Diagnosis and Management of the Patient with Tearing


  • 10.1

  • 10.2

  • 10.3

  • 10.4

  • 10.5

  • 10.6

  • 10.7

  • 10.8

  • 10.9

  • 10.10

  • 10.11

  • 10.12

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When you see a patient with tearing, the goal is to determine the cause of the tearing problem and the appropriate treatment. A pathologic condition may occur anywhere along the path of tearing, from the production to drainage of tears. If you know the specific questions to ask during the history taking, you get a good idea of the cause of the tearing and the severity of the problem. I think of a watery eye as a different problem than a tearing eye. The watery eye can be caused by a number of problems that are usually not specifically related to obstruction of the lacrimal drainage system. The tearing eye is almost always the result of canalicular or nasolacrimal duct (NLD) obstruction. The patient’s age is a good clue to the probable cause of the problem. A tearing eye in a 70-year-old patient almost always has a different cause than a tearing eye in a child. There are three mechanisms that make an eye tear.

  • Overproduction

    • Reflex tearing

  • Poor lacrimal pump

    • Weak or loose eyelids

  • Inadequate drainage

    • Canalicular obstruction

    • NLD obstruction

After you have a good idea from the history of what the problem is, the physical examination either confirms your suspicion or points you to another diagnosis. If a cause of eye irritation or poor pumping of tears is not seen during the examination, the cause is lacrimal drainage obstruction. This is confirmed by the lacrimal system vital signs, which are determined by the dye disappearance test, palpation of the canaliculi, and irrigation of the NLD. When you know the site of obstruction, the treatment choice is clear.

There are many conditions affecting tearing that can cause the patient to seek your help. The examination can be long and unrewarding if your goal is unknown at the start. If you master the concepts in this chapter, the diagnosis of the majority of lacrimal drainage problems becomes easy. The treatments are successful in most patients.

Anatomy and Function

Production, Distribution, and Drainage of Tears

Let us review briefly the anatomy of the lacrimal system. Think of the system in these functional terms:

  • Production

  • Distribution

  • Drainage

Three layers of tears are produced to form the tear film. The lacrimal gland produces aqueous tears ( Figure 10.1 ). The accessory lacrimal glands of Wolfring and Krause produce additional aqueous tears. The middle aqueous layer adheres to the eye with the help of an inner mucous layer from the conjunctival goblet cells. Evaporation of the aqueous layer is reduced by a layer of oil superficial to the aqueous film produced by the oil glands of the eyelid. As you already know, these glands are primarily the meibomian glands of the tarsus and the Zeis glands associated with the eyelashes at the eyelid margin. All the glands producing the tear film must be healthy to keep a healthy thick layer of tears on the eye. Any problem in one layer may upset the system. An example is the eye irritation caused by blepharitis. In theory, the aqueous and mucous layers are okay, but the oil layer is not.

Figure 10.1

Dacryops. Have you ever wondered where the lacrimal gland ductules are? ( A ) When you see a case of dacryops, you have a clear understanding. Dacryops form when the opening of one or more ductules is occluded. The result is a cystic swelling of the ductule filled with aqueous tears. ( B ) Multiple dacryops have been marsupialized. In a normal patient, you cannot see the ductule openings, but they are found overlying the palpebral lobe of the lacrimal gland. A fluorescein Seidel test over the gland viewed with the blue light on the slit lamp or microscope sometimes shows you the dozen or so openings. It may be worth trying.

The Lacrimal Pump and Reflex Tearing

How are the distribution and drainage of tears related? Normal eyelid function is required for both. Normal blinking spreads the tears across the eye. The same normal blinking pumps the tears into the sac and down the NLD, the so-called lacrimal pump. Any abnormality in the frequency or quality of the blinking affects the distribution of tears. You have seen examples of both reduced frequency and quality of blinking. Patients with Parkinsonism blink only occasionally, causing symptoms of eye irritation and watery eyes. Patients with facial nerve palsy have a poor-quality blink. By this, I mean that the blink is not complete; the inferior cornea does not get wet. Ocular irritation resulting from conjunctival and corneal exposure is the result. The irritation may cause reflex tearing resulting in a watery eye . With facial nerve palsy, the strength of the blink is also decreased, reducing the force of the lacrimal pump. If the lid is ectropic or the pump is very poor, a tearing eye may occur. Two causes of the watery eye are:

  • Reflex tearing

  • Poor lacrimal pump

Reread this section on anatomy and function. The concepts of poor-quality tear production, inadequate distribution of tears, and reduced lacrimal pump function are difficult to understand when you are learning to estimate their contribution to a patient’s problem. You are likely to see many patients that suffer from a watery eye. Anatomic blockage of the lacrimal system is easier to diagnose and easier to fix.

Anatomic Sites of Obstruction

Normal tear drainage depends on a functioning lacrimal pump and an intact lacrimal drainage system ( Figure 10.2 ). As you recall from Chapter 2 , the tears enter the upper and lower puncta and travel in a short vertical portion of the puncta for 1 or 2 mm before entering the horizontal portion of the canaliculi. The canaliculi enter the lacrimal sac at an angle, which forms a sort of valve (common internal punctum). The lacrimal sac sits in the lacrimal sac fossa bounded by the anterior lacrimal crest (maxillary bone) and the posterior lacrimal crest (lacrimal bone). The sac narrows inferiorly, forming the NLD (membranous NLD). The duct passes inferiorly through a bony canal (osseous NLD) to open beneath the inferior turbinate into the inferior meatus of the nose. The valve of Hasner at this opening prevents retrograde flow of tears or air up into the duct from the nose. An abnormality anywhere along this path can delay or block the drainage of the tears, usually causing a tearing eye. Anatomic obstruction can occur in the canaliculi or the NLD.

Figure 10.2

The anatomy of the lacrimal system.

As alluded to above, one or more of three possible problems (simplified) exists:

  • Too many tears

  • Poor pumping of tears

  • Poor drainage of tears

Our job is to figure out which of the three problems exist.


