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

SEED Contact Lens
The watery eye, its common cause, and step wise approach by Reda Gomaz

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:

anatomy of lacrimal apparatus


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


  • 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 


Visual Acuity 

  • Best corrected/pinhole


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

Lacrimal sac 

  • Swelling
  • Any punctal regurgitation on palpation 


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


  • Position
  • Scarring
  • Concretions
  • Patency


  • Irritation (chronic conjunctivitis)
  • Inflammation


  • 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


  • Patency of puncta


  • 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.

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

Leave A Reply

Your email address will not be published.