What are the treatment options for a patient with excess tearing (epiphora)?

Treatment of Excess Tearing (Epiphora)

Begin by treating reflex tearing from ocular surface disease with lubricants and anti-inflammatory therapy before considering any anatomical interventions, as this resolves the majority of cases and prevents unnecessary surgery. 1

Diagnostic Framework

The critical first step is distinguishing between two fundamentally different mechanisms 2:

• Reflex tearing (hypersecretion): Excessive tear production triggered by ocular surface irritation, dry eye, or meibomian gland dysfunction 1, 2
• True epiphora (drainage failure): Mechanical obstruction or lacrimal pump failure preventing normal tear drainage 2, 3

Key Clinical Clues

Reflex tearing indicators 1:

• Bilateral presentation
• Associated ocular surface symptoms (burning, foreign body sensation)
• Positive dry eye testing (reduced tear break-up time, Schirmer test abnormalities)
• Patent lacrimal system on irrigation

Anatomical obstruction indicators 3:

• Unilateral presentation (especially in men, older patients)
• Lower lid malposition (39.5% of male cases)
• Punctal stenosis (more common in younger women, 34.6%)
• Nasolacrimal duct obstruction (29% of referred cases)

Treatment Algorithm

Step 1: Optimize Ocular Surface (First-Line for All Patients)

Initiate lubricant therapy 1:

• Carboxymethylcellulose 0.5-1%, carmellose sodium, or hyaluronic acid drops during the day
• Lipid-containing drops if meibomian gland dysfunction is present
• Petrolatum ointment at bedtime, particularly if nocturnal lagophthalmos exists

Add anti-inflammatory treatment for underlying dry eye 1:

• Topical cyclosporine 0.05% or lifitegrast for chronic dry eye disease 4
• Short-term low-dose topical corticosteroids (loteprednol etabonate 0.5% or fluorometholone) for 2-4 weeks to suppress inflammation 4, 5
• Monitor for steroid-induced IOP elevation and cataract formation 4

Recent evidence for unexplained epiphora 5:

• Combined therapy with loteprednol etabonate 0.5% twice daily for 10 days plus nepafenac 0.3% once daily for 1 month significantly reduced tear meniscus measurements and Munk epiphora scores
• This approach is particularly valuable when no clear anatomical cause is identified

Step 2: Address Anatomical Abnormalities (Only After Surface Optimization)

Correct eyelid malposition 1, 3:

• Lower lid laxity repair for ectropion/entropion (33.3% of cases)
• This is especially common in older men

Manage punctal stenosis 1, 3:

• Punctal dilation or surgical punctoplasty
• More prevalent in women (34.6% vs 22.4% in men)

Step 3: Lacrimal Drainage Surgery (Last Resort)

Dacryocystorhinostomy (DCR) for confirmed nasolacrimal obstruction 6:

• External DCR remains the gold standard
• Powered endoscopic DCR shows comparable outcomes
• Only proceed after optimizing ocular surface and correcting anatomical issues 1

Critical Pitfalls to Avoid

Do not perform premature surgical intervention 1:

• Many cases of apparent "obstruction" are actually reflex tearing that resolves with medical management
• Always optimize the ocular surface first

Beware of paradoxical epiphora from punctal plugs 4, 1:

• Punctal occlusion for dry eye can cause overflow tearing
• Use cautious trial occlusion before permanent closure
• 56% of silicone plugs are retained at 2 years, but spontaneous loss can lead to canalicular stenosis (34% at 2 years) 4

Consider malignancy in atypical presentations 7:

• Chronic unilateral epiphora, especially in older patients, warrants thorough evaluation
• Lacrimal sac squamous cell carcinoma can masquerade as simple nasolacrimal obstruction
• Biopsy any abnormal tissue encountered during surgery

Recognize multifactorial etiology 3:

• 22% of epiphora cases have multiple contributing factors
• Address all identified causes sequentially for optimal results

Special Considerations

Gender and age differences 3:

• Women present younger with punctal stenosis and nasolacrimal obstruction, often unilaterally
• Men present older with eyelid laxity as the predominant cause

Avoid punctal plugs in inflammatory conditions 4:

• Contraindicated in rosacea conjunctivitis and allergic conjunctivitis
• May exacerbate symptoms by retaining inflammatory mediators