The Watery Eye Versus the Tearing Eye: The Significance of True Epiphora

The Definition of True Epiphora: Tears on the Cheek

As you have seen earlier, I try to divide the patient’s complaint into the watery eye or the tearing eye . The watery eye does not spill tears onto the cheek. The tearing eye has true epiphora, meaning that tears overflow onto the cheek. Make sure that you understand this difference. When your patient tells you the eye waters, ask “Do the tears flow down your cheek or do they stay in your eye?” It is surprising how many patients tell you that they have tearing but that no tears overflow.

What do the answers to these questions mean? The watery eye can be caused by a number of problems. Most of these problems are related to poor tear film, causing ocular irritation (or reflex tearing). There may be a subtle problem with one of the layers of the tears or the distribution of the tears, as we said above. These conditions improve with medical management, such as lid hygiene and use of artificial tears and lubricating ointments. Watery eyes caused by an abnormal lid position or a poorly functioning pump are usually easy to diagnose on physical examination.

The tearing eye (true epiphora) is usually caused by poor drainage of tears though the lacrimal system. There are exceptions to this, but in the absence of other obvious problems causing reflex tearing (e.g., an inflamed eye or trichiasis) or a lacrimal pump problem (ectropion or a facial nerve palsy), epiphora means obstruction, and an operation is required to eliminate the tearing. I repeat this concept because it is important: in the absence of a cause of reflex tearing or obvious lacrimal pump problem, epiphora means obstruction of the lacrimal drainage system. Read the above two paragraphs again! For me, the difference between a watery eye and a tearing eye (true epiphora) is a huge help toward making the correct diagnosis.

The presence of epiphora depends on how complete the obstruction is and how many tears are being made. If the tears flow down your patient’s cheek, ask, “Do the tears flow down your cheek when you are inside and resting or mainly when you are outside in the cold and wind?” Everyone’s system makes more tears in the wind or cold (this is a tear drainage stress test of sorts). If tearing is present only in the wind and cold, the obstruction is more likely partial or not complete. Remember that young patients’ systems make more tears than older patients’ systems, so tear overflow is seen more readily in younger patients than in older patients with the same anatomic problem. In fact, the lacrimal gland of many older adults makes so few tears that epiphora is not present despite a complete blockage of the lacrimal drainage. With NLD obstruction, these patients may exhibit signs of chronic dacryocystitis (mucopurulent drainage) or acute dacryocystitis (painful swelling of the medial canthus) but have no tearing. On the other hand, a young patient may have bothersome epiphora with only slight eversion of one punctum. An older patient with the same punctal eversion does not notice any epiphora.


  • Remind yourself of one or two problems that can affect tearing:

    • Production: too many tears

    • Distribution: poor pump

    • Drainage: blockage of NLD

  • Make a sketch of the normal anatomy of the lacrimal drainage system.

  • What is the clinical difference between a watery eye and a tearing eye (epiphora)?

  • What is implied by a diagnosis of true epiphora?

  • Remember the questions:

    • “Do the tears flow down your cheek or do they stay in your eye?”

    • “Do the tears flow down your cheek when you are inside and resting or mainly when you are outside in the cold and wind?”

Findings Suggesting Lacrimal System Obstruction

Things are getting a bit complicated, so let us go back to the general rules. Epiphora (tears on the cheek) implies a blockage in the drainage system. Watery eyes suggest a tear film or subtle blinking problem.

We have already discussed the significance of epiphora. There are always exceptions, but in most patients, NLD obstruction occurs initially as a unilateral problem. A history of dacryocystitis means that an NLD obstruction is present. Onset after conjunctivitis suggests that the puncta or the canaliculi have become obstructed as a result of a viral infection (one of the few bilateral onsets). Onset after facial fracture or nasal surgery implies damage to the NLD ( Box 10.1 ).

Box 10.1

Findings Suggesting Obstruction of the Lacrimal System

  • True epiphora: tears on cheek

  • Unilateral symptoms

  • History of dacryocystitis

  • Acute infection

  • Mucoid discharge with pressure on sac

  • Onset after:

    • Conjunctivitis

    • Facial fracture

    • Nasal surgery (history of nasal surgery)

Watery Eyes: Findings Suggesting Other Causes of Tearing

As we discussed in the earlier sections, a patient may complain of watery eyes. No true epiphora is present. The exact meaning of this complaint can vary from patient to patient. Watery eyes may mean ocular irritation, mucoid discharge, a large tear lake, or just the feeling that the patient needs to blot the eyes. Sometimes even patients with low tear production complain of watery eyes.

Because the main cause of watery eyes is poor tear film resulting in ocular irritation, the symptoms are usually bilateral. In some situations, the watery eyes may be explained by lacrimal pump problems, including lid laxity or mild ectropion. These conditions are also usually bilateral in an older patient. Watery eyes may be caused by an incomplete blink related to facial nerve palsy. This is an exception to the general rule that epiphora or a watery eye occurring unilaterally is usually due to an NLD obstruction. However, the diagnosis of a palsy is usually clear.

When a patient complains of watery eyes without true epiphora, ask if the symptoms are bilateral and if any ocular irritation is present. Look for findings during the examination that confirm a poor tear film or inadequate lacrimal pump ( Box 10.2 ).

Box 10.2

Watery Eyes versus Tearing Eyes

Watery eyes

  • No tears on cheek

  • A nonspecific complaint

  • Related to poor tear quality or poor tear distribution

  • Treated with lid hygiene or use of artificial tears or ointment

Tearing eyes

  • Epiphora or tears overflowing onto cheek

  • Suggests obstruction of the lacrimal drainage: blocked NLD or canaliculus

  • Usually treated with an operation to restore drainage

Causes of Tearing by Age

If a patient has true epiphora, you can predict the type of blockage based on the patient’s age ( Figure 10.3 ). The following list is a great place to start for diagnosing the cause of lacrimal obstruction:

  • Children: congenital NLD obstruction

  • Young adults: trauma (canalicular laceration or facial trauma); canalicular disease (usually, postherpetic viral cause)

  • Middle-aged adult: dacryolith (usually, recurrent episodes of epiphora)

  • Older adults: primary NLD obstruction

Figure 10.3

The diagnosis of tearing by age. ( A ) A child with congenital NLD obstruction. ( B ) A young adult with canalicular obstruction caused by viral conjunctivitis (the other cause in this age group is trauma). ( C ) A middle-aged woman with recurrent tearing resulting from a dacryolith. ( D ) An older adult with tearing caused by primary acquired NLD obstruction.


