The tearing system is both simple and complex. The tear film is composed of many different critical components, each made by a different eyelid gland/structure. It is designed to coat the eyeball, protecting the eyeball and essential for vision (by light refraction). A smooth tear film not only depends on the tear glands but also on the tear drainage system, which consists of the eyelids and tear drainage duct system. If there is any disturbance of the tear film, patients can experience blurry vision, irritation, and tearing.
Patients who experience tearing, or epiphora, either have a problem with tear production or tear drainage, including dry eyes, blepharitis, eyelid malposition (ectropion, entropion, eyelid retraction), nasolacrimal duct(tear duct) obstruction (congenital and acquired).
Increased Tear Production and Dry Eyes
As odd as it sounds, the most common cause of tearing is dry eyes. If your eye doesn’t make enough tears, the lacrimal gland responds by secreting watery tears that don’t stick to the eye. So despite the tears spilling from your lids, the eye continues to be dry.
Age, menopause, and various inflammatory conditions (including blepharitis or rosacea) can decreased tear production, with resultant eye dryness, irritation, redness. This irritation causes the brain to send signals to make emergency tears (reflex tearing). As a result, the dry eye paradoxically tears and becomes watery. The dryness and tearing can fluctuate throughout the day. Tasks (such as reading or watching TV) that cause make someone to focus more and hence blink less will cause the eyes to get more dry. Wind is also a frequent cause for worsening of eye dryness.
The treatment for dry eyes includes:
1) Replacing tears with artificial lubricants which can be bought over the counter,
2) Medications like Restasis that decrease inflammation in tear glands and encourages natural tear production to resume and finally
3) Plugging of the tear drain (punctal plugs) – To learn more about punctal plugs, read Dr. Taban's article from the Comprehensive Ophthalmology Update.
Lower eyelid malposition and laxity can also cause excess tearing. If the lower eyelid sits too low relative to the eye, tears will well-up behind the lid and eventually run down the cheek. The tears will also evaporate faster because more of the eye is exposed. Severe lower eyelid laxity can lead to ectropion, where the eyelid rotates outward. Once again, patients experience a cycle of dry eye, and excess tearing. Entropion, on the other hand, causes direct irritation of the eye by lashes poking the eyes. Surgery is usually necessary to correct these conditions.
Insufficient Drainage
Another common cause of excess tearing is nasolacrimal duct (tear duct) obstruction. Normally, tears are made in the lacrimal gland and drain into the nose through small holes in the nasal portion of the eyelids called the punctum. A blockage anywhere from the punctum to the bony lacrimal canal in the nose can cause the tears to back-up and run down the cheek. An obstruction of the tear ducts may occur due to numerous reasons (aging, trauma, inflammatory conditions, medications and tumors) and cause numerous signs and symptoms ranging from wateriness or tearing to discharge, swelling, pain and infection. At times, it can lead to dacryocystitis (infection of the tear duct system). A complete eye tearing examination can determine the cause of the tearing.
A thorough examination by an ophthalmic plastic surgeon can determine the cause of tearing and recommended treatment.
What is Tear Duct Surgery?
If the cause of the tearing is dryness or irritation, then that specific problem needs to be addressed. If the tearing or epiphora is related to a blockage in the tear duct drainage system, then surgery is usually necessary. Nasolacrimal duct blockage is treated by a bypass surgery called dacryocystorhinostomy (DCR surgery). A DCR is performed by creating a new tear drainage passageway from the lacrimal sac into the nose, bypassing the obstruction. A silicone stent may be placed temporarily to keep the new bypass passgeway open. Many surgeons perform an external DCR, where an incision on the skin is made in between the eye and nose. Dr. Taban performs the surgical through the nose, endoscopically, not requiring a skin incision, which does not leave a scar and results in quicker recovery. This approach is called endoscopic (or endonasal) DCR surgery.
In rare cases, the blockage may be in the canaliculi system. In these rare cases, a permanent bypass tube made of glass (Jones tube) may be necessary, which allows direct drainage of the tears from the eye into the nose.
Where is DCR Surgery Performed?
Surgery is usually performed under general anesthesia in an outpatient surgery center. As with most eyelid procedures, the recovery is quick and painless except for a "black eye" for a few days. As discussed earlier, Dr. Taban uses a minimally invasive endoscopic technique (endoscopic endonasal DCR) through the nose without any outside skin incision, with much quicker recovery and lack of scar.
Tearing Before & After Photos
See more before and after tearing pictures.
Pictured below is a patient of Dr. Taban's with an infected tear duct.
Who Should Perform Tear Duct Surgery (DCR)?
An oculoplastic surgeon, who is a member of American Society of Ophthalmic Plastic and Reconstructive Surgery (ASOPRS), is someone who is a board certified ophthalmologist who has completed additional 2-year fellowship training in cosmetic and reconstructive plastic surgery of the eyelids, orbits (eye socket), lacrimal system( tearing system) and surrounding structures. Dr. Taban is triple board certified by American Board of Cosmetic Surgery (ABCS), American Society of Ophthalmic Plastic and Reconstructive Surgery (ASOPRS), and American Academy of Ophthalmology (AAO). Dr. Taban is an oculoplastic surgeon in Beverly Hills and Santa Barbara with expertise in endoscopic DCR surgery.
Next, learn about orbital problems.