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Tears are produced by the lacrimal gland in the upper outer part of the orbit, underneath the upper eyelid, and also from accessory tear tissue around the surface of the eye and inner surface of the eyelids, and serve to keep the eyes moist and vision clear. The tears drain via the puncta (small holes in the corner of the eyelids) into the fine lacrimal ducts (canliculi) which enter the lacrimal sac. The lacrimal sac drains into the nose via the tear duct (nasolacrimal duct).
Watering eyes in adults causes blurred vision, tearing down the cheeks and, often, sore skin. There may be a mucous, sticky discharge . Watering eyes are most commonly due to narrowing or a complete blockage of the tear duct as a result of recurrent inflammation or infection. The tear duct can also be blocked by trauma, some diseases and infections and, rarely, by tumours.
However, in addition to tear duct blockage, there are many other causes of a watering eye, including: reflex tearing, eyelid laxity, blepharitis, facial palsy, eyedrops and drugs. The oculoplastic surgeon assesses the cause of the watering eye. If a watering eye is due to a blocked tear duct, the treatment is surgical.
The tear drainage operation is called a dacryocystorhinostomy (DCR). DCR surgery is either done from inside the nose, an endoscopic endonasal DCR, or via a small skin incision on the side of the nose, known as an external DCR. A very small number of patients have damage to the small ducts called canaliculi and need both a DCR and a Jones lacrimal by-pass tube.
Assessment of a patient with a watering eye is made by the oculoplastic surgeon. A thorough history is taken as watering eyes may be related to allergies, eye drops, drugs and trauma. In particular, a history of nasal problems and sinusitis may be an important factor. The periorbital region, eyelids and surface of the eye are thoroughly examined and additional clinical tests are done. These include dilating the punctum, syringing and probing, followed by a nasal endoscopic examination.
Some patients with a partial blockage of their nasolacrimal duct (functional nasolacrimal duct obstruction) may need a special radiological examination called a lacrimal scintigraphy to determine the level of the functional block. A dacryocystogram (DCG) or a CT scan may be required to look at the outline of the lacrimal sac and to see the orbit bones and the sinuses.
Tests done at Clinica London:
Syringing and Probing
This test is done under topical local anaesthesia (eyedrops) with the patient sitting comfortably in the examination chair.
It helps to help confirm the site of the narrowing or obstruction causing the watering eye. First, the tiny openings called the puncta are dilated and a lacrimal cannula is gently passed along the canaliculus towards the lacrimal sac. This is not felt by the patient. A small amount of saline is used to irrigate the duct and determine the position and extent of the blockage.
This test is also done under local topical anaesthesia (nasal spray) with the patient sitting comfortably in the examination chair.
A fine torch called an endoscope is used to look just inside the nostril. The oculoplastic surgeon can diagnose any disease that may be present and assess the suitability of the space for DCR surgery.
Treatment of the watering eye is entirely dependent on its cause.
If the cause of the watering eye is a dry eye, ocular irritation or blepharitis, it will be treated non-surgically with lubricant eyedrops (artificial tears), lid hygiene and occasionally antibiotic tablets.
If the cause is dacryocystitis with a painful swelling due to a blocked tear duct, it will be treated initially with oral antibiotic tablets for 5 days. Then a DCR will be done. DCR consists of making a permanent opening from the lacrimal sac to the inside of the nose, through which the tears will drain freely, resulting in the relief of the symptoms.
If the cause of the watering is a blocked tear duct (nasolacrimal duct), the choice is either an endoscopic endonasal DCR or an external approach DCR (through the skin).
Soft silicone tubes are placed at the end of surgery, between the corner of the eye and the inside of the nose which are removed 6 - 8 weeks after surgery. Success rates for both external and endoscopic DCR are in the range of 85%-90%. If the cause has been more complicated than obstruction as a result of mucosal inflammation of the tear duct, this figure can be lower.
At Clinica London we specialise in endoscopic endonasal lacrimal surgery. We carry out surgery on patients who have had failed previous DCR, complicated trauma, previous sinus surgery and other nasal disease etc. We use special intranasal instruments which delicately recreate an opening between the sac and the nose.
If the cause of the watering is a blockage of the fine tear ducts (canaliculi), then a DCR is done with the subsequent insertion of a small glass bypass tube called a Jones' tube. This is a permanent bypass tube which has very good results but with the inconvenience of the tube.