Watery Eye and Blocked Tear Ducts in London

Watery eye (epiphora) and the surgery Dacryocystorhinostomy (DCR)

What is a watery eye (epiphora)?

The medical term for watery eye is epiphora. It is a common problem that many people suffer from. It is caused by a failure in the drainage system of the tears. Tears are constantly produced, not just when people cry and they act to lubricate the eye with the fluid draining through the tear drainage system to the nose through a passage known as the nasolacrimal duct. In some people the balance of tear production and tear drainage can fail resulting in the eyes becoming excessively watery resulting in epiphora.

The condition can usually affects children and the older person although it can affect people at any age. The watery eye can irritate the lower eyelid and cause the skin to become sore, irritated and red. The tearing can also affect people socially as people think they are crying even when they are not; causing embarrassment and in some cases even social isolation. 

Treatment for watery eye depends on the cause and can range from the use of hot flannels or a heat eye mask applied to the eyelids daily, to the use of eye drops or surgery to improve the pump function of the eyelid to help drain the tears or surgery on the tear duct (the nasolacrimal duct) when someone has nasolacrimal duct obstruction.

What is the cause?

 

A constant watery eye is not usual. It is usual for the eye to water at times of an eye infection, moments of sadness, or when there is something that entered the eye such as a speck of dust or an eyelash.  In essence, a watery eye is caused by an imbalance in the tear production and drainage by:

 

  • Too many tears being produced

  • The tears not draining away effectively

  • A combination of both too many tears being produced and tears not draining effectively

To identify the cause a thorough assessment of the eyes, the eyelids, the tear drainage and the nasolacrimal duct to reach a conclusion as to what treatment is required.

The most common cause of watery eye particularly when outdoors is dry eye syndrome which paradoxically results in excessive tear production. Other causes include allergies particularly in those that suffer from hay fever or from prolonged contact lens use, infections of the eye such as conjunctivitis or a malposition of the eyelid such as an entropion when the eyelid turns inwards or an ectropion where the eyelid turns outwards.

Watery eye occurs where the tear drainage system no longer works effectively as in a blocked tear duct (blocked nasolacrimal duct) The tears enter the tear duct through a small opening on the eyelid known as the punctum. If the punctum is too small in punctual stenosis then watery eye can occur. It can also occur if the punctum is misplaced or there is laxity in the eyelids resulting in the eyelids no longer being able to pump the tears towards the punctum and the tear duct.

What are the symptoms of watery eye?

 

The symptoms of water eye can be constant tearing which can result is blurred vision and irritation to the eyelid skin. Other symptoms include a constant sticky eye, soreness, blurry vision, irritated eyelids and itchy eye. Other social symptoms caused by a constant watery eye includes people thinking that they are crying and the impact of the embarrassment this causes resulting in social isolation or the inability to perform at work.

What treatment is available for watery eye?

 

As the most common cause of watery eyes is dry eye syndrome it would be good to try using hot flannels or a heat eye mask to the eyelids daily as well as some over the counter dry eye drops to see if this helps your symptoms. If the watery eyes are constant and daily then an assessment can look into the cause including examining the tear ducts to ensure that they are not blocked. The majority of people will be able to treat their watery eye with eye drops, hot flannels or anti allergy medications if they suffer from allergies that are the cause. For those who have eyelid laxity or a blocked tear duct surgery may be necessary to tear the watering. The surgery required will depend on the cause.

Will I benefit from watery eye surgery?

 

There are a range of watery eye surgeries available depending on the cause. The most common surgery deformed is dacryocystorhinostomy (DCR) which is creating a new tear duct when the tear duct is blocked. The medical term for a blocked tear duct is nasolacrimal duct obstruction. DCR surgery bypasses the blocked tear duct to allow the tears to drain into the nose again as they previously did prior to the blockage in the tear duct. The most common was of performing the surgery is through an external approach which results in scar on the side of the nose. Mr Ahmad Aziz specialises in the more modern approach which is telescopic approach through the nose known as endonasal or endoscopic DCR. This results in no scar on the nose or the face. Mr Ahmad Aziz prefers this approach because of the benefit of having no scar.

