Watery eyes CENTER FOR FACIAL PLASTIC SURGERY AT ENT SPECIALISTS

Watery eyes

It’s not “Just Dry Eyes”! Watery Eyes (Tearing) is a treatable condition!

Naturally the tears produced by the lacrimal gland drain from the eyes into the nose through the tear ducts. When these ducts become blocked or when there is an overproduction of tears, the eyes water.

The treatment of watery eyes is always done on an individualized approach because, in the majority of cases, there is not one but multiple causes responsible. This can be a simple office procedure under local anesthesia or a more involved surgery under general anesthesia.

Causes of Tearing

Excessive tearing can result from a great number of individual causes or from a combination of problems. For this reason, an individualized approached to the diagnosing and management of tearing is essential for obtaining the desired result.

The causes of excessive tearing can be classified in 2 main categories:
I. Insufficient drainage of tears

a. Anatomical blockage of the tear duct

i. Punctal Stenosis – Lacrimal punctum is the name of the opening of the tear duct on the eyelid margin. The punctum can get blocked any time there is inflammation present on the eyelid margin, as it occurs with: dry eyes, allergies, glaucoma medication, ectropion, eyelid laxity, eyelid retraction etc. The rest of the lacrimal ducts are usually open, and a simple office procedure called punctoplasty can be performed to open the blocked punctum. However, if the underlying cause of inflammation is not corrected prior to the procedure, the rate of recurrence is over 50%.

ii. Canalicular Stenosis – Lacrimal Canaliculus is the name of the small tear duct present inside each eyelid that connects the punctum with the lacrimal sac. Even though there are 2 canaliculi per eye, the disease processes that lead to the blockage of the canaliculus tend to affect both the upper and the lower ducts. Most common causes are viral conjunctivitis, allergies, certain cancer medications and many different types of eye drops, especially those used to treat glaucoma (high eye pressure). Treatment of canalicular stenosis can sometimes be very difficult because of the high recurrence rate and needs to be done on an individual basis depending on the location and degree of stenosis. When complete canalicular stenosis is present a special permanent tube called Jones tube is used like a stent to create a direct communication between the inner corner of the eye and the nose.

iii. Congenital Nasolacrimal Duct Obstruction (cNLDO) – Approximately 7% of babies are born with congenital obstruction of the tear drainage system in the nose (the Nasolacrimal duct). This resolves itself in the first year of life in over 90% of cases as the Valve of Hasner begins to spontaneously open. In the 10% of infants where the valve does not open by 1 year of age, a quick procedure needs to be done to open it. In rare instances, the nasolacrimal duct is partly or totally absent in which case an endoscopic bypass (Dacryocystorhinostomy) needs to be done around 4 years of age.

iv. Primary Acquired Nasolacrimal duct obstruction (PANDO) – In adults, the most common causes of NLDO are atmospheric pollution, medication, chronic nasal inflammation, allergies, chronic sinusitis or nasal trauma. PANDO leads to tearing and mucus discharge from the eye that can significantly alter one’s quality of life and impair daily activities. The most common complication of PANDO is lacrimal sac infection called Dacryocystitis. This occurs in the majority of patients that have chronic nasolacrimal duct obstruction and can happen at any time. Lacrimal obstruction in adults never resolves itself and surgical intervention called Dacryocystorhynostomy (DCR) is required. Typically this procedure is done using an endoscope and has a success rate of over 95%.

b. Functional blockage of the tear duct – lacrimal pump failure

i. Facial paralysis – Regardless of whether you recover or not from facial paralysis (Facial Palsy, Bell’s Palsy), the lacrimal pump situated in the inner corner of the eye does not function properly. The tear duct is anatomically open but the absence of pump function leads to the stagnation of tears in the eye and constant watering. This condition can be dramatically improved by injecting Botox in the eyelid (if aberrant regeneration is present) or by correcting the paralytic ectropion (when the case).

ii. Eyelid laxity – The lacrimal pump depends on the proper horizontal tightness of the eyelids. Any disease or condition that makes the eyelids become loose can impair the functioning of the lacrimal pump and result in tearing. Floppy Eyelid Syndrome (FES) is seen in the majority of patients suffering from Obstructive Sleep Apnea (OSA) whether or not they are using a CPAP machine.

