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4
Managing the
watery eye
40
Anterior eye and oculoplastics Part 3 C-19163 O/D
Tristan Reuser, MD, FRCOphth
Watery eyes or ‘epiphora’ is a common complaint
presenting to eye
29/06 /12 CET
and
care professionals.
amongst patients
Surprisingly, dry
eyes
watery eyes may have common aetiology. There may be
Figure 1
MRI scan of the nose, indicating a tumour
encroaching the nasolacrimal duct
many reasons for epiphora and this article describes the common
enter the nasal cavity, just lateral to the
types
inferior nasal turbinate. Any dye instilled
and
the
most
effective
examination
and
management.
into the eye may be retrieved from here
main
Tears which are produced in the main
with a small cotton bud, as in Jones’
the
lacrimal gland “fall” over the cornea
test number one (vide infra) (see later).
superolateral part of the anterior orbit.
and conjunctiva and end up on the
It is divided into two parts by the
lower lid. They don’t spill over the
lateral horn of the levator aponeurosis
eyelid margin, as this is hydrophobic,
What’s this patient talking
about?
– the superolateral orbital lobe and the
by virtue of a fatty substance secreted
When a patient complains of ‘watering
inferomedial palpebral lobe. Accessory
by the Meibomian glands. From the
eyes’, it is important to establish what
tear glands are found in the conjunctiva
lower lid, they are actively transported
exactly they mean. Sometimes it is the
(glands of Krause and Wolfring), as
via a lacrimal pump mechanism which
feeling of a moist eye, a slight excess
well
cells.
is thought to be controlled mainly by
of tears, but they do not spill over
From a practical point of view, the
blinking. The lacrimal pump mechanism
onto the cheek. Epiphora means that
accessory
play
involves contraction of the orbicularis
the tears spill onto the cheek. When
production.
muscle to close the eye, which creates
this happens, patients tend to be more
There is a distinction between basic tear
negative pressure in the lacrimal sac.
bothered with it, since apart from
secretion, whereby tears are produced
Since part of its fibres are connected
vision problems (often they complain of
continually to replenish the natural
to the fascia, which envelops the sac,
blurred vision when reading due to an
tear film, and reflex tear secretion,
this contraction ‘opens up’ the sac by
increased tear meniscus) there are also
which occurs after stimulation by, for
enlarging it. The negative pressure
social implications. People think the
example, peeling onions, a foreign body
sucks in the tears which are located
patient is being emotional, which can
in the eye, corneal abrasion or cold wind.
in the lacus lacrimalis.1 The tears then
leave the patient feeling embarrassed.
Tears
are
lacrimal
a
as
role
produced
gland,
by
which
conjunctival
glands
in
excess
don’t
tear
the
sits
in
goblet
ever
Not uncommonly, patients complain of
Grade of epiphora
Degree of epiphora experienced
0
No epiphora
1
Epiphora only outdoors in the wind
2
Epiphora only outdoors but not indoors
3
Epiphora outdoors and indoors
Table 1
Sahlin’s3 system for grading the severity of epiphora
watering eyes, but during their time in the
consulting room, not once do they mop
them. If that is the case, is the problem
really so bad? A semi-quantitative way of
recording the watering is to use Munk’s
classification,2 where the number of
times per day the patient needs to
mop their eyes is recorded. Although
this classification implies reasonable
quantification, in practice, patients can’t
really remember the exact number of
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times they mop their eyes. Another way
of recording the severity of epiphora
has been used by Sahlin (Table 1).3
History taking
When assessing the cause of epiphora,
it is often thought that simply doing
41
a sac washout will tell you enough.
History though, is most important,
since not only can it give valuable clues
might be, it will also indicate how
serious it is. If the patient only needs to
Figure 2
A lacrimal sac full of mucus (mucocele)
wipe their eyes three times a day and
of the LeFort type tend to be horizontal
uveitis
only when outdoors, it may well be that
through the middle of the face and
lamp examination is, therefore, vital
they will be happy to put up with it.
may include the nasolacrimal duct.
to look for signs of any of these and a
The
history
can
provide
valuable
(through
photophobia).
Slit
systematic approach is best. Start by
clues about whether the epiphora is
Examination
looking for anything which might cause
an excess production problem, or a
Facial features
hypersecretion,
blockage in the drainage pathways.
