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1 CET POINT
Epiphora – an update
Cornelia Poitelea MSc, FRCOphth Raman Malhotra FRCOphth
Shruti Malde MCOptom, Dip Tp (AS), Dip Tp (SP)
40
Watery eye is a common cause of referral by optometrists into secondary care. With appropriate assessment
to identify the causes, many of these cases can be suitably managed in primary care by recommending
simple lifestyle changes. It is equally important to recognise those patients who need prompt referral to an
ophthalmologist for appropriate management and to understand these interventions.
Course code: C-37135 | Deadline: August 15, 2014
18/07/14 CET
Learning objectives
To be able to explain to the patient about the implications of epiphora (Group 1.2.4)
To be able to identify cases of epiphora which require referral (Group 2.2.6)
To be able to recognise cases of epiphora not requiring referral and offer appropriate
advice (Group 6.1.4)
Learning objectives
To be able to explain to the patient about the implications of epiphora (Group 1.2.4)
To be able to recognise the presentation of epiphora and its common causes (Group 8.1.1)
Learning objectives
To understand the non-pharmalogical and pharmacological approach to managing
common causes of epiphora (Group 1.1.2)
To be able to consider the various treatments options for epiphora and manage the patient
appropriately (Group 2.1.6)
About the authors
Cornelia Poitelea has recently been appointed as a consultant ophthalmologist for the Western Sussex Hospitals NHS Foundation Trust.
Raman Malhotra is a consultant ophthalmologist at Queen Victoria Hospital in East Grinstead.
Shruti Malde works as an optometrist at the Queen Victoria Hospital in East Grinstead.
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Introduction
Epiphora, or ‘watery eye’, is a common
ophthalmic complaint in general practice
and sometimes requires referral to specialist
ophthalmic units for management. Symptomatic
patients frequently admit to variable degrees
of ocular discomfort, periocular skin changes
due to excess tear spillage, and blurred vision
while reading or driving due to an increased tear
meniscus close to the visual axis. In addition,
there are social embarrassments of epiphora
with the annoyance of frequent wiping and
misperceptions that ‘people think I am crying.’
41
The causes of epiphora are broadly considered
to be related to three factors, with a significant
proportion being more of a spectrum and
multifactorial:
•O
utflow dysfunction (obstructive) due to
nasolacrimal duct, punctal, or rarely, canalicular
stenosis
• E yelid malposition or pump failure including
age-related eyelid laxity, facial nerve weakness
with incomplete blink, misdirection of tears
with ectropion or lower eyelid retraction
•R
eflex tearing, usually secondary to
evaporative-type dry eye, incomplete eyelid
closure or ocular surface inflammation such as
allergic disease.
Evaporative-type dry eye versus
outflow dysfunction
Contrary to popular belief, a watery eye does not
usually equate purely to outflow dysfunction. In
fact, evaporative-type dry eye may be perhaps
the most common cause of epiphora resulting
from reflex tearing.1,2 An international panel
of experts recently revised the classification of
dry eye into either the common evaporativetype or the more rare, aqueous-deficiency.1
Evaporative-type dry eye is classified as intrinsic
due to meibomian gland or lipid dysfunction,
infrequent blink rate, poor eyelid-to-globe
apposition or use of systemic retinoids. Whereas
extrinsic types can result from a vitamin A
deficiency, topical toxic agents, contact lens wear
and ocular surface diseases. Aqueous-deficiency
dry eye is either Sjögren (primary or secondary)
or non-Sjögren (lacrimal gland deficiency,
lacrimal gland ductule obstruction or systemic
treatment). There is strong supporting evidence
that women have a higher risk of evaporativetype dry eye, with androgen deficiency and
postmenopausal oestrogen therapy also
Figure 1 Epiphora resulting from ectropion
significant factors.3 Mainville and Jordan
reported that from 150 consecutive referrals
for epiphora, 48% were suffering from lacrimal
system block and 40% were cases of reflex
tearing secondary to dry eyes.2 It has also been
observed that amongst 237 patients referred
to a lacrimal service for epiphora, evaporative
dry eye was nearly as common as lacrimal
obstruction (29% and 32% respectively).1
The main implication of these findings is that
reflex tearing is under-recognised not only
by general practitioners but also by general
ophthalmologists. Furthermore, surgery may
be detrimental in more than 50% of patients
referred to ophthalmologists, where lifestyle
measures and conservative treatment instituted
in primary care may be more appropriate.
