A detailed history will provide a clue to the appropriate diagnosis in most cases of watering. This is especially important in children where tests like irrigation and probing which are usual part of evaluation in adult patients may not be possible. History should be taken from the patient or the primary care giver in case of a child and should include details about the onset, frequency, type, intermittency, laterality of the symptoms, any previous treatment, etc. Epiphora due to congenital nasolacrimal duct obstruction (CNLDO) will be present since shortly after birth. CNLDO is usually caused by imperforate valve of Hasner and the symptom of watering is mostly constant in these patients [3]. Symptoms of watering which starts a few months after birth may not be due to CNLDO and warrants further evaluation to determine the cause. Epiphora due to complete nasolacrimal duct obstruction (NLDO) is usually continuous with associated intermittent mucoid or purulent discharge. History of intermittency with exacerbation during episodes of upper respiratory tract infection points toward a partial obstruction or nasolacrimal duct stenosis. History of bluish swelling in lacrimal sac area present since early days of life is suggestive of amniontocele and an underlying NLDO. History suggestive of acute dacryocystitis in a child with CNLDO should also be elicited as it might warrant an early probing. Associated history of systemic conditions like Crouzon and Treacher Collins syndrome should also be noted as these syndromes can have associated bilateral NLDO and more likely to have complex NLDO. Symptoms of photophobia with history of watering should raise suspicion of associated corneal or ocular surface problem or eyelid conditions like entropion or lid margin keratinization as seen in cases of Stevens–Johnson syndrome. Congenital glaucoma is a vision threatening condition and can manifest initially with watering and photophobia [4]. Epiphora due to anatomical obstruction in the nasolacrimal duct or canaliculi is more likely to be unilateral while bilateral watering especially if associated with history of itching and seasonal exacerbation more likely points toward a reflex cause of watering like allergic conjunctivitis.

History of trauma to the ocular adnexa or nose should be elicited as injury to the punctum or canaliculus can give rise to watering and naso-orbito-ethmoidal fracture can cause acquired NLDO [5].

History of previous medical therapy should also be elicited, especially use of topical antiglaucoma and antiviral medications as these can cause punctual scarring and stenosis [6]. Occasionally a history of antineoplastic drugs like Paclitaxel and 5-Fluorouracil may similarly give a clue toward possible punctal and canalicular stenosis. History of nasal symptoms and previous nasal surgery like sinus surgery can provide a clue to the cause of watering. Any history of previous surgical intervention for epiphora like previous sac surgery, probing or incision, and drainage for lacrimal abscess should be elicited as it has a bearing on the management decision.

External examination should begin with inspection of the face and periorbital region (Figs. 6.2a–d and 6.3a–f). Position of the eyelids, punctum, gross nasal deformity, and facial symmetry should be looked for. Presence of any swelling or mass in the lacrimal sac area should be noted.

Severe entropion and trichiasis with lashes rubbing on the ocular surface can cause reflex watering. Ectropion due to facial palsy can affect the lacrimal pump mechanism and thus cause epiphora. Ectropion and eyelid laxity can also cause epiphora by causing lagophthalmos and displacement of the punctum from the tear lake thereby decreasing the tear outflow. Horizontal laxity of the eyelid can be checked by doing the pinch test where the lower eyelid is pinched at the center and pulled away from the globe [1, 2]. More than 6 mm distance between the pinched eyelid and cornea indicates a lax eyelid which can cause epiphora due to disturbed tear flow. The tone of the orbicularis muscle is tested by doing the snapback test where the lower eyelid is pulled away from the globe, released, and the speed with which the eyelid goes back to its normal position is assessed. When the orbicularis tone is good, the eyelid snaps back immediately and quickly to its normal position. In cases of decreased orbicularis tone as in cases of facial palsy the eyelid moves slowly or sometimes after a blink to its actual position. Such cases can have associated weakness of the lacrimal pump function and can manifest as epiphora. Poor orbicularis tone can also cause watering by disturbing the tear flow along the lower eyelid.