A child who is seen with a tearing eye, often associated with mattering, has a congenital NLD obstruction until proven otherwise. This obstruction presents in the first month or two of life. In some children the mattering is present throughout the day and in others the mattering may be present only upon wakening. The cause of the obstruction is a congenital membrane occurring at the valve of Hasner. In more than 90% of children, this membrane ruptures spontaneously within the first year of life. Acute dacryocystitis can occur but is rare.

Young Adults: Canalicular Disease or Trauma

When a young adult is seen with epiphora, the cause is usually related to canalicular obstruction or trauma. Canalicular obstruction can occur after viral conjunctivitis. Often this obstruction is in all four canaliculi, causing complete scarring of each canaliculus. In other patients, traumatic lacerations of the eyelid may be associated with canalicular lacerations. In these patients, the obstruction is usually focal and in one canaliculus. Facial fractures may cause damage to the NLD, but obstruction is less common that you might expect. As you might expect, trauma is more common in young men than in young women.

Middle-Aged Adults: Dacryolith

A middle-aged adult, usually a woman, describes to you recurrent symptoms of true epiphora. In some cases, the epiphora is associated with slight pain and tenderness in the medial canthus, suggesting mild dacryocystitis. In most patients, the epiphora resolves spontaneously over days or weeks. Interestingly, some patients may sneeze a small cast of stones out the nose. Passing of the dacryolith usually results in resolution of the symptoms. In some cases, your irrigation of the NLD improves the symptoms. In some patients, symptoms are recurrent and the patient may require surgical treatment ( Figure 10.4 ).

Figure 10.4

An unusually large dacryolith removed from the nasolacrimal sac and duct of a middle-aged woman (see Figure 10.2 ), showing a cast of the entire lacrimal excretory system.

Almost as common as stones, it seems, is the woman with canalicular obstruction due to breast cancer treatment with docetaxel anhydrous. You recognize that patient from the past medical history or review of systems. Most patients with this cause of tearing equate the start of the tearing with the initiation of the chemotherapy. Fortunately, this problem has become less common as the dosage and schedule for the drug have been decreased over time. Most patients with canalicular obstruction due to this drug can be cured with lacrimal stent placement.

Older Adults: Nasolacrimal Duct Obstruction

An older adult, again usually a woman, is seen with epiphora resulting from primary acquired NLD obstruction. The cause of this scarring in the distal portion of the NLD is not known. Symptoms include epiphora, chronic mucopurulent discharge (chronic dacryocystitis), and acute cellulitis of the lacrimal sac (acute dacryocystitis; Figure 10.5 ).

Figure 10.5

Dacryocystitis means an NLD obstruction is present. ( A ) Acute dacryocystitis. ( B ) Chronic dacryocystitis.

Although these diagnoses by age are generalizations, they are correct for most patients. The physical examination proves or disproves your tentative diagnosis.


  • What findings in the history suggest lacrimal duct obstruction?

  • What are the two common causes of the watery eye?

  • Review the causes of epiphora based on age (very important; do not skip this).

Upper and Lower Lacrimal Drainage Systems

Tear drainage can be blocked at any point from the punctum to the valve of Hasner. The lacrimal drainage system can be divided into upper and lower systems. The upper system starts at the punctum and includes the canaliculi and the common internal punctum. The lower system consists of the lacrimal sac and NLD. Upper system obstruction, at the punctum or in the canaliculus, causes tearing only. Normally, mucoid secretions drain down the duct. Lower system obstruction, usually in the NLD, causes retention of mucus or pus in the lacrimal sac. NLD obstruction may present as tearing and/or mucopurulent discharge. Partial obstruction (also called functional obstruction) of the NLD commonly occurs. Patients with partial obstruction often have tearing in the cold and wind, as discussed earlier. Mucus produced in the sac is drained sufficiently to prevent signs and symptoms of dacryocystitis.

Physical Examination

It is almost a cliché, but it is true that the examination starts when the patient walks into the room. You may notice an obvious cause of epiphora, such as ectropion, entropion, discharge, ocular inflammation, dacryocystitis, or facial nerve palsy. The patient may have a large tear lake or frank epiphora. The patient may have a tissue in hand. If so, watch to see if the patient wipes the eyes when epiphora is present or merely wipes the eyes as a habit.

The patient with tearing needs a complete eye examination with an emphasis on the eyelid, eyelash, and lacrimal system ( Box 10.3 ).

Box 10.3

Causes of Tearing by Age


  • Congenital NLD obstruction

Young adults

  • Trauma (canalicular laceration or facial trauma)

  • Canalicular disease (usually, postherpetic viral cause)

Middle-aged adults

  • Dacryolith (usually, recurrent symptoms)

  • Canalicular obstruction in woman treated with docetaxel

Older adults

  • Primary acquired NLD

Eyelid Problems

Ectropion and Entropion

A number of eyelid problems may cause tearing. Ectropion resulting from any cause may prevent tears from reaching the lower punctum and canaliculus. Minor amounts of ectropion may go unnoticed but may cause punctal eversion. More severe cicatricial or paralytic ectropion may prevent the lacrimal pump from functioning properly. Entropion is a cause of reflex tearing. If an older patient describes intermittent inward turning of the eyelid that is not seen on the examination, ask him or her to squeeze the eyes tightly. Forceful spasm of the orbicularis muscle may elicit entropion. Patients with cicatricial entropion have eyelashes or keratinized skin against the ocular surface. Posterior lamellar scarring may be associated with damage to the conjunctiva, causing a poor tear film.

Eyelash ptosis is a sure sign of floppy eyelid syndrome , which can be the cause of a watery eye because of either reflex irritation or lacrimal pump problems caused by the extreme laxity (see next section). These patients, most commonly heavy middle-aged men, have very loose eyelids that are easily everted ( Figure 10.6 ). Erythema of the bulbar and palpebral papillary conjunctiva is usually seen accompanying the eyelash ptosis. Remember to ask about snoring, and if it is severe, refer your patient for evaluation of obstructive sleep apnea. Patients with obstructive sleep apnea also have a higher incidence of glaucoma, possibly related to nighttime hypoxia. Eyelids with floppy eyelid syndrome have been shown to have decreased elastin as well as an altered ultrastructure, possibly because of upregulation of elastin degradation enzymes.

