Mr Uddin has been treating both children and adults with watery eyes for over 25 years. He understands how much of a nuisance, socially embarrassing and uncomfortable it can be. He also very aware that the perception of water filled eyes and crying can lead to social and professional misunderstanding. Mr Uddin has expertise in nasolacrimal (tear) duct surgery and performed the first endonasal dacryocystorhinostomy (DCR) at Moorfields Eye Hospital nearly twenty years ago.
"It's important to ascertain the cause of the watery eye. This may be due to excess tear production, abnormalities in the lid position, or problems with outflow drainage of tears. Treatment needs to be tailored to the cause, which can sometimes be multifactorial, and often is non-surgical."
Normal flow of tears
Potential areas of tear drainage blockage
Is it normal to have watery eyes?
Some watery eyes are normal, especially in cold weather, wind or dusty environments. Tears naturally lubricate, protect and nourish the eyes. At times, the tear-drainage system (lacrimal system) may fail to adequately drain tears from the surface of the eye surface into the nose. This can cause excessively watery eyes, also known as Epiphora.
As well as watery eyes (tearing), a person may also experience eye discomfort, redness and inflammation. Blurred vision, especially reading, looking down or in the morning is common.
It is also important to distinguish a watery eye from a ‘sticky’ and irritable eye.
- Watery eyes alone may physiological or due to poor tear drainage.
- A sticky eye can be caused by an infection, a cyst or mucocele (mucous accumulation in the tear sac).
- Irritable eyes may be associated with dry eyes (and reflex tearing) or conditions causing irritation to the eye such as blepharitis, abnormal lashes or inturning lower lid.
Watery eyes can occur due to an increase in tear production, problems with the drainage of tears and issues with the eyelids.
Overproduction of tears
This can be caused by a number of factors including ingrowing eyelashes, foreign bodies on the cornea (outer layer of the front of the eye) and eye strain. It can also be caused by irritation from the lower eye lid being in an abnormal position, turning outwards or inwards (ectropion or entropion). Dry eyes or dry eye syndrome can cause excessive tearing as the lack of moisture can make the eyes sore which cause reflex tears.
Failure with tear drainage can be caused by an infection, such as dacryocystitis, or by inflammation in part of the eyelid drainage, such as canaliculitis. There may also be a partial or functional blockage of the nasolacrimal (tear) duct.
Primary acquired nasolacrimal duct obstruction (PANDO) is common in the older age group; typically there is a narrowing and partial obstruction of the tear duct.
Lid, facial trauma and previous surgery may damage the tear drainage system, resulting in a watery eye.
Newborn babies may experience a failure of the opening of the drainage system into the nose, this is called congenital nasolacrimal duct obstruction (CNLDO).
Lid, facial trauma and previous surgery may damage the tear drainage system, resulting in a watery eye.
Sometimes watery eyes may be a sign of a nasal or eyelid disease, or a condition affecting the cornea (clear outer layer of the eye). In rare cases in babies, it can be an indicator of a congenital glaucoma.
Swelling on the side of the nose by the inner corner of the eyelid (where the lacrimal/tear sac resides) may be an indication of a mucocele (mucous in the tear sac) or occasionally a tumour. If the tears are bloody or blood stained these will need to be investigated carefully to exclude any tumours.
Watery eyes are sometimes a symptom of facial nerve palsy. As the person is unable to close their eye, their lower eyelid may sag (ectropion or poor muscle tone). Sometimes those with a facial palsy may experience “crocodile tears” syndrome (gustatory lacrimation) which is uncontrollable tearing when eating or drinking.
To determine the cause of the watery eyes a full examination of the eyes and eyelids is completed, as well as the nose. To check the tear duct function the tear drainage system can be syringed with a salt-based fluid at the clinic appointment.
In some cases, a dacryocystogram may need to be performed. This is a type of x-ray where a contrast dye is injected into the tear drainage system. This makes it easier to identify the anatomy and any blockages or narrowing. Very rarely a lacrimal scintigraphy is completed; this is a type of imaging using a radioactive tracer to assess the tear drainage system. This procedure is used when there is no apparent blockage (called functional epiphora). In rare cases where a tumour or trauma is suspected, a magnetic resonance imaging (MRI) or computed tomography (CT) scan is carried out.
How can watery eyes be treated?
For many, issues with watery eyes can be improved by treating the underlying cause such as blepharitis, dry eyes or an eyelid problem. In some cases where there is a blockage in the overall system or tear duct, surgery may be necessary. A botulinum toxin (Botox) injection is sometimes used for those with crocodile tear syndrome.
