Article

WHEN YOUR PATIENTS ARE IN TEARS

RECOGNIZE AND MANAGE EPIPHORA TO PROVIDE YOUR PATIENTS WITH RELIEF

EPIPHORA, OR excessive watering of the eye, can be inconvenient and annoying for patients. It is one of the most common disorders I see in our medical clinic, at a rate of about five to 10 patients per week, who have a chief complaint of watery eyes. In comparison, I also see about 15 to 20 dry eye patients per week, or about 10 new lid lesion patients per week.

Several causes for the overwatering eye are suspected and eliminated through patient history and treatment. Here, I take you through each.

GATHER INFORMATION

First, you must gather the following information from your patient when he or she has complaints of excessive tearing. The answers to these questions will help to identify the cause and, subsequently, your treatment plan:

  • Is the tearing laterally or nasally?
  • When did the excessive tearing begin?
  • Are you experiencing excessive tearing in both eyes; the right eye or the left eye?
  • Have you recently been sick with a cold resulting in sinus congestion or pressure?
  • Do you have any known allergies? If so, what are they?
  • Have you recently made any changes to your eye care-related products, such as eye drops?

CAUSES

Allergic conjunctivitis. This type of watery eye is a diagnosis of elimination, ruling out most of the causes below. Papillae, though, on the inside palpebral conjunctiva and under the upper lids, is a tell-tale sign for allergy.

Diagnose the allergen, via a comprehensive history and allergy tests.

Treatment plans begin with avoidance of the allergen. Topical combination mast-cell stabilizer/antihistamine eye drops work well, especially in combination with an oral antihistamine to relieve most symptoms. If a patient has more severe symptoms, you may also want to include a topical anti-inflammatory eye drop, such as loteprednol 0.2% b.i.d. to q.i.d., for a few weeks or the duration of allergy season for more severe cases.

If the patient still needs help, then immunotherapy is the next step. (For more information, see February’s “Itching for Baseball Season,” also by Dr. Schmit.)

Medicamentosa. This is the term to describe exposure to a toxin that causes these types of symptoms. Sometimes, a topical agent, such as BAK, often found in most store-brand, bottle eye drops, can cause irritation, redness and watery eyes.

What can lead me to this diagnosis is a recent change in drops, recent onset of symptoms while using new drops and, more likely, when patients report overuse of drops, every five to 10 minutes throughout the day.

Allergic conjunctivitis is a common cause of epiphora. Diagnosis is via elimination.
Courtesy of Vance Thompson Vision

For treatment, think removal of the toxin, to help in these situations, such as switching to preservative-free artificial tears.

Meibomian gland dysfunction. Tears are made up of an oil, water and mucous layer. If there is compromise in the oil layer, then evaporative dry eye occurs. In its early phases, there is a reflexive aqueous production, leading to epiphora. The oil layer helps to hold the tear in the eye so a patient’s body heat doesn’t evaporate the tears. If the water (aqueous) layer is functioning properly, then a watery eye, or epiphora, occurs.

In this instance, manage the dry eye condition to provide relief of epiphora. I image the glands to quantify the anatomy of the meibomian glands and gather information on what to expect with directed treatment.

Treatment plan can include: thermal pulsation treatment (LipiFlow (TearScience) or MiboFlow (Mibo Medical Group)), warm compresses, doxycycline/minocycline 50 to 100 mg/b.i.d., omega-3 fish oil, containing at least 2,000mg of DHA/EPA, and lipid-based artificial tears.

Conjunctivochalasis. As we age, the connective tissue becomes loose on the eye, which, at times, causes the bulbar conjunctiva to rest on the lower lid and tears to spill out of the eye. For treatment in minor presentations, a steroid eye drop can be used to decrease inflammation. I usually prescribe a steroid eye drop q.i.d. for a month. If symptoms persist, then electrocautery or excision of the conjunctiva will be necessary and would be performed by a surgeon or ophthalmologist.

Nasolacrimal duct obstruction. Recent onset epiphora may point to an obstruction, such as a mucous plug or filamentous blockage, as the cause.

To treat, I first prescribe a steroid nasal spray b.i.d. for two to three weeks, specifically for more recent onset of epiphora. If the epiphora is a long-standing problem, I also add an oral steroid, 20 to 40mg q.d., for about a week.

Conjunctivochalasis can cause tears to spill out of the eye.
Courtesy of Vance Thompson Vision

If this course of treatment doesn’t improve symptoms, then there may be a true obstruction, such as stenosis, scaring or a mucous plug, which would lead to bypassing nasolacrimal passageway altogether or possibly surgery, either a dacryocystorhinostomy (DCR) or Jones tube insertion. Allow two to four weeks for initial treatment to show its effects. If you do not see an improvement, refer your patient to an ophthalmologist.