Figure 10.6

Entropion and ectropion. Rule out conditions related to the eyelids or eyelashes that may be a cause of reflux tearing or poor lacrimal pump function. It is best to treat these obvious causes before looking for an obstructive etiology. ( A ) Involutional entropion. ( B ) Cicatricial entropion. Both the lower and upper eyelashes are directed inward. ( C ) Eyelash ptosis seen in floppy eyelid syndrome. ( D ) Extreme upper eyelid laxity with erythematous conjunctiva and strands of mucus in floppy eyelid syndrome.

On occasion, you see a patient who is constantly rubbing one or both eyes in an attempt to pull out mucous strands. In some cases, the rubbing can be fairly aggressive. This syndrome is known as mucous fishing syndrome . Dryness is probably the original cause of the irritation, but the constant rubbing seems to aggravate the problem, making the situation worse. Other factors may play a role; the condition is poorly understood.

Lacrimal Pump Problems

Lacrimal pump problems are associated with lid deformity, incomplete blink, and involutional laxity of the eyelids. Scar tissue may cause the lids to be stiff and unable to blink completely and spontaneously. Facial nerve palsy is associated with an incomplete and weak blink that prevents normal lacrimal pump function. In the absence of a strong Bell phenomenon, corneal exposure may also be present, creating an element of reflex tearing as well.

The most common lacrimal pump problem is related to the laxity of the eyelids associated with aging. These involutional changes do not allow tight apposition of the eyelid against the eye. Lid laxity can be diagnosed by the lid distraction test and the snap test. In the lid distraction test, the normal lower eyelid cannot be pulled more than 6 mm off the eyeball. If more than 6 mm of distraction is present, the lid is said to be lax. The snap test is performed by pulling the lid downward off the eyeball. A lid with normal tone and no laxity should snap into position spontaneously. Greater amounts of laxity are associated with increasing numbers of blinks required to return the lid to normal position. I usually record the results of the snap test like this: Eyelid returns to normal position with one blink or two blinks (see Chapter 3 ).

Punctal Problems

Eversion of the lower punctum may be subtle and associated with tearing, especially in a young patient ( Figure 10.7 ). The normal punctum is not visible on slit lamp examination until the eyelid is manually inverted. A vertical punctum is abnormal (the punctum is visible without physically everting the eyelid). Stenosis of the punctum often follows eyelid eversion because of drying and shrinkage of the mucosa of the punctum. Spontaneous stenosis or closure of the punctum was commonly associated with echothiophate iodide drops for glaucoma treatment, but this medication is rarely used now. Punctal stenosis can, uncommonly, be associated with most antiglaucoma medications, however. A more common punctal problem related to these medications is a dermatitis of the eyelid skin causing eyelid eversion. A change in glaucoma drops often corrects this problem. Do not forget that almost any glaucoma drop can become irritating over time and exacerbate any subtle lubrication, pump, or drainage problem. Congenital punctal atresia is uncommon but may be present in children, often seen as a family trait (see Figure 10.17 ). In rare patients, the canalicular system may be normal but the puncta may be covered with a thin membrane. A discharge from a dilated punctum (pouting punctum) should alert you to a diagnosis of canaliculitis, an uncommon but frequently overlooked cause of a mattering eye. An even less common congenital problem is an accessory punctum (discussed later).

Figure 10.7

The normal punctum should be apposed to the globe. Punctal eversion ( arrow ) may be subtle and a cause of epiphora, especially in a young patient.

Eyelash Problems

Any condition that results in eyelashes rubbing against the eye may cause corneal or conjunctival irritation, resulting in reflex tearing. Marginal entropion is a common cause of trichiasis (see Chapter 5 ). Secondary eyelid margin changes resulting from posterior lamellar shortening may be caused by chronic blepharitis. In these patients, reflex tearing is the result of abnormal lashes rubbing the eye and a poor tear film.


  • At this point in the examination, you have eliminated eyelid or eyelash problems as a cause of tearing. What are some eyelid and eyelash problems that can cause tearing? Make a checklist for your examination.

  • You have established that the patient has true epiphora and have made a tentative diagnosis based upon the patient’s age.

  • The lacrimal examination confirms your tentative diagnosis.

The Lacrimal Examination

Rule Out Dacryocystitis First

Although the lacrimal system examination may seem daunting at first, it is really quite easy and quick when you get familiar with it. One shortcut is to look for signs of dacryocystitis if you suspect an NLD obstruction; the diagnosis is made if:

  • Signs of acute dacryocystitis are present

  • You can express pus or mucoid material from the lacrimal sac

  • A mucocele is present

Any one of these three findings makes the diagnosis of NLD obstruction. No further testing is necessary. The signs of acute dacryocystitis include swelling, erythema, and tenderness in the medial canthus. Any purulent or mucoid discharge that can be manually expressed from the sac is diagnostic for NLD obstruction. A mucocele is diagnosed when a palpable cystic mass is present in the medial canthus ( Figure 10.8 ). A mucocele results when obstruction at both the NLD below and the common internal punctum above causes the lacrimal sac to fill with mucus.

Figure 10.8

Mucocele. ( A ) Patient presented with tearing in the right eye. A large mass was palpable in the area of the sac. (B) Axial CT scan. This is an unusually large mucocele with extension into the orbit. Most mucoceles are not visible; they are only palpable by touch. Although you may never see a mucocele this large, it is a good example of an easy diagnosis of a blocked NLD. You can make the diagnosis by palpation. ( C ) Coronal CT scan. You can see this is a long-standing problem as evidenced by expansion of the NLD taking place over years. It is surprising there is no history of dacryocystitis ever being present. (See also Figure 14.32 .)

Slit Lamp Examination

After you have checked the obvious signs of NLD obstruction, move the slit lamp into position and evaluate the tear lake. If lacrimal obstruction is present, the tear lake is high. Obstruction of the NLD may cause reflux of debris seen floating in the tear lake. A block at the puncta or canaliculi results in a large tear lake without any debris present. Remember to evaluate the lacrimal lake before placing any drops in the eye. Next take a look at the cornea to rule out any obvious corneal pathologic changes. Watch the patient blink spontaneously and see how much of the cornea is covered with a blink. Look at the lid margins for signs of blepharitis or marginal entropion. Evaluate the position of the punctum. Remember that the normal punctum is not easily visible without slight manual eversion of the eyelid.

