimal gland
2. Reflex hyperlacrimation- stimulation of
sensory branches of 5th nerve due to
irritation of cornea or conjunctiva
3. Central hyperlacrimation- emotional
states, voluntary lacrimation and
hysterical lacrimation

5. Epiphora
Physiological- lacrimal pump failure due to
lower lid laxity or weakness of orbicularis
muscle

6. • Anatomical- obstruction of lacrimal outflow
system at any level from punctum to
nasolacrimal duct opening in the inferior
meatus

7. Punctal causes- obstruction
• Congenital absence or
primary punctal stenosis
• Ciciatricial closure following
injuries, burns or infections-
punctal stenosis.
Treatment- dilatation or
puntoplasty(2 or 3 snip
procedure)
• Foreign body- eg: eye lash
Treatment- removal
• Prolonged use of drugs like
iodoxyuridine and
pilocarpine.
Prevention-using drugs
judiciously

8. • Punctoplasty- for primary punctal stenosis
involves removal of the posterior wall of the
ampulla by a two- or three-snip technique
(video)

9. Malposition
 Punctal malposition- tear
film is not in contact with the
malpositioned punctum to
drain.
• Old age due to laxity of lids
causing punctal eversion
• Following chronic
conjunctivitis, chronic
blepheritis or ectropion
• Centurion syndrome-
characterized by anterior
malposition of the medial
part of the lid, with
displacement of puncta out
of the lacus lacrimalis due
to a prominent nasal bridge

10. Treatment
Treatment-
Ziegler cautery- Burns are applied to the
palpebral conjunctiva, 5 mm below the
punctum for punctal eversion
Medial conjunctivoplasty: A diamond-shaped
piece of tarsoconjunctiva is excised.
approximation of the superior and inferior
wound margins with sutures for punctal
eversion.
Lower lid tightening: with a lateral canthal
sling with or without medial conjunctivoplasty

11. Canalicular causes
Congenital stenois
Acquired-
• trauma
• foreign body
• strictures
• canaliculitis-
pouting of punctum

12. Treatment of canalicular
obstruction
• Partial canalicular obstruction
intubation using silicone stents through one
or both canaliculi, which are left in situ for 3–
6 months
• total canalicular obstruction
conjunctivodacryocystorhinostomy and the
insertion of a special (Lester Jones) tube

13. Management of traumatic
damage to lacrimal apparatus
• Lesions of the lacrimal drainage system
occur in up to 16% of all eyelid injuries.
• The main causes are road traffic accidents,
animal bites and violence.
• Canalicular lacerations are the most
common injury of the lacrimal drainage
system because of their exposed location in
the upper and lower lid. The lower
canliculus is more frequently involved
• Lacerations of the lacrimal sac or
nasolacrimal duct are often associated with
severe head trauma and midface fractures
and needs multidisciplinary treatment
approach.

14. Procedure of canalicular repair
• First the punctum is dilated, then the medial
(portion closest to nose) cut end of canalicular
system is identified. The stent is then
introduced through punctum.
• When silicon stent is used, the collar of stent is
placed securely in punctum so that the top edge
is flushed with the eyelid margin, stent is then
cut to appropriate length to- bridge the
laceration.
• The length of stent should be cut with excess
remaining as a small amount of excess stent
should extend to the nasolacrimal sac. The
stent is then placed into the medial cut end of
canaliculus.

15. • The laceration is then re-
approximated with fine suture like 6-0
vicryl. The sutures should not pass
through the cut ends of the
canaliculus, The pericanalicular
tissues are meticulously
approximated.
• In cases where IV intubation tubes are
used, the technique is essentially the
same but the difference is the lateral
portion of the tube is sutured to eyelid
margin to prevent extrusion.
• If the medial canthal tendon is
disrupted, it is also repaired to re-
establish anatomic position and lid
function.

