Epiphora is a very frequent reason for medical consultation and has increased considerably in recent years due on the one hand to the aging of the population, and on the other hand to new life habits and environmental factors.
Closure of the tear duct, one of the causes of epiphora, usually occurs after the age of 50 years, affecting more women than men, and its frequency increases with age. The use of screens, environmental factors such as air conditioning and heating, and increased contact with different chemical products are the most frequent causes of epiphora as they provoke tear hypersecretion.
Epiphora occurs when excess tears overflow the ocular surface and fall down the cheek. When there is an excess of tears but they do not fall, we speak of “watery eye”. Excess tears, besides being annoying for the patient, can affect vision and make some habitual activities such as reading and driving difficult. It can also cause chronic irritation of the eyelid skin.
Different types of epiphora
Hypersecretory epiphora: there is an excess tear production that exceeds the drainage capacity of the tear duct. Epiphora due to hypersecretion is mainly related to inflammatory pathology of the ocular surface (allergic conjunctivitis, blepharitis…), environmental factors and certain habits. In all these cases the treatment is mainly medical.
Reactive epiphora: epiphora related to environmental factors or due to a self-limited alteration of the tear balance and ocular surface, which usually subsides without treatment in a few months, is becoming more and more frequent. These are cases of intermittent reactive epiphora, showing in the consultation an eye without tear excess, without conjunctival hyperemia and with a clean tear. These are frequent causes of reactive epiphora:
- Dry eye syndrome
- Tear film alterations
- Allergic conjunctivitis
- Blepharitis and meibomian gland dysfunction.
- Floppy syndrome and lax eyelid syndrome
- Facial paralysis
Epiphora, which is accompanied by a gritty sensation and only occurs when using screens or reading, usually improves with the use of artificial tears. Epiphora in the first 6 months after cataract surgery is also common, self-limited and improves with the use of artificial tears.
It is indicative of reactive epiphora: clear tear, conjunctival hyperemia, normal or low tear meniscus, and when it is intermittent.
Epiphora due to decreased drainage: It can be obstructive or functional. It is obstructive when there is an anatomical alteration in the lacrimal duct that impedes the passage of tears. This obstruction can occur at the level of the canaliculi (high) or at the level of the lacrimonasal canal (low). When the tear duct is normal in its anatomy, but there is no tear passage, we speak of functional epiphora. It may be due to failure of the lacrimal pump or due to alterations in nasal ventilation.
It is indicative of lacrimal duct obstruction: unilateral and constant epiphora, presence of chronic secretion without conjunctival hyperemia, pain on pressure of the lacrimal sac, outflow of mucus or purulent material through the lacrimal punctum on pressure of the lacrimal sac, and a history of some DCA.
Obstruction of the lacrimal duct in a young adult is usually secondary to trauma or inflammation/infection at the level of the canaliculi. From the 6th decade of life onwards, obstruction occurs in most cases due to closure of the lacrimonasal duct.
When there is obstruction of the lacrimal duct posterior to the lacrimal sac, at the level of the lacrimonasal duct (low obstruction), this can lead to chronic inflammation of the lacrimal sac, chronic dacryocystitis (CDD), with frequent discharge, ocular irritation and increased sensitivity to pressure in the lacrimal sac. Acute infection of the lacrimal sac, acute dacryocystitis (ACD), may also occur, requiring oral antibiotic treatment. ACD can be complicated by preseptal cellulitis, and less frequently, by orbital cellulitis.
In order to avoid major complications, an ophthalmologist evaluation is recommended when epiphora has been present for more than three months.