Good Hope Eye Clinic

Watery Eyes in Adults  (Epiphora) 

David Kinshuck

An explanation of the common causes of watery eyes, and related problems.

 

Normal tears

Tears are made in a gland under the skin above the eye. They flow over the front surface of the eye, and drain into tiny tear ducts in the eyelids, near the nose (under the skin).

The tears then flow into a tear 'sac', and from there they pass through a wide channel, the 'naso-lacrimal duct' into the inside of the nose. See Animation.

the lacrimal gland, where tears are made, and the lacrimal sac, where the tears drain out of the eye

 

healthy tear flow over the eye into the nose:

 

normal tears, made in the lacrimal galnd, flow over the eye, and drain into the nose

Symptoms

  • constant watering of the eyes, indoor and outdoors
  • gritty feeling followed by watering
  • watering of eyes, mostly when outside
  • watery eyes made worse by cold wind or bright light
  • sore eyelids

 

Main causes of watery eyes (epiphora)

a blocked tear sac causes a watery eye

The causes often occur in combination

 

Too many tears

There are some conditions that can cause your eye make too many tears. Many people with watery eyes have a combination of too many tears and blocked tear duct. Conditions that 'cause' watery eyes include

 

Irritation...ingrowing lashes and dry eyes and other causes

 

ingrowing eyelashes may cause a watery eye

In-growing eyelashes (trichiasis)

In-growing eyelashes or anything that irritates the eye may cause a watery eye.. In-growing lashes need to be removed, although they may grow in again.

If there is only one lash growing in, in an eye clinic, the lash is epilated (removed) once, and if it grows in again then electrolysis may help.

 

Dry eyes

Surprisingly, if your eyes are 'dry' you may notice watery eyes: your eyes become sore and this makes your eye make more tears. But these tears may not spread properly, and dry patches develop on the surface of the eyes (as below).

Using artificial tears can help make the eye feel a lot more comfortable; the artificial tears may spread more evenly, and you can buy them from the chemist. See 'dry eye'. Gel type of artificial tears are generally best to try first.

 

Other causes of irritation

  • Grit or sand under the eyelid cause too many tears. Eyes may water if anything irritates them: a small scratch, a piece of grit under the upper eyelid.
  • Eye drops for glaucoma are common causes of irritation, especailly if they have preservative.
  • Thyroid eye disease is an unusual cause
  • or an allergy

 

Blepharitis....causing poorly spreading tears

treatment of blepharitis

Blepharitis is the medical term for inflamed eyelids. The inflammation is like eczema of the skin, with red, scaly eyelids. You may notice watery, tired, or gritty eyes, which may be uncomfortable in sunlight or a smoky atmosphere. They may be slightly red, and feel as though there is something in them.

The eyelids have tiny glands in them, especially the lower lids. These glands make substances that mix with tears, and help the tears to spread across the eye. If these glands are blocked they will not release these chemicals (wetting agents).

The tears then become too thin and do not spread evenly across the eye dry patches may develop on the surface of the eye. These dry patches make the eye feel sore and then your eyes may start to water. This is discussed in more details on the blepharitis page.

poorly spreading tears cause a sore eye

Blepharitis...poorly spreading tears makes the eyes water. The blepharitis is a mild inflammation of the lower eyelid.

 

Lower lid position (laxity, entropian, ectropian)

an ectropian of the lower eyelid can cause a watery eye

 

A saggy or 'lax' lower eyelid may develop. This also can be corrected with a small operation in the outpatient department. Also, the eye lid may turn in (entropian) or out (ectropian). Minor eyelid surgery can correct the eyelid position.

Here are some of the causes, but there are others as below, or there may be a number of causes in combination.

lax eyelids cause epiphora

entropian causes ephiphora

ectropain cauese epiphora

lid laxity cuaes ephiphora, side view

entropian cuaes epiphora

ectripain causes epiphora..side view

 

Reduced drainage of tears

 

Blocked naso-lacrimal duct

If the tear passages near the nose block, you may notice both

The tear duct apparatus may block at any point along the tear passage, but the commonest place for a blockage is just below the tear sac. The cause of this blockage is not usually known.

