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What is epiphora?

Epiphora is watering eyes as a result of a reduced tear outflow, i.e. you have defective tear drainage.
It is also a diagnosis we make only after excluding hypersecretion, which is a reactive watering or lacrimation as we already described in a previous blog post.
By taking an accurate history and doing a systematic examination of the eyelids, eye surface and lacrimal system, I can distinguish between hypersecretion and epiphora, and this is very important because the treatment of hypersecretion is largely medical and that of epiphora is surgical.
There are many causes of epiphora or watering eyes. There are congenital causes and acquired causes.
The most common cause of epiphora in the first two years of life is a congenital obstruction of the tear outflow system called congenital nasolacrimal duct obstruction.
In adults, especially in the elderly and more commonly in women, the most common cause of a watering eye when it is not due to blepharitis or dry eye is in acquired nasolacrimal duct stenosis. Also, a lower eyelid malposition can cause watering eyes, by the tears not being caught by the little puncta or holes at the medial end of the lower lids.
Normally the tears enter the puncta and drain through the canaliculi into the tear sac and down the tear outflow system. Complete obstruction of the nasolacrimal duct or tear outflow system is relatively easy to diagnose with the right sequence of tests and diagnostic imaging and probing and syringing. A partial tear duct obstruction can be more difficult to confirm and may require you to have special x-rays and nuclear medicine scanning.
Any point of the lacrimal drainage system can become obstructed, from the punctum up near the eye, down to inside the nose where the tear duct opens and can cause epiphora.
The symptoms of epiphora are watering with tears overflowing onto the cheek in very severe lacrimal drainage impairment, to just intermittent tearing with a partial block mainly in winter and the cold. Symptoms can be unilateral or bilateral, and watering eyes from epiphora are usually much worse in winter months and windy weather.
If there is a collection of mucous within the lacrimal sac (a mucocoele) the eye can also be sticky, or there can be reflux of tears from an enlarged sac back across the eye giving sudden symptoms of gushing of water, which then goes down the cheek after first blurring the vision. Sometimes a stagnant collection of tears within the lacrimal sac can get infected and cause an acute dacryocystitis.
With epiphora and an elevated tear meniscus, the vision can become quite blurred. This effect is secondary to the prismatic effect of the elevated tear meniscus. The tear meniscus prismatic effect and blurring is particularly noticed on downgaze, for instance when reading or playing golf.
The vision can also be simply blurred because the tears have splattered the glasses making them mucky. Also, chronic watering eye or epiphora can cause red sore lower lid skin and even help to turn the lower lid called an ectropion. Excessive wiping away of tears can exacerbate an ectropion and weaken the medial canthal tendon.
We assess all of this in a tears assessment for watering eyes at Clinica London.


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