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Sunday, August 17, 2025

Watering eyes


Introduction

Watering eyes, medically known as epiphora, refers to excessive tear production or impaired tear drainage. While occasional watering can be normal—such as in response to wind, bright light, or strong emotions—persistent or excessive watering may indicate underlying ophthalmological or systemic disease. It can affect one or both eyes and occurs across all age groups, from infants with congenital tear duct obstruction to older adults with age-related eyelid or drainage issues.

Causes of Watering Eyes

Watering eyes result either from overproduction of tears (reflex tearing) or impaired drainage of tears through the nasolacrimal system.

1. Reflex Tearing (Overproduction of Tears)

  • Irritation and Inflammation:

    • Conjunctivitis (viral, bacterial, allergic)

    • Keratitis (corneal inflammation)

    • Foreign body in the eye

    • Trichiasis (misdirected eyelashes)

    • Dry eye syndrome (paradoxical reflex tearing due to ocular surface dryness)

  • Environmental Factors:

    • Wind, smoke, bright light, strong fumes.

2. Impaired Tear Drainage

  • Congenital Nasolacrimal Duct Obstruction (NLDO):

    • Common in infants, presents with constant watering and discharge.

  • Acquired Nasolacrimal Duct Obstruction:

    • Due to infection, trauma, inflammation, or age-related narrowing.

  • Eyelid Malpositions:

    • Ectropion (outward turning of eyelid → poor tear drainage).

    • Entropion (inward turning → lashes irritate cornea).

  • Lacrimal Pump Failure:

    • Weak orbicularis oculi muscle in facial nerve palsy.

3. Other Causes

  • Blocked puncta: Scarring or narrowing of punctal openings.

  • Systemic diseases: Sarcoidosis, Wegener’s granulomatosis, tumors compressing lacrimal pathway.

Clinical Presentation

  • Persistent or intermittent tear overflow on the cheeks.

  • Associated features depending on cause:

    • Redness, discharge (conjunctivitis).

    • Itching (allergic conjunctivitis).

    • Grittiness, burning (dry eye).

    • Pain, swelling near inner canthus (dacryocystitis).

    • Distorted eyelid position (ectropion/entropion).

Diagnosis

  1. History: Onset (since birth, recent), laterality, associated discharge, pain, itching, or trauma.

  2. Examination:

    • Inspect eyelid position, puncta, conjunctiva, cornea.

    • Palpate lacrimal sac for swelling or discharge.

  3. Special Tests:

    • Fluorescein dye disappearance test (assesses tear drainage).

    • Lacrimal syringing/irrigation (checks for duct blockage).

    • Imaging (dacryocystography, CT/MRI) if tumors suspected.

Treatment and Management

1. General Measures

  • Protect eyes from wind, dust, smoke.

  • Avoid rubbing the eyes.

  • Use lubricating eye drops (artificial tears) for dry eye syndrome.

2. Pharmacological Treatment

  • Bacterial Conjunctivitis:

    • Chloramphenicol 0.5% eye drops: 1 drop every 2 hours initially, then 4 times daily for 5 days.

    • Fusidic acid 1% eye gel: 1 drop twice daily.

  • Allergic Conjunctivitis:

    • Olopatadine 0.1% eye drops: 1 drop twice daily.

    • Sodium cromoglicate 2% eye drops: 1 drop 4 times daily.

    • Oral antihistamines (e.g., Loratadine 10 mg daily) if systemic symptoms present.

  • Dry Eye (Reflex Tearing):

    • Artificial tears (e.g., Hypromellose 0.3% drops, 1–2 drops as needed).

    • For severe cases: Cyclosporine 0.05% eye drops twice daily.

  • Dacryocystitis (Infection of the Lacrimal Sac):

    • Co-amoxiclav 625 mg orally three times daily for 7–10 days.

    • Warm compresses.

    • Surgical drainage if abscess forms.

3. Surgical and Procedural Interventions

  • Congenital NLDO in infants:

    • Lacrimal sac massage (“Crigler massage”) several times daily.

    • If unresolved by 1 year, probing of nasolacrimal duct under anesthesia.

  • Acquired Obstruction in Adults:

    • Dacryocystorhinostomy (DCR): Surgical creation of a new drainage pathway into the nasal cavity.

    • Punctoplasty: Enlarging punctal openings if narrowed.

  • Eyelid Malpositions:

    • Corrective eyelid surgery for ectropion or entropion.

Precautions and Monitoring

  • Infants with congenital watering eyes should be monitored for recurrent infection.

  • Recurrent dacryocystitis can cause permanent scarring if untreated.

  • Prolonged use of topical antibiotics should be avoided due to resistance.

  • Chronic dry eye should be managed carefully to avoid corneal damage.

Drug Interactions

  • Topical antihistamines (e.g., Olopatadine) + systemic sedatives/antihistamines: May increase drowsiness when oral forms are also used.

  • Chloramphenicol eye drops + bone marrow-suppressing drugs (e.g., chemotherapy agents): Increased risk of systemic bone marrow suppression (though rare with topical use).

  • Cyclosporine eye drops + systemic cyclosporine: Additive immunosuppressive effects.

  • Artificial tears containing preservatives may interact with contact lenses—preservative-free formulations are preferred for contact lens wearers.

Red-Flag Symptoms Requiring Urgent Referral

  • Painful swelling near the inner corner of the eye (dacryocystitis).

  • Sudden onset of unilateral watering with bloody discharge (possible tumor).

  • Recurrent or persistent eye redness and photophobia (possible keratitis or uveitis).

  • Watering associated with vision loss




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