Most tears are produced in the lacrimal gland and are vital for the health of your eyes. Blinking helps spread the tear film over the eye and assists in draining the tears into two small ducts called the lacrimal puncta, which are in the inner corner of the eye. The tears collect in the lacrimal sac and drain into the nose through the nasolacrimal duct. Together, these parts comprise the nasolacrimal system, responsible for the production and drainage of tears.
Excess tears from any cause give the eye a moist appearance and can cause trouble with reading. Also, continuous tearing onto the cheek is annoying and may cause skin irritation.
When a patient presents with tearing, it's important to determine if it is the result of:
These are the most common causes of tearing:
Improper tear drainage
The causes of tearing in adults and infants differ, and are therefore treated differently.
Most excessive tearing problems in infants and very young children are congenital or present at birth.
Tearing in infants is often the result of the outflow pathway not fully opening. This is due to a membrane blocking the lower end of the tear duct, where it empties into the nose. Normally, this membrane pops open at or before birth.
If the blockage is present, it usually opens spontaneously in most children within the first year of life. If it has not resolved by 12 months, however, intervention is required. Before any such intervention, your eye doctor will of course rule out any other possible causes of the tearing, such as congenital glaucoma, malpositioned eyelids with eyelashes rubbing against the cornea, and irritation from wind, pollen, smoke or chemicals.
Tear Sac Massage or Probing
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 required. This can be done with or without anesthesia, and no pain is felt by the infant.
A thin 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 drainage 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 one week. If the probing is done by 13 months, there is a 97% success rate, but this decreases as the infant gets older. So, be sure to book an appointment at Clemson Eye as soon as you notice excessive tearing in your infant.
If probing is unsuccessful, a second attempt can be made and silicone tubes can be placed into the nasolacrimal system. These tubes keep the system open while the tissues heal and are removed in the office six to 12 months later. It is rare that intubation fails, but if it does then a procedure called a dacrocystorhinostomy (DCR) can be performed.
As in children, the treatment of tearing in adults depends on the problem.
In tearing resulting from an over-production of tears due to some kind of irritation (called “reflex tearing”), identification and elimination of the irritant can solve the problem. For example, if tearing is due to irritation from an in-turned 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 causing excessive tearing may require simple reconstructive procedures done under local anesthesia in the office setting.
Dry Eye Syndrome
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.
Causes and Treatment of Obstructive Tearing in Adults
A gradual narrowing and eventual blockage 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, dacryocystorhinostomy or DCR surgery is required to open it is.
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, which 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.
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 occasionally may produce an odor, which, if persistent, will lead to early removal.
The new tear duct passageway occasionally will scar shut (3% to 5% of cases). If this occurs, inserting 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.