Tearing of the eyes can be do to numerous causes to include: partial or complete tear duct drain obstruction(s); local irritation of the eyes from a misdirected eyelash or eyelid mattering; eyelid malpositions (pulled away from eye surface or turned inward onto eye surface, eyes too open); incomplete or inadequate eyelid closure; laxity of the eyelid tissues causing poor tear pump mechanism; dry eye “states” that cause poor quality of tear film and excess reflex tearing that overwhelms the tear drains ability to remove tears from the ocular surface; seasonal eye allergies; poor positioning of the tear drains caused by outward turning of the eyelids (“ectropion”); coverage of the tear drains with swollen eye surface tissues (conjunctivochalasis, chemosis); and rarely tumors of the tear drains system or exit drain into the nose. The tear drain anatomy is shown. The main lacrimal gland (1) along with the accessory lacrimal glands(2), which are on the eye surface and the on the eyelids produce the tears. They then drain at the inner corner of the eyelids at the punctal openings (3). Each eyelid has its own punctal opening, so there are 4 total. The puncta drain into the canaliculi (one per eyelid) that then drain into the lacrimal (tear) sac. The nasolacrimal duct (4) is a bony canal that runs through the outside bone of the nose, and final drainage point is under the inferior turbinate (5) inside the nose. Any portion of the drainage system may get an obstruction and the treatments may be different from individual to individual. In infants tear duct blockages are generally at the bottom (end-point) of the tear drain system in the nose at a valve (Hasner) that has failed to open. Quite often it will spontaneous open in infants as they grow and with appropriate tear sac massage. However, in adults the obstructions tend to be higher up in the tear drain system (3-4) and require different surgical approaches depending upon the site(s) of obstruction.
Frequently asked questions about tearing:
1. How can my eyes be watery when I was told I have dry eyes?
Our tear film depends upon 3 main components from superficial to deep: lipid (oily layer); aqeous (watery layer); and the mucinous layer that is directly against the eye. Any deficiency of the these components can lead to a dry eye state; although, the eyes may seem very watery. A useful anatomy is that we could fill our car fuel tank with water and it would be technically full but the engine wouldn’t run well or at all. For patients with excess tearing from a tear deficiency need to be evaluated and first managed with tear supplements and eye lubricants to see if this will resolve or make their tearing at least tolerable.
2. Why does my vision get blurry when my eyes tear?
Our ocular surfaces require a thin but healthy layer of tear film to see properly. If the tear film is too thick or excessive the vision can get distorted and blurred similar to when we try to see under water.
3. Is it dangerous to have watery eyes that tear too much?
It can be if it affects your vision when trying to drive or perform other important visual activities. Too much tearing can also be a sign of an obstruction that could be due to a tumor or other serious medical problem.
4. Are there other concerns if my eyes water too much?
Yes, if their is a tear drain obstruction that is causing the tearing this can lead to an infection of the eye and even the eye socket and facial tissues. Stagnant tears that are not draining properly away from the eye and through the entire tear drain system can become infected with bacteria that can cause an abscess. This can be very serious sometimes and Dr. Burroughs has had to admit some patients to the hospital for more serious cases for IV antibiotics and surgical drainage. Dr. Burroughs sees about 1-2 of tear sac (dacryocystitis) infections a month. When there is a tear duct or canalicular obstruction, infections can occur at any time, and though the severity is quite variable it is better to address a tear drain obstruction prior to a serious infection occurring. Shown are various patients with dacryocystitis (tear sac infections). Patients with canaliculitis infections.
5. How is a tear duct obstruction diagnosed?
A small, hollow syringe probe is inserted into the canaliculus and then fluid is irrigated through. There can be a small amount of pressure from this but it is generally not very painful to have performed.
6. I have been diagnosed with a nasolacrimal duct obstruction, how is this fixed?
It depends on the severity and your wishes. In children probing of the nasolacrimal duct with/without a stent placement has nearly a 90% success rate. In adults, probing of the nasolacrimal tear duct and stent placement only has about a 50% success, but it requires no outside incisions or suturing. A dacryocystorhinostomy surgery in adults in the gold standard procedure to restore tear drainage, and carries a 90% or better success rate. A dacryocystorhinostomy (DCR) surgery, creates a new tracts for tears to drain higher in the nose by bypassing the old system that is no longer functioning properly. A small incision (less than an inch) is made in the inner lower eyelid area. The scarring is usually minimal (see photos; blue encircled area shows the incision in case you didn’t notice it in first picture as quite often the scarring is nearly invisible). Dr. Burroughs advocates on all DCR patients that they have they have an external approach wherein the skin incision is placed as shown. This allows for a direct visualization of the tear sac as sometimes tearing problems are secondary to a tumor or medical condition that can be identified by biopsying the tear sace. Endonasal or endoscopic approaches do not afford an easy manner to biopsy the tear sac and direct visualization is not optimal compared to the external approach. Dr. Burroughs does advocate an endonasal/endoscopic approach for revision DCR surgeries as they tear sac has already been inspected the first time and the bone window has already been removed during the primary DCR surgery. Dr. Burroughs diagnoses a few tear sac tumors or blockages from medical conditions (e.g., lymphoma, sarcoidosis) that the external approach was critical in making the proper diagnosis.
7. What is a stent?
A stent is a thin flexible silicone material that can be placed through the canaliculi and through the nasolacrimal duct or the new tract as part of a DCR surgery. It generally should be left for 3-4 months, but can remain for longer periods of time in certain circumstances. One should avoid rubbing or pulling on it or it can become loosened and require repositioning or more commonly premature removal, which can affect the surgical success. The first picture shows a nicely positioned stent, while the second shows a stent that a patient accidentally loosened. Fortunately accidental loosening of a stent is not easy as Dr. Burroughs ties a small knot of suture material around the stent to keep it from becoming loose or sutures the stent to the lower part of the nose.