Lacrimal System Vital Signs

Next check the lacrimal system vital signs ( Box 10.4 ):

  • Dye disappearance test

  • Palpation of the canaliculus

  • Lacrimal irrigation

Box 10.4

Lacrimal System Vital Signs

  • Dye disappearance test

  • Palpation of canaliculi

  • Irrigation of lacrimal system

The dye disappearance test ( Figure 10.9 ) is one of the most important lacrimal tests that you do. After instilling a drop of a topical anesthetic, place a well-formed drop of 2% fluorescein into each conjunctival fornix. A fluorescein drop or strip works, but poor drainage is less obvious. After 5 minutes, check to see how much dye is retained in each eye. The dye disappearance test is very good for confirming lacrimal obstruction. The yellow dye spontaneously clears from a normal eye. A normal result is recorded as spontaneous symmetric dye disappearance. An abnormal result is recorded as dye retained in the right or left eye. This test is most valuable when symptoms of epiphora are asymmetric. This is a very good test to use in both children and adults. In most patients, the results of the tests are obvious. However, in some older adults, the conjunctiva stains with fluorescein in both eyes. Nevertheless, you may be able to evaluate the size of the tear film as an indicator of spontaneous tear drainage.

Figure 10.9

Dye disappearance test showing delay of fluorescein drainage and overflow of dye unilaterally.

Next, demonstrate the patency of the upper and lower canaliculi using a lacrimal probe. This diagnostic test should not be confused with therapeutic NLD probing. To emphasize this distinction, we call this diagnostic procedure canalicular palpation ( Figure 10.10A ). After gentle punctal dilation, a 0 Bowman probe is carefully placed in the canaliculus ( Figure 10.11 ). The lid should be pulled laterally and the probe directed toward the sac. If you meet resistance or the lid moves with the probe, you are probably pushing against the wall of the canaliculus and may cause a false passageway. The probe should pass easily to the lacrimal sac, where a hard stop should be present. This hard stop represents normal passage of the probe into the sac against the lacrimal bone. A soft stop is said to be present if a soft tissue obstruction at the lacrimal sac is encountered ( Figure 10.12 ).

Figure 10.10

Lacrimal examination. ( A ) Canalicular palpation using a no. 0 or 00 Bowman probe (Storz E4200–E4205 for a complete set) to test patency of the canaliculus. ( B ) Lacrimal irrigation using a lacrimal cannula (Storz E4406 or E4404) to test patency of the NLD. No reflux through the opposite canaliculus should be present.

Figure 10.11

Introducing an instrument into the canaliculus. ( A ) Stabilize the lid with a finger. The probe should be placed vertically in the punctum for 1 to 2 mm. The lid should be pulled temporally and the probe directed toward the canthal angle. If the eyelid moves with palpation of the canaliculus, you are either hitting an obstruction or pushing against the wall of the canaliculus, risking a false passageway. ( B ) Stop. Pull the lid temporally again and redirect the probe.

Figure 10.12

( A ) A hard stop with canalicular palpation, indicating a normal canaliculus. ( B ) A soft stop, indicating obstruction of the canaliculus.

Careful passage of a 0 Bowman probe should not cause pain. A mild to moderate amount of tenderness may be encountered as the probe passes through the common internal punctum. Under no circumstances should you probe into the NLD as a diagnostic procedure.

Lacrimal irrigation (see Figure 10.10B ) tells you if the NLD is normal, partially obstructed, or closed. Using a lacrimal irrigation cannula in the lower canaliculus (not the sac), you should be able to irrigate saline or water easily into the nose without any reflux around the cannula or out the upper canaliculus (normal NLD). If you cannot irrigate at all, make sure the cannula is properly placed and is not against the wall of the canaliculus. Any reflux from the lower or upper canaliculus is abnormal, suggesting resistance to flow down the duct. If the patient does not taste the fluid in the throat, occlude the upper punctum with a cotton-tipped applicator (an assistant can help with this) and irrigate again. If you can irrigate into the nose with pressure on the syringe, the patient has a partially obstructed or narrow duct (functional obstruction). If you cannot irrigate with pressure on the syringe, the duct is closed (anatomic obstruction). After you are comfortable with the irrigation process, try this: When your patient has a functional obstruction, try to irrigate with progressively more pressure until you get a bit of reflux. This gives you an idea of how much fluid the NLD can drain; it is a form of tear drainage stress test.

You may notice that I am not recommending the historically used Jones test for epiphora (which you may have read about elsewhere); it is time consuming and not necessary for making any decision regarding therapy.

Nasal Examination

The last portion of the lacrimal examination includes a nasal examination. Three options for illumination and exposure are available. A handheld illuminated speculum is a handy office tool (Welch Allyn no. 26030 illuminator and speculum or no. 26035 speculum only, welchallyn.com ). Alternatively, a nonilluminated speculum may be used for exposure and a headlight can be worn to provide illumination. If you do many lacrimal operations, you may want to purchase a fiberoptic nasal endoscope, which permits you to do the best intranasal examination. An inexpensive option is the Hawkeye borescope, a nonmedical endoscope used to inspect the barrel of a firearm ( gradientlens.com/RigidBorescopes.aspx ). This battery-operated scope gives a decent view of the nasal anatomy. The best option is the JedMed MobiLED light source and battery pack. You can attach a surgical endoscope of your choice ( jedmed.com/products/mobiled ). This unit is more expensive than the borescope, but the view is better and normal autoclave sterilization is possible. Regardless of the instrument used, intranasal tumors or mucosal abnormalities should be ruled out ( Box 10.5 ).

