What is the best approach to manage a patient with tear duct issues and symptoms like excessive tearing, eye discharge, or redness?

SOAP Note for Tear Duct Issues

For patients presenting with excessive tearing, eye discharge, or redness suggestive of tear duct problems, begin by distinguishing between epiphora (drainage failure) and reflex hypersecretion (lacrimation), as this fundamental distinction drives all subsequent management decisions. 1

Subjective (History)

Document the following specific elements:

• Duration and time course of tearing symptoms 2
• Laterality: unilateral symptoms suggest mechanical obstruction rather than dupilumab-related or systemic causes 2
• Character of discharge: mucopurulent discharge indicates nasolacrimal duct obstruction with possible dacryocystitis 3
• Associated symptoms: 2
  • Conjunctival injection
  • Mattering and adherence of eyelids upon waking
  • Itching (suggests allergic component)
  • Pain or photophobia (red flags requiring urgent evaluation)
  • Blurred vision
• Exacerbating factors: exposure to wind, smoke, pollution, or cooling fans 2
• Recent exposures: infected individuals, trauma (mechanical, chemical, UV), recent surgery 2
• Contact lens wear: type, hygiene practices, wearing schedule 2
• Systemic symptoms: genitourinary discharge, dysuria, fever, upper respiratory infection, skin lesions 2
• Past ocular history: previous conjunctivitis episodes, chronic blepharitis, atopic keratoconjunctivitis, herpes simplex virus, prior lacrimal surgery 2
• Medications: topical and systemic drugs, particularly dupilumab (associated with ocular surface disorders in 13-49% of cases) 2
• Allergies and atopic conditions: asthma, eczema 2

Objective (Physical Examination)

Essential Components:

• Visual acuity testing (establish baseline) 2
• Inspection: 3
  • Eyelid position and closure (exposure keratopathy)
  • Punctal position and patency
  • Lacrimal sac region for swelling or erythema
  • Conjunctival injection pattern and location
  • Character of discharge (mucoid, mucopurulent, watery)
• Palpation of lacrimal region: assess for dacryocystitis (tenderness, fluctuance, reflux of material from puncta) 1, 3
• Slit lamp examination: 2
  • Tear meniscus height
  • Tear film break-up time
  • Conjunctival staining (lissamine green or fluorescein)
  • Corneal staining and integrity
  • Meibomian gland assessment
  • Follicles or papillae on palpebral conjunctiva
• Diagnostic probing and syringing: determines location and extent of obstruction (pre-saccal, intra-saccal, or post-saccal) 1, 3

Red Flags Requiring Urgent Ophthalmology Referral (within 24 hours):

• Worsening visual acuity 2
• Ocular pain 2
• Photophobia 2
• Visible corneal damage 2
• Signs of acute dacryocystitis (severe pain, swelling, fever) 3

Assessment

Primary Diagnoses to Consider:

Epiphora (drainage failure): 1

• Nasolacrimal duct obstruction: most common cause, presents with tearing ± mucopurulent discharge 3
• Canalicular obstruction: may require retrograde canaliculostomy 4
• Punctal stenosis or malposition
• Lacrimal pump failure: functional obstruction despite patent system 1

Reflex hypersecretion (lacrimation): 1

• Dry eye syndrome: paradoxical tearing from ocular surface irritation 2
• Blepharitis: chronic lid margin inflammation 2
• Allergic conjunctivitis: itching predominates 2
• Infectious conjunctivitis: bacterial (mucopurulent), viral (watery), or fungal 2
• Conjunctivochalasis: redundant conjunctiva obstructing tear flow 2
• Meibomian gland dysfunction: tear film instability 2

Dupilumab-related ocular surface disorders (DROSD): if patient on dupilumab, consider conjunctivitis (49%), dry eye (36%), keratitis (38%), or blepharitis (29%) 2

Plan

For Epiphora (Mechanical Obstruction):

Initial conservative management: 3

• Warm compresses to lacrimal sac region
• Lacrimal sac massage (if no acute infection)
• Topical antibiotics if mucopurulent discharge present

Definitive surgical management: 3, 4

• External dacryocystorhinostomy (DCR): gold standard for nasolacrimal duct obstruction, success rate >90% 4
• Retrograde canaliculostomy: add if proximal canalicular blockage present 4
• Canalicular bypass tube: secondary option if DCR fails 4
• Nasolacrimal duct stent: alternative with 50% long-term success rate at 2 years, lower than conventional DCR but fast, safe, and reversible 5
• ENT consultation mandatory prior to lacrimal surgery 3

For Reflex Hypersecretion (Dry Eye/Ocular Surface Disease):

First-line therapy: 2

• Preservative-free artificial tears: frequent application (every 1-2 hours initially)
• Lipid-based emulsion drops: if meibomian gland dysfunction present
• Lid hygiene: warm compresses, lid massage for blepharitis 2

Anti-inflammatory therapy: 2

• Topical loteprednol 0.5%: first-line anti-inflammatory, use for 2-4 weeks 2
• Cyclosporine A 0.05%: steroid-sparing, 2-4 times daily 2
• Lifitegrast 5%: FDA-approved for dry eye signs and symptoms 2
• Varenicline nasal spray: FDA-approved neuroactivator of tear production 2

Punctal occlusion: 2

• Contraindicated in active inflammation (rosacea, allergic conjunctivitis) as it may worsen symptoms by retaining inflammatory mediators 2
• Use only after achieving tear homeostasis 2
• Silicone plugs: 56% retention at 2 years, but 34% develop canalicular stenosis 2
• Caution: may exacerbate dry eye in some patients by concentrating inflammatory mediators 4

Adjunctive therapies: 2

• Moisture chamber goggles: reduce evaporation
• Bandage contact lenses: for severe epithelial disease with pain 2
• Cryopreserved amniotic membrane (CAM): anti-inflammatory and neurotrophic effects, 78.57% tolerance rate in neuropathic pain patients 2

For Infectious Conjunctivitis:

• Bacterial: topical broad-spectrum antibiotics (fluoroquinolone or aminoglycoside) 2
• Viral: supportive care, cool compresses, preservative-free tears 2
• Prevent spread: hand hygiene, avoid sharing towels, no contact lens wear 2

For DROSD (Dupilumab-related):

Mild cases: 2

• Continue dupilumab
• Preservative-free lubricants
• Topical anti-inflammatory therapy

Moderate to severe cases: 2

• Ophthalmology referral for comprehensive evaluation
• May require dupilumab dose adjustment or temporary discontinuation
• Multiple diagnoses often coexist (conjunctivitis, dry eye, blepharitis, keratitis)

Critical Pitfall to Avoid:

Never perform punctal occlusion in dry eye patients without first controlling inflammation and achieving tear homeostasis, as this concentrates inflammatory mediators and toxic debris on the ocular surface, potentially worsening symptoms and causing corneal damage 2, 4. The paradox is that while punctal plugs increase tear volume, they may worsen dry eye by retaining harmful substances 4.

Follow-up:

• Epiphora with obstruction: ENT and ophthalmology co-management for surgical planning 3
• Dry eye/ocular surface disease: 2-4 weeks to assess response to therapy 2
• Red flag symptoms: same-day ophthalmology evaluation 2
• DROSD: ongoing monitoring while on dupilumab 2