16. • Associated lid injuries are promptly repaired. In any
patient with suspected orbital or mid face fractures,
orbital computed tomography is advised.
• Even though the patient has nil visual prognosis after
globe rupture the lid and canalicular suturing should be
meticulous because a good lid contour is essential for
fitting a custom artificial eye later.
• Patients should be reviewed at regular intervals, at 2
weeks when the sutures are removed, one month when
the IV Cannula is removed, 3 months when the
monocanalicular stent is removed

17. Lacrimal sac causes
• Congenital mucous
membrane folds
• Traumatic strictures-
post perforating trauma,
chemical injuries
• Dacryocystitis
• Dacryolithiasis
• Tumours
1. Meyer sinus, 2. rosenmuller
valve3. Arlt sinus, 4. krause valve, 5.
spiral valve of Hyrtl, 6. Taillefer valve,
7. valve of hasner
Acute dacryocystitis
Chronic dacryocystitis

18. Acute dacryocystitis
Stages:
1. Stage of cellulitis
2. Stage of lacrimal
abscess
3. Stage of fistula formation

19. Treatment of acute
dacryocystitis
• Topical antibiotic eye drops
• oral antibiotics and anti-inflammatory
drugs
• IV antibiotics in orbital cellulitis
• Incision and drainage if lacrimal abscess is
not responding to treatment. But may end
up in lacrimal fistula which requires more
demanding surgery later on.

20. Chronic dacryocystitis
1. Stage of chronic cattrahal
dacryocystitis
2. Stage of mucocele
3. Stage of chronic suppurative
dacryocystitis
4. Stage of chronic fibrotic sac

21. Treatment of chronic
dacryocystitis
• Type of surgery depends on the site of
obstruction in the lacrimal outflow tract.
Site of obstruction Surgery
Lacrimal sac or
Nasolacrimal duct
DCR
Common canaliculi Canaliculo
cystorhinostomy
Canaliculi or punctum Conjunctivo
canaliculocysto
rhinostomy

22. Naso Lacrimal Duct causes
Congenital-
• non canalization
• partial canalization
• imperforate membranous valves most
common one is imperforate valve of hasner
Acquired-
• Trauma
• Inflammation- dacryocystitis
• Tumors
• surrounding bony diseases

23. Congenital Nasolacrimal Duct
Obstruction
• most common cause of epiphora or watering in
children
• because of failure of canalization of the
nasolacrimal duct which normally occurs by 8
months of gestation
• Obstruction can be membranous occlusion (most
common- imperforate valve of hasner) or bony
occlusion
• Though congenital nasolacrimal duct obstruction
at birth is very common, symptoms of watering are
seen only in about 5% of cases

24. Congenital dacryocystitis
• Inflammation of lacrimal sac as a result of congenital
nasolacrimal obstruction seen in children is called as
congenital dacryocystitis
• infection of the secretions of the lacrimal sac
• Staphylococcus aureus, Haemophilus influenzae,
Pneumococci and beta hemolytic Streptococci are the
commonest causative organisms for congenital
dacryocystitis
• Congenital dacryocystitis usually presents as chronic
dacryocystitis.
• Epiphora starts from second week as tears production
from eyes starts only in second week, followed by
mucoid or mucopurulent discharge
*dacryocystocoele/amniocoele/encysted mucocoele
.

25. Management
Age of child Procedure
< 2 months Lacrimal sac massage and antibiotic eye
drops
2-6 months Lacrimal sac massage and antibiotic eye
drops and Lacrimal syringing
6-18 months Probing
18 months
to 4 years
Silicone tube intubation and Balloon catheter
dilatation
>4 years DCR

26. Lacrimal massaging
• Lacrimal sac massaging acts by
increasing the hydrostatic
pressure within the lacrimal sac
and opens up membranous
lacrimal obstruction
• Start at the medial canthal
tendon and gently massage
downwards along the lateral
nasal margin

27. Surgical treatment
Dilatation and probing
• Probing is done between 6 months to 1
year of age
• has got success rate of upto 95%.
• Probing after 18 months of age is
associated with high failure rate.
Technique: video

