Watery Eyes and Tear Duct (Lacrimal) Surgery

The main causes of tearing are:

1) Unstable tear film due to underlying “dry” eye or ocular irritation.
2) Loose eyelids that can no longer pump away the tears and
3) Narrowing or obstruction of the nasolacrimal / tear duct (toilet of the eye) 

UNSTABLE TEAR FILM: The quality/osmolarity of the tear film is just as important as the amount of the tears. Patients with an abnormal tear film often complain of itchy, scratchy eyes that are worse in the evening, with reading, or when wind blows in their eyes.  Good tears are not made up of just water. Normal tears have mucin and lipid, and if these components are not being made appropriately, the tears are unstable and will drip out of the eye. Using ocular lubricants (tear drops or ointment) six or more times per day may help to stabilize the tear film. One of my most difficult jobs is trying to convince patients with “dry” eyes and tearing to use ocular lubricants (e.g. Celluvisc, Refresh liquigel, TearGel) to help stabilize the tear film.   Ocular irritation (e.g. from inturned lashes or foreign bodies) can cause tearing. Removing the offending lashes can improve the irritation.

The EYELIDS pump the tears from the eye to the tear duct.  If the eyelid is loose from age or trauma, or does not contact the eyeball, tearing may result. There is a small hole (punctum) near the nasal corner of each eyelid that is a drainage hole for the tears. If the punctum is not in the proper position, tears may not exit the eye properly.  If the eyelids are abnormal, various surgical remedies can be performed. The hole that drains the eyelids can be enlarged (punctoplasty) if the puncta are too small.  The eyelids can be retightened to improve the tear pump. The eyelid margin can be realigned if the eyelid abnormally turns out (ectropion) or turns in (entropion).  Do not rub or tug your eyelids if you tear.  Pat the lids gently, or gently wipe the lids upwards.

BLOCKED TEAR DUCTS   The nasolacrimal duct or tear duct is the “toilet” of the eye.  Overflow tearing (with or without pus) may occur if the tear duct is blocked.  If the tear duct becomes infected,the infection may spread to the structures surrounding the tear duct resulting in a cellulitis. Although the cellulitis can be temporarily quelled with antibiotics, definitive treatment requires opening the blocked tear duct. 

CHILDREN may be born with a blocked tear duct,because a membrane in the nose fails to open naturally. Often massaging the inner nose with a Q tip in a downwards direction helps to resolve the tearing. If after 9 months this does not work 1) probing, 2) plastic tubing to keepthe duct open [stent] or 3)balloon dilation may be required.  (The Lacricath balloon is similar to technology used in angioplasty, to open blocked heart arteries) 

 

 

In ADULTS the most common site of nasolacrimal obstruction is near the end of the tear duct that is encased by bone. Nasal fractures and sinus surgery may increase the frequency of this type of obstruction.  If the tearing is treated early before fibrosis occurs, plastic tubing (stent) or balloon dilation procedures may occasionally work. More frequently however, the tearing is long-standing and the scarring of the tear duct is so extensive that a new conduit for the tears must be established through the nose (dacryocystorhinostomy = DCR). DCR is conven-tionally performed with a 2.5 cm incision by the side of the nose.  A very common problem after tear duct surgery in both children and adults is that the plastic tube (stent) works its way out of the nose.  If this happens, it is NOT an emergency. If the tube cannot be pushed back in the nose, tape the tube to the side of the nose, and use lubricating eye drops for comfort as necessary.  The stent can usually be easily removed the next working day in the doctor’s office.  A potential problem  after DCR, is uncontrolled nosebleeding. For this reason patients should refrain from blood thinning medication (e.g. aspirin, Advil, vitamin E, gingko biloba) 2 weeks prior to surgery, if agreeable with their primary doctor. Following DCR do not blow your nose forcefully.If the DCR does not work patients may require a glass tube bypass (Jones tube). The major nuisance with Jones tubes is their potential to dislodge, even with sneezing.

To help Dr. Ing sort out your problem, answer the following questions:  Do you tear on the right, left or both sides? Is the discharge clear or is there mucous or pus? Is the tearing constant, or worse in the evening? What makes the tearing worse?  Do the eyes feel itchy, gritty or scratchy? Have you had sinus surgery or nasal fracture?