Look at the areas in the upper part of
position (ectropion) where the tear
Soreness and a foreign body sensation
the face. A crooked nose may point
punctum is not turned towards the tear
will point to excess production, due
to
involve
lake. Then instil fluorescein to check the
to
secretion.
the deeper parts of the nose and the
tear film break up time (TBUT). Follow
This is how dry eye may be a cause
nasolacrimal duct too. A swelling in
this by instilling dilating drops, since
for epiphora if basic tear secretion is
the medial canthus may point to a
each patient will need a full dilated fundal
reduced, causing discomfort, which
swollen lacrimal sac full of mucus (a
examination. Once any reflex tearing
in turn causes reflex tear secretion.
mucocele – Figure 2) or mucus mixed
from the instillation of tropicamide
It is also important to enquire about
with purulent material (mucopyocele),
has subsided, a drop of 2% fluorescein
problems with areas around the eyes,
which may cause epiphora. Such a
should then be instilled into the lower
which
excessive
reflex
tear
a
fracture,
which
may
eg
abnormal
eyelid
mucocele or mucopyocele must be
conjunctival sac for the Jones dye test
possible
treated before any intraocular operation
to be performed. The patient now waits
underlying diseases. Nasal history is
is considered (eg cataract extraction).
5-10 minutes, after which the remaining
important here, since hay fever may
If the sac is infected and inflamed
fluorescein in the conjunctival sac is
cause reflex tear secretion, post-nasal
(dacryocystitis), the surrounding area
assessed – has there been any dilution of
surgery may indicate damage inflicted
will also be red, swollen and painful. A
the highly concentrated 2% fluorescein
by the surgeon to the nasolacrimal duct
scar near the area of the medial canthus,
drops? If so, it means these drops have
(which is located in the lateral wall of
may point to previous trauma which
either spilt over onto the cheeks, which
the nose), with infection of the lacrimal
may
you can see, or discover from the patient’s
sac a possible result. A bloody nasal
A
have
report. If this has not occurred, the
discharge may point to a malignant
developed, causing an outflow problem.
fluorescein will have diluted and drained
might
regarding
the
provide
cause
information
and
growth (Figure 1) encroaching the
have
stenosis
involved
the
(narrowing)
canaliculi.
may
into the lacrimal drainage apparatus.
meatus,
Ocular features and assessment
blocking the exit of the distal part of
Reflex hypersecretion may be caused
one. See whether the dye has reached
the nasolacrimal duct into the nose.
by blepharitis, trichiasis, distichiasis,
the nose. The presence of fluorescein
Wegener’s disease is an autoimmune
entropion,
concretions,
may be assessed by applying a cotton
disorder which may involve the nasal
foreign bodies, dry eyes, eyelashes
bud into the nose. The tips used for
mucosa and cause symptoms such as
‘stuck’ in the tear punctum, corneal
viral swabs are the right size, however,
discharge and ‘catarrh’. Facial fractures
ulcers, corneal abrasions, and anterior
standard cotton buds are too big. The
area
under
the
inferior
conjunctival
It is now time for the Jones test number
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as to what the mechanism of watering
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Another aspect of the Jones test two
is whether the patient feels something
at
the
back
of
their
nose/throat.
However, patients can be unreliable
in their responses and so objective
observation of the dye is preferred.
42
Advanced assessment
Where the optometric investigations
described above do not offer conclusive
evidence, patients can be referred to
the hospital eye service (HES) for more
29/06 /12 CET
advanced assessment, as described below.
Dacryocystogram (DCG)
A DCG is performed in a hospital
radiology department, with both eyes
tested at the same time. Both inferior
canaliculi are cannulated with a small
Figure 3
A dacrysocystogram (see text for details)
cannula and these are connected to a
Y-connector leading to the same syringe.
presence of dye on the bud indicates a
the dye to appear in the nose increases.
In the syringe is a radio-opaque solution,
positive Jones test number one result,
The Jones test number two is much
which is then squirted into the lacrimal
such that the dye has gone through a
easier to do (and only really done if
drainage system. As the solution flows
patent lacrimal drainage system. In the
the Jones test one was negative). One
through the system, x-rays are taken to
presence of a positive Jones test one,
has to clear all remaining fluorescein
locate the solution. This solution blocks
epiphora may still be possible as a
from the conjunctival sac, and then do
x-rays and, therefore, appears black on
result of hypersecretion. If there is no
a simple washout of the tear apparatus
the image. The outlines of this black
dye, the result is negative. This can be
using a syringe (being careful not to
area correspond to where the solution
problematic, since 20% of people with
cause any damage to the canaliculi). Do
is sitting (Figure 3). Modern digital
a normal lacrimal drainage will have
this with the patient leaning slightly
subtraction techniques create shadows
a negative test result (false negative).
forward so that you will be able to see
of the surrounding tissues while the
Visualising the inside of the nose can
the fluid coming from their nose. It may
bones are invisible. Complete blockages
reduce this number significantly, hence
be either non-coloured or fluorescein
of the sac are visible as a stop in the
the need for nasal endoscopy. Referral
stained. If the fluid is clear, then it
nasolacrimal duct; the fluid does not
to an ophthalmologist is advisable for
means the dye has not gone into the
go beyond the block and accumulates
this and often the presence of dye in
lacrimal system, indicating an ‘upper
the nose will confirm a patent drainage
system’ failure (vide supra) ie lacrimal
system. In addition, it will allow the
pump failure, such as in facial palsy,
presence of any abnormalities in the
punctal stenosis, canalicular block,
nose, which might be contributing
or punctal eversion. If the fluid is
to the tearing, to be detected too.
