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Managing the watery eye: anterior eye and oculoplastics part 3 C-19163 O/D.

Watery eyes or 'epiphora' is a common complaint amongst patients presenting to eye care professionals. Surprisingly, dry eyes and watery eyes may have common aetiology. There may be many reasons for epiphora and this article describes the common types and the most effective examination and management.

Tears are produced by the main lacrimal gland, which sits in the superolateral part of the anterior orbit. It is divided into two parts by the lateral horn of the levator aponeurosis--the superolateral orbital lobe and the inferomedial palpebral lobe. Accessory tear glands are found in the conjunctiva (glands of Krause and Wolfring), as well as conjunctival goblet cells. From a practical point of view, the accessory glands don't ever play a role in excess tear production. There is a distinction between basic tear secretion, whereby tears are produced continually to replenish the natural tear film, and reflex tear secretion, which occurs after stimulation by, for example, peeling onions, a foreign body in the eye, corneal abrasion or cold wind. Tears which are produced in the main lacrimal gland "fall" over the cornea and conjunctiva and end up on the lower lid. They don't spill over the eyelid margin, as this is hydrophobic, by virtue of a fatty substance secreted by the Meibomian glands. From the lower lid, they are actively transported via a lacrimal pump mechanism which is thought to be controlled mainly by blinking. The lacrimal pump mechanism involves contraction of the orbicularis muscle to close the eye, which creates negative pressure in the lacrimal sac. Since part of its fibres are connected to the fascia, which envelops the sac, this contraction 'opens up' the sac by enlarging it. The negative pressure sucks in the tears which are located in the lacus lacrimalis. (1) The tears then enter the nasal cavity, just lateral to the inferior nasal turbinate. Any dye instilled into the eye may be retrieved from here with a small cotton bud, as in Jones' test number one (vide infra) (see later).

[FIGURE 1 OMITTED]

What's this patient talking about?

When a patient complains of 'watering eyes', it is important to establish what exactly they mean. Sometimes it is the feeling of a moist eye, a slight excess of tears, but they do not spill over onto the cheek. Epiphora means that the tears spill onto the cheek. When this happens, patients tend to be more bothered with it, since apart from vision problems (often they complain of blurred vision when reading due to an increased tear meniscus) there are also social implications. People think the patient is being emotional, which can leave the patient feeling embarrassed. Not uncommonly, patients complain of watering eyes, but during their time in the consulting room, not once do they mop them. If that is the case, is the problem really so bad? A semi-quantitative way of recording the watering is to use Munk's classification, (2) where the number of times per day the patient needs to mop their eyes is recorded. Although this classification implies reasonable quantification, in practice, patients can't really remember the exact number of times they mop their eyes. Another way of recording the severity of epiphora has been used by Sahlin (Table 1). (3)

History taking

When assessing the cause of epiphora, it is often thought that simply doing a sac washout will tell you enough. History though, is most important, since not only can it give valuable clues as to what the mechanism of watering might be, it will also indicate how serious it is. If the patient only needs to wipe their eyes three times a day and only when outdoors, it may well be that they will be happy to put up with it. The history can provide valuable clues about whether the epiphora is an excess production problem, or a blockage in the drainage pathways. Soreness and a foreign body sensation will point to excess production, due to excessive reflex tear secretion. This is how dry eye may be a cause for epiphora if basic tear secretion is reduced, causing discomfort, which in turn causes reflex tear secretion. It is also important to enquire about problems with areas around the eyes, which might provide information regarding the cause and possible underlying diseases. Nasal history is important here, since hay fever may cause reflex tear secretion, post-nasal surgery may indicate damage inflicted by the surgeon to the nasolacrimal duct (which is located in the lateral wall of the nose), with infection of the lacrimal sac a possible result. A bloody nasal discharge may point to a malignant growth (Figure 1) encroaching the area under the inferior meatus, blocking the exit of the distal part of the nasolacrimal duct into the nose. Wegener's disease is an autoimmune disorder which may involve the nasal mucosa and cause symptoms such as discharge and 'catarrh'. Facial fractures of the LeFort type tend to be horizontal through the middle of the face and may include the nasolacrimal duct.

