What is Epiphora (Excessive Tearing or Watery Eye)?
People may sometimes experience the feeling of having “a watery eye” or “a tearing eye.” This condition is historically known as epiphora. Here, we will understand the various medical terminologies related to it.
“Lacrimation” or “lachrymation” comes from the Latin word “lacrima,” meaning tear. It describes the process that leads to the production or shedding of tears. Lacrimation can occur due to three things: basic tear production (basal), reaction to irritants like too much light or physical damage to the eye (reflexive), and emotional responses (psychic). Deeper studies are suggesting that animals might not show emotional lacrimation, but recent observations of elephant mothers responding to their dead offspring have reignited this debate. This tear production process can decrease with age, leading to changes in the eye’s tissue and resulting in less tear production. This process is completely normal, and it doesn’t imply any obstruction or issue preventing the effective clearing of tears.
Epiphora, traced back as far as 1475 in English texts, essentially describes an abnormal excess of tears overflowing from the eye onto the face. The specific cause is unspecified. More recently, some have tried to restrict the term to denote tearing caused specifically by blockage, but this doesn’t align with historical usage. “Epiphora” originates from Greek, with “epi” meaning “on,” “upon,” or “in addition,” and “phérein” indicating “bring” or “carry.” This term has been used throughout history to address excessive tearing, whether due to overproduction or inadequate drainage. Epiphora sometimes further divides into “gustatory epiphora” (excessive tears due to nerve damage), “reflex epiphora” (response to eye injuries or irritations), “obstructive epiphora” (caused by blockages in the tear drainage system), and “hypersecretory epiphora” (excess tear production) – though this last one is extremely rare.
A different scenario is considered if a patient complains about “a pool of tears in the eyes that interferes with vision,” but is not experiencing epiphora. This case could also occur after specific eye surgery, where tear flow improves but the blockage isn’t eliminated entirely. A term that accurately captures this condition is “plerolacrima,” which denotes excessive tearing or accumulation of tears that can cause problems for patients.
Epiphora can cause blurry vision and lead to eyelid skin damage from constant wiping, among other symptoms. Understanding this, we can start to unravel the tear film, which consists of three layers: the mucin layer that prepares the cornea to handle tears, the aqueous layer that provides a smooth eye surface and hydration, and the lipid layer that reduces surface tension and increases tear break-up time. Any problem in these layers could disrupt normal tear operation and result in discomfort, abnormal refraction of light, and blurred vision.
The secretory lacrimal system is responsible for producing tears. It consists of the main lacrimal gland, located in the lacrimal fossa of the frontal bone, and other accessory glands located in the fornices and eyelids. The excretory lacrimal system works to ensure tears are drained properly. Any imbalance between tear production and drainage can lead to the manifest of symptoms of epiphora.
The functional excretory system works during blinking. When the eyelid contracts, this creates a pump-action system that helps draw tears into the punctum, canaliculus, and lacrimal sac. When facial nerve palsy is present, this pump mechanism is disturbed, leading to issues with tear drainage.
What Causes Epiphora (Excessive Tearing or Watery Eye)?
Epiphora, or excessive tearing, can happen for a few reasons:
1. Reflex tearing can occur due to irritation from allergies, inflammation, foreign objects in the eye, injury, dry eyes, and certain conditions that affect the surface of the eye.
2. If tears aren’t able to leave the eye properly, this could also cause excessive tearing. This may occur due to a number of reasons, such as issues with the eyelids (like an abnormally positioned eyelid or lax eyelid), facial nerve issues that disrupt the function of tear drainage, or blockage in parts of the tear drainage system. The latter can take many forms, from issues with the tear duct channels to blockages in the nasal tear duct, obstructions in tear duct openings, plugs in tear ducts, or conditions existing from birth that cause the nasal tear duct to not develop correctly.
3. Rarely, there’s simply an overproduction of tears. This is usually seen when facial nerves recover in an unusual manner after a facial nerve issue.
In adults, excessive tearing could point to many different underlying issues, which could cause either excess overall tears or excessive reflexive tearing due to a decrease in base tears. There may be multiple causes for this symptom in some people. Some patients note that their eyes tear up more when it’s cold or windy; this can be a normal response, or it might be due to conditions like dry eye or a partially blocked nasal tear duct. Indoor tearing often happens because of problems with the lower eyelid or tear drainage. Older people are more likely to experience eyelid problems and other complications causing excessive tearing, while younger people commonly face obstructions in the nasal tear duct, narrowing of the tear duct opening, or blockages in the tear duct channels. Women tend to have blocked nasal tear ducts more often than men because they tend to have narrower and longer tear duct channels.
Epiphora is often seen in infants due to a blocked nasal tear duct present at birth.
This condition could affect one or both eyes. With one affected eye (unilateral epiphora), it’s typically local conditions like a blocked nasal tear duct or presence of a foreign body causing the issue. When both eyes are affected (bilateral epiphora), it could be due to various causes, such as an oversupply of tears seen in ‘pink eye’ or allergies, issues with the eyelids, or local conditions that cause one side to produce more tears than the other.
Risk Factors and Frequency for Epiphora (Excessive Tearing or Watery Eye)
Epiphora, or excessive tearing, is a common issue in children. Notably, about 20% of British infants experience this condition within their first year of life, with 95% showing symptoms by the time they’re a month old. As people get older, the number experiencing epiphora tends to increase due to a loosening of the lower eyelids, a higher occurrence of blockages in the tear duct, and related health issues like facial nerve palsy.
- About 20% of British infants experience epiphora in their first year of life.
- 95% of these children show symptoms by the age of one month.
- The frequency of epiphora increases with age due to factors like loosening of the lower eyelids and blockages in the tear duct.
- The problem is more common in women because of a higher likelihood of tear duct blockage.
- The rate of tear duct blockages is about 20.24 per 100,000 people.
- About 31.8% of patients who experience chronic epiphora have a tear duct blockage.
- Tear duct blockages account for 67.6% of all instances of obstructions in the tear drainage pathway.
Signs and Symptoms of Epiphora (Excessive Tearing or Watery Eye)
Epiphora is a medical condition where tears overflow from the eye, usually due to the tear ducts not draining tears efficiently. When a patient with this condition visits a doctor, there are several factors to consider:
- Was the onset of tearing sudden or gradual?
- How long has the patient experienced the condition?
- Do symptoms happen all year or only during certain seasons?
- Is there more pain or tearing first thing in the morning?
- Is it affecting one or both eyes?
- Is tearing constant or does it come and go?
- How severe are the symptoms?
- Is there any associated pain or itching?
- Has the patient recently used new makeup or medication?
- Did the patient go through chemotherapy or radiation treatments?
- Does the patient have a history of sinus disease, nasal surgery, or trauma to the nose?
- Has the patient had previous eye or eyelid surgery?
The doctor will then conduct a physical examination of the eye, face, and tear ducts to establish the cause of the symptoms. This could include looking for signs of facial weakness, any history of trauma, evidence of prior surgeries, inflammation, and abnormalities of the eyelids, tear ducts, or cornea.
In some cases, even though the outflow tear system works properly, the patient may experience excess tearing. This condition is known as functional epiphora and could be due to anatomical narrowing or scar tissue development. In such instances, further tests may be required for accurate diagnosis.
Epiphora can also occur due to dry eyes, where there’s an imbalance in tear production and evaporation. Patients with this condition generally complain of burning, itching, blurry vision, and discomfort, especially worse in the morning.
Sometimes, patients with facial nerve dysfunction may experience tearing, especially when chewing, laughing, or talking, due to aberrant nerve regeneration. Also, individuals with facial palsy may deal with multiple factors leading to tearing, like orbicularis pump weakness, lower eyelid laxity, retraction, or ectropion. This is typically due to a combination of issues and might warrant a comprehensive treatment approach.
Testing for Epiphora (Excessive Tearing or Watery Eye)
If you have a watery eye, also known as epiphora, your doctor might need to carry out certain tests to find out why. These tests can be split into two categories: secretory tests and excretory tests.
Secretory tests involve an examination of your tear film and cornea, which is the clear front surface of your eye. These tests measure the quality and quantity of your tears. One common test is the tear break-up time which checks how long it takes for dry spots to appear on your eye after a blink. Another set of tests, known as the Schirmer’s tests, are done using small strips of filter paper that are placed in your eye to measure how much tear production is occurring.
Excretory tests are the second category and they help the doctors to understand how well your tears are being drained from your eyes. These tests include the saccharin test (a taste test to see if tears are draining into the throat), the fluorescein dye disappearance test (where dye is used to track tear flow), and the Jones tests (which help evaluate tear drainage). Some of these tests might involve using a thin instrument to gently probe the tear ducts, a nasal endoscopy (looking inside the nose with a special camera), or different types of imaging tests.
