Epiphora

Epiphora is overflow of tears onto the cheek, caused by either excess tear production or inadequate drainage. It is a very common symptom in infants and older adults, and it may cause skin irritation, blurred vision and secondary infection. The key distinction is between hypersecretion (reflex tearing from an irritated ocular surface) and obstruction of the lacrimal drainage system.

• Hypersecretion: dry eye disease, blepharitis, conjunctivitis, allergy, trichiasis or entropion, foreign body, corneal abrasion or keratitis, uveitis, irritants, emotional crying, drugs (cholinergics, docetaxel).
• Eyelid malposition: ectropion, lower lid laxity, facial nerve palsy, punctal eversion.
• Punctal causes: punctal stenosis or agenesis, punctal occlusion.
• Canalicular disease: stenosis from infection (herpes, Chlamydia, actinomyces), trauma, drugs (topical antivirals, 5-fluorouracil, docetaxel, idoxuridine), radiation.
• Nasolacrimal duct obstruction: congenital (6 to 20 percent of infants; 90 percent resolve by 12 months), acquired involutional stenosis in middle aged and older women, trauma, sinus disease, nasal tumours, granulomatous disease (sarcoid, granulomatosis with polyangiitis), dacryolith.
• Complications: dacryocystitis, lacrimal sac abscess, mucocele, orbital cellulitis, chronic skin irritation.

• Watering eye, wetness of the cheek and lid margin, sticky discharge, blurred vision, eczematous lower lid skin, medial canthal swelling.
• Congenital: wet eye with mattering from the first weeks, normal cornea and conjunctiva.
• Acute dacryocystitis: painful, red, tender swelling at the medial canthus below the tendon, with fever; chronic: mucopurulent reflux on pressing the sac.
• Examination: lid position, punctal size and position, tear meniscus, lid margin and cornea, regurgitation on pressure over the sac, intranasal examination.
• Red flags: acute painful swelling over the sac with fever or spreading cellulitis (urgent treatment), blood stained tears, a mass at the medial canthus or lacrimal sac, facial trauma, unilateral epiphora with nasal bleeding, systemic disease (sarcoid, vasculitis), pain and photophobia (corneal disease), eyelid lesion, infant with other eye abnormalities (congenital glaucoma: watering with photophobia, large cloudy cornea).

• Clinical assessment of lids, puncta, tear meniscus, ocular surface and nose.
• Fluorescein dye disappearance test: delayed clearance after 5 minutes in drainage obstruction; Jones tests for primary and secondary dye recovery.
• Lacrimal syringing and probing (under anaesthesia in children): reflux from the same punctum suggests canalicular obstruction; reflux through the opposite punctum suggests nasolacrimal duct obstruction; passage into the nose indicates patency.
• Imaging: dacryocystography, dacryoscintigraphy, CT dacryocystography for complex cases, tumours, trauma; CT of sinuses.
• Dry eye tests; intraocular pressure and corneal examination in infants with watering.
• Differentials: dry eye with reflex tearing, blepharitis, allergy, ectropion, trichiasis, congenital glaucoma, uveitis.

• Treat the cause of reflex tearing: lubricants (preservative free carmellose 0.5 percent 4 to 6 times daily), lid hygiene, treatment of blepharitis or allergy (olopatadine 0.1 percent twice daily), removal of trichiasis, correction of lid malposition.
• Congenital nasolacrimal duct obstruction: parental reassurance; lacrimal sac massage (Crigler): press over the lacrimal sac and stroke downward firmly 10 times, two to three times daily; wipe discharge with cooled boiled water; topical antibiotic (chloramphenicol 0.5 percent drops four times daily for 5 to 7 days, or erythromycin ointment) only for infective discharge. Probing at 12 months if symptoms persist (earlier if recurrent infection or dacryocystocele); balloon dilatation or intubation for failed probing.
• Punctal stenosis: punctal dilatation or one snip punctoplasty.
• Canalicular obstruction: dilation and intubation, or conjunctivodacryocystorhinostomy with a Lester Jones tube.
• Acquired nasolacrimal duct obstruction in adults: dacryocystorhinostomy (external or endoscopic) with success of 90 percent or higher.
• Acute dacryocystitis: warm compress, systemic antibiotics for 7 to 10 days, such as co-amoxiclav 625 mg orally three times daily or flucloxacillin 500 mg four times daily (children: co-amoxiclav 25 mg/kg/day in two to three doses, or cefalexin); incision and drainage of an abscess; intravenous antibiotics (for example ceftriaxone) if orbital cellulitis is suspected; dacryocystorhinostomy after the infection settles.
• Dacryolith, tumour or severe disease: ENT or oculoplastic surgery.
• Reassess in 2 to 4 weeks; refer to ophthalmology or oculoplastic surgery for failed treatment, recurrent infection, tumour suspicion or surgery.