The treatment that the doctor will recommend depends on how much the watery eye bothers you, and whether you find it very uncomfortable, or just a nuisance in the wind.

a blocked tear duct...between the eye and the nose

naso-lacrimal duct occlusion...one cause of watery eyes

 

A partial or functional blockage or 'pump failure'

This is essentially a combination of the problems above. The (naso-lacrimal) tear duct is open, but not quite wide enough to drain away all the tears.
This may be due to problems such as reduced blinking or weak muscles in the eyelids. This is called pump failure. It is treated in the same way: if the watery eyes are very bothersome and you are young and fit, DCR surgery as below may help.
If you are not really bothered, then surgery is best avoided.

 

Treatment

DCR Operation: the operation to open the duct at the lower end

If the nasolacrimal duct is blocked, and if you are young or middle aged, and your eyes water and are uncomfortable much of the time, an operation can be helpful. Such patients would notice watery eyes at least 10 times a day.

a DCR operation creates a channel from the tear sac into the nose

DCR surgery

This operation generally requires a general anaesthetic and an overnight stay in hospital. This is a 'DCR' operation, which translates into 'making a channel from the tear sac into the nose'.

One common operation is a  cut on the skin over the tear sac, and then a small hole made in the bone between the tear sac and the nose. Next the surgeon connects the tear sac to the inside of the nose, and closes the cut in the skin. The skin scar fades and is usually nearly invisible after six months.

There are other types of operation, such as using balloons that can be blown up to expand the blocked tear duct. These may not be quite as successful, and are only available in a few hospitals. Alternatively the DCR operation can be carried out by using special instruments 'up the nose'.

Instructions after surgery. Leaflet DCRs operation

 

Frail people or no operation

If you are frail this operation is not generally recommended unless you have developed infections of the tear sac, as below. Even if you are well, if your watery eye is not really bothersome, you may prefer to manage as you are without having an operation. You may notice a small lump under the skin: the swollen tear sac. Unless there is an infection, you hardly feel the lump at all.

These is no harm in having watery eyes.

 

Infection of the tear sac (acute dacrocystitis)

acute dacrocystitis ...an acute infection of the lacrimal sac

an infected nasolacrimal sac..a tender lump on the size of the nose

A few people with a blocked tear duct can develop an infection in the tear sac. This is quite uncomfortable, just like an abscess anywhere else in the body.

It is called 'acute dacrocystitis'. This begins as a blocked tear duct and watery eye. The tears then get trapped in the tear sac, and stagnate.

The stale tears may then become prone to infections.If you develop an infection in the tear sac,  like any other abscess under the skin, you need treatment, as below.

See

 

The treatment for an infection of the tear sac.

  1. Bathe the 'abscess' with a hot flannel four times a day.
  2. See your GP for antibiotics
    • co-amoxyclav 625mg three times a day 1 week if you are not allergic to penicillin
    • Clarithromycin   500mg twice daily 1 week if you are allergic to penicillin
  3. If the abscess is rather severe you need to attend an Eye Emergency Department: sometimes the abscess needs draining.

After the infection.

After the attack of dacrocystitis and all the infection has gone, the tears ducts may be open. However, the infection may damage the tear drainage, and the eyes may be watery. In this case a DCR operation is necessary after you have had acute dacrocystitis. The operation is carried out when the infection has been treated.
Anyone with more than one episode of infection needs a DCR operation unless there are contraindications (they are ill etc).

 

Less common causes of watery eyes

 

Blocked canaliculus

a blocked common canaliculus cause a watery eye

Blockages may develop in the canaliculi. More sophisticated surgery is needed.

 

 

 

 

 

blocked canaliculi cause a watery eye

Sometimes the entrance to the canaliculi can block.

The blockage can often be opened with a small operation.

 

 

 

In the nose

disease in the nose may cause a watery eye

Uncommon causes of watery eyes include conditions inside the nose, such as polyps.

 

 

 

 

Leaflet

This is a slightly old version of this page in a leaflet form: 200k AdobePDF

 

Professionals

Think of

  • watery 10x day significant
  • watery cold and windy..dry eye
  • illness that cause dry eyes
  • nasal congestion..try beconase
  • measure tears see how wet
  • syringe...see if tight, check punctum
  • lid position