Watery Eye in Adults: Causes and Work-Up

Watery eye is a very common complaint in adults.

It arises from overproduction of tears or failure of drainage.

A structured assessment finds the cause.

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Tear Production vs Drainage

Tears are made by the lacrimal gland and cleared through the puncta.

They pass through the canaliculi, sac and nasolacrimal duct.

A fault at any step causes tearing.

Therefore, separate hypersecretion from obstruction.

Dry Eye as a Cause of Watery Eye

Dryness triggers reflex tearing.

The surface irritates and the gland overreacts.

Patients also have burning and grittiness.

So treat the surface first (see dry eye disease).

Lid Malposition and Watery Eye

Ectropion pulls the punctum away from the eye.

Entropion rubs the lashes on the cornea (see ectropion).

Both cause tearing.

Also check for lid laxity.

Punctal Stenosis and Watery Eye

Narrow puncta block tear entry.

Causes include aging, inflammation and drugs.

A slit lamp shows a pinpoint opening.

So dilate or open the punctum when needed.

Canalicular Obstruction and Watery Eye

Scarring from infection or trauma blocks the canaliculus.

Syringing may meet a hard stop.

Surgery is needed in some cases.

Therefore, refer when the block is complete.

Nasolacrimal Obstruction and Watery Eye

Acquired obstruction is common in older women.

The sac may become infected (see dacryocystitis).

Tearing is constant and mucus may collect.

So consider surgery when symptoms are bothersome.

Allergy and Infection

Allergic conjunctivitis causes itching and tearing.

Viral conjunctivitis causes watery discharge.

Chronic blepharitis irritates the surface.

Also treat these conditions before surgery.

History

Ask when the tearing started and whether it is constant or provoked.

Ask about wind, cold and sneezing.

Then ask about previous surgery, injury and radiotherapy.

Therefore, tailor the exam to the story.

Examining a Watery Eye

Look at the lids, puncta and lashes.

Check tear meniscus height and signs of dryness.

Press over the sac for reflux.

Also examine the nose.

Dye Disappearance Test

Place fluorescein in both eyes and watch the clearance.

Delayed disappearance suggests obstruction.

The test is simple and quick.

So use it as a screen.

Syringing and Probing

Syringing tests patency of the system.

Reflux from the opposite punctum indicates block below the canaliculus.

Probing adds information.

Therefore, reserve it for selected cases.

Imaging

Dacryocystography and CT define complex anatomy.

Scintigraphy shows function.

They are needed before surgery in some patients.

Also image to exclude masses.

Treatment

Treat dryness, lid disease and infection first.

Punctoplasty opens a narrowed punctum.

Dacryocystorhinostomy bypasses nasolacrimal obstruction.

So match the procedure to the level.

Watery Eye: Practical Summary

Distinguish overproduction from obstruction, treat the surface and examine the lids.

If obstruction is confirmed, consider surgery.

Because infection can complicate, treat early.

Finally, explain the likely outcome.

Pitfalls to Avoid

• Do not assume tearing is always blocked drainage
• Never skip the lid and punctum exam
• Avoid surgery before treating dry eye
• Do not miss a sac mass

Cold and Wind Tearing

Many people tear in cold wind.

This is normal and not a disease.

Because it settles indoors, reassure the patient.

Therefore, ask about triggers.

Medication Causes

Some chemotherapy drugs and eye drops cause tearing.

Docetaxel can block the canaliculus.

Because prompt care prevents scarring, ask oncology patients.

So review the medication list.

Facial Palsy and Tearing

Facial weakness causes lower lid sag and poor blink.

The tears spill over the lid.

Because the cornea is at risk, protect the surface.

Therefore, treat the lid position.

Sac Massage and Home Care

Warm compresses and gentle massage may help mild blockage.

Antibiotics treat infection.

Because surgery has risks, try conservative care first.

Then refer if symptoms persist.

Dacryocystorhinostomy Outcomes

The operation succeeds in most patients.

Endoscopic and external routes have similar results.

Because scarring can cause failure, follow up.

So explain the likelihood of success.

When to Refer

Refer for suspected sac mass, blood in tears or repeated infection.

Refer when conservative care fails.

Because tumors can present as tearing, remain alert.

Finally, document the exam findings.

Watery Eye: Key Message

Most watery eyes have a treatable cause.

If the eye is dry, treat the surface first.

Because obstruction needs surgery, confirm it with testing.

Therefore, take time to examine the lids and puncta.

Watery Eye: Follow-Up

Review the response to treatment after four weeks.

If tearing persists, repeat the lacrimal tests.

Because some causes overlap, look for a second problem.

Finally, plan surgery when conservative care fails.

For the latest studies, see the PubMed results for watery eye.

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References

1. Mainville N, