Watery Eye Clinic

Watery Eyes (Epiphora) 

The cause of watery eyes can be multifactorial. In addition to a general eye assessment, it is essential that you receive comprehensive tear duct, eyelid, and ocular surface evaluations, by a fellowship-trained specialist so that the proper diagnosis is made. The successful management of the watery eye depends on the underlying issue. 

Common causes of Watery Eyes 

• Tear duct (lacrimal duct) narrowing or obstruction. 

• Eyelid malposition such as Ectropion (out-turning of eyelid) or entropion (in-turning of eyelid).

• Poor lacrimal pump function secondary to eyelid laxity.

• Ocular surface diseases (OSD).

  Common OSD include dry eye syndrome, meibomian gland dysfunction, blepharitis, ocular rosacea and allergies.

• Facial palsy.

  Weakness of the facial muscles can result in poor lacrimal pump function and paralytic ectropion respectively. Reduced blink rate, incomplete blink and the inability to close the eye properly (lagophthalmos) can each result in an exposure dry eye (exposure keratopathy). This in turn may lead to hyperlacrimation (excessive secretion of tears). Some individuals with facial palsy may also develop gustatory lacrimation (shedding of tears when one eats or drink) and this is secondary to an abnormal nerve connection.

Management of Watery Eyes.

• Dacryocystorhinostomy (DCR) surgery is commonly performed for the management of a watery eye caused by a blocked tear duct located inside the nose. A new channel is surgically created to bypass the existing blocked tear duct allowing the tears to drain directly into the nasal cavity. There are 2 surgical approaches to DCR surgery: endonasal DCR (EndoDCR) and external DCR. Surgery is usually performed as a day case; the patient goes home the same day unless there is a clinical indication for the patient to stay in overnight. At your consultation, the surgeon will advise you on the most appropriate surgical approach to treat your condition. The success rate for a DCR surgery is comparable between the 2 surgical approaches and range from 90-95%. In the majority of cases, a silicone tube is inserted at the end of the surgery to keep the new channel patent. The silicone tube is usually removed either as an in-office procedure or in a treatment room at the hospital about 2-4 weeks later.

  In cases of co-existing medical condition, a redo surgery for a previously failed DCR, or a complex tear duct obstruction, the success rate may be lower. Your surgeon will be able to advise you further at the consultation.

  Some tear duct blockages may not be treated with a DCR surgery alone; your surgeon will tailor the surgery to your case and discuss the management plan at your consultation.

  If a tear duct surgery is contraindicated or the individual declines a surgical procedure to manage the bothersome watery eye symptom, botulinum toxin injection into the tear gland (lacrimal gland) can be performed.

  Botulinum toxin type A is a neurotoxin produced by Clostridium botulinum bacteria. Injection of botulinum toxin type A (BtA) into the lacrimal gland can temporarily reduce the production of tears (without damaging the gland). Botulinum toxin has been used successfully to treat watery eyes for over two decades on an off-label basis. There is good evidence in the scientific literature to support its use as an alternative treatment option.

  The decision to use botulinum toxin for treating watery eyes is therefore made on an individual basis. The administration of botulinum toxin is accomplished by injecting a small amount of toxin into the lacrimal gland to reduce tear production. This is performed as an in-office procedure following the instillation of anaesthetic eye drops. Any benefits resulting from botulinum toxin tend to wear off. Hence, a repeat injection every 3-6 months is required if the benefit is to be maintained. Overall, it is a safe and minimally invasive treatment alternative to surgery.

• Eyelid malposition (such as ectropion or entropion) can be surgically corrected, and the success rate is high. Surgery is performed under local anaesthesia as a day procedure.

• Lower lid laxity can result in a poor lacrimal pump function secondary to eyelid laxity. Surgically tightening a lax lower eyelid will help restore tear drainage and improve the symptom of a watery eye. Surgery is performed under local anaesthesia as a day procedure.

• Some individuals may have one or more ocular surface diseases (OSD) that contribute to their watery eye symptom. Your eye care specialist will carry out a comprehensive eye assessment of the tear duct, eyelid, and ocular surface to determine the cause of the OSD. The evaluation may include the analysis of your tear quality (tear osmolarity test and tear film analysis) and meibography (assessment of eyelid oil glands). The treatment of OSD may include artificial tears, medicated eye drops, eyelid scrubs, eyelid heat compresses, or intense pulsed light (IPL) treatment.

• Paralytic ectropion due to facial palsy can be addressed surgically. Injection of botulinum toxin into the lacrimal gland can be used to treat gustatory lacrimation.