Punctal stenosis. This is a common occurrence where the punctal opening becomes overgrown with a thin layer of epithelial tissue or possibly becomes stenotic. For treatment, I first try to breakthrough where the puncta might have been, when possible. Otherwise, a three-snip punctoplasty is needed, which may require co-management with an ophthalmologist. (Consult scope of practice laws in your state.)

At this point in patient care, it is unknown if there is a blockage below the puncta, so I discuss with patients that this may, or may not, be successful. After opening the puncta and before any eyelid alignment is performed, I perform a Jones test to confirm the nasolacrimal passageway is working. I do this with a 27 to 30 gauge cannula and 5 to 10ml of balanced salt solution to irrigate. If this is not successful, and steroid prescription, as described under “nasolacrimal duct obstruction,” doesn’t help, then surgical intervention or a DCR or other procedure, may be warranted.

Ectropion/punctal eversion. This presentation is discernable via the lower eyelid extending outward and visible palpebral conjunctiva noted (the eyelid will have a more red appearance). Punctal eversion will also show tear duct opening points away from the eye, either up or out from the globe. This patient’s tears are not able to drain out of the eye because of the ectropion presentation of the lower lid and punctal eversion. (You may see these as a simultaneous presentation or separate events).

Particularly in the elderly population, there are cicatricial forces, scarring and traction, pulling the lower eyelid away from the globe. Before a surgical lateral tarsal strip can be performed, a topical steroid ointment, such as dexamethasone, is prescribed to the eyelid q.i.d. for a month. This course of treatment will soften the eyelid for surgery. However, it also has the potential to allow the eyelid to re-approximate back to the globe and relieves symptoms.

Lower lid laxity. Presence of inferior sclera showing an upward slope of lower eyelid confirms diagnosis.
Courtesy of Vance Thompson Vision

If the patient only presents with punctal eversion, then a medial spindle suture may successfully relieve symptoms, however, this also leads to nasal epiphora. In either case follow co-management standards, and refer to an ophthalmologist.

Lower lid laxity/retraction. Since tears have to move from the lateral aspect of the eye to the nasal punctal opening, the lower lid anatomy needs to slope slightly downward temporal to nasal. When laxity/retraction is present, you can see from looking at the patient the downward slope of the eye from the temporal aspect to the nasal aspect of the eye. In this case, the temporal aspect of the lower lid sits slightly lower than the nasal aspect and can result in the pooling of tears. In this case, a lateral tarsal strip is needed. Refer to an ophthalmologist for the lateral tarsal strip procedure, and discuss follow up care with your patient.

Trichiasis/entropion. Trichiasis can occur by itself or along with entropion. You can first try to trim/epilate eyelashes to relieve symptoms, but eyelashes can grow back within a couple months. A more permanent solution, if there are only a few lashes present, is to perform an electrocautery of the lash follicles to eliminate them altogether.

Another in-office procedure to address the entropion is a Quickert suture, which will turn the lower lid outward, or a lateral tarsal strip (LTS) will be needed. The LTS is indicated if the lid has too much laxity, or to the contrary, if it is very rigid. If the lid has normal elasticity and can easily be reapproximated by pushing slightly with your finger on the lid, then the Quickert is a great option. If a Quickert is used and the entropion occurs again, then we do a LTS for more permanent solution.

Trichiasis/entropion. Eyelash trimming can provide relief, but more permanent solutions are available.
Courtesy of Vance Thompson Vision

Refer to an ophthalmologist for the procedure(s), and discuss follow up care with your patient.

Also, look inside the eye to rule out ocular cicatricial pemphigoid, evident by the presence of scarring and inflammation. See more below.

Ocular cicatricial pemphigoid. This rare, autoimmune disorder is characterized by inflammation and scarring of mucous membranes, seen via slit lamp exam or by everting the eyelid. Surgery on any eye like this can further exacerbate the symptoms by causing more inflammation and scarring. This patient needs to be referred to a rheumatologist, as it is indicative of an autoimmune situation. This diagnosis is confirmed by conjunctival biopsy and immunofluorescence staining.

BE AWARE

These are some of the most common causes of epiphora in the clinic setting. By paying more attention to the anatomical positioning of the eyelid and some simple tests to determine whether the nasolacrimal passageway is functioning, you too can be more confident in providing relief to patients who have a watery eye. OM