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Ophthalmic Tearing (Epiphora)

What is Ophthalmic tearing (epiphora)?

Epiphora is the medical term for excessive tearing from the eyes. While tears are essential for lubricating the cornea, protecting the eye from debris, and maintaining clear vision, an over‑production or impaired drainage of tears can cause watery eyes that spill over the lower lid. This overflow is what patients commonly notice as “watering” or “tearing.”

Epiphora can be primary (the lacrimal glands produce too much fluid) or secondary (the tear‑draining system is blocked or dysfunctional). The condition may be intermittent or constant and can affect one eye or both.

Common Causes

The underlying reason for epiphora often falls into three categories: excess production, obstruction of drainage, or eyelid malposition. Below are the most frequently encountered causes.

• Dry‑eye syndrome – Paradoxically, inadequate lubrication triggers a reflex increase in tear production.
• Allergic conjunctivitis – Pollen, dust, or animal dander cause inflammation and watery discharge.
• Infection (bacterial or viral conjunctivitis) – Inflammation of the conjunctiva leads to crusty, watery secretions.
• Blepharitis – Inflammation of the eyelid margin can disturb the tear film and cause overflow.
• Ectropion or entropion – Outward‑turning (ectropion) or inward‑turning (entropion) eyelids prevent proper tear spread and drainage.
• Nasolacrimal duct obstruction (NLDO) – Blockage of the duct that carries tears into the nose; may be congenital or acquired (e.g., from infection, trauma, aging).
• Punctal stenosis or closure – The tiny openings (puncta) on the eyelid margin become narrowed.
• Foreign body or eyelash (cilium) impaction – Mechanical irritation stimulates tearing.
• Medication side‑effects – Certain eye drops (e.g., prostaglandin analogs for glaucoma) or systemic drugs (e.g., antihistamines) can affect tear dynamics.
• Systemic conditions – Autoimmune diseases (e.g., Sjögren’s syndrome) and neurological disorders (e.g., facial nerve palsy) may disrupt normal tear production or drainage.

Associated Symptoms

Patients with epiphora often notice other eye‑related signs that help identify the cause.

• Redness or pinkness of the sclera (conjunctival injection)
• Itching, burning, or gritty sensation
• Eye discharge that is clear, mucoid, or purulent
• Blurred vision that clears when blinking
• Swelling of the eyelid margins
• Soreness or pain around the inner corner of the eye (punctal area)
• Recurrent styes or chalazia
• Difficulty keeping contact lenses in place
• Upper or lower eyelid crusting, especially after sleep

When to See a Doctor

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

• Persistent tearing that lasts more than a week despite home measures.
• Discharge that is yellow, green, or foul‑smelling (possible infection).
• Significant eye redness accompanied by pain or light sensitivity.
• Sudden onset of tearing after eye injury or trauma.
• Double vision, loss of visual acuity, or a sensation of a foreign body that does not resolve.
• Swelling or a palpable lump near the inner corner of the eye.
• History of cancer, recent sinus surgery, or facial fractures.

Prompt evaluation is especially important for children with congenital NLDO, as untreated blockage can lead to recurrent infections.

Diagnosis

Eye doctors (ophthalmologists or optometrists) use a systematic approach to pinpoint the cause of epiphora.

History and Physical Examination

• Detailed symptom timeline, triggers, and any associated systemic illnesses.
• Medication review – including eye drops and over‑the‑counter products.
• External eye inspection for lid position, skin changes, or visible blockage.

Special Tests

• Fluorescein dye test – Highlights corneal abrasions and assesses tear film stability.
• Schirmer test – Measures tear production using a small strip of filter paper placed under the lower eyelid.
• Lacrimal irrigation (Jones test) – Saline is flushed through the puncta; the flow out of the nose indicates an open drainage system.
• Dacryocystography or CT dacryocystography – Imaging (contrast X‑ray or CT) visualizes the nasolacrimal passage when blockage is suspected.
• Meibomian gland evaluation – Expressing the glands on the eyelid margin to detect dysfunction.

Treatment Options

Treatment is tailored to the underlying cause and the severity of symptoms.

Home and Lifestyle Measures

• Warm compresses (10‑15 minutes, 3‑4 times daily) for blepharitis or meibomian gland dysfunction.
• Lid hygiene – Gentle cleaning with diluted baby shampoo or commercial lid scrubs.
• Artificial tears – Preservative‑free lubricants help dilute excess tears and soothe irritation.
• Allergy control – Antihistamine eye drops, nasal sprays, or oral antihistamines.
• Avoid irritants – Smoke, wind, and harsh cosmetics can exacerbate tearing.

Medical Therapies

• Topical antibiotics or steroid‑antibiotic combos for bacterial conjunctivitis or severe blepharitis.
• Prescription anti‑inflammatory drops (e.g., cyclosporine A) for chronic dry‑eye‑related epiphora.
• Oral doxycycline (often 100 mg twice daily for 2‑4 weeks) for meibomian gland dysfunction.
• Allergy immunotherapy for patients with seasonal allergic conjunctivitis.

Surgical and Procedural Interventions

• Punctal dilation or silicone punctal plugs – Expand or block the puncta to retain tears when the problem is excessive drainage.
• Nasolacrimal duct probing and intubation – First‑line for congenital or acquired NLDO; a thin silicone tube maintains patency.
• Dacryocystorhinostomy (DCR) – Creation of a new drainage pathway between the lacrimal sac and the nasal cavity; performed endoscopically or externally.
• Eyelid surgery – Correction of ectropion, entropion, or ptosis to restore normal tear spread.
• Botulinum toxin injection – Used rarely to reduce reflex tearing in severe hypersecretion.

Prevention Tips

• Maintain eyelid hygiene – clean the lid margins daily, especially if you have blepharitis or rosacea.
• Use preservative‑free artificial tears before long periods of screen time, air‑conditioning, or windy environments.
• Protect eyes from allergens and irritants; wear wrap‑around sunglasses on windy days.
• Manage systemic conditions (e.g., diabetes, thyroid disease) that can affect tear production.
• Regular eye exams—especially for children—help detect congenital duct obstructions early.
• Avoid rubbing the eyes vigorously, as mechanical trauma can induce reflex tearing.

Emergency Warning Signs

If you notice any of the following, seek emergency medical care (e.g., urgent care, emergency department, or call 911 if vision is rapidly deteriorating):

• Sudden, severe eye pain accompanied by swelling or bulging of the eye.
• Rapid loss of vision or a large “black spot” in the visual field.
• Significant eye trauma (penetrating injury, chemical splash).
• Persistent, profuse tearing with intense redness and fever – possible orbital cellulitis.
• Yellow/green discharge with increasing pain – may indicate a serious infection.

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References:

• Mayo Clinic. “Epiphora (excessive tearing).” https://www.mayoclinic.org
• American Academy of Ophthalmology. “Dry Eye.” https://www.aao.org
• Cleveland Clinic. “Nasolacrimal Duct Obstruction.” https://my.clevelandclinic.org
• National Eye Institute (NEI). “Blepharitis.” https://www.nei.nih.gov
• World Health Organization. “Allergic Conjunctivitis.” https://www.who.int

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