Conditions: Watering Eye

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Watering Eyes

Excessive tearing or the bothersome problem of tears overflowing down the cheek is called epiphora (watering eye or watery eye). This can have many different causes. A careful clinical examination is performed to determine the underlying cause. Treatment will depend on the cause e.g. if the lower eyelid is sagging away from the eye (ectropion) and causing watery eye, the treatment will be surgery designed to reposition the eyelid. Epiphora (watery eye) commonly develops from abnormalities in the lacrimal drainage system from scarring due to injury, recurrent infection, the ageing process, or from unknown causes. Surgery is required to improve watery eye which is caused by abnormalities in the tear drainage system. Occasionally a dacryocystogram (a special form of X-ray examination of the tear drainage pathway) or lacrimal scintigraphy (a test utilizing a radiolabelled tracer) is required to assist in your assessment.

(Paradoxically a dry eye can lead to tearing. Glands in the eyelids (the Meibomian glands) secrete an oily material which lines the tears covering the cornea, the clear and extremely sensitive window at the front of the eye. The oily secretion retards the evaporation of the tear film in between blinks. If these glands do not function properly (e.g. in blepharitis), the tear film evaporates quickly leaving the sensitive cornea exposed. The tear glands then produce an excessive volume of tears as a reflex which overwhelms the tear drainage system (as in emotional crying). This often leads to confusion with patients failing to understand why they have been prescribed artificial tears to improve their symptoms! There is a variety of artificial tear preparations available. Some patients prefer one preparation over another for no scientific reason. It is therefore wise to try different preparations. If the tears need to be used more frequently than 4 times a day it is better to choose preparation which is preservative free e.g. Hyabak, Systane preservative free, or Viscotears preservative free, or Liquifilm tears preservative free, or Celluvisc, and Lacrilube at night).

The Lacrimal (Tear) System

The lacrimal glands, situated in the outer portion of the upper eyelids, produce the tears which drain downward and inward across the eye. Blinking of the lids helps to spread the tears to lubricate and protect the eyes. The tears drain into the superior and inferior puncta, located at the inner part of the upper and lower eyelids, and are carried by the superior and inferior canaliculi to the common canaliculus, then into the lacrimal sac. The lacrimal sac is a small pouch located next to the nose. The tears then drain into the nose (see figure). A blockage at the lower end of the nasolacrimal duct is the most common cause of a tear drainage outflow problem leading to a watery eye.

The tear drainage pathway

What happens before lacrimal drainage surgery?

You will visit the hospital a few days/weeks before the date of your surgery, to have a preoperative consultation with your surgeon. He/she will ask you questions about your current and past health, and will need to know about any allergies you may have, medications you are taking (including over the counter products e.g. aspirin, indomethacin or vitamin supplements), previous surgery, and whether you smoke. You may also be required to have a physical examination of your heart and lungs by your GP to make sure it is safe for you to have an anaesthetic. You may need to have some routine laboratory tests, such as urinalysis (tests of your urine), chest x- rays, or complete blood cell counts. These should reveal potential problems that might complicate the surgery if not detected and treated early. No testing may be necessary if you are in good health and younger than age 55.

Please answer all questions completely and honestly as they are asked only for your own well being, so that your surgery can be planned as carefully as possible. If you are unsure of the names of any medications, bring them with you. You will be told whether or not to stop any medications at this preoperative clinic visit. For example, if you are taking aspirin-containing medicines or anticoagulants, they may need to be temporarily withdrawn or reduced in dose for two weeks before the procedure. If you can, try to stop smoking at least six to eight weeks prior to surgery.

Your eyes are examined carefully; your vision in each eye is measured, the pressure within each eye is measured, and the back of the eye (called the retina) is examined as well as the eyelids and nose. The positioning of the eyelids is noted. A "sac washout" or syringing of the tear drainage pathway is often performed using a fine blunt lacrimal cannula and some sterile saline solution. This is performed to determine whether or not there is a blockage of the tear drainage pathway. If there is a blockage this also provides important information about the precise location of the blockage and whether the blockage causing a watery eye is partial or complete. Your nose will be examined with an endoscope to ensure that you have no nasal abnormalities.

What should I expect at the hospital?

The procedure most appropriate to your individual case will be explained to you and you will then be asked to sign a consent form saying that you understand the procedure and that you have been told about any possible complications. Very rare complications will be described, as well as any more common ones, so try to keep things in perspective. If you have any questions or worries, make sure they are answered, before you sign the consent form. You are quite free to go away and consider the options before committing yourself to any surgery. You can then write to us or email us requesting further information if required.

Dacryocystorhinostomy (DCR)

Surgery can be performed to create a functioning tear drainage system where there is an obstruction causing a watery eye. A dacryocystorhinostomy (abbreviated as DCR), an operation performed for an obstruction in the nasolacrimal duct, is performed through a small incision on the side of the nose (external DCR), or through the nose with the use of an endoscope (a surgical telescope) (endoscopic DCR). The use of an endoscope is preferable as it avoids the need for a skin incision and so does not leave a visible scar. Only a very small proportion of patients are unsuitable for this approach. The success rate of both approaches in our hands is better than 95%. In the event of a failure the surgery can be repeated. During the surgery, the lining of the lacrimal sac is attached to the inner lining of the nose (the nasal mucosa) to create a new passageway for the tears. A fine silicone tube (a stent) is usually placed at surgery to maintain an opening in the tear drainage system. This is removed after a few weeks in the clinic.

An example of a silicone stent

The endoscopic approach cannot be used for patients who have a blockage in the common canaliculus or the canaliculi. If the surgery has failed in spite of a re-operation the symptoms may instead be overcome with the use of a Lester Jones tube (see below). It is very rare not to be able to overcome the problem of a watery eye due to a blockage of the tear drainage pathway for a patient.

This operation is usually performed under general anaesthesia although it can be performed under local anaesthesia with intravenous sedation by an anaesthetist for patients unfit for general anaesthesia.

Conjunctivo-dacryocystorhinostomy (CDCR) + Lester Jones tube

This operation is performed for patients who have a watery eye due to a complete blockage of the canaliculi e.g. following trauma. The operation is very similar to a DCR but instead of a removable silicone stent, a tiny pyrex tube is placed between the inner corner of the eye and the nose. Unlike a stent this remains in place indefinitely. This is prone to problems in some patients e.g. foreign body reactions. On the whole, however, these tubes are very well tolerated in patients of all ages as long as the patient is able to comply with simple daily cleaning. This simply involves cleaning any mucus from around the tube morning and evening using a moistened cotton tip applicator and instilling simple watery artificial tears (Hypromellose drops) twice a day and sniffing while occluding the opposite nostril. The tube is not visible to others.

This surgery is most often performed endoscopically avoiding the need for an external incision and a scar. Occasionally there is insufficient space within the nose to accommodate the tube e.g. due to a deviation of the nasal septum which divides the nose into 2 separate cavities. If the septum is deviated a septoplasty is performed, also endoscopically.

	A patient with a Lester Jones tube.

What are the risks of lacrimal drainage surgery?

No operation is free from risk. There are small risks associated with general anaesthesia common to all operations. The main risks of this type of surgery are bleeding, and infection, but such problems are very rarely encountered. All precautions are taken before, during and after surgery to reduce the risk of bleeding.

Before surgery

After surgery

Instructions for patients following endoscopic DCR surgery

In order for the wound to heal well and to prevent infection, please follow these instructions:

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