Box 10.5

Lacrimal Examination

  • Confirm diagnosis suggested by history of true epiphora versus a watery eye

  • Confirm diagnosis suggested by age

  • Rule out lid or lash problems

  • Diagnosis of NLD obstruction is made if:

    • Acute dacryocystitis is present

    • Mucoid or mucopurulent material can be expressed from the sac

    • A mucocele is present

  • Perform a slit lamp examination looking for:

    • A large tear lake

    • Debris in tear lake

    • Abnormal punctal position or patency

    • Cornea and lid margin abnormalities

  • Evaluate lacrimal system vital signs

    • Dye disappearance test

    • Palpation of canaliculi

    • Lacrimal irrigation

  • Do not probe the NLD into the nose!

  • Perform a nasal examination

  • If the pieces of the puzzle do not fit, look for an uncommon cause.

Nasal Endoscopy

You need to learn to use the endoscope in the operating room if you plan on doing lacrimal surgery. This is a must in my opinion. We use Stryker endoscopy equipment. The setup includes:

  • Endocamera

  • Endoscope

    • Adult 4-mm straight

    • Adult 4-mm 30-degree angle

  • Fiberoptic cable

  • Tower

    • Light source

    • Camera

    • Recording system

  • Monitor(s)

Let me share some tips on using the scope. The operating room team can show you what system is available. Get familiar with the equipment, including knowing what the different pieces are, how to assemble them, what is in the tower, and how to turn on the equipment. Assuming you are right-handed, stand on the patient’s left side. Cradle the camera in your left hand. I usually use an underhand grip. Position the monitor so that it is directly in your view at eye level, across the patient (see Figure 10.34 ). Make sure the orientation of the camera on the endoscope is rotated into the correct vertical orientation. It is easiest to use a zero-degree scope when learning. The exact rotation of the endoscope camera does not matter. As you get more adept, you can use one of the angled scopes to get a better view of the lateral wall in the nose (30-degree endoscope, most commonly, but you have to rotate the angled end of the endoscope and orient the camera to get the correct view and orientation of the nose). If you have the instruments in proper position, the image on the monitor should be oriented correctly. Wipe the endoscope lens with an antifogging agent before entering the nose.

To introduce the scope into the nose, look at the patient. Rest the endoscope against the superior edge of the nostril for stability. Think of the position where the scope rests as a fulcrum for your further movements. Enter the nose and orient the scope using external landmarks depending on what you want to see. For instance, if you want to see the middle turbinate, the external landmark is the medial canthus. Now look at the monitor as you advance the scope. Ideally, to avoid smearing the image, you do not touch the lens of the scope to the nasal tissue. Practice moving the scope in and out while watching the monitor as a guide to your movements. Always keep the scope against the edge of the nostril. If you get lost, back the scope out a bit and get a broader view. As you get more comfortable, move the scope around and try to view both the middle and inferior turbinates.

The next step is to introduce an instrument with your right hand. Start with a suction-tip catheter. Keep the scope against the nostril almost out of the nose. Now introduce the suction inferior to the scope. When you see the suction, move both the scope and the suction together, always keeping the suction tip in the view. Try touching the middle turbinate tip and then the inferior turbinate. Soon you are able to look under the turbinates. Look at the posterior pharynx. Like all procedures, this takes practice. Some of us catch on faster than others, but it is in the skill-set of all surgeons that I have ever taught. For those of you that have done vitrectomy surgery, the bimanual manipulation of the instrumentation is familiar.

As you gain facility with moving the scope and suction around, try other instruments such as the Freer elevator. Soon you are using the scope for the injection of local anesthesia, packing the nose, and retrieving stents. Take every opportunity to use the endoscope. If you do not already operate with a skilled ear–nose–throat sinus surgeon, seek one out as a colleague to share cases and exchange techniques. There are also an amazing variety of cutting tools on a sinus instrument tray. Ask the operating room team to set up a tray so you can experiment with the various tools.

If you are interested, you can extend your skills to endoscopic dacryocystorhinostomy (DCR). You can learn to use powered endoscopic tools such as the microdebrider (Medtronic M4 Straightshot Microdebrider, medtronic.com ; check out this website). This is a full system of cutting devices. A variety of drills and burs can extend your capabilities. A cleaning sheath, the Endo-Scrub, can be placed over the endoscope to improve visualization. Medtronic makes several endoscopic drills useful for other skull base procedures with which you may become involved (e.g., Midas Rex Legend Stylus).

On rare occasions, the examination does not fit with the history. The patient gives a history typical of primary acquired NLD obstruction, but you cannot demonstrate an obstruction. In these patients, dacryoscintigraphy can be helpful. In this nuclear medicine procedure, a labelled teardrop is placed in the conjunctival cul de sac. Its passage into the nose is imaged over time. This test is similar in concept to the dye disappearance test. It gives an estimate of the physiologic drainage of tears. Sometimes an area of obstruction can be identified. If any delay is noted, a drainage procedure is recommended. It is rare that I use this examination. In most cases, I proceed directly with either a DCR or stent intubation (more on stents for functional NLD obstruction later in this chapter).

If a mass presents in the medial canthus, it is likely a mucocele. Be suspicious if the mass extends superior to the medial canthal tendon, which suggests that a solid mass is displacing the tendon superiorly. The soft fluid collection of a mucocele does not extend above the medial canthal tendon ( Figure 10.13 ). A CT scan or MRI of the sac is necessary when a lacrimal sac tumor is suspected.

Figure 10.13

Displacement of the medial canthal tendon due to an osteoma. ( A ) Mass in right medial canthus in a young man. His complaints are tearing of the right eye. The mass is visible and palpable. ( B ) Coronal CT bone window; a large bony mass is visible. ( C ) Axial CT bone window; the mass is extending from the ethmoid sinus into the orbit, compressing the lacrimal sac and displacing the medial canthal tendon. ( D ) Lateral rhinotomy incision exposing the mass. ( E ) Mass is removed using a curet, drill, and rongeurs. A lacrimal stent was placed. ( F ) Postoperative appearance: There is no tearing, the tendon is in normal position, and the scar is minimal.

Remember, common things happen commonly. When you become familiar with the presentation of the common problems and the pathophysiology of these problems, you quickly identify the outlier, or zebra— the unusual problem. Assume a common diagnosis, but if the pieces of the puzzle do not fit together well, look for an uncommon problem.


  • What are the lid distraction and lid snap tests?

  • What are three signs of NLD obstruction seen on the external examination that can create a shortcut for your lacrimal system examination?

