There are many different causes of watering eyes, which can blur vision, make the skin around the eyes very sore and make one look as though they are crying all the time. When associated with sticky mucous discharge, it can be very unpleasant. The oculoplastic surgeon’s job is to diagnose what the cause of the watering eyes is and to offer the appropriate treatment, which may be medical or surgical.
Tears are naturally 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 the inner surface of the eyelids. The tears serve to keep the eyes moist and the vision clear and are therefore necessary. The tears drain via the puncta (tiny holes in the corner of the eyelids) into the fine lacrimal ducts (canaliculi) which enter the lacrimal sac. The lacrimal sac, in turn, drains into the nose via the tear duct, (nasolacrimal duct).
Watering eyes cause blurred vision, tearing down the cheeks and often sore skin. There may also be a mucous sticky discharge if there is stagnation of tears in the lacrimal sac, which then becomes inflamed or infected. Watering eyes are most commonly due to a narrowing, or complete blockage, of the tear duct as a result of low-grade recurrent inflammation or infection. The tear duct can also be blocked by some diseases, infections, trauma, and rarely by tumours.
However, in addition to tear duct blockage, there are many other causes of watering eye, including reflex tearing, eyelid laxity, blepharitis, dry eyes, facial palsy, eye drops and drugs. The oculoplastic surgeon assesses the cause of the watering eye. If the watering eye is due to a blocked tear duct the treatment is surgical.
A tear drainage operation is called a dacryocystorhinostomy (DCR). DCR is either done from the inside of the nose, known as an endonasal or endoscopic endonasal DCR, or via a small curvilinear skin incision hidden in the tear trough, which is known as an external DCR. A very small number of patients have damage to the small ducts (canaliculi) and they will need, initially a DCR and subsequently a Jones’ lacrimal bypass glass tube.
Assessment of a patient with a watering eye is made by the oculoplastic surgeon at the consultation. First, a thorough history is taken, as the watering eyes may be related to blepharitis or dry eyes, allergies, eye drops, drugs and trauma. In particular, a history of nasal problems and sinusitis may be an important factor in contributing to the lacrimal duct narrowing and subsequent blockage, with resultant watering. The peri-orbital region, eyelids and surface of the eye are then thoroughly examined and additional clinical tests are done which can involve simple orange coloured dye called fluorescein, syringing and probing, and nasal endoscopic examination. A very small number of patients with a partial blockage of their nasolacrimal duct (functional nasolacrimal duct obstruction) may require a special radiological examination called lacrimal scintigraphy, which helps to determine the level of the functional block. A dacryocystogram, or CT scan, may be required to look at the outline of the lacrimal sac and to see the orbital bones, the nasolacrimal duct and the sinuses.
This test is done under topical local anaesthesia (eye drops) with the patient sitting comfortably in the examination chair. It helps confirm the site of the narrowing or obstruction causing the watering eye. First, a small drop of topical anaesthetic is put onto the eyes, then the tiny openings, called the puncta, are dilated gently and a lacrimal cannula is passed carefully 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. A lot of inflammation can be obtained from this simple test.
This test is also done under local topical anaesthesia (nasal spray or soaked cotton buds) with the patient sitting comfortably in the examination chair. The fine torch, called an endoscope, is used to look just inside the nostril. From this position the oculoplastic surgeon can see right up into the nose and diagnose any disease that may be present, and assess the suitability of the nasal space for DCR surgery and whether any other small procedures need to be done within the nose to assist the surgery.
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