New Hope Eye Center
2070 Pleasant Hill Rd., Ste. 100
Duluth, GA
770-622-2020
JUNHEE LEE, M.D.
PLASTIC SURGERY OF THE EYES
Tearing/Watering Eyes
Tearing problems are extremely common, and may arise from a number of causes.
Epiphora/watery eye
(yellow color is a dye that highlights the tear lake)
Tears are produced by one large
lacrimal gland deep to the outer corner of the upper eyelid
and numerous small "accessory"
lacrimal glands behind the eyelids.
Canaliculi
Punctum
Punctum
Tears exit at puncta
Nasolacrimal Duct
Lacrimal Sac
Tears flow into nose
Tears drain from the eyes into the nose through a series of ducts caused the nasolacrimal system. This is why crying causes a runny nose—because water flows from the eyes to the nose. Tears exit the eyes through tiny openings called puncta (singular punctum) at the inner corner of each eyelid, then flow through ducts in the eyelids called canaliculi, then into a dilated portion called the lacrimal sac, then through a narrower passage surrounded by bone called the nasolacrimal duct, and finally into the nostrils.
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Excess tearing from the eyes occurs for two basic reasons: either over-secretion of tears or inadequate drainage.
Over-secretion of tears almost always occurs because of irritation from allergies or dryness; the irritation causes the eye to produce extra tears to compensate for the irritation. Making the eyes more comfortable with lubricating or anti-allergy eyedrops actually decreases tearing in this situation because the eye no longer feels the need to over-produce tears.
Inadequate drainage of tears occurs because of narrowing or blockage somewhere in the nasolacrimal system. In order to determine if a blockage in the tear drainage system exists, fluid is flushed through it using a blunt-tipped tube. This irrigation test is performed in the office and does not require any numbing injections or cutting. It may cause a pressure sensation and rarely may cause some stinging, but in the majority of cases, does not cause pain.
Epiphora/watering from one eye
(yellow color is a dye that highlights the tear lake)
Punctum in lower eyelid
Narrowing at the opening in the eyelid (punctum) may arise from allergies causing the punctum to swell closed. If so, anti-allergy eyedrops should help by decreasing the swelling and allowing the punctum to open. Sometimes scarring narrows or closes off the punctum. This may be due to an infection that the patient may or may not have noticed, scarring from a medication, or reasons we never discover. If the punctum is closed or very narrow, a small office procedure called punctoplasty may be performed to open the punctum. This procedure hurts very little, if at all, and does not change the appearance of the eyelid.
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The most common obstruction of tear drainage occurs in the nasolacrimal duct. When the nasolacrimal duct is narrow but not completely blocked, anti-allergy treatments such as eyedrops, nasal sprays, and anti-allergy pills may help. Tearing due to a narrow nasolacrimal duct may be bothersome, but does not absolutely require surgery.
If the nasolacrimal duct is completely blocked, on the other hand, an infection in the lacrimal sac called dacryocystitis is possible. Dacryocystitis requires antibiotics and may require hospitalization and emergency surgery in severe cases. For this reason, the standard of care for a complete nasolacrimal duct obstruction (with or without dacryocystitis) is surgery called dacryocystorhinostomy to relieve the obstruction and reestablish tear flow from the eye to the nose.
Dacryocystitis: infection in lacrimal sac due to blockage in tear drainage system
Dacryocystorhinostomy incision after healing
Dacryocystorhinostomy incision after healing
Dacryocystorhinostomy (DCR) is performed in an operating room under heavy sedation or general anesthesia and typically requires about 45 minutes. The patient goes home the same day. It traditionally involves a ½ inch incision along the side of the nose through which a small tunnel is made between the lacrimal sac and the inside of the nose. This reestablishes tear flow from the eye into the nose by creating a detour around the blockage. A small silicone tube is left in the newly creating passage for 3 to 6 months to prevent it from healing closed. The success rate of this surgery is about 95% according to the medical literature (Med Arch. 2014; 68(1):54-6., J Ophthalmol. 2013; 2013:287524., Clin Ophthalmol. 2013; 7:2281-2285.), but in my experience the success rate is even higher than that. This means that up to 5% of patients may need additional surgery to relieve their tearing. The incision along the side of the nose heals beautifully: it is barely visible after complete healing, and in many patients, the incision is literally invisible (see photos). I have performed this surgery on hundreds of patients and have never had a patient regret having the surgery because of the scar. The adjacent photos show healed dacryocystorhinostomy incisions. Can you see them?
Dacryocystorhinostomy incision after healing
Dacryocystorhinostomy may be performed endoscopically (which avoids a skin incision), but this approach has a lower success rate in the medical literature (around 90%, depending on the study: Eur J Ophthalmol. 2020 Sep; 30(5): 998-1003., Eye (Lond). 2020 Aug; 34(8): 1449-1453., Otolaryngol Head Neck Surg. 2020 Nov 24; 194599820972677., Cochrane Database Syst Rev. 2017 Feb 24; 2(2):CD007097.). For this reason and because I have never had a patient unhappy with the skin incision (including young people with smooth skin), I perform dacryocystorhinostomy via a skin incision almost exclusively.