Excessive tearing

Excessive tearing is overflow of tears onto the cheek. It arises from overproduction (lacrimation, a reflex response to irritation) or reduced drainage (epiphora, from obstruction or lid malposition).

Anatomy and physiology. The lacrimal gland secretes the reflex tear; accessory glands and goblet cells supply the basal tear film. Tears drain through the upper and lower puncta into the canaliculi, then the common canaliculus, lacrimal sac, nasolacrimal duct and the inferior meatus of the nose. The lacrimal pump depends on blinking and normal lid tone and position.

Classification. Hypersecretion (reflex tearing from surface irritation, dry eye, inflammation, emotion, drugs), drainage failure (punctal stenosis, canalicular obstruction, nasolacrimal duct obstruction, lid malposition and laxity, lacrimal pump failure), and mixed. Congenital nasolacrimal duct obstruction affects about 5 to 20 percent of infants and resolves spontaneously in most by 12 months.

Key distinctions. Tearing with a red, painful, photophobic eye indicates surface or intraocular inflammation. Tearing with a swollen tender mass at the medial canthus indicates acute dacryocystitis. Tearing that is worse outdoors in wind or cold suggests reflex tearing from dry eye or lid disease. A watery eye in an infant with photophobia, corneal haze and enlarged eye indicates congenital glaucoma.

History. Onset, laterality, constant or intermittent, relation to wind, cold or reading, discharge, pain, redness, photophobia, itch, grittiness, vision change, previous eye surgery, trauma, sinus or nasal surgery, facial palsy, radiotherapy, chemotherapy (docetaxel, fluorouracil), topical drops, contact lens use, systemic disease (sarcoidosis, granulomatosis with polyangiitis, thyroid disease), and in infants birth history, onset and reflux of mucus.

Drug history. Topical glaucoma drops (prostaglandin analogues, echothiophate), docetaxel, fluorouracil, S-1, idoxuridine, epinephrine drops, cholinergic drugs, and chemotherapy.

Examination. Lids (ectropion, entropion, trichiasis, laxity, lagophthalmos, blepharitis), puncta (position, stenosis, occlusion), tear meniscus height, conjunctiva, cornea (fluorescein staining), anterior chamber, medial canthal area (swelling, tenderness, mucocoele, mass), nose (polyps, septal deviation), and facial nerve function.

Tests: fluorescein dye disappearance test (retention of dye after 5 minutes indicates obstruction), Jones tests, lacrimal irrigation and probing (syringing) by ophthalmology, and regurgitation of mucus on pressure over the sac.

Red flags

• Infant with photophobia, corneal haze, large eye or blepharospasm (congenital glaucoma)
• Painful red swollen medial canthus with fever (acute dacryocystitis, orbital cellulitis)
• Hard medial canthal mass, bloody tears or recurrent bleeding (lacrimal sac tumour)
• Corneal opacity, ulcer or reduced vision
• Chronic unilateral watering with epistaxis or nasal obstruction (sinonasal tumour)
• Facial palsy with lagophthalmos
• Trauma with canalicular laceration
• Recent chemotherapy with watering and canalicular stenosis

Special groups. Infants: congenital nasolacrimal duct obstruction and glaucoma. Pregnancy: tearing from hormonal dry eye changes. Older adults: ectropion, punctal stenosis, involutional lid laxity. Region specific: trachoma related trichiasis and scarring.

Hypersecretion (reflex tearing)

• Dry eye disease and meibomian gland dysfunction, blepharitis, conjunctivitis (allergic, viral, bacterial), keratitis, corneal abrasion and foreign body, trichiasis, entropion, floppy eyelid
• Anterior uveitis, angle closure and congenital glaucoma, intraocular inflammation, corneal dystrophy
• Allergy, irritants and environmental triggers (wind, smoke, cold), emotion
• Drugs and toxins (chemotherapy, topical drops, cholinergic agents), crocodile tears (aberrant facial nerve regeneration), trigeminal irritation, cluster headache

Drainage obstruction and failure

• Punctal stenosis or agenesis, punctal eversion
• Canalicular obstruction: trauma, infection (herpes, chlamydia, actinomyces), drugs (docetaxel), radiotherapy, tumour
• Nasolacrimal duct obstruction: congenital, acquired involutional stenosis, dacryolithiasis, chronic dacryocystitis, sinonasal disease, trauma (midface fracture), sarcoidosis, granulomatosis with polyangiitis, tumour
• Lid malposition: ectropion, lower lid laxity, facial nerve palsy, orbicularis weakness, entropion

Acute infection and mass

• Acute dacryocystitis and dacryocystic abscess, canaliculitis, dacryocoele, lacrimal sac and gland tumours (lymphoma, carcinoma), orbital mass

Reasoning. Look at the surface, lids and puncta first. If the surface is normal and the eye is wet, assess drainage with dye tests and irrigation, and image when a mass, bleeding or recurrence is present.

First line. Visual acuity, slit lamp examination with fluorescein, lid assessment, punctal inspection, dye disappearance test, and examination of the medial canthus and nose.

Targeted tests.

