Epiphora, etiologies, signs and symptoms, differential diagnosis, management

1. EPIPHORA
Raju Kaiti
Optometrist
Dhulikhel Hospital, Kathmandu University Hospital
Epiphora is defined as the overflow of tears. The clinical spectrum of epiphora ranges from the
occasionally bothersome trickle to the chronically irritating overflow. Epiphora is caused by a
disruption in the balance between tear production and tear drainage. Epiphora, or ‘watery eye’, is
a common ophthalmic complaint in general practice and sometimes requires referral to specialist
ophthalmic units for management. Epiphora can develop at any age. It is, however, more
common among babies aged less than 12 months, and adults over the age of 60 years.
When faced with a patient who complains of tearing, the first step is to determine whether the
epiphora is caused by an increase in lacrimation or a decrease in tear drainage. Trichiasis,
superficial foreign bodies, eyelid malpositions, diseases of the eyelid margins, tear deficiency or
instability, and cranial nerve V irritation may cause an abnormal increase in tear production. In
the absence of these conditions, an abnormality in tear drainage is the most likely cause.
Abnormalities of tear drainage may be subdivided further into functional and anatomical.
Functional failure is related to poor lacrimal pump function, which may be due to a displaced
punctum, eyelid laxity, weak orbicularis, or cranial nerve VII palsy. Anatomical obstruction may
occur at any point along the lacrimal drainage pathway and may be congenital or acquired.
Congenital obstructions tend to produce symptoms during the neonatal period.
Signs and Symptoms:
Symptomatic patients frequently admit to variable degrees of ocular discomfort, periocular skin
changes due to excess tear spillage, and blurred vision while reading or driving due to an
increased tear meniscus close to the visual axis. In addition, there are social embarrassments of
epiphora with the annoyance of frequent wiping and misperceptions that ‘people think I am
crying.’ The eyelashes get matted due to continuous watering. It may be a cause of ocular
infection as well.
Etiology:
The causes of epiphora are broadly considered to be related to three factors, with a significant
proportion being more of a spectrum and multifactorial:

2. •Outflow dysfunction (obstructive): Due to nasolacrimal duct, punctal, or rarely, canalicular
stenosis
•Eyelid malposition or pump failure: Including age-related eyelid laxity, facial nerve weakness
with incomplete blink, misdirection of tears with ectropion or lower eyelid retraction
•Reflex tearing: Usually secondary to evaporative-type dry eye, incomplete eyelid closure or
ocular surface inflammation such as allergic disease.
Another cause could be poor reconstruction of the nasolacrimal duct system after trauma to the
area. Cause of trauma could be facial fractures (including nasoethmoid fractures or maxillary and
soft tissue trauma involving the nose and/or the eyelid. In a new born baby, continuous watering
or epiphora may be due to Congenital Nasolacrimal Duct Obstruction (CNLDO).
Systemic medication and epiphora
Various systemic medications such as antihypertensive, antihistamines and tricyclic
antidepressants have been reported as exacerbating factors for dry eye and reflex epiphora. The
decision to alter the systemic treatment has to take into account the severity of epiphora versus
the benefit and side effects of alternative medication.
Examination and Diagnosis
A pertinent history is essential to provide clues to the diagnosis. History of sinus disease, sinus
surgery, mid-facial or ocular trauma, or history of nasolacrimal duct probing as a child may all
suggest obstructive problems. In addition, pus or blood in the tear film may indicate infection or
malignancy, respectively. Associated symptoms such as pain, itching, burning, etc., are
important to elicit, as they may provide further insight into the etiology. A full ocular
examination is warranted to pinpoint the cause of tearing.
Inspection:
The ophthalmologist should look for facial and periorbital asymmetry, eyelid malposition and
midface ptosis. Any inflammation, discharge or fistulas should be noted. It is also necessary to
evaluate the corneal surface, assess the blink reflex and check for lagophthalmos.
Palpation:
Fullness over the lacrimal sac region and/or reflux of mucopurulent drainage upon palpation of
the lacrimal sac may indicate dacryocystitis. Nodules or firmness superior to the medial canthal
tendon may suggest neoplasm.
Functional testing: Functional tests include
•Assessing lid laxity. Horizontal lid laxity is assessed by pulling the lid down or away from the
globe. If the lid can be stretched more than 8 mm, this is considered to be excessively lax. The
lid is also considered lax if it takes more than 8 seconds for the lid to return to its normal
position. The laxity is severe if the lid does not oppose the globe before the first blink.
•Assessing for dry eyes and other tear film abnormalities. Evaluate tear breakup time (TBUT)
by having the patient refrain from blinking after placing fluorescein in the conjunctival cul-de-
sac. If TBUT is less than 10 seconds, there may be a problem with tear film stability.

