Obstruction anywhere along the lacrimal drainage system can lead to epiphora (watery eye). This can be congenital or acquired.
Epiphora (watery eye)
There are 2 mechanisms of epiphora: nasolacrimal drainage failure and hyper-secretion.
Causes
Obstruction of the nasolacrimal system
- Punctal eversion
- Canalicular fibrosis
- Lacrimal sac obstruction
- Nasolacrimal duct obstruction.
Orbicularis pump failure
- Lid laxity
- CN7 palsy
- Lateral dermatochalasis
- Overzealous punctoplasty
Hypersecretion
- Irritation hyper-secretion is typically caused by a foreign body on the ocular surface or lashes rubbing on the ocular surface as in trichiasis and entropion
- Autonomic abnormalities and pro-secretory drugs like pilocarpine can also cause hypersecretion.
Management
Hypersecretion
- Lubricants and other drops (steroids/antibiotics) to manage specific causes of irritation.
Drainage failure
- Management of obstructions are discussed below and depend on the cause (congenital or acquired)
Congenital Nasolacrimal Duct Obstruction
A classic cause of infant epiphora.
Pathology
- Imperforate membrane over the valve of Hasner (between the nasolacrimal duct and inferior nasal meatus)
Presentation
- Infant
- Epiphora
- Discharge when the lacrimal sac is squeezed.
Management
<12 months of age
- Massage + topical antibiotics + observation
>12 months of age
- Syringing and probing
- Silicone stent intubation
- Dacryocystorhinostomy (DCR)
If the blockage is severe enough to negate the passage of the probe, intubation will prove difficult and DCR might have to be attempted instead.
Acquired Lacrimal System Obstruction
A variety of causes can lead to obstruction at various points of the tear drainage system. Each cause has its own specific treatment but all present with a watery eye.
Cause |
Treatment |
|---|---|
Punctal stenosis |
Punctoplasty |
Punctal eversion |
Cautery |
Orbicularis pump failure |
Lower lid tightening with LTS |
Dermatochalasis/lateral wicking |
Upper lid blepharoplasty |
Nasolacrimal duct obstruction |
Dacryocystorhinostomy (DCR) (by-pass nasolacrimal duct and drain to middle nasal meatus) ± intubation |
Canalicular obstruction |
DCR with retrograde intubation. 2nd line → Lester jones tube |
Dermatochalasis is seen in the elderly and obese compared to orbicularis pump failure which is seen in neuropathies such as Bell’s palsy
