Watery eye is a 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:
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.
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)