  • What are the lacrimal system vital signs? (Do not skip this one.)

  • What is the difference between a hard stop and a soft stop?

At this point, you have determined the cause of the tearing and are ready to make a plan to correct the problem.


Treat Eyelid and Eyelash Problems First

Ectropion, Entropion, and Lacrimal Pump Problems

In all cases, eyelid and eyelash problems should be treated before lacrimal surgery. You should treat any existing blepharitis. This improves lubrication and often helps the watery eye. Standard treatments for involutional ectropion and entropion should be used. Conditions affecting the lacrimal pump, including lid deformities such as cicatricial ectropion, should be treated with skin grafting. Laxity of the lower lid can be repaired using standard horizontal lid-tightening procedures. Do not forget to look for floppy eyelid syndrome as a cause of watery eyes. The eyelash ptosis is usually the first clue to an extremely lax upper eyelid. Cicatricial entropion should be treated with eyelid-everting procedures or mucous membrane grafting. Incomplete blinking due to paralytic causes can be treated with topical lubricants and gold weight placement in the upper lid. Additional procedures are available for facial nerve palsy and are discussed in Chapter 9 . In most patients, the lacrimal pump can be improved, but it is often difficult to eliminate all symptoms of tearing ( Box 10.6 ).

Box 10.6

Treatment of Lacrimal Pump Problems

  • Lid deformity: treat deformity

  • Incomplete blink of upper lid

    • Lubricants

    • Gold weight

    • Tarsorrhaphy

  • Laxity of lower lid

    • Lateral tarsal strip procedure

  • Facial nerve palsy

    • Lubricants

    • Lateral tarsal strip operation plus additional procedures (medial tarsorrhaphy, cheek lift, facial suspension)

After appropriate treatment of the eyelid abnormalities, the lacrimal symptoms should be reevaluated. Before we move on to treatment of NLD obstruction, we discuss treatment of punctal problems. Instruments and sutures of special interest in lacrimal surgery are listed in Boxes 10.16 and 10.17 later in the chapter.

Punctal Stenosis

Stenosis of the punctum can be treated with dilation; however, the effect of punctal dilation is usually temporary. Substitution of an alternative antiglaucoma medication for an offending drug is appropriate if possible. Although punctoplasty procedures are described, I find that I seldom use them. Two-snip and three-snip punctoplasties are possible. The two-snip punctoplasty consists of a V-shaped excision of the posterior portion of the punctum and vertical part of the canaliculus. A three-snip punctoplasty is somewhat more useful. In this operation, a small triangle of the posterior wall of the vertical and horizontal portion of the canaliculus is excised ( Box 10.7 ).

Box 10.7

Three-Snip Punctoplasty

Vertical cut (snip 1)

  • Use a Westcott scissors to open the posterior portion of the punctum and ampulla of the canaliculus.

Horizontal cut (snip 2)

  • Rotate the scissors and cut 2 to 3 mm along the horizontal portion of the canaliculus.

  • Stay posterior so the cut is not visible anteriorly.

Diagonal cut (snip 3)

  • Excise a triangle of tissue off the posterior portion of the canaliculus.

  • The mucosa of the canaliculus should be visible.

The steps of the three-snip punctoplasty are:

  • 1.

    Vertical cut of punctum: snip 1

    • A.

      Place a Westcott scissors in the vertical portion of the canaliculus and cut inferiorly.

  • 2.

    Horizontal cut of the canaliculus: snip 2

    • A.

      Turn the scissors 90 degrees and slide one tip into the horizontal portion of the canaliculus.

    • B.

      The scissors are parallel to the lid margin.

    • C.

      Make a 2-mm cut slightly posterior to the lid margin. It is important to place this horizontal cut posteriorly; otherwise you disturb the normal appearance of the lid margin.

  • 3.

    Diagonal cut of the canaliculus: snip 3

    • A.

      Grasp the cut corner and make a diagonal cut, removing a posterior triangle of canaliculus.

    • B.

      The excised area should not be visible when you are looking at the lid margin.

    • C.

      The mucosa of the inside of the canaliculus should be visible from the posterior aspect of the eyelid ( Figure 10.14 ).

      Figure 10.14

      ( A ) Punctal stenosis: The punctal opening is present but very small ( arrow ). The most common causes are ectropion or medication. If aggressive punctal dilation does not give your patient long-term relief, you should proceed to a punctoplasty (usually, the three-snip punctoplasty). ( B ) Three-snip punctoplasty. You can see the triangle of tissue removed from the back wall of the canaliculus (see Box 10.7 ).

In some patients, the stenosis of the punctum is associated with stenosis of the canaliculus, as well. For these patients, intubation of the entire nasolacrimal system with silicone stents is appropriate. An alternative for one canaliculus is a monocular stent such as the Mini Monoka stent (S1–1500, fci-ophthalmics.com ). Monocanalicular stents block the drainage while the stent is in place because it is held in place by a punctal plug type of fitting. Make sure any stenting is not required before you perform a punctoplasty procedure. Once the integrity of the punctum is disturbed with a punctoplasty, bicanalicular stents can easily erode the canaliculus. Mini Monoka stents do not seat properly after a punctoplasty. We discuss the various types of stents in detail soon.

Punctal Eversion

Eversion of the punctum is most commonly caused by laxity in the lower eyelid. The lid distraction or snap test demonstrates whether laxity is present. Before proceeding with any lid-tightening procedure, be sure that there is no anterior lamellar shortening pulling the puncta outward. If cicatricial causes are present, a full-thickness skin graft is usually required. If laxity alone is present, evaluate the potential effectiveness of the lateral tarsal strip procedure during the slit lamp examination. While viewing the punctum, place your index finger at the lateral canthus and simulate tightening the eyelid. If the punctum returns to normal position, a horizontal lid-tightening procedure is effective. If the punctum remains somewhat everted, consider adding a medial spindle operation. If no horizontal lid laxity is present, use the medial spindle operation alone. This is a rare situation, however.

The medial spindle procedure is simple to perform and quite effective. It is a combination of a posterior lamellar shortening procedure and a mechanical inversion of the lid margin with an absorbable suture (see Chapter 3 ). It is most commonly performed on the lower eyelid but can be performed on the upper eyelid.