28. Clinical evaluation of a watering
eye
External examination-
• to rule out other causes of reflex lacrimation
like abnormalities of the eyelids as in
ectropion, punctal ectropion or eversion,
lagophthalmos, Lacrimal pump weakness
because of laxity of the eyelids, weakness of
orbicularis oculi
• Punctal abnormalities like atresia of punctum,
punctal ectropion
• Presence of swelling in the lacrimal sac
indicating nasolacrimal duct obstruction

29. Regurgitation test
• done by applying pressure
over the lacrimal sac area
with either thumb or index
finger and observing the
puncta.
• In cases with nasolacrimal
duct obstruction like chronic
dacryocystitis the contents of
the sac regurgitate through
the punctum

30. Fluorescein dye disappearance
test
• Fluorescein dye is instilled into
conjunctival sac and tear meniscus is
observed for disappearance of dye
• Normally no dye is seen in conjunctival
sac after 5 minutes
• Prolonged retention of the dye and a high
marginal tear strip for more than 5
minutes indicates epiphora

31. Lacrimal syringing test
• Done under topical anesthesia by injecting
normal saline into the lacrimal sac from lower or
upper punctum with a lacrimal cannula (26G)
fixed to syringe filled with saline
Interpreted as follows
• Saline is passing freely into throat as seen by
swallowing reflex and appreciation of salt taste
by patient- normal patent lacrimal passage.
• Fast regurgitation of clear fluid from same
punctum- obstruction in same canaliculi.
• Fast regurgitation of clear fluid from opposite
punctum- obstruction at common canaliculi.
• Slow regurgitation of mucoid/mucopurulent fluid
from same and opposite punctum- obstruction
in lacrimal sac or nasolacrimal duct.
• Partial regurgitation of saline from punctum and
partial saline going into throat- partial
obstruction in the lacrimal passage.

32. Jones dye test
The primary test -a drop of 2% fluorescein is
instilled into the conjunctival sac. After about 5
minutes, a cotton-tipped bud moistened in a
local anaesthetic is inserted under the inferior
turbinate at the nasolacrimal duct opening. The
results are interpreted as follows:
 Positive: fluorescein recovered from the
nose indicates patency of the drainage
system
 Negative: no dye recovered from the nose
indicates a partial obstruction (site unknown)
or failure of the lacrimal pump mechanism.
 In this situation the secondary dye test is
performed immediately.

33. 2. The secondary (irrigation) test- Topical anaesthetic is
instilled and any residual fluorescein washed out. The
drainage system is then irrigated with saline with a cotton
bud under the inferior turbinate.
• Positive: fluorescein-stained saline recovered from the
nose indicates that fluorescein entered the lacrimal
sac, thus confirming functional patency of the upper
lacrimal passages. Partial obstruction of the
nasolacrimal duct is inferred.
• Negative: unstained saline recovered from the nose
indicates that fluorescein did not enter the lacrimal
sac. This implies partial obstruction of the upper
lacrimal passages (puncta, canaliculi or common
canaliculus) or a defective lacrimal pump.

34. Probe test
• A probe is passed into the lacrimal sac.
• Normally probe can be advanced till it
touches the medial wall of lacrimal sac and
lacrimal bone, which is felt as hard stop.
• If the probe stops proximal to common
canaliculi because of obstruction in canaliculi,
soft stop is felt as the probe is pressed
against the soft tissue of common
canaliculus, lateral wall of lacrimal sac, and
medial wall of lacrimal sac before touching
the lacrimal bone

35. Dacryocystography
• Involves the injection of radio-opaque contrast medium into
the canaliculi followed by capture of magnified images.
• The test is usually performed on both sides simultaneously.
• Not to be performed in a patient with acute dacryocystitis.
• Technique
 The inferior puncta are dilated.
 Plastic catheters are inserted into the inferior canaliculi on
either side; alternatively the upper puncta may be used.
 Contrast medium, usually 1–2 mL of Lipiodol, is
simultaneously injected on both sides and postero-anterior
radiographs are taken.
 Ten minutes later an erect oblique film is taken to assess the
effect of gravity on tear drainage. Digital subtraction DCG
provides a higher quality image capture than conventional

36. Dacryocystography (DCG). (A) Conventional DCG without subtraction shows
normal filling on both sides; (B) normal left filling and obstruction at the junction of
the right sac and nasolacrimal duct