Are there any other types of surgery available?

 

Watery eye surgery other than treating a tear duct blockage in the nasolacrimal duct include correcting any laxity in the eyelid, correcting the position of the punctum where the tears enter the tear duct or enlarging the punctum if it is small or stenosed. Eyelid laxity results in the tears not being guided to the punctum with every blink which leads to watery eye. Tightening the lower eyelid can help correct this. If the punctum is out position or too small the tears cannot enter the tear duct effectively and surgery to make it larger and correctly positioned will aid the tera drainage. Not every watery eye requires a DCR or even surgery at all and Mr Ahmad Aziz can assess and explain the options from his London clinic.

What is a dacryocystorhinostomy (DCR)?

DCR surgery is used to treat blocked tear ducts. It allows the tears to drain normally by creating a new passage for the tears to drain from the tear sac and the nose.  It is performed under a general anaesthetic with you asleep during the operation and typically takes 1 hour to complete. In cases where having a general anaesthetic may be less safe, an external DCR can be performed under local anaesthetic.  This will be discussed with you prior to the procedure. 

There are two approaches to DCR surgery. An external approach and an endonasal approach.  Most people prefer to go for an endonasal approach because it avoids a scar on the side of the nose. An external approach is used in people who are unable to have a general anaesthetic and in cases where going through the nose is not possible. This will be discussed with you during your consultation.

  • Endoscopic DCR – A telescope is used up the nose to access the tear sac and bypass the blockage site. The tear sac is then opened and allowed to drain through a new passage. A flexible tube is inserted to keep the passage open as the nose heals. This tube is colourless and is hardly noticeable to most people. The tune is then removed about 6 weeks later once the nose as healed. The advantage of this procedure is that is leaves no scar on the side of the nose and is usually entirely scar-less. The success rate for this is about 90%.

  • External DCR – Is the most common operation done for blocked tear ducts although endonasal DCR is gaining in popularity for its advantages. It has a success rate of over 90%. A small incision is made on the side of the nose to access the tear sac. The tear sac is opened and a new passage is made for the tears to drain.  A flexible tube is then passed to keep the new passage open as the nose heals. The tubes are removed 6 weeks later. The incision is sutured with stitches which are removed 2 weeks after the procedure.

Your surgeon will discuss both options and which is most suitable for you.

Which surgery is best for me?

 

An endoscopic DCR or Endonasal DCR avoids the scar and is usually the preferred choice for nasolacrimal duct obstruction or tear duct blockage. An external DCR does result in a small scar on the side of the nose although the scar tends to fade with time in most people. 

Endonasal DCR is best for those who want to avoid a scar or who may have problems with their sinus, a deviated nasal septum or nasal polyps that can also be operated on at the same time as with the blocked tear duct. It requires a general anaesthetic.

External DCR is best for those who are unable to have a general anaesthetic or those that have a blockage of the portion of the tear duct that lies within the eyelid (canaliculi). 

Your Oculoplastic surgeon will assess the tear ducts and the nasolacirmal duct at the time of your consultation to determine which procedure is best for you.

Why do I need A DCR?

The tears in the eye usually drain through the tear duct the starts from the corner of the eye by the nose and ends inside the nose itself.  When the tear duct becomes blocked the tears are unable to drain resulting in watering of the eye and the risk of infections in the tear duct. An infection in the tear duct is known as dacryocystitis.

To assess if your tear duct is blocked your Oculoplastic surgeon may use a dye test to see if it drains. This test takes 5 minutes to perform. They may then try to flush the tear duct to see if there is an obstruction. If there is no obstruction you will taste the water down your throat during the test. If the tear duct is blocked you will not taste the water in your throat and it will reflux back and create a watery eye.

