Epiphora Unplugged

Submit a question to Dr. Ajamian

Answer: As you indicate, pseudoepiphora is not too difficult to uncover. Simply ask the patient, “Are the tears streaming down your cheeks, or only giving you watery eyes?” The number-one cause of a watery eye is actually a dry eye. If the patient has watery eyes but not tears down the cheeks, then do a full dry eye workup to look for the cause of pseudoepiphora.

If the tears stream from the eyes, first do a basic gross observation. Epiphora often is due to malposition or malfunction of the lid, says Carl Spear, O.D., of Navarre, Fla. Ectropion or entropion can cause excess tearing; if the punctum is not in apposition to the globe, the tears won’t drain properly. Refer these patients to an oculoplastic surgeon who can reattach and strengthen those weak tissues.

True epiphora is linked to blockage of the drainage system. Often this is due to an inflammatory or infectious condition such as dacryocystitis or canaliculitis, or secondary to some sort of trauma, Dr. Spear says.

The best tests for patency include a dye disappearance test (Jones test) and lacrimal dilation and irrigation. For the dye disappearance test, put a drop of fluorescein in the cul-de-sac. After 2-3 minutes, have the patient blow into a tissue, or swab inside the nose to see if the dye drained through. A positive response indicates normal drainage. No dye means a blockage.

If the dye disappearance test is negative, do lacrimal dilation and irrigation. “Sometimes the puncta may just be occluded,” Dr. Spear says. “Take a lacrimal dilator and dilate the puncta. Then take a syringe attached to a 23-gauge cannula, and flush saline through the lacrimal system. If you can’t flush fluid through the system, then you know it’s completely blocked off. If you can force the fluid through, then you’ve probably relieved whatever the blockage was.”

Ascertaining the etiology underlying true epiphora can be difficult. “Even though it’s typically trauma or infection, it could be a space-occupying lesion, or it could be other things,” Dr. Spears says. Some of those other things: stones or concretions. Most commonly, the problem is a nasolacrimal duct obstruction, which calls for a dacryocystorhinostomy (DCR).

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Question: When should a patient with epiphora be referred, and to whom?

Answer: When the patient has a nasolacrimal duct obstruction, refer directly to an oculoplastic surgeon. Many general ophthalmologists don’t do this procedure. The oculoplastic surgeon will perform a thorough exam of the lacrimal drainage system and the nose, and if need be will do a DCR.

To perform a DCR, the surgeon creates an opening from the lacrimal sac directly into the nose, says oculoplastic surgeon James R. Patrinely, M.D., of Pensacola, Fla. The surgeon implants tiny tubes in the tear ducts that keep the bypass open, then removes the tubes in 6-12 weeks. Dr. Patrinely says that optometrists should check the corneas post-op to make sure the tubes aren’t causing irritation. And be aware that the tearing complaints won’t completely go away until the tubes are removed.

If there is a canalicular obstruction, the oculoplastic surgeon may insert a Jones tube, a tiny permanent glass tube that opens from the corner of the eye into the nose, bypassing the tear ducts altogether. “That’s kind of a last-ditch procedure when the tear duct system keeps scarring and closing,” Dr. Patrinely says.

A Jones tube can require more maintenance. Sometimes it clogs with mucus and has to be exchanged, Dr. Patrinely says. Sometimes it falls out. It also creates a larger-than-normal drainage tract and can drain too well, causing dry eye.

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Send it to 
Dr. Paul C. Ajamian
c/o Review of Optometry
11 Campus Blvd., Suite 100
Newtown Square, PA 19073
Attn.: CMQA
Or fax it to 610-492-1039, or e-mail it to reviewofoptometry@jobson.com.

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