The medial spindle operation of the lower eyelid includes:

  • Patient preparation

  • Excision of a diamond of conjunctiva inferior to the punctum

  • Closure of the conjunctiva to invert the punctum

  • A lateral tarsal strip operation (usually)

The steps of the medial spindle operation are:

  • 1.

    Prepare the patient.

    • A.

      Instill topical anesthetic drops.

    • B.

      Inject local anesthetic into the inferior fornix of the medial conjunctiva.

    • C.

      Inject local anesthetic under the skin at the orbital rim inferior to the punctum.

  • 2.

    Excise a diamond of conjunctiva.

    • A.

      Place a no. 1 Bowman probe into the canaliculus and evert the lid margin.

    • B.

      Excise a diamond of conjunctiva (and, theoretically, lower eyelid retractors) inferior to the punctum and the tarsal plate (3 to 4 mm by 3 to 4 mm; Figure 10.15A ).

      • (1)

        Make the diamond-shaped excision by grasping the conjunctiva with a Paufique forceps and using Westcott scissors, or a microdissection needle, to excise a V of conjunctiva inferiorly. Cut a similar V of conjunctiva superiorly so the two incisions form a diamond. The excised area of conjunctiva is closed vertically, shortening the posterior lamella and turning the punctum inward.

      • (2)

        Take care not to cut the vertical portion of the canaliculus when performing the excision.

      Figure 10.15

      The medial spindle operation. ( A ) Place a no. 1 Bowman probe in the canaliculus and evert the medial aspect of the lower eyelid. Excise a diamond of conjunctiva and lower lid retractors inferior to the punctum. ( B ) Close the diamond using a double-armed 5-0 chromic suture through the retractors, through the superior apex of conjunctiva, and through the lower edge of the conjunctiva, continuing full thickness through the eyelid and emerging superior to the inferior orbital rim. ( C ) Lateral view showing closure of the diamond using the spiral suture to create slight inversion of the punctum.

  • 3.

    Close the conjunctiva to invert the punctum.

    • A.

      Use a double-armed 5-0 chromic suture (Ethicon 792G G-3 needle) to close the diamond, incorporating a pass through the lower lid retractors in the center of the diamond excision (see Figure 10.15B ). (You are not always able to recognize retractors.)

    • B.

      Next pass the two arms of the suture backhanded through the apex of the diamond adjacent to the punctum. This part of the operation theoretically advances the lower lid retractors to the top of the diamond.

    • C.

      The remainder of the closure involves collapsing the diamond and passing the sutures out through the eyelid. Pass each suture arm through the inferior apex of the diamond and continue the full-thickness pass through the lid, exiting at the junction of the eyelid and cheek skin. The suture pass can be visualized as a spiral when viewed as a sagittal projection (see Figure 10.15C ). The conjunctival suture passes close to the posterior lamella, resulting in a posterior lamellar shortening. The full-thickness pass of the suture through the eyelid, emerging inferiorly, causes a mechanical inversion of the punctum. A significant mechanical inversion of the punctum occurs when the sutures are pulled tightly on the skin side of the eyelid.

  • 4.

    Do a lateral tarsal strip operation (usually).

    • A.

      Cut the needles of the spindle suture off, and clamp the suture ends out of the way. If a lateral tarsal strip operation is also being done, it should be performed at this point.

    • B.

      The medial spindle suture should be tied after the strip is sewn into position. The amount of inversion can be titrated by tying the suture with more or less tension. At the conclusion of the medial spindle procedure, a slight overcorrection (inversion) is desired.

The chromic suture falls out on its own in approximately 10 to 14 days. The overcorrection reduces spontaneously, leaving the punctum in its normal position. Occasionally, the suture creates a small abscess and requires removal. Remember that the medial spindle operation must be performed before the lateral tarsal strip operation is completed. Once the lateral tarsal strip sutures are tied, the medial eyelid cannot be everted to perform the medial spindle operation ( Box 10.8 ).

Box 10.8

The Medial Spindle Operation

Patient preparation

  • Instill topical anesthetic.

  • Inject local anesthetic into the conjunctiva and skin on the medial one third of the lid.

Conjunctival diamond excision

  • Evert the lid margin with a Bowman probe.

  • Excise a diamond of conjunctiva and lower lid retractors.

Closure of diamond

  • Pass each arm of a double-armed 5-0 chromic (Ethicon 792 G) suture through

    • Lower lid retractors, then the

    • Apex of spindle near punctum, then the

    • Apex of spindle inferiorly, and finally

    • Out full thickness through the eyelid

  • Do a lateral tarsal strip operation for most patients.

  • Tie sutures to invert the punctum slightly.


Patients with canaliculitis most commonly complain of a persistent discharge or red eye. In some cases, this is confused with tearing, but true epiphora is not usually present. Usually, you see canaliculitis in an older patient. Often the patient has been treated with antibiotic drops for some time before the correct diagnosis is made. On your external examination, you see a swelling and erythema of the canalicular portion of the eyelid ( Figure 10.16 ). In some cases, this finding is subtle. Usually, it is an easy diagnosis if you remember to think of canaliculitis in the differential diagnosis of a watery or discharging eye (no one comes in saying “The inside corner of my eyelid is red and swollen”).

Figure 10.16

Canaliculitis. ( A ) Swelling and erythema over canaliculus for several months. ( B ) “Pouting” punctum is apparent with pressure on canaliculus. ( C ) A three-snip punctoplasty was used to open and curet sulfur granules from recesses within the canaliculus. ( D ) Irrigation is used to wash out any small stones. You can see the open punctoplasty.

A canalicular mucocele is a localized accumulation of mucous filling between two obstructions in the canaliculus ( Figure 10.17 ). There are usually no signs of infection (although any mucocele can get infected). There is no mucous discharge or ocular inflammation. Tearing can be present depending on the patient’s tear production. If no tearing is present, you can marsupialize the mucocele using a three-snip operation or a variation that leaves the posterior wall of the canaliculus open. If tearing is present, you need to repair the proximal obstruction using the canalicular reconstruction techniques discussed later in this chapter.

Mar 21, 2021 | Posted by in OPHTHALMOLOGY | Comments Off on Diagnosis and Management of the Patient with Tearing

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