Ocular Tearing (Epiphora)

What is Ocular Tearing (Epiphora)?

Epiphora (pronounced /ˌe-pɪˈfrɔːr-ə/) is the medical term for excessive tearing from the eyes. While crying produces tears as a normal emotional response, epiphora refers to a chronic, often painless overflow of tears that cannot be cleared by the normal drainage system. Tears may spill onto the cheeks, cause a constant “wet‑eye” feeling, or make glasses fog continuously.

Under normal circumstances, three layers of tears—basal, reflex, and emotional—coat the ocular surface, lubricating the cornea and washing away debris. After spreading across the eye, tears drain through tiny puncta (tiny openings on the inner eyelid), travel into the canaliculi, then into the lacrimal sac and finally the nasolacrimal duct, which empties into the nose. Any interruption in production, outflow, or eyelid anatomy can lead to epiphora.

Common Causes

Epiphora is a symptom rather than a disease itself. Below are the most frequent conditions that disrupt tear dynamics.

• Nasolacrimal duct obstruction (NLDO) – blockage of the duct that drains tears into the nose, often due to infection, inflammation, or age‑related stenosis.
• Punctal stenosis – narrowing or closure of the puncta, sometimes from ageing, scarring, or chronic inflammation.
• Ectropion – outward turning of the lower eyelid that prevents tears from contacting the ocular surface properly, leading to overflow.
• Entropion – inward turning of the eyelid causing irritation and reflex tearing.
• Blepharitis – inflammation of the eyelid margin that triggers reflex tearing and can block tear outflow.
• Allergic conjunctivitis – allergens provoke histamine release, causing excessive reflex tears.
• Foreign body or corneal abrasion – mechanical irritation stimulates tear production.
• Dry eye syndrome (aqueous‑deficient or evaporative) – paradoxically, a dry surface can trigger reflex tearing.
• Medications – drugs such as isotretinoin, antihistamines, or certain glaucoma drops can alter tear production or eyelid position.
• Systemic conditions – rheumatoid arthritis, Sjögren’s syndrome, or thyroid eye disease may affect the lacrimal system.

Associated Symptoms

Patients with epiphora often notice other ocular or facial signs, including:

• Blurred vision that improves after wiping tears away
• A persistent “watery” feeling on the cheek or under the eye
• Redness or mild irritation of the conjunctiva
• Skin maceration or dermatitis around the eyes from constant moisture
• Frequent need to adjust or clean glasses
• Feeling of a “foreign body” in the eye
• Swelling or a palpable lump near the inner corner of the eye (possible lacrimal sac swelling)
• Headache or facial pressure if the nasolacrimal duct is completely blocked

When to See a Doctor

Most cases of mild, intermittent tearing can be managed with simple home measures, but you should schedule an eye‑care appointment if you experience any of the following:

• Tearing that persists for more than two weeks without improvement
• Accompanying pain, severe redness, or sudden vision loss
• Swelling or a tender lump near the inner corner of the eye
• Recurrent eye infections (conjunctivitis or dacryocystitis)
• Difficulty keeping glasses clean or frequent fogging of contact lenses
• History of trauma, recent eye surgery, or known eyelid malposition

Early evaluation helps prevent complications such as chronic inflammation, infection of the lacrimal sac (dacryocystitis), or damage to the cornea from constant moisture.

Diagnosis

Eye care professionals use a stepwise approach to pinpoint the source of epiphora.

1. History & Symptom Review

Questions focus on onset, duration, triggers (allergens, activities), medication use, and any prior eye surgeries.

2. Visual Inspection

• Examination of eyelid position (checking for ectropion/entropion)
• Assessment of puncta size and patency
• Inspection for signs of blepharitis, conjunctival redness, or skin changes

3. Fluorescein Dye Test & Slit‑Lamp Examination

Fluorescein dye highlights corneal abrasions and allows the clinician to observe tear film breakup time, aiding distinction between dry eye‑induced reflex tearing and true overflow.

4. Lacrimal Drainage Evaluation

• Fluorescein Dye Disappearance Test (FDDT) – a drop of dye is placed in the eye; normal drainage clears the dye in <30 seconds.
• Jones Dye Test – assesses whether tears are draining into the nose.
• Dacryocystography (CT or MR dacryocystography) – imaging used for suspected nasolacrimal duct blockage.
• Nasolacrimal probing and irrigation – a fine probe is inserted to check for obstruction; saline irrigation confirms patency.