What are the complications or risks of a DCR?

 

The possible risks of DCR surgery include:

  • Bleeding from the nose or incisionfor 2-3 days

  • Bruising around the surgery site

  • A scar if you have an external DCR

  • Displacement of the flexible tube which is less common

  • A nose bleed that may be more significant that requires packing of the nose

  • A nose bleed that requires another procedure to find the bleeding site and stop it

  • A further procedure

  • Rarely, double vision or loss of vision

  • Risks associated with general anaesthetic such as anaesthetic reactions and blood clots.

What happens before the operation?

 

On having a consultation with your surgeon the tear ducts will be assessed with a dye test and syringing and flushing the tear ducts to assess if there is a blockage. if the tear duct is blocked your surgeon will discuss DCR surgery and may look up the nose to see if a scar-less DCR procedure is suitable for you. The options of surgery and what type of surgery will be discussed.

 

As the surgery is most commonly done under general anaesthetic you will need a pre-operative assessment at the hospital.  At the pre-operative assessment you will be asked questions about your general health, medications, have some simple blood tests and had a heart tracing ECG to ensure that a general anaesthetic will be safe for you.

How do I prepare for the operation?

 

Most of the preparation for surgery will happen with the tests carried out at the pre-assessment appointment at the hospital.

 

If you are on medication that thins the blood this will need to be stopped before the operation and will be discussed at the pre-operative assessment.

 

The surgery is usually done as a day case where you are able to attend and go home the same day.  In some cases you may need to stay in hospital for one night - particularly if there is no one at home to stay with you on the day of the operation or if you are still drowsy after the anaesthetic.

What happens afterwards?

 

After the operation there may be some blood spots from the nose and possible some bruising around the operation site which should resolve over a few weeks. There may be some discomfort around the area which usually settles with simple painkillers such as paracetamol. Usually you can go home on the day of the operation.

You will be sent home with a nasal spray and some eye drops to use for a period of 3 weeks. The nasal spray is used twice a day and the eye drops used three times a day.

A follow up appointment will be arranged 2 weeks later to see how you are getting on following the surgery, remove any stitches if you have had an external DCR and plan for when to remove the tubes. 

At 6 weeks the tubes are removed in the clinic.

A final check is done at 6 months to ensure the tears are now draining well.

In the unlikely event that you have a nose bleed that does not stop you should call your surgeon immediately who will give you a contact number to call.

Is there anything that I should avoid after the operation?

 

To encourage success of your DCR:

  • Try to sit up and sleep on 1 or 2 extra pillows at night

  • Avoid blowing or picking your nose for one week after having had you surgery.

  • Use paracetamol painkillers for any discomfort but avoid taking aspirin and ibuprofen which can encourage bleeding.

  • Try to avoid any strenuous exercise or activity for two weeks after you procedure

  • Also avoid exercise especially swimming for two weeks after surgery.

  • Try to avoid travelling by plane for seven days after your operation.

Results

90% of people have resolution or improvement of their watery eye following DCR surgery and are satisfied with the results  The results of the surgery usually last a lifetime but in 10% of people the surgery may not help and they may require another procedure.

 

Any bruising usually settles within 2 weeks giving you confidence to go out in public. If you have had an endonasal DCR you will have no scar. An external DCR does have  a small 1 cm scar on the side of the nose that usually fades with time.  You should protect the scar site from sun exposure as you do for the rest of your skin.

Final remarks

Watery eye is a common problem with multiple causes. It requires a thorough assessment to identify the cause of which there are many. Self help remedies include using  hot flannel or het eye mask daily as well as dry eye drops. Should these not help or the watering be continuous or persistent an assessment is required to identify the cause. Surgical options include addressing a blocked tear duct, to correcting any laxity in the eyelid or addressing an issues with the tear duct opening (the punctum). 

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