iii. Ectropion (eyelid turned out) – An eyelid turned outwards can lead to chronic tearing by 3 mechanisms. First, the eye becomes excessively exposed to the air which makes it drier and irritated. Consequently, the lacrimal gland produces an excessive amount of tears. Second, the lacrimal punctum does not come any longer in contact with the tear lake when the eyelid turns out. And, third, the lacrimal pump does not function in the presence of a loose eyelid turned outwards. All 3 mechanisms need to be addressed in order to obtain an adequate improvement in tearing. Sometimes, a 4 th mechanism is associated: punctal stenosis from the chronic inflammation of the eyelid exposed to the air. This is usually addressed at the same setting.

iv. Eyelid retraction – When the eyelid is pulled downwards from various pathologies, is not protecting the eyeball and does not function as a good windshield wiper, the eye becomes dry and irritated. This results in a reflex overproduction of tears by the lacrimal gland. Frequently, the lacrimal pump is also impaired due to the associated eyelid laxity, further exacerbating the tearing. Proper correction of any eyelid malposition (inadequate eyelid position) is mandatory to improve tearing in theses cases.

II. Excessive production of tears
a. After facial paralysis – Aberrant regeneration of the facial nerve after VII nerve palsy (Bell’s palsy) can lead to a branch of the trigeminal nerve (the 5 th cranial nerve involved in chewing) being mis-wired to innervate the lacrimal gland. Consequently, the eye starts to water spontaneously during eating. This condition cannot be prevented but can be successfully treated with Botox injections into the lacrimal gland.

b. Trichiazis (misdirected lashes) – Any eyelash rubbing on the eyeball leads to the reflex over-production of tears. This condition can be treated by permanently removing the offending lashes in the office with a special radiofrequency device.

c. Entropion (Eyelid turned in) – When the entire eyelid is turning in, a condition known as entropion, the eyelashes and the lid margin can rub severely against the eyeball resulting in irritation and sometimes a corneal ulcer. The lacrimal gland immediately starts producing tears in excess in an effort to relieve the severe irritation. Untreated, entropion can result in corneal scarring and permanent vision loss.

d. Dry eyes – A great number of conditions can result in dry eye syndrome or simply dry eyes. Systemic diseases such as Sjögren’s, Reumatoid arthritis, Lupus and Graves disease are among the most common. Dry eyes is also an occupational disease encounter in over 60% of the population today. The combination of computers, smart-phones and air conditioning has a very severe impact on the ocular surface for which reason dry eyes is now seen in many young people, including children. Dry eyes is a frequent cause of reflex tearing (secondary to eye irritation) in which case it is frequently mis-diagnosed and treated as conjunctivitis. Dry eyes can also result from anatomical problems related to the eyelids functioning as windshield wipers and protecting and lubricating the eyeballs. These eyelid malpositions (abnormal eyelid position) always need to be corrected, otherwise the use of artificial tear drops and ointments has only a minimal benefit. The most common eyelid problems leading to dry eyes and consecutive tearing are:

i. Ectropion (eyelid turned out) – when the lower eyelid turns outward, it doesn’t protect the eyeball any more and it doesn’t function as a windshield wiper to lubricate the eye. Consequently, the eye surface gets dry and irritated which triggers an overproduction of tears from the lacrimal gland. This results in watery eyes, worse when reading, watching TV or working on the computer. Patients are frequently misdiagnosed as having a conjunctivitis and are given antibiotic-steroid drops that do more harm than good. The only therapeutic option for ectropion is surgical repair which will both correct the dry eye syndrome and will reactivate the lacrimal pump.

ii. Eyelid laxity – When the eyelids become loose from different pathologies, they don’t protect and lubricate the eyes as they should, and the eyes become dry. Through a trigeminal reflex, the lacrimal gland is stimulated to produce an excess of tears and the eyes become watery. However, the eyes feel more dry than whet and the episodes of tearing are usually preceded by dry eye symptoms such as: irritation, burning, itching and blurry vision.

iii. Eyelid retraction – When the upper or the lower eyelid is retracted and not protecting the eyeball, dry eyes and irritation occur which trigger the production of tears by a reflex mechanism. Unfortunately, these tears are not of good quality because they are produced by the lacrimal gland and are too watery. This is the reason why, when one cries because of feeling sad, the eyes become red and irritated. Using artificial tears that are lubricating can temporarily relieve the symptoms and paradoxically block the tearing. However, permanent correction of the eyelid retraction is usually necessary.

e. Allergies – There are two mechanism by which allergies lead to watery eyes. The itching and irritation produced by the release of inflammatory molecules onto the ocular surface leads to reflex tearing. In addition, the inflammation throughout the lacrimal drainage system can frequently lead to anatomical blockage (obstruction) of the tear duct. This can happen anywhere from the punctum to the nasolacrimal duct and can be permanent. Sometimes, rapid and effective intervention can decrease the inflammation and allow the tear duct to reopen. The treatment is usually with allergy eye drops but surgical intervention is sometimes necessary.

