The tear film on the surface of the eye is a critical component of maintaining vision. Tears nourish and lubricate the surface of the eye as well as wash away debris. A smooth, balanced tear film (consisting of water, oil and mucus) also allows light to enter the eye in an optimal fashion. If there is a disturbance of the tear film, patients will often experience tearing, burning, irritation and most importantly blurred vision. 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. The eye has two sets of structures that produce tears. Smaller tear glands help maintain a baseline level of moisture on the surface of the eye. Unfortunately, inflammatory conditions like rheumatoid arthritis, Sjogrens disease as well as aging and menopause lead to decreased tear production. As tear production diminishes, the surface of the eye starts to dry out. Further, inflammation of the oil glands along the edge of the eyelid, common in patients with rosacea (blepharitis), also causes early breakdown and evaporation of the tear film. The brain senses the eye is both dry and irritated and in turn signals the main tear gland to flush the eye. As a result, the dry eye paradoxically tears and becomes watery. Patients with dry eyes note intermittent tearing of the eyes during activities like reading, driving, watching TV, using a computer or going outside on a windy day. These all cause the eye to dry out because the eye blinks less during these activities. 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) – Click on this link for an article published by Dr. Taban on punctal plugs.
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.
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.
A thorough examination by an ophthalmic plastic surgeon can determine the cause of tearing and recommended treatment.
How is an Obstructed Tear Duct Treated or Repaired?
Depending on your symptoms and their severity, your specialist will suggest an appropriate course. In mild cases, a treatment of warm compresses and antibiotics may be recommended. In more severe cases, surgical intervention to bypass the tear duct obstruction (dacryocystorhinostomy or DCR surgery) may be recommended. A DCR is performed by creating a new tear passageway from the lacrimal sac into the nose, bypassing the obstruction. 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.
A small silicone tube called a stent may temporarily be placed in the new passageway to keep it open during the healing process. In a small percentage of cases, the obstruction is between the puncta and the lacrimal sac. In these cases, in addition to the DCR procedure, the surgeon will insert a tiny artificial tear drain called a Jones Tube. A Jones Tube is made of Pyrex glass and allows tears to drain directly from the eye to the lacrimal sac.
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