5. Laboratory Work‑up (Selective)

If an autoimmune condition is suspected, blood tests for rheumatoid factor, anti‑CCP, ANA, or Sjögren’s antibodies may be ordered.

Treatment Options

Treatment is tailored to the underlying cause. Options range from simple lifestyle changes to minimally invasive procedures.

1. General Home Care

• Warm compresses (5‑10 minutes, 2‑3 times daily) can help open clogged puncta or relieve blepharitis.
• Lid hygiene – gentle scrubbing with diluted baby shampoo or commercial lid wipes reduces bacterial load.
• Artificial tears (preservative‑free) lubricate the surface and may break the cycle of dry‑eye‑induced reflex tearing.
• Allergen avoidance – use hypoallergenic bedding, keep windows closed during high pollen counts, and rinse eyes with saline after exposure.
• Medication review – discuss with your physician whether any current drugs might be contributing to tear overproduction.

2. Pharmacologic Therapies

• Topical antihistamine/mast cell stabilizer drops for allergic conjunctivitis (e.g., olopatadine, ketotifen).
• Topical antibiotics if bacterial conjunctivitis or dacryocystitis is present.
• Corticosteroid eye drops (short‑term) for severe inflammation, prescribed by an ophthalmologist.

3. Procedural Interventions

• Punctal Dilatation or Stenting – using small dilators or silicone tubes to keep puncta open.
• Lacrimal Probing & Silicone Intubation – a thin probe or tube is placed through the nasolacrimal duct to restore drainage; often used in children and adults with NLDO.
• Dacryocystorhinostomy (DCR) – surgical creation of a new drainage pathway between the lacrimal sac and nasal cavity. Can be performed externally or endoscopically (the latter has a quicker recovery).
• Eyelid surgery – correction of ectropion, entropion, or ptosis to restore proper tear flow.

4. Adjunctive Therapies

• Botulinum toxin A injections into the lacrimal gland can reduce tear production in refractory cases (off‑label use).
• Oral doxycycline (100 mg twice daily for 2‑4 weeks) can improve meibomian gland function in patients with concurrent blepharitis.

Prevention Tips

While some causes (age‑related duct narrowing) cannot be fully prevented, many lifestyle and eye‑care habits reduce the risk of developing epiphora.

• Maintain eyelid hygiene—clean lids daily, especially if you wear makeup.
• Protect eyes from wind, dust, and irritants with sunglasses or protective goggles.
• Stay hydrated and use a humidifier in dry indoor environments to support normal tear film.
• Limit prolonged screen time; follow the 20‑20‑20 rule (every 20 min, look 20 feet away for 20 seconds) to reduce ocular surface stress.
• Manage allergies proactively with antihistamines and nasal corticosteroid sprays.
• Schedule regular eye examinations (at least every 1–2 years) to catch early lid or drainage abnormalities.
• Avoid rubbing eyes vigorously, which can damage puncta and eyelid margins.

Emergency Warning Signs

Key Take‑aways

Epiphora is a common yet often overlooked symptom that can arise from a wide spectrum of ocular or systemic conditions. Understanding the underlying cause—whether it is a blockage in the nasolacrimal system, eyelid malposition, allergy, or dry‑eye‑driven reflex tearing—is essential for effective treatment. Most cases are manageable with simple hygiene measures and topical therapy, but persistent or painful tearing warrants a thorough ophthalmologic evaluation.

References

• Mayo Clinic. “Epiphora (excessive tearing).” https://www.mayoclinic.org. Accessed April 2024.
• Cleveland Clinic. “Dry Eye and Excessive Tearing.” https://my.clevelandclinic.org. Accessed April 2024.
• American Academy of Ophthalmology. “Lacrimal System Disorders.” https://www.aao.org. Updated 2023.
• National Institute of Allergy and Infectious Diseases (NIAID). “Allergic Conjunctivitis.” https://www.niaid.nih.gov. 2022.
• World Health Organization. “Guidelines for the Management of Eye Health.” WHO, 2021.