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Examination

Facial features

Look at the areas in the upper part of the face. A crooked nose may point to a fracture, which may involve the deeper parts of the nose and the nasolacrimal duct too. A swelling in the medial canthus may point to a swollen lacrimal sac full of mucus (a mucocele--Figure 2) or mucus mixed with purulent material (mucopyocele), which may cause epiphora. Such a mucocele or mucopyocele must be treated before any intraocular operation is considered (eg cataract extraction). If the sac is infected and inflamed (dacryocystitis), the surrounding area will also be red, swollen and painful. A scar near the area of the medial canthus, may point to previous trauma which may have involved the canaliculi. A stenosis (narrowing) may have developed, causing an outflow problem.

Ocular features and assessment

Reflex hypersecretion may be caused by blepharitis, trichiasis, distichiasis, entropion, conjunctival concretions, foreign bodies, dry eyes, eyelashes 'stuck' in the tear punctum, corneal ulcers, corneal abrasions, and anterior uveitis (through photophobia). Slit lamp examination is, therefore, vital to look for signs of any of these and a systematic approach is best. Start by looking for anything which might cause hypersecretion, eg abnormal eyelid position (ectropion) where the tear punctum is not turned towards the tear lake. Then instil fluorescein to check the tear film break up time (TBUT). Follow this by instilling dilating drops, since each patient will need a full dilated fundal examination. Once any reflex tearing from the instillation of tropicamide has subsided, a drop of 2% fluorescein should then be instilled into the lower conjunctival sac for the Jones dye test to be performed. The patient now waits 5-10 minutes, after which the remaining fluorescein in the conjunctival sac is assessed--has there been any dilution of the highly concentrated 2% fluorescein drops? If so, it means these drops have either spilt over onto the cheeks, which you can see, or discover from the patient's report. If this has not occurred, the fluorescein will have diluted and drained into the lacrimal drainage apparatus. It is now time for the Jones test number one. See whether the dye has reached the nose. The presence of fluorescein may be assessed by applying a cotton bud into the nose. The tips used for viral swabs are the right size, however, standard cotton buds are too big. The presence of dye on the bud indicates a positive Jones test number one result, such that the dye has gone through a patent lacrimal drainage system. In the presence of a positive Jones test one, epiphora may still be possible as a result of hypersecretion. If there is no dye, the result is negative. This can be problematic, since 20% of people with a normal lacrimal drainage will have a negative test result (false negative). Visualising the inside of the nose can reduce this number significantly, hence the need for nasal endoscopy. Referral to an ophthalmologist is advisable for this and often the presence of dye in the nose will confirm a patent drainage system. In addition, it will allow the presence of any abnormalities in the nose, which might be contributing to the tearing, to be detected too. The presence of fluorescein in the nose is dependent on the rate of tear production and how long after instillation of fluorescein the nose is examined. (4) As we get older, tear secretion reduces and, therefore, the "normal" time taken for the dye to appear in the nose increases. The Jones test number two is much easier to do (and only really done if the Jones test one was negative). One has to clear all remaining fluorescein from the conjunctival sac, and then do a simple washout of the tear apparatus using a syringe (being careful not to cause any damage to the canaliculi). Do this with the patient leaning slightly forward so that you will be able to see the fluid coming from their nose. It may be either non-coloured or fluorescein stained. If the fluid is clear, then it means the dye has not gone into the lacrimal system, indicating an 'upper system' failure (vide supra) ie lacrimal pump failure, such as in facial palsy, punctal stenosis, canalicular block, or punctal eversion. If the fluid is fluorescein stained, then it means that the dye has reached the outflow system and has collected in the lacrimal sac but has not drained normally into the nasal cavity. This is called a functional block and is due to a partial stenosis, or narrowing of the nasolacrimal duct. Another aspect of the Jones test two is whether the patient feels something at the back of their nose/throat. However, patients can be unreliable in their responses and so objective observation of the dye is preferred.

