Treatment of Tearing in Children and Adults

The causes of tearing in adults and infants differ. Most excessive tearing problems in infants and very young children are congenital or present at birth. The tear outflow pathway has not fully opened due to a persistent membrane that blocks the lower end of the tear duct where it empties inside the nose. Normally, this membrane pops open at or before birth. In many infants it is still closed at 6 months of age causing a backup of tears. This blockage opens spontaneously in most children within the first year of life. If it has not resolved by 12 months intervention is required. Other cause if tearing must be ruled out such as congenital glaucoma, malpositioned eyelids with eyelashes rubbing against the cornea, and irritation from wind, pollen, smoke or chemicals.

Often simple massage of the tear sac in a downward direction can encourage opening of the lower end of the tear duct. If it does not probing of the duct is indicated. This can be done with or without anesthesia and no pain is felt by the infant. A thin, blunt metal probe is carefully passed through the tear drainage system from the eyelid down through the duct in the nasal bone to pop the membrane causing the obstruction. Fluid is then irrigated through the system to ensure the pathway is open. Some blood staining of the tears or nasal secretions is common and antibiotic drops are used for about 1 week. If the probing is done by 13 months there is a 97% success rate, but this decreases as the infant gets older.

If probing is unsuccessful, a second attempt can be made and silicone tubes can be placed into the nasolacrimal system and left in place for several months. These tubes keep the system open while the tissues heal and are removed in the office 6 to 12 months later. It is rare that intubation fails but if it does then a procedure called a DCR can be performed. This will be described under treatment for tearing in adults.

As in children the treatment of tearing in adults depends on the problem. In general, there are two broad categories: tearing resulting from an over-production of tears due to some kind of irritation (reflex tearing), and tearing secondary to obstruction of tear drainage (obstructive tearing). In the former, identification and elimination of the irritant can solve the problem. If tearing is secondary to irritation by an inturned eyelash, the lash is removed. This can be done manually at first. If the lash recurs, it can be ablated with cryotherapy, electrolysis, or with a laser. Abnormal eyelid position may require simple reconstructive procedures done under local anesthesia in the office setting.

Dry Eye Syndrome (DES) is a common cause of reflex tearing. The baseline level of tear production or tear quality is not sufficient to keep the eye comfortable and a feedback signal results in a gush of tears that overwhelms the system. A trial of artificial tears and/or RestasisTM may be helpful. If this does not help, the punctal openings in the eyelids can be blocked with small plugs to allow more retention of tears.
 
A gradual narrowing and eventual blocking of the nasolacrimal (tear drainage) duct in the bony part of the nose is a common cause of obstructive tearing in adults. If this is determined to be the cause, surgery to open it is required (dacryocystorhinostomy or DCR).

This procedure is done under local anesthesia with sedation. The tear sac and surrounding tissues are numbed with local anesthesia. The inside of the nose is also anesthetized with medication such as cocaine, which also decreases bleeding. During surgery a small cut is made on the side of the nose and the nasolacrimal (tear) sac is opened. An opening is created in the nasal bone and the tear sac is joined to the lining tissue inside the nose. A silicone tube is then placed in the nasolacrimal system and left for six to 12 months to maintain the passageway. Removal of the tube is carried out in the office simply by cutting the tube and letting it fall out.

This procedure can also be done from inside the nose using an endoscope but the success rate is not as high as the external approach.  Inflating a balloon inside the tear duct to stretch it open has also been tried but is generally not as effective as a DCR.

In rare cases, the nasolacrimal sac is scarred shut and cannot be opened. In these instances, a small pyrex glass tube (Jones tube) is put in place to drain tears from the eye into the nose. The tubes are generally well tolerated. They occasionally need rinsing to keep them open and sometimes need to be exchanged, each of which requires minor adjustments that can be done in the office.

Are there possible complications?

The vast majority (95% to 97%) of the DCR surgeries work fine and the tearing is resolved. Complications are generally of a minor nature. Swelling around the incision and eyelids may be present post-operatively. This is easily settled with ice packs.

The incision for this surgery sits at the junction of the nose and eyelid and blends into the surrounding tissue nicely. By three months, it is almost invisible in more than 95% of patients. As with any surgical procedure, there is the possibility of infection, but it is uncommon. Bleeding from the nose or surgical site occasionally occurs to a minor degree on the day of surgery and it is common to develop a black eye after the surgery. Continued and heavy bleeding resistant to manual compression of the nose is uncommon and may require a return to the hospital with placement of a nasal pack for 24 to 48 hours.

The silicone tubes may cause some minor eye irritation for one or two weeks. The tubes generally are very well tolerated for the six to 12 months that they are in place, but occasionall6y may produce an odor, which, if persistent, will lead to early removal.

The new tear duct passageway occasionally will scar shut (three to five percent of cases). If this occurs, simply replacing the tubes back into the passage for an additional six months may be all that is needed to re-open the system. At other times, a revision of the procedure may be suggested.