fluorescein stained, then it means that
The presence of fluorescein in the nose is
the dye has reached the outflow system
dependent on the rate of tear production
and has collected in the lacrimal sac
and how long after instillation of
but has not drained normally into the
fluorescein the nose is examined.4As
nasal cavity. This is called a functional
we get older, tear secretion reduces and,
block and is due to a partial stenosis,
therefore, the “normal” time taken for
or narrowing of the nasolacrimal duct.
Figure 4
Lacrimal scintillogram to determine the location
of a blockage in the lacrimal system
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above it. Partial blockages can
the stenosis is more than 8mm
be seen as narrowing, sometimes
away from the punctum then a
seen
dacryocystorhinostomy
combination
with
(DCR)
is
dilation of the sac just proximal
performed following excision of
to the block. On other occasions,
the stenosis and intubation. DCR
one will see contrast in the
consists of removing the intervening
sac on a ‘late’ x-ray of the face.
bone between the tear sac and the
nasal cavity, so that the lacrimal sac
Lacrimal scintillogram
and the nasal mucosa lie directly
This test is also performed at
next to each other. The tissues are
the radiology department, but it
involves a radioactive solution. This is
instilled into the conjunctival sac and
allowed to flow naturally through the
Figure 5
Patients often aren’t afraid of being left with small
scars following surgical procedures such as DCR
it is forced by a syringe). It is, therefore,
a physiological test, and very valuable.
After every few minutes, an image
is taken to determine the location of
the radioactivity within the lacrimal
drainage system. Once a series of
images are created they can be analysed
to locate the blockage (Figure 4). This
test is complimentary to DCG, where it
may be impossible to establish the exact
site of a narrowing in functional blocks.
connected with sutures and little
silicone tubes are then inserted into
the canaliculi (not all surgeons use
these tubes in all cases), and out into
the newly created opening. They are
drainage system (unlike in DCG, where
left in the tear passages for anything
Too little drainage
Punctal ectropion due to horizontal
eyelid
laxity
performing
an
needs
eyelid
treating
by
shortening
procedure. The lateral tarsal strip
operation, where the eyelid is cut in the
lateral canthus and shortened at this
end, is currently the preferred method.
This will often result in an eyelid which
is sufficiently tight to correct the punctal
position. On other occasions, this may
need to be combined with excision of
Treatment of watery eyes
a diamond of tarsoconjunctiva just
Too much tear production
inferior to the punctum. This shortening
between six weeks and six months.
If the block is nearer than 8mm from
the punctum, then technically, it is
impossible to excise the stenosis. One
then has to insert a glass tube (Jones’
tube) through the caruncle and the
soft tissues into the nasal cavity. This
tube acts simply by gravity and its
function is thus position dependent.
Sometimes, the canalicular blockages
are localised and consist of a little
membrane
where
the
common
canaliculus enters the tear sac. This
can be removed, and intubation with
distichiasis,
of the back part of the eyelid will then
entropion, conjunctival concretions,
correctly position the punctum again.
foreign bodies, dry eyes, eyelashes
Quite often punctal stenosis (narrowing
‘stuck’ in the tear punctum, corneal
of the tear punctum) is associated with
ulcers, corneal abrasions, and anterior
punctal ectropion. It is due to reduced
uveitis
appropriate
tear flow through the punctum, and this
treatment if one of these is the cause
will return to normal once the duct is
of the watery eye. Many of these will
correctly positioned again. If the punctal
require treatment with ocular lubricants
ectropion is due to shortening of the
and lid hygiene with baby shampoo or
anterior lamella (front part of the eyelid)
bypass the block. Several procedures
using commercially available products.
due to, for example, skin conditions,
have been tried, but the gold standard
However, there may be more than one
then a skin graft may be required.
against which all other procedures
cause for the epiphora and therefore
Canalicular blockages may occur due
are judged is the open DCR, which
more than one treatment may be
to a variety of causes. If the stenosis is
has
required. Recently, attempts have been
only in a short section, then excising
The
made to treat some patients, who do not
the narrowed part of the canaliculus
involves expansion of the nasolacrimal
want major operations, with injections
and intubating this is enough. If the
duct with a balloon. The tear duct
of botulinum toxin instead, although
canaliculi are stenosed over a larger
system is then intubated with the
this has produced varying results.
