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The watery eye, its common cause, and step wise approach

watery eye
Watery eye is the common complaint, particularly in the elderly population. It ranges from the transient and trivial (associated with a local irritant) to the permanent and disabling.

Step wise approach  for watery eye:

anatomy of lacrimal apparatus
Symptoms 
  • Episodic/permanent
  • Frequency of wiping eyes
  • Exacerbating factors (in/outside, cold/warm)
  • Site where tears spill over (laterally/medially) 

History 

  • Previous surgery/trauma
  • Concurrent eye disease (Herpes Simplex Virus)
  • Previous Ear, Nose and Throat (ENT)  problems, such as sinusitis, surgery/nasal fracture, granulomatous disease.
  • Pro-secretory drugs (pilocarpine)
  • Allergies or relevant drug contraindications 

Examinations:

Visual Acuity 

  • Best corrected/pinhole

 Face 

  • Scars (previous trauma/surgery)
  • Asymmetry
  • Prominent nasal bridge
  • Mid-face hypoplasia
  • Age-related sag

Lacrimal sac 

  • Swelling
  • Any punctal regurgitation on palpation 

Lid 

  • MGD  disease
  • Lash malposition
  • Lid position (ectropion,entropion,or low lateral canthus)
  • Laxity (lid and canthal tendons)

Punctum 

  • Position
  • Scarring
  • Concretions
  • Patency

Conjunctiva

  • Irritation (chronic conjunctivitis)
  • Inflammation

Cornea

  • Chronic corneal disease

Tear film

  • Meniscus high/low
  • Tear Break Up Time (TBUT)
  • Dry eye (Schirmer’s test)

Fluorescein dye disappearance test (FDT)

  • Tear  film height
  • Symmetry
  • Dilution
Dye recovery
  •  Jones I (physiological—without syringing)
  • Jones II (non-physiological—after syringing)
  •  Retrieve dye with cotton bud under inferior turbinate or ideally visualize with nasendoscope

Canulation

  • Patency of puncta

Syringing

  • Do gently with lateral distraction of lid to avoid false passage
  • Do not advance through an obstruction
  • Careful assessment will indicate site of obstruction
  • Assess  flow and regurgitation through upper or lower punctum, and presence of  fluoresceine or mucous in the  fluid
  • Perform nasendoscopy where possible
  • CT DCG (Dacrocystogram )if previous trauma/destructive disease/suspected tumour. 
  • Lacrimal scintigraphy is more useful than DCG as it simulates physiologic tear drainage conditions.
Dacryocystography

Lacrimal scintigraphy

lacrimal passage

Most common causes of watery eye

Increased production:

  • Autonomic disturbance
  • Pro-secretory drugs
  • Chronic lid disease (Blepharitis)
  • Local irritant (FB, trichiasis)
  • Systemic disease (TED)
  • Chronic conjunctival disease (OMMP)
  • Chronic corneal disease (KCS)

 Lacrimal pump  failure 

  • Lid laxity
  • Orbicularis weakness (VII Nerve palsy)
  • Lid position Entropion or Ectropion              

Decreased drainage:

Punctal obstruction
  • Congenital
  • punctal atresia
  • accessory punctum
  • Idiopathic stenosis (Elderly) 2° to punctal eversion
  • HSV infection 
  • post-irradiation
  • Trachoma
  • Cicatricial conjunctivitis
Canalicular obstruction
  • Idiopathic  fibrosis
  • HSV infection
  • Actinomyces 
  • Chronic dacrocystitis 
  • Cicatricial conjunctivitis
  • 5-FU administration (Systemic)
 Lacrimal sac obstruction
  • Granuloma, 
  • Sarcoid
  • Syphilis
  • Fungi 
  • Papillomas
  • Epithelial papillary (Squamous and transitional cell) carcinomas 
  • Lymphoma
  • Invasive pharyngeal or sinus carcinoma
Nasolacrimal duct obstruction (NLDO)
  • Congenital(Delayed canalization)
  • Idiopathic stenosis
  • Trauma (Nasal or orbital fracture)
  • Nasal pathology (chronic inflammatory polyps)
  • Post-irradiation
  • Granulomatosis with polyangiitis (GPA) 
  • Tumours (Nasopharyngeal carcinoma)
Never to forget the most important Differential Diagnosis of watery eye 
  • In children (Glaucoma)
  • In adults ( Sebaceous gland carcinoma may resemble chronic conjunctivitis)

About the Author
Dr. Reda Gomah, Consultant ophthalmologist , Egypt

Heading Photo source: Pixino, CC0 license 

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