Any eyelid retraction or lagophthalmos as seen in cases of thyroid eye disease and facial palsy can cause reflex hypersecretion due to corneal or conjunctival exposure [7, 8]. In addition, in thyroid eye disease, the tear outflow facility is also disturbed due to a caruncular swelling or disturbance of canalicular function.

Anterior insertion of the medial canthal tendon is seen in patients with Centurion syndrome [9]. This clinical condition is usually detected in the older children and has a spectrum of facial and ocular findings including steep nasal bridge, anterior insertion of medial canthal tendon, punctal ectropion, punctal stenosis, lagophthalmos, etc. Presentation is usually with an unexplained epiphora. Treatment is required in symptomatic patients and is usually done by a medial canthoplasty with or without punctoplasty.

Inspection of the medial canthal area can also reveal swelling below the canthus suggestive of a lacrimal mucocele [1, 2]. Mucocele of the sac rarely extends above the level of medial canthal tendon and extension of the swelling above the level of canthus might indicate a malignant sac swelling or mass lesion arising from the surrounding structures like nasal cavity or ethmoid sinus. Swelling arising from ethmoid sinus or nasal cavity can cause secondary NLDO and can extend to the medial orbit causing unilateral telecanthus which if present points to an underlying sinonasal pathology. Presence of any skin scar from previous surgery or fistulae in the medial canthal area should be noted. Congenital lacrimal fistulae are located inferolateral to the canthus and are usually single [10]. Acquired lacrimal fistulae following trauma or a granulomatous sac infection can be situated above or below the canthus and can be multiple.

Palpation of the lacrimal sac area might reveal the presence of mucocele or occasionally lacrimal sac masses (Fig. 6.4a, b). Pressure over the lacrimal sac can cause mucopurulent material to regurgitate through the punctum confirming a diagnosis of chronic dacryocystitis or lacrimal mucocele [1, 2]. If pressure regurgitation over the lacrimal sac (ROPLAS) is positive, note is made of the type of the regurgitated material (watery, mucoid, mucopurulent, blood stained) and whether it is coming from the same or opposite punctum. To avoid false negative results, it is important to apply pressure over the lacrimal sac in the lacrimal fossa in a slightly backward and upward direction. A positive regurgitation test is a confirmatory test for chronic dacryocystitis with NLDO and no further diagnostic testing is usually necessary in these cases. Interpretation of ROPLAS test results is given in Table 6.1.

A detailed slit lamp evaluation is also must in cases of watering (Fig. 6.5a–c). Size, site, and position of the punctum should be noted to rule out any stenosis or agenesis of the punctum. The normal position of the punctum is at the summit of the lacrimal papilla facing the tear lake. Eversion of the punctum out of the tear lake can occur due to eyelid laxity or loss of eyelid tone as in cases of facial palsy. A red, swollen, pouting punctum can be a sign of canaliculitis. The diagnosis of canaliculitis is can additionally be confirmed by expressing out concretions through the punctum by applying pressure with cotton bud. Blepharitis and meibomitis can also be detected on slit lamp examination which can cause watering due to disturbance of the tear film layer. Blepharitis can also be associated with marginal keratitis and can cause reflex watering. Watering in cases of allergic conjunctivitis will have associated conjunctival papillae and follicles on slit lamp examination. Presence of punctate corneal staining due to corneal exposure and xerosis can cause reflex watering in patients with lagophthalmos. Height of the marginal tear meniscus is noted by staining the tear film with fluorescein dye (Fig. 6.6). Increased tear meniscus height is seen in cases of obstructive and functional epiphora and a decreased meniscus height if associated with other signs like corneal filaments, ocular surface inflammation, and punctate staining, and low Schirmer values can indicate a dry eye disease.

Diagnostic tests in cases of watery eyes include both excretory and secretory tests [2]. The excretory tests check for the anatomical patency and function of the lacrimal outflow pathway, whereas the secretory tests check for any evidence of dry eye which can cause reflex hypersecretion. The anatomical patency of the lacrimal outflow pathway is tested by lacrimal irrigation, diagnostic probing, and dacryocystography.