3. Schirmer’s test can also be performed.
Assessing for lacrimal obstruction: Syringing test, Probing
Differential Diagnosis:
 Dry Eyes
 Entropion/Ectropion
 Trichiasis
 Punctal stenosis
 Canaliculitis/canaliculi block
 Acute Dacryocystitis
 Meibomianitis/Blepharitis
 Allergic rhinitis
Management of epiphora
Epiphora is most commonly a multifactorial condition; therefore, the treatment should target all
of the contributing factors. Educating patients and managing their expectations plays a
significant role in compliance to treatment.
Interventions should be staged depending on the severity and etiology of epiphora. A holistic
approach should consider the diet and the environmental factors, including increased fluid intake,
reduction in daily caffeine and alcohol intake, taking breaks from working on computers or
reading, and increasing humidification.
Treating co-existing blepharitis and MGD is important and can bring significant improvement in
symptoms.
 Warm compresses
 Massaging of the eyelids is effective in MGD,
 Mechanical lid hygiene to treat blepharitis is recommended in addition to treating MGD.
 In addition to blepharitis/MGD treatment, artificial tears have a significant role in
relieving the symptoms and improving the tear film and ocular surface appearance.
In CNLDO, lacrimal sac massage is the important form of intervention and if done correctly
cures 90-95 % of children with CNLDO.
Surgical treatment has an important role to play by resolving eyelid malposition and lid laxity
issues and can significantly improve watering and discomfort. Punctal stenosis can be managed
with punctoplasty. In cases of reflex epiphora due to aqueous deficiency, punctal blockage with
plugs is beneficial, resulting in reduced tear outflow and maintaining better ocular lubrication. In
obstructive cases, dacryocystorhinostomy (endonasal or external) and Lester Jones tubes are the
surgical options for nasolacrimal duct and canalicular obstruction, respectively.
A rare entity of epiphora is ‘crocodile tears’, which is a synkinetic phenomenon in cases of facial
nerve aberrant regeneration. This condition can be debilitating and botulinum toxin injection to
the lacrimal gland may alleviate the symptoms.

4. Management of epiphora by an optometrist:
Counseling about the conditions is the foremost important part of management. Epiphora is most
commonly a multifactorial condition; therefore, the treatment should target all of the contributing
factors. Educating patients and managing their expectations plays a significant role in
compliance to treatment.
Treating co-existing blepharitis and MGD is important and can bring significant improvement in
symptoms.
 Warm compresses
 Massaging of the eyelids is effective in MGD,
 Mechanical lid hygiene to treat blepharitis is recommended in addition to treating MGD.
 In addition to blepharitis/MGD treatment, artificial tears have a significant role in
relieving the symptoms and improving the tear film and ocular surface appearance.
In CNLDO, lacrimal sac massage is the important form of intervention and if done correctly
cures 90-95 % of children with CNLDO.
Interventions should be staged depending on the severity and etiology of epiphora. A holistic
approach should consider the diet and the environmental factors, including increased fluid intake,
reduction in daily caffeine and alcohol intake, taking breaks from working on computers or
reading, and increasing humidification.
Appropriate referral after primary treatment failure is very important. Timely referral of surgical
cases helps patients for timely recovery.