Imaging tests like Dacryocystography (DCG) involve using dye and X-rays to visualize the tear ducts. Dacryoscintigraphy is a similar imaging test that uses a small amount of radioactive material instead of dye. Computed tomography (CT) and magnetic resonance imaging (MRI) are also options and provide detailed pictures of the structures around the eye and tear ducts. Dynamic magnetic resonance dacryocystography (MRDCG) is another imaging test that can provide pictures of the tear drainage system while it’s working.
Your doctor will decide which tests are needed based on your symptoms and the result of your eye examination.
Treatment Options for Epiphora (Excessive Tearing or Watery Eye)
Epiphora, a condition that causes excessive tearing, is managed based on what’s causing it. If the problem is linked to surface irritation, treatment could involve helping the eye to stay moisturised or potentially performing corrective surgery on the eyelid.
Sometimes, the issue may be that a small drainage opening on the lower eyelid, called a punctum, is too tight. When this happens, a procedure known as punctoplasty may be done to widen it. This involves using a pair of scissors to make a small snip to create a larger opening for tears to flow out.
If an obstruction in the nasolacrimal system (the part of the eye that drains tears) is causing the excessive tearing, balloon dacryoplasty might be done. This procedure involves inserting a balloon into the system, inflating it to expand the blocked area, and then deflating and removing it.
Another method to bypass obstructions is through surgery procedures like dacryocystorhinostomy (DCR) or conjunctivodacryocystorhinostomy (CDCR). These create a new path for the tears to flow from the eye into the nose. The decision on which procedure is chosen depends on the location of the blockage.
For some patients, such as those with nasolacrimal duct obstruction (NLDO) due to cancer, surgery may not be the best choice. In these cases, an injection of botulinum toxin into the lacrimal duct might provide relief. This treatment is a medication that temporarily paralyzes muscles and helps to manage tear production.
For children with epiphora, your doctor may recommend a “watchful waiting” approach, as a high rate of these cases often improves on their own. But if your child’s NLDO doesn’t improve, the first step might be probing — a minimal procedure that helps clear the blockage. This might also involve balloon dilation or silicone tube placement, procedures designed to open up the tear drainage path. If the NLDO still persists, they might suggest DCR or CDCR surgery to help improve tear flow.
What else can Epiphora (Excessive Tearing or Watery Eye) be?
For adults, excessive tearing, or epiphora, can result from various anatomical issues. These include:
- Problems with the punctum (35% of cases), such as narrowing, presences of a punctal membrane, abnormal position, obstructions, or diseases that cause scarring.
- Issues with the canaliculus (15% of cases), such as narrowing, infections, scarring, presence of foreign bodies, or certain medications.
- Blockages in the nasolacrimal duct (24% of cases), or damage to the duct due to trauma.
- Weakness in the lacrimal pump (11% of cases), typically due to age-related eyelid laxity, nerve issues, or floppy eyelid syndrome.
- Conditions that mimic excessive tearing (11% of cases), such as dry eye syndrome or inflammation in the eye.
- Nasal and sinus diseases (4% of cases), such as polyps, tumors, surgery, or allergies.
- Aberrant nerve regeneration (2% of cases), generally following facial palsy.
In children, excessive tearing may be caused by other problems, including:
- Dacryocystocele
- Obstruction of the nasolacrimal duct present from birth
- Developmental absence of the punctum or canaliculus
- Blockage of the punctum
- Eye infection
- Foreign body in the eye
- Inflammation of the cornea
- Conditions that cause abnormal positioning of the eyelashes or eyelids
- Glaucoma
- Inflammation of the iris
- Nerve issues
What to expect with Epiphora (Excessive Tearing or Watery Eye)
Epiphora, or excessive tearing, is treatable in most patients once it is appropriately diagnosed. However, a few people might still experience tearing without any underlying reason; this is occasionally referred to as “functional epiphora”.
Several treatments have been tried for functional epiphora. They include intubation (inserting a tube), dacryocystorhinostomy (surgery to create a new tear drainage pathway), and injecting the tear gland with botulinum toxin (a substance used in various medical treatments). The success of these treatments varies from patient to patient.
Possible Complications When Diagnosed with Epiphora (Excessive Tearing or Watery Eye)
The complications that can occur from various procedures used to treat tearing or watery eye issues will be discussed in relation to each specific procedure.
Preventing Epiphora (Excessive Tearing or Watery Eye)
Patients should be informed that rubbing their eyes can stretch the skin and tissues around the eye, which can exacerbate irritation on the eye’s surface. It’s also crucial for many patients to learn the correct method to apply eye lubricants.
