Epiphora

Dr Ben Wild

Overview

The lacrimal system starts with the lacrimal gland and 2 other accessory glands that produce the watery (aqueous) portion of the tears responsible for oxygen transmission, removal of debris, antimicrobial activity, and optimal optical performance. The tears then pool along the lower eyelid margin and migrate towards the nose towards 2 small holes, one on the upper lid and one lower, called the puncta. These puncta connect to the canalicular canals which connect to the nasolacrimal sac and then into the nose. That is why when you cry, your nose starts to run.

Frontal view of a healthy eye with tears pooling on the lower lid (grey) flowing towards the puncta (black dot).

Epiphora, or excessive tearing, and tears running down your cheeks, are signs of either over production of tears or defective drainage. Over production usually stems from inflammation, medications, or, paradoxically, dry eyes. Defective drainage often stems from improper or incomplete eyelid blinks, displaced puncta (eyelid deformities or congenital deformation), obstruction along any point from the lower eyelid margin to the nose, or weakness of the facial muscles around the eyes responsible for pumping the tears into the nasal passages (facial palsies like Bell’s palsy).

Frontal view demonstrating punctal stenosis (lack of black hole on lower eyelid) with tears building up on the lower lid and overflowing down the cheek.

Signs and Symptoms

Signs

Tears running down the cheeks or upwards onto the upper eyelid, skin erythema around the eyes.

Symptoms

Dry eyes, watery eyes in the wind or with the cold.

Causes and Risk Factors

Causes

Either excess tear production or blockage of tear drainage.

Risk Factors

Inflammation	Dacryoadenitis, conjunctivitis, uveitis, keratitis, canaliculitis, dacryocystitis, trichiasis, dry eyes, others.
Medications	Pilocarpine, steroids, epinephrine, chemotherapy drugs.
Defective drainage	Punctal stenosis, entropion, ectropion, lagophthalmos, canaliculitis, weakened facial muscles, nasolacrimal duct obstruction.

Prevention and Treatment

Prevention

There are no known preventative measures.

Treatments (depending on the cause)

· Steroid drops or pills for inflammation.

· Antibiotic drops or pills for infection.

· Dry eye therapy.

· Dilation and irrigation of puncta.

· Surgery for conjunctivochalasis or nasolacrimal duct obstruction.

· Eyelid reconstruction.

Prognosis

Although irritating, epiphora is not vision threatening unless it is due to an inflammatory cause. It will likely take several treatments and through trial and error you may be able to get relief.