Differentiating between obstructive and
reflex epiphora is often easier in a lacrimal clinic
than in general practice. An observation of the
frequency of eye wiping has been shown to be
a predictive factor in differentiating between
the two types. The average number of wipes per
hour was 4.4 in patients with reflex tearing in
comparison to 9.6 in patients with obstruction.1
Also, patients with reflex tearing were more
likely to report symptoms of burning, grittiness,
itching, blurred vision or photophobia. Activities
that involve reduced blink-rate such as reading,
watching television, computer work, particularly
in the evening, increase epiphora in evaporative
dry eye and reduce it in obstructive causes.
Eyelids and epiphora
Eyelid anomalies, both static (position) and
dynamic (blink), may result in reflex epiphora or
pump failure (punctal ectropion or facial palsy).
Lower lid retraction or increased laxity with
secondary entropion/ectropion can result in
ocular surface exposure, dryness, inflammation
or trichiasis, causing secondary epiphora (see
Figure 1). These conditions should always be
referred to an ophthalmologist due to the risk
of irreversible corneal damage and infection.
A useful method of assessing the degree of
lower lid laxity is the ‘snap test’; the lower eyelid
is gently displaced away from the globe and
the speed and recovery of the initial position is
observed while instructing the patient not to
blink and are graded as no laxity if the recovery
is immediate, mild laxity when it is slightly
delayed, moderate when it is prolonged and
severe if the position is only restored after
blinking.
Blepharitis is a common contributing factor to
reflex tearing, both in evaporative dry eye and
also ocular surface inflammation. Blepharitis
is, however, a general term and non-specific,
describing inflammation of the eyelid as a
whole. It was traditionally considered as being
either anterior or posterior in terms of eyelid
involvement, referring to inflammation either
anterior or posterior to the grey line (marginal
region of orbicularis muscle demarcating
anterior lamella – skin and orbicularis from the
posterior one – tarsus and conjunctiva).
Anterior blepharitis presents with
inflammation and debris around eyelashes,
collarettes and skin changes. Posterior
blepharitis describes inflammation of the
eyelid margin posterior to the grey line.
However, we now recognise that in fact,
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What are the causes?
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42
meibomian gland dysfunction (MGD) is the
most common pathology of the posterior
lamella in conditions such as evaporative dry
eye, rather than inflammation (see Figure 2).
The two terms, posterior blepharitis and MGD
are not synonymous and not interchangeable.
The posterior lid margin contains the marginal
mucosa, the mucocutaneous junction, the
meibomian gland orifices and associated
terminal ductules, and the neighbouring
keratinised skin. Beyond MGD, other causes
of posterior blepharitis include infectious or
allergic conjunctivitis and systemic conditions
such as acne rosacea. MGD may not feature
signs of inflammation and may be diagnosed
by meibomian gland expression alone,
with demonstration of an altered quality
of expressed secretions, and/or by a loss of
gland functionality (decreased or absent
expressibility). As it progresses along with
ocular symptoms then lid margin signs of
inflammation such as posterior lamella redness
and thickening become more apparent and
only at this point is MGD-related posterior
blepharitis said to be present.
The importance of blink
Resting blink rate is estimated to be around
17 per minute but increases when engaged in
conversation to 26, dropping to an average of
4.5 blinks per minute when reading.4 Tiredness,
watching a movie and playing computer games
have also been found to reduce blink rates.5
Reduced blinking is associated with greater tear
film break-up and thus explains the increased
level of discomfort symptoms reported at the
end of the day, particularly in dry eye patients.
The blink rate is often seen to be reduced in
patients with poor corneal sensation and in
these patients, the force of orbicularis closure
may be further reduced as a result of rigidity of
eyelid tissue due to cicatricial changes or partial
orbicularis denervation following multiple
surgical procedures.