8. If both my tear ducts are blocked can they be repaired at the same time?
Generally a DCR surgery is safest to be done one side at a time to minimize the potential for severe postoperative bleeding from the nose. If both sides required DCR surgery then they may be safely done as soon as a few days apart. If only a stent is being placed through the tear ducts then both sides may be done during the same surgery.
9. Why is my eye still tearing after a DCR surgery or having had a stent placed?
The stents are not hollow tubes (e.g., a straw), but rather a solid material that has the purpose of keeping the repaired tear drain or canaliculus from scarring closed. Imagine fitting a thick rope through a garden hose then trying to run water through the hose. It wouldn’t work well as the rope would take up nearly all the available space within the h0se. It is important after the surgery that the stent remain long enough to give the reconstructed tear drain time to heal, so that upon the stent removal in the office the drains can function properly. Other causes can be retained nasal packing material, swelling, eye irritation from the stent, and/or crusting around the new tear drain opening in the nose. Usually within a few weeks after a DCR surgery the tears drain well unless the system is “stressed” by cold air, wind, or an irritated eye that is causing too many tears to be produced. Rarely, the eyes will still tear and water until the stents are removed. Other causes may include laxity of the eyelids, a misdirected eyelash, and untreated or under treated dry eye state.
10. What can I do if my DCR surgery isn’t working?
Dacrycystorhinostomy (DCR) surgery has between a 90-05% success, so there is a 5-10% failure rate. This does not mean tearing has to go on forever. Revision surgery is often not as involved as it can be done endoscopically through the nose (no outside sutures), and a different type of temporary stent can often be used that sits in one of the eyelid drains (not both) and doesn’t have the “loop” in the inner corner of the eyelids. It usually is very comfortable and not noticed by patients. The revision surgery does best just like the original by leaving the stent in place for 3-4 months. This is to give the internal drains time to heal and lessen the risk of them scarring shut or becoming so narrow that they don’t work well enough. Tearing of the eyes can be due to many causes to include: reflexive tearing from dry eyes (so try lubricating eye drops during the day such as Systane Ultra or Genteal); poor eyelid tone or tear drain positions (fixed with surgery); excessively wide open eyelids or protrusion of the eyes from the eye socket; local irritants (eyelashes rubbing the eyes); external irritants (wind, pollen etc.); stenosis (excessive narrowing or blockage) of the tear drain opening (puncta), canaliculus (drain from eyelid opening to tear sac), or the nasolacrimal duct (within the bone itself or at the opening in the nose from excessive mucous congestion); and rarely from a tumor or stone within the lacrimal sac or pressing upon it. Dr. Burroughs strives for 100% success, but this does not always happen. He does try on every patient to achieve the best result possible. Dr. Burroughs is often referred patients from other surgeons, including oculoplastic subspecialists, that perform tear drain surgery that has failed. He has a very high success rate on these revision surgeries.
11. Is it painful or difficult to have the stents removed?
In adults it is an easy in-office procedure after some topical anesthetic eye drops are placed on the eyes. In children, sometimes a return to the OR for safety reasons is required. Generally, stent removal is not painful at all.
12. Are watery, bloody tears ever serious?
Yes, this can be a warning sign of a tear sac tumor or serious medical condition. Any time a patient has blood on the eye surface (e.g., in the tear film) it is imperative to look for an explanation. A thorough eye exam needs to be performed to identify any superficial (e.g., eyelid, eye surface issue) cause for the bloody tears. If the superficial eye exam is normal then more extensive evaluation is required. As part of Dr. Burroughs’ subspecialty practice of oculoplastic surgery, he sadly see several cases every year of tumors and cancers around and in the eye. Dr. Burroughs regrets having to inform any patient that their eye symptoms could have a very serious cause and even more so when a cancer is diagnosed, but it is his ethical responsibility as a physician to be honest and forthright about these possibilities. If a patient has unexplained blood in the tears, any prolonged delay (e.g., greater than 4-6 weeks) in exploring and getting a tear sac biopsy is not prudent and potentially dangerous as untreated malignancies (cancers) can cause premature loss of life and in the eye region risk of vision loss or loss of the eye. Tearing surgery in this situation can be very important beyond getting the biopsy and the improvement of having your eyes less “watery” or reducing the overflow of tears onto your cheeks. Patients with either complete or partial tear drain blockages can develop both superficial eye infections as well as infections that can go into the face and/or eye sockets. Dr. Burroughs has personally had to treat many such patients over the years and some of the face infections had been quite severe requiring hospitalization and surgery to first drain the infection followed later by the tear drainage surgery to avoid future infections and to improve tearing symptoms. One can never tell when a deeper infection may occur. Some signs to watch out for are pain, redness, swelling in the inner corner of the eyelids. A “goopy” eye discharge in addition to persistent watery eyes can also be concerning. Furthermore, once infections have occurred in the tear drainage system, it can make the definitive reconstructive surgery more difficult and with potentially lower success.
13. Besides a stent placement or a DCR are there other ways to help eyes water less?
Yes, depending on the problem other less invasive procedures in the office may be performed. Sometimes patients punctal (eyelid tear drain openings) have become narrowed or scarred shut and a relatively quick and comfortable procedure can be done in the office to restore the tear drain openings to an optimum size. Misdirected tear drains can be repositioned with sutures, and eyelid malpositions that are weakening the tear drainage pump mechanism can be addressed. Furthermore, some tearing is due to eyelid malpositions as discussed earlier (e.g., eyelids to far apart or not in proper position against the eye).