The type of surgery required depends on what is causing the tear drainage dysfunction.
Eyelid surgery is performed if the eyelid is in abnormal position (entropion/ectropion). Punctoplasty surgery is usually performed when there is a blockage in the tear puncta (tiny holes in the inside corners of the eyelids where tears first drain). The procedure involves enlarging these holes, allowing tears to drain more easily. This is usually done under local anaesthetic and takes about 30 minutes.
If the underlying cause is an obstruction in the nasolacrimal (tear) duct, an operation called a dacryocystorhinostomy (DCR) is frequently performed. This procedure allows tears to bypass the blockage, by creating a new connection between the tear duct sac and the nose. This is an effective operation for most children and adults, with a success rate of over 90%. If there is a nasal condition that also needs to be addressed, this can be done at the same time by an Ear, Nose and Throat (ENT) surgeon.
There are two methods of DCR surgery, external DCR and endoscopic endonasal DCR (EndoDCR). With an external DCR a small incision (1cm) is made on the side of the nose to gain access to the tear sac. With EndoDCR there are no skin incisions and therefore no scarring. The entire operation is performed through the nose using a small camera (endoscope). With both of these approaches, small soft rods are somtimes inserted internally to make sure the new passage remains open during the healing process. The surgery takes about forty minutes to an hour and is frequently performed under general anaesthetic but can be done under local anaesthetic with sedation.
Lester Jones Tubes
In complex cases or where the canaliculus (channel near inner corner of eyelid) is blocked a Lester Jones tube may be used. This is a small glass tube that is inserted into the corner of the eyelid, which acts as a channel for the tears to drain into the nasal space.
Small soft silicone tubes are sometimes placed for a few weeks before being removed
A silicone tube is hardly noticible in the right eyelid
The tube is being demonstrated with the eyelid being pulled down
A lester Jones by-pass tube drains tears directly into the nose
Most patients are uncomplicated, with some nose discomfort and swelling. You should take it easy for 5 days.
A nose bleed can sometimes occur in the first five days after surgery and the nose will also feel crusty and a little bit blocked for the first week or two. If rods have been inserted, these are usually removed 2 to 8 weeks after surgery, in an outpatient’s appointment. Most people take 7-10 days off work, avoiding exercise or heavy lifting. External DCR surgery may leave a small scar on the side of the nose; this usually fades after a few months.
Canaliculitis is an inflammation of the short channel near the inner corner of the eyelid, known as the canaliculus. As well as watery eye, they may also experience red sticky eye, tenderness around the eyelids and a discharge from the inner corner of the eye. The most common cause of canaliculitis is an infection, such as conjunctivitis. In rare cases it can be caused by a foreign body, such as a previous punctal plug.
Dacryocystitis is an inflammation of the tear (lacrimal) sac, which is located in the inner corner of the eye near the nose. A person with dacryocystitis can experience watery eyes, a discharge from the corner of the eyelids, a fever and swelling (abscess) over the inner corner of the eye near the nose. The most common cause of dacryocystitis is a blockage in the nasolacrimal duct, which leads from the tear sac into the nose. Sometimes it can be caused by previous nasal or sinus surgery but this is rare.
Watery eyes are common for newborns, and usually disappear spontaneously with time. This condition occurs in about 10% of newborns and symptoms usually appear in the first few weeks of life. Up to 90% of babies improve spontaneously in the first year. On some occasions there may be a blockage of the tear duct causing infection, conjunctivitis and irritation; this is called Congenital Nasolacrimal Duct Obstruction (CNLDO). Symptoms to look out for are mucus or pus on the eyelashes and redness of the skin surrounding the eye.
Rarely, corneal or congenital glaucoma can be the cause of a watery eye in the newborn.
The majority of cases resolve without treatment or with minimal medical intervention. 90% of cases improve within the first year. However, it is important to establish the cause of the watering is not due to corneal inflammation or congenital glaucoma.
a course of antibiotics may be necessary if there is an infection. Massaging the area of the tear sac regularly can help to release the blockage (Lacrimal sac massage).
If the blockage is persistent or causing damage to the skin, a small probe may be used to open the blockage or narrowing in the tear drainage system called a syringe and probe (S+P). This is done under general anaesthetic. A dacryocystogram, a procedure in which an injectable dye highlights the blockages or narrowing is also useful. In some cases, a surgical procedure called a dacryocystorhinostomy (DCR) is undertaken. This creates a new connection between the tear duct sac and the nose.