The International Dry Eye Workshop (DEWS)
classified a low blink rate as a major intrinsic
cause for evaporative dry eye.3 This is the
basis for the Ocular Protection Index (OPI)
used by specialists to evaluate the risk for the
development of the signs and symptoms of
evaporative dry eye. It is calculated by dividing
tear film break-up time (TFBUT) by inter-blink
interval (IBI).
frequency of blink further compounds this
problem. These patients may benefit from
blink training to maintain more frequent,
complete blinking. Emphasising the
importance of frequent, complete blinking to
the patient’s friends and relatives may further
help enforce compliance.
Systemic medication
and epiphora
Figure 2 Meibomian gland dysfunction
Beyond the three types of blink in humans,
involuntary (responsible for moisturising the
ocular service and maintaining the optimum
optical clearance), reflex blink (protecting
ocular surface) and voluntary blink,
researchers have in fact described further
sub-types of blink.6 The twitch blink describes
the small movement of the upper eyelid.
Incomplete blink describes upper eyelid
movement covering two-thirds or less of the
cornea and the complete blink describes
excursion of the eyelid over two-thirds of
the cornea. Lastly, the forced voluntary
blink describes involvement of both the
preseptal and even the orbital component
of orbicularis oculi during eyelid blinking.
During forced, voluntary blinking,
the lower eyelid will also rise to meet the
upper eyelid.
Blink lagophthalmos is the degree of
incomplete eyelid closure observed during
twitch or incomplete blinking. It is seen
during spontaneous blink but not during
voluntary gentle closure. It results in the
loss of the so-called eyelid wiper effect
and is an under-recognised cause of reflex
epiphora. It can be easily identified by simply
observing a patient without specifically
instructing them to blink and represents
the incomplete excursion of the upper lid
during the involuntary blink cycle. Any
instruction to blink often elicits gentle or
even forced closure; therefore, a useful
assessment is to observe movement of
the lower eyelid orbicularis to confirm that
this is not occurring. An impaired twitch or
incomplete blink is often responsible for the
superficial punctate staining of the inferior
corneal epithelium seen in patients with
dry eye by causing exposure keratopathy
and inadequate tear film spread. Reduced
Various systemic medications such as
antihypertensives,7 antihistamines and
tricyclic antidepressants have been reported
as exacerbating factors for dry eye and reflex
epiphora.8 The decision to alter the systemic
treatment has to take into account the
severity of epiphora versus the benefit and
side effects of alternative medication.
Treatment of epiphora
Epiphora is most commonly a multifactorial
condition; therefore, the treatment should
target all of the contributing factors.
Educating patients and managing their
expectations plays a significant role in
compliance to treatment.
Interventions should be staged depending
on the severity and aetiology of epiphora. An
holistic approach should consider the diet
and the environmental factors, including
increased fluid intake, reduction in daily
caffeine and alcohol intake, taking breaks
from working on computers or reading, and
increasing humidification.9 Recent studies
have shown the potential benefit of flaxseed
and omega-3 fatty acid supplements in
improving MGD.10,11
Recent reports suggest epiphora due
to evaporative dry eye in postmenopausal
women with testosterone deficiency may be
further improved using systemic testosterone
patch therapy in conjunction with specialist
gynaecologist input.12
Treating co-existing blepharitis and
MGD is important and can bring significant
improvement in symptoms:
• Eyelid warming is commonly recommended
as it can be beneficial for melting
meibomian gland secretions. One
hypothesis is that various ester fractions
found in these secretions have different
melting points and they are higher in
patients with MGD. Eyelid warming can
Reflective learning
Having completed this CET exam, consider whether
you feel more confident in your clinical skills – how will
you change the way you practice? How will you use this
information to improve your work for patient benefit?