Treatment of Tearing
Congenital Nasolacrimal Duct Obstruction

In babies, the initial treatment involves massaging the area around the affected lacrimal sac to force the tears down the duct, and to push open the membrane causing the obstruction. This works in about 90% of cases. If the symptoms do not resolve by 9 months of age, a small office-based procedure is necessary to open the membrane in the nose. After 1 year of age, the membrane can only be opened in the operating room using an endoscope under general anesthesia. The advantage of using an endoscope to directly visualize Hasner’s valve is the high success rate of the procedure and the decreased risk of complications. This outpatient procedure takes less than 15 min.
In the rare instance where the bony nasolacrimal duct is absent (congenital malformation), a bypass procedure that directly connects the lacrimal sac with the nose can be done endoscopically (without skin incision) around 4 years of age. This reestablishes the missing anatomy and is usually permanent.

Acquired (Adult) Tear Duct Blockage
There are different treatments for adults depending on the location of the blockage:
Punctoplasty

When the opening of the tear duct (punctum) is blocked, a small office-based procedure called punctoplasty is performed to open it. It takes about 5 minutes and is done under local anesthesia. There is no downtime and the patient can resume normal activities immediately after. Although the success of the procedure is high and immediate, failure to treat the underlying inflammation (dry eyes, allergies etc) can lead to recurrence of punctal occlusion and tearing.

Intubation (Stenting)
An upper obstruction in one or both of the tear duct located inside the eyelid (canaliculus) can usually be resolved with placement of a small silicone tube (lacrimal stent) in the natural canal, for a couple of months. This is done in the operating room under general anesthesia and takes about 20 minutes. The patient can go home immediately after and resume normal activities the next day. The patient needs to use anti-inflammatory eyedrops and nasal spray for a couple of weeks. The tube is removed in the office through a painless procedure. Intubation is rarely used by itself today since better techniques are available but in certain situations (cancer treatments) they can be quite effective.

Jones Tube
A severe upper canalicular obstruction at the level of the eyelids can be solved by placing a rigid glass tube, called the Jones tube, in the inner corner of the eye. This will directly drain the tears into the nose. The permanent tube is generally well tolerated and does not cause discomfort. Rarely, the tube can get blocked by scar tissue or fall out. If this happens, an additional procedure to replace it will be required. Surgery is done under general anesthesia and takes about 20 minutes. The patient can go home soon after.
Using an endoscopic technique, this procedure does not require a skin incision and recovery is quick, although the patient cannot blow the nose for 2 weeks.

Dacryocystorhinostomy (DCR)
A lower obstruction in the nasolacrimal duct can be resolved with a dacryocystorhinostomy (DCR). This is the only effective long-term treatment. The DCR is done under general anesthesia or MAC sedation using an endoscope through the nose. A new communication between the lacrimal sac and the nose is made to allow tears to drain. A silicone stent is usually placed for 6 weeks and removed in the office. This outpatient surgery takes about 20 min and the patient goes home 30-60 minutes after (as soon as full recovery from the anesthesia is obtained).
Patients prefer the endoscopic DCR to the external DCR because no skin incision is necessary, the recovery time is shorter and there is less postoperative discomfort.

Eyelid Problems
Whenever the eye watering (tearing) is the result of an eyelid pathology, functional eyelid surgery needs to be performed in order to correct the abnormal eyelid position.

Ectropion, entropion, eyelid laxity and eyelid retraction can all result in reflex tearing and functional NLDO from lacrimal pump failure.

Eyelid surgery is typically performed at the same time with lacrimal duct surgery or as a standalone procedure if the tear duct is anatomically normal. Most cases require horizontal tightening of the eyelid and repositioning of the lacrimal punctum. Sometimes a vertical eyelid lift is necessary to correct the eyelid retraction.

Recovery
The recovery from both lacrimal and eyelid surgery is relatively quick. The advantage of performing both the tear duct and the eyelid surgery at the same setting is having only one recovery. Minimal bruising can be seen for a couple of weeks if eyelid surgery is performed. Antibiotic ointment is applied on the incisions 3 times a day for 3 weeks. Stitches dissolve themselves. It is essential to stop all anti-inflammatory medication such as Aspirin, Ibuprofen, Advil, Naproxen, Diclofenac etc. and all vitamins and supplements 2 weeks prior to surgery with the accord of the primary care physician to avoid unnecessary bruising.