extent, then several options exist. If
silicone tubes again. This procedure
Blepharitis,
all
trichiasis,
need
their
43
silicone stents done. These silicone tubes
prevent the formation of a scar, which
would otherwise block the affected
part again. Classically, this operation
has been done in combination with a
DCR, but this may not be necessary.5
More distal blockages, which are in
the sac itself, need a procedure to
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success
rates
alternative,
of
over
90%.
dacryocystoplasty,
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has generally not been as successful
the sac. A monitor shows the images
The British Journal of Ophthalmology.
as DCR, with success rates of 50%.
obtained through the little endoscope
He is an honorary senior lecturer at
Laser procedures include cutting
in the probe, while an irrigation
Birmingham and Aston Universities.
open the soft tissues (the lacrimal
cannula and a laser or microdrill
sac and nasal mucosa),l but also the
for treating stenoses and dacryoliths
References
bone in between the two. Several
(stones
1.
Hurwitz JJ. (1996) The lacrimal
laser types have been tried, of which
available options. This technique has
system.
the holmium-YAG appears to be
mainly been described in the German
2.
Munk
the most useful for cutting through
ophthalmic
(1990) Epiphora: treatment by means
bone. The other slight difference is
success with hundreds of cases treated
of
that the mucosal surfaces of the tear
so far, is claimed. Of importance is
dilatation of the nasolacrimal drainage
sac and the nose are not sutured,
that many patients are not afraid to
apparatus.
since this is really impossible in
be left with small scars after DCR
3.
Sahlin
S,
an endonasal approach. Also, the
procedures (Figure 5) and so this gold
Lacrimal
drainage
size of the bony opening is smaller
standard will still be hard to beat.
symptomatic
in
the
lacrimal
literature,
sac)
and
are
good
than the one used in the external
Lippincott-Raven.
PL,
Lin
DT,
Dacryocystoplasty
Morris
with
Radiology,
Rose
DC.
balloon
177:687-690.
GE.
(2001)
capacity
and
improvement
dacryocystorhinostomy
after
in
adults
approach. Both of these differences
About the author
perhaps explain the lower success
Tristan Reuser is a consultant eye
drainage systems. Orbit, 20:173-179.
rates achieved with these procedures.
surgeon, with a special interest in
4.
Hagele
Due to advances in technology, it is
eye plastics. He works at the Heart of
MPH.
now possible to visualise the entire
England Foundation Trust and at Aspen
Age as a factor in Jones testing.
lacrimal
Eye Care at Midland Eye. He trained in
Ophthalmology,
Two systems currently on the market
the UK, and the Netherlands. He was
5.
Fulcher T, O’Connor M, Moriarty
allow a probe to be introduced into
a clinical director in ophthalmology,
P.
the canaliculi, and from there into
and is a reviewer for both Eye and
in
outflow
system
directly.
presenting
with
JE,
(1994)
(1998)
adults.
patent
Guzek
lacrimal
JP,
Shavlik
Lacrimal
testing.
101:612-617.
Nasolacrimal
British
intubation
Journal
Module questions Course code: C-19163 O/D
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1. Which of the following is TRUE regarding tear production?
a) The bulk of tears are produced by the lacrimal gland
b) Only a minor component of tears is produced by accessory tear glands
c) Meibomian glands perform a very important function in the tear complex
d) All of the above
2. Which of the following statements about a patient with a watery eye
is FALSE?
a) The underlying cause may be due to dry eye and a trial of lubricants is
advisable
b) All patients will require a dacryocystorhinostomy operation
c) It should be distinguished from what is merely a non-bothersome ‘moist eye’
d) It can occur due to punctal stenosis, which reduces tear drainage
3. When establishing the cause of the watering eye problem, which is
TRUE?
a) History-taking is of minor importance
b) Advanced investigations, such as DCG, should always be performed
c) The Jones dye test number two should always be performed
d) Asking about any recent or previous nose surgery can be useful
4. Which of the following statements about examining the patient
with a watery eye is TRUE?
a) The Jones dye test differentiates reflex tear secretion from blockage of tear
passages
b) Eyelid eversion may give useful clues about the cause
c) Facial features should be examined for any sign of raised bumps by the inner
canthus
d) All of the above
5. Which of the following statements about the Jones dye diagnostic
test is TRUE?
a) It will provide all of the information about the presence and location of a
blockage
b) A simple ‘sac washout’ (test two) can be diagnostic and could be curative
c) The absence of dye in the nose indicates a completely patent drainage
system
d) 40% of patients with a normal lacrimal drainage system may have a negative
test one
6. Which of the following statements regarding the treatment of
watery eyes is TRUE?
a) If it is due to a drainage problem, it requires a DCR operation
b) Dacryocystoplasty is the most successful option available
c) It may be that a simple lid tightening operation will be effective
d) It should always be conducted before a cataract extraction operation
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of