37. Radionucleotide lacrimal
scintillography
• Scintigraphy is a sophisticated test which assesses tear
drainage under more physiological conditions than DCG
• more sensitive in assessing incomplete blocks
• also useful in assessing physiological obstruction beyond the
sac.
Technique
• Radionuclide technetium-99 is delivered by a micropipette to
the lateral conjunctival sac as a 10 µl drop. The tears are thus
labelled with this gamma-emitting radioactive substance.
• The tracer is imaged by a gamma camera focused on the
inner canthus and a sequence of images is recorded over 45–
60 minutes

38. • nuclear lacrimal scintigraphy shows passage of tracer
in the right lacrimal system but obstructed drainage in
the left nasolacrimal duct

39. Obstruction
site
C/F Syringing Jones test Treatment
Single
canaliculus
Pouting of
punctum, soft
stop (probing)
Reg through
same
canaliculus
Test 1- pos Astringent
drops
Both canaliculi Soft stop Reg through
same
canaliculus
Test 1 and 2-
neg
CDCR-lester
jones tube
Common
canaliculus
Soft stop Immediate reg
thro opp
canaliculus
Test 1 and 2-
neg
Canaliculo
DCR
Complete
NLD
Pr over
sacregurgita
tion, Hard stop
reg thro opp
canaliculus
after some
time
Test 1 and 2-
neg
DCR
Partial NLD Pr over
sacregurgita
tion, Hard stop
reg thro opp
canaliculus
after some
time+some
fluid in nose
Test 1- some
fluoroscein in
nose
Pressure
syringing with
antibiotics
Lacrimal
pump failure
No
regurgitation
patent Test 1- neg
Test 2- pos
Astringent
drops

40. Acquired NLD obstruction
treatment
• Conventional DCR
• Endoscopic DCR
• Endolaser DCR
• DCT- dacryocystectomy

41. Conventional DCR (video)
• The blood vessels in the middle nasal mucosa are constricted with ribbon gauze or
cotton buds lightly wetted with 1 : 1000 adrenaline or cocaine 4–10% solution.
• A straight vertical incision is made 10 mm medial to the inner canthus, avoiding the
angular vein The anterior lacrimal crest is exposed by blunt dissection and the
superficial portion of the medial palpebral ligament divided.
• The periosteum is divided from the spine on the anterior lacrimal crest to the fundus
of the sac and reflected forwards. The sac is reflected laterally from the lacrimal fossa
• The anterior lacrimal crest and the bone from the lacrimal fossa are removed
• A probe is introduced into the lacrimal sac through the lower canaliculus and the sac
is incised in an ‘H-shaped’ manner to create two flaps.
• Membranous obstruction at the common canalicular opening or distal canalicular
obstruction can be opened by excision or trephine of obstructing tissue (canaliculo-
DCR).
• A vertical incision is made in the nasal mucosa to create anterior and posterior flaps
• The posterior flaps are sutured
• Silicone intubation may be performed.
• The anterior flaps are sutured
• The medial canthal tendon is resutured to the periosteum and the skin incision closed
with interrupted sutures.

42. Complications
Intra operative
• Excessive uncontrollable bleeding may require abandoning the
operation and reattempting it at a later date.
• Damage to the medial rectus and superior oblique may
cause diplopia.
• Blindness may occur from damage to the intraorbital vessels or
optic nerve.
• Cerebrospinal fluid leak due to penetration of the cribriform plate
• Injury to the orbital contents from rongeurs or drill
• Injury to the canaliculi from improper probing
• Shredding of the lateral nasal mucosa due to improper bone
removal

43. Postoperative Complications
• Sump syndrome may occur if the rhinostoma is small and high up in
the lacrimal sac. This causes tears and mucus to accumulate in the
sac and discharge into the eye.
• Ocular-orbital lesions, especially from orbital fat exposure
• Persistent watering may indicate scarring of the rhinostoma and may
require reoperation.
• Orbital hematoma
• Subcutaneous emphysema
• Cerebrospinal fluid leakage (leading to greater risk of infection, such
as meningitis)
• Air regurgitation through puncta, especially when sneezing and
when talking
• Dry eye
• Complete failure

