Epiphora

Epiphora: Description, Causes and Risk Factors:An abnormal overflow of tears down the cheek or face is called epiphora. Tears are formed by a lacrimal gland (special tear gland) and their function is to lubricate the cornea, supply nutrients and carry away wastes. The tears drain out through a tear duct form the eye to the nose (nasolacrimal duct).Epiphora is caused by an overproduction or and inadequate removal of tears. There are numerous potential causes for epiphora. In some cases, there is excessive tear production associated with a response to irritation. Excessive tearing can results from irritating abnormal eyelashes (Distichia, Ectopic Cilia), hairs in the inner corners of the eyelids creating a wicking effect (Medial Caruncular Trichiasis), or corneal ulcers or various other eye problems (allergies, eyelid inflammation, infections, foreign bodies, intraocular problems, etc.) that present with similar clinical signs. In other cases, tears spill onto to the face instead of flowing down the normal tear drainage pathway, called the nasolacrimal system. Either the nasolacrimal system may not have developed properly, or a blockage of the system can occur. More commonly, the nasolacrimal system is anatomically normal, but there is a mechanical or functional abnormality that results in the tears spilling onto the face. For example, if the lower eyelids roll inward (Medial Canthal Entropion) and block access to the nasolacrimal openings (puncta), tears will flow by the path of least resistance, which may be onto the face. Medial caruncular trichiasis can exacerbate this type of epiphora.In adults the commonest cause of epiphora is primary acquired nasolacrimal duct obstruction (NLDO) which is associated with inflammation of the nasolacrimal duct.Risk Factors:A blockage somewhere in the system of the eye.
  • An over-production of tears.
  • Scars from old injuries or infections are blocking the lacrimal duct drainage system.
  • Eyelid deformities are preventing drainage of tears.
  • A punctum is blocked due to old age, infection, or trauma.
  • The mucous membranes of the ducts have some degree of age-related atrophy.
  • Dry eye syndrome.
  • Irritating matter in the eye.
  • Smog, smoke or pollen in the air.
  • Cold wind in the face.
  • Lack of sleep.
  • Looking at bright lights.
  • Eyestrain.
  • Irritation to the eye from ingrown eyelashes or an injury to the eye.
  • Build-up of debris.
Symptoms:EpiphoraTears on the cheeks and in the eyelashes, which may become matted.
  • Mucus or pus-like discharge from the lacrimal duct openings (puncta).
  • Red, irritated eyelids.
  • Blurred vision because of the amount of tears in the eyes.
  • A tender lump and redness on the inner corner of the eyelid; this may indicate infection of the lacrimal sac where the tears gather but deteriorate because they don't drain properly.
Diagnosis:Your optometrist will ask about your symptoms and examine your eyes to check for irritation, infection, injury and other conditions. Tests may include:Dye Test: Two or three drops of sodium fluorescein are instilled into the lateral fornix. Dye may drain completely (dye disappearance) and be collected by a swab at the inferior meatus (Jones I), when the drainage system is patent. No more tests are necessary at this stage. With compromised drainage, dye usually overflows medially onto the cheek. In the presence of lid malpositions it overflows medially, centrally or laterally, according to the lid position.The ocular surface is examined simultaneously. Conjunctival and corneal staining should be noted to rule out ocular surface disease. On the whole dye tests are objective and not reliable.Macro dacryocystography (MDCG) and scintigraphy:These further investigations may be used to confirm the diagnosis. MDCG is particularly useful to reveal details of lacrimal sac anatomy and the site of nasolacrimal duct obstruction.MDCG with a delayed erect film 5 minutes after injection of contrast medium can detect functional NLDO by showing delayed clearance of the lacrimal sac.Scintigraphy is mainly used to confirm a diagnosis of functional blockage when there is delayed or no out- flow of radioactive media in the presence of a normal DCG.Canalicular Endoscopy: More recent investigative tools are available such as the microcanalicular endoscope, which can demonstrate the site and type of blockage. However, experienced lacrimal surgeons can usually gather sufficient information by simply probing the canaliculi.Treatment:Since there are multiple potential causes of epiphora, a thorough ophthalmic examination is necessary to determine the best course of treatment. Since the condition is often multi-factorial, treatments may involve a combination of medical and surgical management,If the epiphora is due to the eye diseases, such as conjunctivitis and keratitis, then treatment of these diseases will usually clear up the problem. Cases caused by blockage of the tear ducts often respond to medical treatments with antibiotic eye ointment and sometimes oral antibiotics, but many require flushing the ducts under anesthesia or surgical opening of the ducts.Nasolacrimal duct blockageExternal DCR is still the most popular choice for NLDO and dacryocystitis and has a success rate of 80-95%. If there is canalicular damage or a narrow upper nasal cavity it may be necessary to insert a silicone tube. Day-case external DCR under local anaesthesia is gaining popularity.Endonasal DCR is acknowledged to have a lower success rate. Power tool and laser assisted DCR's can be performed as day case procedures and can be less time consuming. Balloon dilatation dacryoplasty his also been shown to be effective in partial nasolacrimal duct obstruction with a claimed success rate of 60%.NOTE: The above information is educational purpose. The information provided herein should not be used during any medical emergency or for the diagnosis or treatment of any medical condition.DISCLAIMER: This information should not substitute for seeking responsible, professional medical care.

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