could be an epiphenomenon however, rather
than the cause of the disease. The presence of
increased bacterial flora has both direct effects
(increase in toxins, including lipases) as well as
indirect (modifying local homeostasis, matrix
metalloproteinases (MMP), cytokine and
macrophage balance). In the UK, commonly
available topical antibiotics include fusidic
acid and Chloramphenicol. Fusidic acid
has a narrower spectrum of action; it stops
protein synthesis by blocking aminoacyl
sRNA synthesis. Chloramphenicol inhibits
protein synthesis, by binding itself to 50S
ribosomal subunit. More recently, topical
macrolides (for example Azythromycin) have
been increasingly used. Their antibacterial
effect (inhibition of protein synthesis and
also breaking down microbacterial biofilms)
is complemented by the anti-inflammatory
action (cytokine regulation, neutrophils
and macrophage actions). They have a long
Figure 3 Punctal plug in situ
half-life and current recommended regimes
include two days of one drop twice-a-day,
followed by five days of one drop daily
• Systemic lipophillic tetracyclines (for
example Doxycycline, Minocycline,
Lymecycline) have been found to be useful
in treating MGD and rosacea. The low
dose used in these conditions make the
antibacterial effect less important, and their
efficacy is given by the anti-inflammatory,
anti-MMP, anti-lipase, anti-angiogenic,
anti-apoptotic action. Current regimes
include either Doxycycline and Minocycline
50–100mg and Lymecycline 408mg for six
to 12 weeks
• Steroids have a role for short-term acute
inflammation relief, in addition to the above
treatment. Long-term use should be avoided
due to the risk of high intra-ocular pressure.
Topical preparation is available with or
without antibiotics and ointments have a
better application than drops
• Topical calcineurin inhibitors (for example
Cyclosporin) have been approved in the US
as steroid-sparing drugs. They are also used
in the UK, but so far have not been licensed
for human ophthalmic use.
In addition to blepharitis/MGD treatment,
artificial tears have a significant role in
relieving the symptoms and improving the
tear film and ocular surface appearance.
Guttae preparations should be prescribed for
daytime and a lubricant gel or ointment can
be used at night. Preservative-free preparations
are advisable if artificial tears are used more
than four times daily. It is important for patients
to understand that one drop will not suffice for
a whole day, and frequent use is often required.
Surgical treatment has an important
role to play by resolving eyelid malposition
and lid laxity issues and can significantly
improve watering and discomfort. Punctal
stenosis can be managed with punctoplasty.
In cases of reflex epiphora due to aqueous
deficiency, punctal blockage with plugs is
beneficial, resulting in reduced tear outflow
and maintaining better ocular lubrication. In
obstructive cases, dacryocystorhinostomy
(endonasal or external) and Lester Jones tubes
are the surgical options for nasolacrimal duct
and canalicular obstruction, respectively.
Treatment of blink lagophthalmos involves
patient education and the use of artificial
tears. More severe cases can be managed with
punctal plugs (see Figure 3) and if this is not
sufficient, surgical treatment to reduce ocular
exposure can be effective. Eyelid weight loading
with gold or platinum has significant benefits
for more severe cases.
A rare entity of epiphora is ‘crocodile tears’,
which is a synkinetic phenomenon in cases
of facial nerve aberrant regeneration. This
condition can be debilitating and botulinum
toxin injection to the lacrimal gland may
alleviate the symptoms.
Conclusion
Epiphora is a common and multifactorial
condition, whose treatment can be started
in the community even before ophthalmology
specialist input. A holistic approach, taking
into account socio-dietary and environmental
factors should be considered, in addition to
topical treatment. Typically, only half of cases
are due to obstructive causes and, therefore,
conservative measures are often preferred.
Exam questions
References
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43
18/07/14 CET
be achieved with simple warm compresses
(flannels, towels, rice bags), or with infrared
or hot air sources. The technique has yet to
be standardised but according to the DEWS
should be a cumulative four minutes of
hot compression followed by meibomian
gland expression
• Massaging of the eyelids is effective in MGD,
usually after eyelid warming. Patients may
be instructed to apply traction in the area of
the lateral canthus with one finger, fixing the
eyelids, and then applying mild compression
upwards and downwards with fingers of the
opposite hand
• Mechanical lid hygiene to treat blepharitis is
recommended in addition to treating MGD.
A common technique is cleaning the eyelid
margin and the base of the eyelashes using
commercially available lid scrubs
• The role of topical antibiotics is indeterminate,
though over-colonisation with bacteria in
MGD has been frequently reported.13 This