CHRONIC EPIPHORA

Signs and Symptoms

Epiphora describes the spillover of tears from the eye onto the lids and ocular adnexa. It is not a diagnosis, but rather a clinical sign indicating insufficient tear drainage or, in some cases, overproduction. Numerous etiologic factors can lead to this phenomenon.1-4 A distinction must be made, however, between chronic and acute epiphora. Chronic epiphora results from long-standing or unremitting disorders and presents a greater clinical challenge than acute epiphora. The acute variety most often results from irritative ocular conditions such as corneal foreign bodies or allergic conjunctivitis and usually resolves following the treatment of the associated disorder.

Patients with chronic epiphora report excessive lacrimation, in some cases to the point of tears actually streaming down their face. Symptoms may be exacerbated by environmental factors such as excessive cold, wind, pollen or other airborne particulate matter, sleep deprivation, near-point strain or emotional stress. Patients may report that they “cry very easily,” or that they are constantly wiping their eyes. Associated signs and symptoms of epiphora vary with the underlying etiology. Often, the patient complains of intermittently reduced acuity, owing to the excessive tears. Irritation to the lids, and in particular the inner canthus, is common because of the constant wetting of that area as well as the continuous mechanical abrasion of tissues, potentially leading to fissure formation.

Signs may include trichiasis, punctate epithelial keratopathy, lid-globe appositional abnormalities, punctal stenosis or other lacrimal outflow disorders (e.g., dacryocystitis or canaliculitis). Conjunctivochalasis—a condition in which redundant, “sagging” conjunctiva covers the lacrimal punctum and impedes drainage through the nasolacrimal canaliculus—may also be observed on biomicroscopy.5,6

Pathophysiology

Epiphora may result from a variety of conditions, but all presentations can be ascribed to one of four basic categories: (1) lid-globe appositional abnormalities, (2) obstructive lacrimal drainage disorders, (3) ocular surface disorders and (4) rarely, neurogenic lacrimal hypersecretory disorders.4

In conditions that alter the normal proximity of the lacrimal puncta to the ocular surface, elimination of tears is physically impeded. The most obvious illustration of this situation is acquired ectropion; other examples include entropion and floppy eyelid syndrome. Patients with chronic blepharitis may have punctal ectropion, which will be subtle compared to lid ectropion.

Obstructive disorders of the lacrimal system are similar to appositional abnormalities, except that in these conditions there is mechanical impedance of the outflow channel. Conditions that constitute obstructive disorders include acquired punctal stenosis, punctal atresia, canalicular stenosis or canaliculitis, retained or migrated punctal plugs, dacryocystitis, or lacrimal sac tumors. Occasionally, a large hordeolum or chalazion may induce punctal or canalicular stenosis. Additionally, they may also impair lid-globe apposition with subsequent punctal ectropion. Congenital nasolacrimal obstruction is quite common and results from a lack of patency at the valve of Hasner.

Ocular surface disorders can, in some instances, induce excessive and symptomatic reflex tearing.2,7,8 While this is typically not significant enough to constitute epiphora, it should be considered when patients present with complaints of “excessive tearing.” Moderate to severe dry eye disease or exposure secondary to proptosis or facial nerve palsy are conditions that may induce reflex tear production resulting in epiphora.

Finally, hypersecretion of tears may be encountered in rare conditions affecting the nervus intermedius (that collection of nerves containing, among other things, parasympathetic lacrimal fibers, which joins the facial nerve at the level of the cerebellopontine angle). Compressive irritation of these fibers, or aberrant regeneration of cranial nerve VII after trauma may result in enhanced, inappropriate lacrimation, sometimes referred to as the gustolacrimal reflex or “crocodile tearing.”4 Neurogenic complications must be ruled out prior to initiating therapy for a lacrimal outflow problem.

Management

The treatment for the symptom of epiphora involves correcting the underlying disorder. For lid-globe appositional abnormalities (e.g., ectropion), the only cure is to physically reorient the punctum to be in proper alignment with the globe. Most often, this involves modified surgical resection of the lid tissue, or what is known as “horizontal lid shortening procedures.”9,10 Trichiasis and entropion can be corrected via serial eyelash epilation (or electrolysis) or by surgical repositioning, respectively. Obstructive disorders generally require invasive therapeutic measures.

Punctal and/or canalicular dilation and irrigation is the most common management for stenosis of the lacrimal system; balloon canaliculoplasty may be performed in more severe instances.11,12 For cases of chronically flaccid or stenotic puncta, snip punctoplasty may be undertaken to more permanently enlarge the outflow orifice.12,13 If the blockade exists more distally within the nasolacrimal system, probing alone may be inadequate to alleviate the problem. In these cases, dacryocystorhinostomy (DCR) is often required; this creates a surgical bypass of the common canaliculus directly into the nasal mucosa, and is performed either with or without the use of a synthetic conduit (Lester Jones tube).14-16 Probing procedures are contraindicated in cases of inflammation, such as chronic dacryocystitis, or suspected neoplasm; DCR is used for these conditions.

When an ocular surface disorder is the etiology of chronic epiphora, treatment should be aimed at removing the provocative substance (foreign body, chemical) or replenishing the normal basal tear volume and improving the overall quality of the tear film. This may be achieved by using artificial tear preparations, immunomodulatory agents (e.g., Restasis, Allergan) or oral secretagogues (e.g., Salagen, Evoxac). Neurogenic hypersecretory disorders, when suspected, should be referred to a neurologist for evaluation and management.

Clinical Pearls

“Tearing” is a common complaint in most optometric practices. For proper management, a clear distinction needs to be made between functional epiphora and occasional, symptomatic lacrimation.

True epiphora constitutes a chronic problem warranting intervention, whereas normal tearing does not. Dilation and irrigation, the most common management strategy for punctal and canalicular obstruction, is a quick and easy in-office procedure for managing appropriate cases. Realize, however, that this procedure is generally not permanent, and may need to be repeated several times each year to maximize patient comfort and satisfaction. Surgical intervention, when necessary, should be directed to an experienced oculoplastic specialist.

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