THE WATERING EYE

It is characterised by overflow of tears from the
conjunctival sac. The condition may occur either due
to excessive secretion of tears (hyperlacrimation) or
may result from obstruction to the outflow of normally
secreted tears (epiphora).
Etiology
(A) Causes of hyperlacrimation
1. Primary hyperlacrimation. It is a rare condition
which occurs due to direct stimulation of the lacrimal
gland. It may occur in early stages of lacrimal gland
tumours and cysts and due to the effect of strong
parasympathomimetic drugs.
2. Reflex hyperlacrimation. It results from stimulation
of sensory branches of fifth nerve due to irritation of
cornea or conjunctiva. It may occur in multitude of
conditions which include:
Affections of the lids: Stye, hordeolum internum,
acute meibomitis, trichiasis, concretions and
entropion.
Affections of the conjunctiva: Conjunctivits which
may be infective, allergic, toxic, irritative or
traumatic.
Affections of the cornea: These include, corneal
abrasions, corneal ulcers and non-ulcerative
keratitis.
Affections of the sclera: Episcleritis and scleritis.
Affections of uveal tissue: Iritis, cyclitis,
iridocyclitis.
Acute glaucomas.
Endophthalmitis and panophthalmitis.
Orbital cellulitis.
3. Central lacrimation (psychical lacrimation). The
exact area concerned with central lacrimation is still
not known. It is seen in emotional states, voluntary
lacrimation and hysterical lacrimation.
(B) Causes of epiphora
Inadequate drainage of tears may occur due to
physiological or anatomical (mechanical) causes.
I Physiological cause is ‘lacrimal pump’ failure due
to lower lid laxity or weakness of orbicularis muscle.
II Mechanical obstruction in lacrimal passages may
lie at the level of punctum, canaliculus, lacrimal sac
or nasolacrimal duct.
1. Punctal causes include:
Eversion of lower punctum: It is commonly
seen in old age due to laxity of the lids. It may
also occur following chronic conjunctivitis,
chronic blepharitis and due to any cause of
ectropion.
Punctal obstruction: There may be congenital
absence of puncta or cicatricial closure
following injuries, burns or infections. Rarely
a small foreign body, concretion or cilia may
also block the punctum. Prolonged use of
drugs like idoxuridine and pilocarpine is also
associated with punctal stenosis.
2. Causes in the canaliculi. Canalicular obstruction
may be congenital or acquired due to foreign
body, trauma, strictures and canaliculitis.
Commonest cause of canaliculitis is actinomyces.
3. Causes in the lacrimal sac. These include
congenital mucous membrane folds, traumatic
strictures, dacryocystitis, specific infections like
tuberculosis and syphilis, dacryolithiasis, tumours
and atonia of the sac.
4. Causes in the nasolacrimal duct. Congenital
lesions include non-canalization, partial
canalization or imperforated membranous valves.
Acquired causes of obstruction are traumatic
strictures, inflammatory strictures, tumours and
diseases of the surrounding bones.
Clinical evaluation of a case of ‘Watering eye’
1. Ocular examination with diffuse illumination
using magnification should be carried to rule out
any cause of reflex hypersecretion located in lids,
conjunctiva, cornea, sclera, anterior chamber, uveal
tract and so on. This examination should also exclude
punctal causes of epiphora and any swelling in the
sac area.
2. Regurgitation test. A steady pressure with index
finger is applied over the lacrimal sac area above the
medial palpebral ligament. Reflux of mucopurulent
discharge indicates chronic dacryocystitis with
obstruction at lower end of the sac or the nasolacrimal
duct.
3. Fluorescein dye disappearance test (FDDT). In
this test 2 drops of fluorescein dry eye are instilled in
both the conjunctival sacs and observations are made
after 2 minutes. Normally, no dye is seen in the
conjunctival sac. A prolonged retention of dye in
conjunctival sac indicates inadequate drainage which
may be due to atonia of sac or mechanical obstruction.
4. Lacrimal syringing test. It is performed after
topical anaesthesia with 4 percent xylocaine (Fig. 15.5).
Normal saline is pushed into the lacrimal sac from
lower punctum with the help of a syringe and lacrimal
cannula. A free passage of saline through lacrimal passages
into the nose rules out any mechanical
obstruction.
In the presence of partial obstruction, saline
passes with considerable pressure on the syringe.
In the presence of obstruction no fluid passes
into nose and it may reflux through same punctum
(indicating obstruction in the same or common
canaliculus) or through opposite punctum
(indicating obstruction in the lower sac or
nasolacrimal duct).
5. Jones dye tests. These are performed when partial
obstruction is suspected. Jones dye tests are of no
value in the presence of total obstruction.
i. Jones primary test (Jones test I). It is performed
to differentiate between watering due to partial
obstruction of the lacrimal passages from that
due to primary hypersecretion of tears. Two drops
of 2 percent fluorescein dye are instilled in the
conjunctival sac and a cotton bud dipped in 1
percent xylocaine is placed in the inferior meatus
at the opening of nasolacrimal duct. After 5
minutes the cotton bud is removed and inspected.
A dye-stained cotton bud indicates adequate
drainage through the lacrimal passages and the
cause of watering is primary hypersecretion
(further investigations should aim at finding the
cause of primary hypersecretion). While the
unstained cotton bud (negative test) indicates
either a partial obstruction or failure of lacrimal
pump mechanism. To differentiate between these
conditions, Jones dye test-II is performed.
ii. Jones secondary test (Jones test II). When primary
test is negative, the cotton bud is again placed
in the inferior meatus and lacrimal syringing is
performed. A positive test suggests that dye was
present in the sac but could not reach the nose
due to partial obstruction. A negative test
indicates presence of lacrimal pump failure.
6. Dacryocystography. It is valuable in patients with
mechanical obstruction. It tells the exact site, nature
and extent of block (Fig. 15.6). In addition, it also
gives information about mucosa of the sac, presence
of any fistulae, diverticulae, stone, or tumour in the
sac.
To perform it a radiopaque material such as lipiodol,
pentopaque, dianosil or condray-280 is pushed in the
sac with the help of a lacrimal cannula and X-rays are
taken after 5 minutes and 30 minutes to visualize the
entire passage. For better anatomical visualization the
modified technique known as substraction
macrodacryocystography with canalicular
catheterisation should be preferred.
7. Radionucleotide dacryocystography (lacrimal
scintillography). It is a non-invasive technique to
assess the functional efficiency of lacrimal drainage
apparatus. A radioactive tracer (sulphur colloid or
technitium) is instilled into the conjunctival sac and
its passage through the lacrimal drainage system is
visualised with an Anger gamma camera