What is the treatment for epiphora (excessive watering eyes) in adult patients?

Treatment for Watering Eyes in Adult Patients

The most effective treatment for epiphora (excessive watering eyes) in adults depends on identifying and addressing the underlying cause, with options ranging from artificial tears for dry eye-related reflex tearing to surgical intervention for nasolacrimal duct obstruction.

Diagnostic Approach

Before initiating treatment, it's crucial to determine the cause of epiphora, which generally falls into two categories:

• Reflex tearing: Paradoxically, dry eye syndrome can cause watering eyes due to reflex tear production in response to ocular surface irritation 1
• Impaired drainage: Obstruction or dysfunction in the tear drainage system

Key diagnostic findings to assess:

• Presence of conjunctival injection (redness)
• Character of discharge (if present)
• Eyelid position and function
• Punctal patency
• Tear film quality and quantity
• Associated symptoms (burning, irritation, foreign body sensation)

Treatment Algorithm Based on Underlying Cause

1. Reflex Tearing Due to Dry Eye

If epiphora is caused by dry eye syndrome (paradoxical tearing):

• First-line: Preservative-free artificial tears 4-6 times daily 2
• For moderate cases: Add nighttime lubricating ointment
• For persistent cases: Consider punctal plugs to retain tears on the ocular surface 2
• For inflammatory dry eye: Consider topical anti-inflammatory agents

2. Blepharitis and Meibomian Gland Dysfunction

When lid margin disease contributes to epiphora:

• Warm compresses: Apply for 5-10 minutes daily followed by gentle lid massage 2
• Lid hygiene: Cleansing with commercial lid wipes or diluted baby shampoo
• For significant inflammation: Consider topical tacrolimus 0.1% ointment to the external eyelids and lid margins 2

3. Conjunctival Chalasis

When redundant conjunctiva blocks tear drainage:

• Conservative management: Lubricating drops
• Definitive treatment: Surgical excision of redundant conjunctiva 2

4. Punctal or Canalicular Stenosis

For narrowing of the tear drainage system:

• Punctal dilation: May provide temporary relief
• Punctal snip procedure: For punctal stenosis
• Canalicular intubation: For canalicular stenosis

5. Nasolacrimal Duct Obstruction

For blockage in the nasolacrimal duct:

• Minimally invasive options: Balloon dacryocystoplasty or nasolacrimal stent placement 3
• Definitive treatment: Dacryocystorhinostomy (DCR) - either external or endoscopic approach 4

6. Eyelid Malposition

When epiphora is due to eyelid abnormalities:

• Ectropion/entropion: Surgical correction of lid position
• Eyelid laxity: Horizontal lid tightening procedures

Special Considerations

Giant Fornix Syndrome

For elderly patients with chronic mucopurulent conjunctivitis and enlarged superior fornix:

• Targeted therapy: Topical antibiotics with attention to the superior fornix 2

Mucus Fishing Syndrome

When patients repeatedly remove mucus from the eye surface:

• Break the cycle: Counsel patients to avoid touching eyes
• Treat underlying irritation: Address dry eye, allergic conjunctivitis, or blepharitis 2

Monitoring and Follow-up

• Patients with mild epiphora can be monitored every 3-6 months
• Those with severe symptoms or corneal involvement should be seen more frequently
• Patients should be referred to an ophthalmologist if they experience:
  • Visual loss
  • Moderate or severe pain
  • Severe purulent discharge
  • Corneal involvement
  • Conjunctival scarring
  • Lack of response to therapy 2

Common Pitfalls to Avoid

1. Misdiagnosing the "wet" dry eye: Many patients with watering eyes actually have dry eye syndrome with reflex tearing 1
2. Overlooking lid abnormalities: Eyelid malposition is a common cause of epiphora that requires surgical correction
3. Delaying referral: Persistent epiphora unresponsive to conservative measures warrants ophthalmology evaluation
4. Focusing only on tear production: Both production and drainage issues must be addressed
5. Neglecting systemic conditions: Some cases of epiphora may be associated with systemic diseases requiring additional management

By following this structured approach to diagnosis and treatment, most cases of epiphora can be effectively managed, improving patients' quality of life and preventing potential complications.