[FIGURE 3 OMITTED]

Advanced assessment

Where the optometric investigations described above do not offer conclusive evidence, patients can be referred to the hospital eye service (HES) for more advanced assessment, as described below.

Dacryocystogram (DCG)

A DCG is performed in a hospital radiology department, with both eyes tested at the same time. Both inferior canaliculi are cannulated with a small cannula and these are connected to a Y-connector leading to the same syringe. In the syringe is a radio-opaque solution, which is then squirted into the lacrimal drainage system. As the solution flows through the system, x-rays are taken to locate the solution. This solution blocks x-rays and, therefore, appears black on the image. The outlines of this black area correspond to where the solution is sitting (Figure 3). Modern digital subtraction techniques create shadows of the surrounding tissues while the bones are invisible. Complete blockages of the sac are visible as a stop in the nasolacrimal duct; the fluid does not go beyond the block and accumulates above it. Partial blockages can be seen as narrowing, sometimes seen in combination with dilation of the sac just proximal to the block. On other occasions, one will see contrast in the sac on a 'late' x-ray of the face.

[FIGURE 4 OMITTED]

Lacrimal scintillogram

This test is also performed at the radiology department, but it involves a radioactive solution. This is instilled into the conjunctival sac and allowed to flow naturally through the drainage system (unlike in DCG, where it is forced by a syringe). It is, therefore, a physiological test, and very valuable. After every few minutes, an image is taken to determine the location of the radioactivity within the lacrimal drainage system. Once a series of images are created they can be analysed to locate the blockage (Figure 4). This test is complimentary to DCG, where it may be impossible to establish the exact site of a narrowing in functional blocks.

Treatment of watery eyes

Too much tear production

Blepharitis, trichiasis, distichiasis, entropion, conjunctival concretions, foreign bodies, dry eyes, eyelashes 'stuck' in the tear punctum, corneal ulcers, corneal abrasions, and anterior uveitis all need their appropriate treatment if one of these is the cause of the watery eye. Many of these will require treatment with ocular lubricants and lid hygiene with baby shampoo or using commercially available products. However, there may be more than one cause for the epiphora and therefore more than one treatment may be required. Recently, attempts have been made to treat some patients, who do not want major operations, with injections of botulinum toxin instead, although this has produced varying results.

[FIGURE 5 OMITTED]