• Lacrimal irrigation (syringing), with patency judged by passage of saline into the nose and reflux pattern, and diagnostic probing by ophthalmology.
• Dacryocystography, dacryoscintigraphy, CT dacryocystography or MR dacryography for complex obstruction.
• CT or MRI of the orbit, sinuses and midface for mass, trauma, fracture, chronic sinus disease or tumour.
• Nasal endoscopy for the nasal end of the duct. Culture of expressed pus or swab. Biopsy of any lacrimal sac mass.
• Schirmer test (under 5 mm in 5 minutes without anaesthetic), tear break up time, and ocular surface staining for dry eye.
• Intraocular pressure and gonioscopy in infants (under examination if needed) with corneal diameter measurement for congenital glaucoma.
• Angiotensin converting enzyme, ANCA and chest radiograph for suspected granulomatous disease.

Limitations. Normal syringing does not exclude functional obstruction. Dye tests are subjective. Imaging may not show membranous obstruction.

Congenital nasolacrimal duct obstruction. Reassurance (spontaneous resolution in most by 12 months), massage of the lacrimal sac (Crigler massage, 3 to 4 times daily with firm downward pressure), cleaning of discharge, and topical antibiotic only for purulent discharge (chloramphenicol 0.5 percent drops 4 times daily for 5 days). Probing by ophthalmology at 12 months or earlier for acute dacryocystitis, with balloon dacryoplasty, intubation or dacryocystorhinostomy for failure.

Congenital glaucoma. Urgent paediatric ophthalmology for surgery (goniotomy or trabeculotomy).

Acute dacryocystitis. Warm compresses, analgesia, amoxicillin with clavulanic acid 625 mg orally three times daily for 7 days (children 40 to 50 mg/kg of the amoxicillin component daily in 3 divided doses); IV ceftriaxone 2 g every 12 hours (children 50 mg/kg every 12 hours, maximum 2 g) plus metronidazole 500 mg IV every 8 hours for severe infection with cellulitis or systemic illness; incision and drainage of abscess by ophthalmology; dacryocystorhinostomy once the infection settles. Do not probe or syringe during acute infection.

Canaliculitis. Canalicular curettage by ophthalmology, topical antibiotic (moxifloxacin 0.5 percent drops 4 times daily for 7 to 10 days), hot compresses, and oral antibiotic for cellulitis.

Acquired nasolacrimal duct obstruction. Dacryocystorhinostomy (external or endoscopic) by ophthalmology or ENT for symptomatic obstruction.

Punctal and canalicular stenosis. Punctoplasty or dilatation, silicone intubation or canalicular surgery; for chemotherapy related stenosis, early intubation, preservative free lubricants and steroid drops.

Lid malposition. Surgical repair of ectropion, entropion, lid laxity or trichiasis. Facial palsy: lubricants, tape at night, and tarsorrhaphy or lid weight when persistent.

Reflex tearing from dry eye and blepharitis. Preservative free lubricants (hypromellose 0.3 percent or sodium hyaluronate 0.1 to 0.2 percent, 1 drop 4 to 6 times daily), lid hygiene (warm compress for 5 to 10 minutes then lid cleaning twice daily), doxycycline 100 mg orally daily for 6 to 12 weeks for meibomian gland dysfunction (avoid in pregnancy and in children under 12 years), and ciclosporin 0.05 percent drops twice daily for moderate to severe disease by ophthalmology.

Allergic conjunctivitis. Olopatadine 0.1 percent 1 drop twice daily, avoidance of allergens, and cold compresses.

Keratitis, uveitis and glaucoma. Same day ophthalmology. Keratitis: ofloxacin 0.3 percent 1 drop every 15 to 60 minutes after scraping. Uveitis: prednisolone acetate 1 percent 1 drop every 1 to 2 hours with cyclopentolate 1 percent 1 drop twice daily. Angle closure: acetazolamide 500 mg IV or orally, timolol 0.5 percent 1 drop and apraclonidine 1 percent 1 drop.

Crocodile tears. Botulinum toxin into the lacrimal gland by specialists.

Lacrimal sac tumour and orbital mass. Urgent imaging, biopsy and multidisciplinary oncology care.

Drug induced tearing. Review with the prescriber, switch the offending drop, or give preservative free alternatives.

Trauma with canalicular laceration. Surgical repair within 24 to 48 hours with stenting by ophthalmology.

Monitoring. Review at 2 to 4 weeks for response. Infants: review at 6 and 12 months. Post-operative review at 1 week, 1 month and 6 months, with stent removal at 3 to 6 months.

Referral and escalation. Same day ophthalmology for acute dacryocystitis, congenital glaucoma, keratitis, or canalicular trauma. Urgent oncology for suspected tumour. ENT for sinonasal disease. Oculoplastic referral for persistent obstruction and lid malposition.

Admission criteria. Orbital cellulitis, severe dacryocystitis with systemic illness, or infants needing surgery for glaucoma.

Discharge and safety netting. Return for red swollen eyelid or canthus, fever, pain, reduced vision, light sensitivity, bloody tears, or no improvement within 2 to 4 weeks.