44. Complications associated with silicon
intubation as part of DCR
• Pyogenic granulomata may occur at the puncta
or the site of rhinostomy if the tubing is left in too
long.
• Retrograde migration and corneal irritation
• Soft tissue infection
• Retained silicon tube and DCR failure
• Adhesions, elongation, slitting or erosion of the
puncta
• Nasal migration
• Traumatic injury to the nasal septum

45. Endoscopic DCR
Technique: A slender light pipe is passed through the lacrimal puncta
and canaliculi into the lacrimal sac and viewed from within the nasal
cavity with an endoscope. The remainder of the procedure is performed
via the nose.
a The mucosa over the frontal process of the maxilla is stripped.
b A part of the nasal process of the maxilla is removed.
c The lacrimal bone is broken off piecemeal.
d The lacrimal sac is opened.
e Silicone tubes are passed through the upper and lower puncta,
pulled out through the ostium and tied within the nose.

46. Advantages
Endoscopic DCR External DCR
No external scar More success rate (95%)
Relatively bloodless surgery Easily performed by ophthalmologists
Less chances of injury to ethmoidal
vessels and cribriform plate
Expensive equipment not required
Less time consuming Does not require familiarity with
endoscopic anatomy
No post operative moorbidity

47. Disadvantages
Endonasal DCR External DCR
Less success rate (70-90%) Cutaneous scar
Requires skilled rhinologist or
ophthalmologist
Relatively more bleeding during
surgery
Expensive equipment Potential injury to adjacent structures
with unskilled hands
Requires reasonable access to middle
meatus and familiarity with endoscopic
anatomy
More operating time

48. Endolaser DCR
• Performed with a Holmium:YAG or KTP
laser, this is a relatively rapid procedure
which can be carried out under local
anaesthesia.
• It is therefore particularly suitable for elderly
patients.
• The success rate is only about 70% but
because normal anatomy is not disrupted it
does not prejudice subsequent surgical
intervention in the cases that fail.
• Video

49. Other methods
• Balloon dacryocystoplasty
• Recanalisation with endodiahermy

50. Dacryocystectomy
Indications
• Lacrimal causes
1. Lacrimal sac tumours
2. Atrophic lacrimal sac (ch dacryocystitis in aged)
3. TB lacrimal sac
4. Dry eyes (severe)
• Other causes
1. Atrophic rhinitis
2. Chron’s disease
3. Ocular phemphigoid
4. SLE

51. Technique
• Anaesthesia- local/General
• Skin incision-curved incision along the anterior lacrimal
crest
• Exposure of medial palpebral ligament (MPL) and
Anterior lacrimal crest. MPL cut with scissors and
anterior lacrimal crest exposed
• Dissection of lacrimal sac.
• Removal of lacrimal sac. Curettage of bony NLD
• Closure. MPL is sutured to periosteum, orbicularis
muscle is sutured with 6-0 vicryl and skin is closed with
6-0 silk sutures

52. Conjunctivo-canaliculo-
dacryocystorhinostomy- Lester Jones Tube
• A DCR is performed as far as
suturing the posterior flaps.
• The caruncle is partially excised.
• A stab incision is made with a Graefe
knife from a point about 2 mm behind
the inner canthus (under the former
caruncle) in a medial direction, so
that the tip of the knife emerges just
behind the anterior flap of the
lacrimal sac The track is enlarged
sufficiently with dilators to allow the
introduction of a Pyrex Lester Jones
tube
• The incision is sutured as for a DCR
• Video

53. References
• Kanski and bowling clinical ophthalmology- 7th edition
• Duanes ophthalmology
• Parson’s diseases of the eye
• Comprehensive ophthalmology by A.K.Khurana
• Ophthalmology clinicals by Dr.Dadapeer
• Ani sreedhar et al; canalicular tear repair; kerala journal
of ophthalmology; 2011; 342-345

54. THANK YOU