THE WATERING EYE
Brigita Drnovšek-Olup
Eye Hospital, University Medical Centre
Ljubljana, Slovenia
Introduction
• Watering eye is an extremely common ocular
symptom.
Watering eye
lacrimation
epiphora
Failure to differentiate these two conditions can
result in unwarranted and improper
medication of a large number of patients.
THE WATERING EYE
• Lacrimation is watering that occurs
secondary to excessive tear production in
the presence of a normal excretory
system.
• Epiphora is watering that occurs
secondary to abnormal excretory system
in the presence of normal tear secretion.
Secretory system
• Lacrimal gland: orbital part (2/3)
palpebral part (1/3)
• Accessory lacrimal glands: Krause
Wolfring
Secretory system
• Normal tear secretion is necessary to keep the ocular
surface moist. The tears form a thin film, which integrity
is crucial for normal corneal physiology.
• Tear composition and secretion - three layers:
• the mucin layer: secreted by the goblet cells; alters the surface
tension of the tears and increases its adherence to the cornea.
• the aqueous layer: secreted by the accessory lacrimal glands
(Krause and Wolfring) or in the presence of ocular irritation the main
lacrimal gland.
• the oily layer: secreted by the Meibomian glands; prevents tear film
evaporation.
A new tear film model showing additional layers
and interfaces (a six-layer model):
Previous reports had vastly underestimated the thickness
of mucus.
Ocular surface and lacrimal glands function as an
integrated unit.
Secretory system
• Pathology of the tear film:
• deficiency of the aqueous layer - keratoconjunctivitis
sicca.
• deficiency of mucous or meibomian secretions instability of the tear film (compensatory excessive
aqueous secretion - paradoxical watering).
Lacrimal drainage system - anatomy
The anatomy of tear production
and flow
The anatomy of tear production
and flow
Lacrimal drainage system - physiology
• The puncta should be open and in firm apposition
to the globe.
• The tears drain into the puncta from the tear
meniscii along the lid margins by capillary action
and also due to the negative pressure created by
the sac.
• As the sac is surrounded by the orbicularis
muscle, normal blinking movements result in
negative pressure in the sac when the lids are
open and positive pressure when, the lids are
closed.
Lacrimal drainage system physiology -lacrimal pump
• The valves at the common canaliculus (Rosen Muller)
and nasolacrimal duct opening into the nose (Hassner)
ensure unidirectional flow of tears into the nose.
Paralysis of the orbicularis can result in epiphora due to
lacrimal pump failure.
Lacrimal pump
Causes of watering eye
Lacrimation (hypersecretion):
• Secondary to ocular inflammation or surface
disease.
• Emotional distress
• Irritation of the eyes ( smoke, dust, foreign
bodies, injury)
Causes of watering eye
Epiphora:(defective drainage): compromise of
the lacrimal drainage system:
• a) malposition of the lacrimal puncta (e.g.
ectropion)
• b) obstruction (anywhere along the lacrimal
drainage system, from puncta to the
nasolacrimal duct)
• c) lacrimal pump failure (lower lid laxity or
weakness of the orbicularis muscle)
Aquired obstruction
• Primary punctal stenosis (chr. blepharitis, idiopathic
primary stenosis, herpetic infection of eyelid, irradiation,
cicatrizing conjunctivitis and trachoma, cytotoxic drugs,
porphyria cutanea tarda, acrodermatitis enteropathica)
• Secondary punctal stenosis (punctal eversion)
• Canalicular obstruction (cong., trauma, herpetic
infection, drugs and irradiation, chr. dacryocystitis)
• Nasolacrimal duct obstruction (idiopathic stenosis,
trauma, previous surgery, granulomatous disease,
tumours)
• Dacryolithiasis
Congenital obstruction
• Nasolacrimal duct obstruction
• Congenital dacryocele
Evaluation of an adult patient with
watering eye
• Pseudoepiphora: epiblepharon, distichiasis, trichiasis,
glaucoma…
The lacus is dry and syringing is patent.
• Lacrimation secondary to corneal disorders or
conjunctivitis is obvious due to associated
symptomatology or on examination. Two conditions
which can be mistaken for true epiphora are dry eye
syndrome and blepharitis.
• Dry eye: Dry eye secondary to deficiency of mucous or
meibomian secretions can have paradoxical watering. A
diagnosis is usually based on reduced lower tear
meniscus, and increased debris in tear film on slit-lamp
examination. Increased tear break-up time (BUT) and
reduced Schirmer's strip wetting corroborate the
diagnosis.
Evaluation of an adult patient with
watering eye
• Blepharitis: thickened, hyperaemic lid margins with
scales deposited on the lashes, blocked meibomian
openings, excessive abnormal meibomian secretions,
and frothy discharge on the lid margins.
• True epiphora: secondary to either an anatomical
obstruction or functional deficiency like ectropion or
lacrimal pump failure – differentiated on the basis of
syringing.
Evaluation
• External examination:
– The puncta and eyelids (ectropion, punctal
obstruction – eyelash, conjunctivochalasis,
eversion of punctum by large caruncle,
canaliculitis, canturion syndrome – prominent
nasal bridge)
– The lacrimal sac (palpation)
Evaluation tests
• Fluorescein disappearance test (no dye
after 3 mins)
• Probing and irrigation (hard stop or soft
stop)
• Jones dye testing (the primary and
secondary test)
• Contrast dacryocystography
• Nuclear lacrimal scintigraphy
Probing: a) hard stop, b) soft stop
Jones dye testing: a) primary, b) secondary
Dacryocystography
Diagnostic procedures
Treatment
• Lacrimation - treatment usually medical.
• Dry eye: treatment consists of topical
lubricants.
• Blepharitis: treatment consists of lid
scrubs, oral tetracycline and topical
lubricants.
Treatment
• Ectropion or entropion - lid repair.
• Primary punctal stenosis – dilatation with
Nettleship dilatator, punctoplasty.
• Secondary punctal stenosis – Ziegler cautery,
medial conjunctivoplasty, Lower lid tightening.
• Canalicular obstruction – partial: intubation;
total: canaliculodacryocystorhinostomy and
intubation or CDCR and the insertion of
Lester Jones tube.
Treatment
• Nasolacrimal duct obstruction
infants: massage, probing;
adults: DCR, TCL-DCR, intubation, stents,
balloon dilatation.
• Dacryolithiasis – DCR
• Congenital dacryocele - probing
Lacrimal surgery
•
•
•
•
•
Conventional dacryocystorhinostomy
Lester Jones tube
Endonasal surgery
Endocanalicular laser DCR
Balloon dacryocystoplasty
1. Insertion of light probe into lacrymal
sac.
2. Transillumination of nasal
bone.
5. Insertion & fixation of
stents.
7. Osteotomy with stents at end.
6. Haemostasis & tamonade.
8. Open osteotomy 1 mo post-op.
Transcanalicular laser DCR
Conclusions
• The proper diagnosis and treatment of
watering eye is important due to its impact
on the outcome of many other ocular
procedures.
• Undiagnosed and untreated watering eye
substantially decreases the patients'
quality of life, visual acuity and impairs
social contacts.
Thank You!