Too little drainage

Punctal ectropion due to horizontal eyelid laxity needs treating by performing an eyelid shortening procedure. The lateral tarsal strip operation, where the eyelid is cut in the lateral canthus and shortened at this end, is currently the preferred method. This will often result in an eyelid which is sufficiently tight to correct the punctal position. On other occasions, this may need to be combined with excision of a diamond of tarsoconjunctiva just inferior to the punctum. This shortening of the back part of the eyelid will then correctly position the punctum again. Quite often punctal stenosis (narrowing of the tear punctum) is associated with punctal ectropion. It is due to reduced tear flow through the punctum, and this will return to normal once the duct is correctly positioned again. If the punctal ectropion is due to shortening of the anterior lamella (front part of the eyelid) due to, for example, skin conditions, then a skin graft may be required. Canalicular blockages may occur due to a variety of causes. If the stenosis is only in a short section, then excising the narrowed part of the canaliculus and intubating this is enough. If the canaliculi are stenosed over a larger extent, then several options exist. If the stenosis is more than 8mm away from the punctum then a dacryocystorhinostomy (DCR) is performed following excision of the stenosis and intubation. DCR consists of removing the intervening bone between the tear sac and the nasal cavity, so that the lacrimal sac and the nasal mucosa lie directly next to each other. The tissues are connected with sutures and little silicone tubes are then inserted into the canaliculi (not all surgeons use these tubes in all cases), and out into the newly created opening. They are left in the tear passages for anything between six weeks and six months. If the block is nearer than 8mm from the punctum, then technically, it is impossible to excise the stenosis. One then has to insert a glass tube (Jones' tube) through the caruncle and the soft tissues into the nasal cavity. This tube acts simply by gravity and its function is thus position dependent. Sometimes, the canalicular blockages are localised and consist of a little membrane where the common canaliculus enters the tear sac. This can be removed, and intubation with silicone stents done. These silicone tubes prevent the formation of a scar, which would otherwise block the affected part again. Classically, this operation has been done in combination with a DCR, but this may not be necessary. (5) More distal blockages, which are in the sac itself, need a procedure to bypass the block. Several procedures have been tried, but the gold standard against which all other procedures are judged is the open DCR, which has success rates of over 90%. The alternative, dacryocystoplasty, involves expansion of the nasolacrimal duct with a balloon. The tear duct system is then intubated with the silicone tubes again. This procedure has generally not been as successful as DCR, with success rates of 50%. Laser procedures include cutting open the soft tissues (the lacrimal sac and nasal mucosa), (1) but also the bone in between the two. Several laser types have been tried, of which the holmium-YAG appears to be the most useful for cutting through bone. The other slight difference is that the mucosal surfaces of the tear sac and the nose are not sutured, since this is really impossible in an endonasal approach. Also, the size of the bony opening is smaller than the one used in the external approach. Both of these differences perhaps explain the lower success rates achieved with these procedures. Due to advances in technology, it is now possible to visualise the entire lacrimal outflow system directly. Two systems currently on the market allow a probe to be introduced into the canaliculi, and from there into the sac. A monitor shows the images obtained through the little endoscope in the probe, while an irrigation cannula and a laser or microdrill for treating stenoses and dacryoliths (stones in the lacrimal sac) are available options. This technique has mainly been described in the German ophthalmic literature, and good success with hundreds of cases treated so far, is claimed. Of importance is that many patients are not afraid to be left with small scars after DCR procedures (Figure 5) and so this gold standard will still be hard to beat.

References

(1.) Hurwitz JJ. (1996) The lacrimal system. Lippincott-Raven.

(2.) Munk PL, Lin DT, Morris DC. (1990) Epiphora: treatment by means of Dacryocystoplasty with balloon dilatation of the nasolacrimal drainage apparatus. Radiology, 177:687-690.

(3.) Sahlin S, Rose GE. (2001) Lacrimal drainage capacity and symptomatic improvement after dacryocystorhinostomy in adults presenting with patent lacrimal drainage systems. Orbit, 20:173-179.

(4.) Hagele JE, Guzek JP, Shavlik MPH. (1994) Lacrimal testing. Age as a factor in Jones testing. Ophthalmology, 101:612-617.

(5.) Fulcher T, O'Connor M, Moriarty P. (1998) Nasolacrimal intubation in adults. British Journal of Ophthalmology, 82: 1039-1041.

Tristan Reuser, MD, FRCOphth

Tristan Reuser is a consultant eye surgeon, with a special interest in eye plastics. He works at the Heart of England Foundation Trust and at Aspen Eye Care at Midland Eye. He trained in the UK, and the Netherlands. He was a clinical director in ophthalmology, and is a reviewer for both Eye and The British Journal of Ophthalmology. He is an honorary senior lecturer at Birmingham and Aston Universities.
Table 1

Grade of epiphora Degree of epiphora experienced

0 No epiphora
1 Epiphora only outdoors in the wind
2 Epiphora only outdoors but not indoors
3 Epiphora outdoors and indoors
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Title Annotation:CONTINUING EDUCATION & TRAINING: PEER REVIEWED
Author:Reuser, Tristan
Publication:Optometry Today
Article Type:Report
Geographic Code:4EUUK
Date:Jun 29, 2012
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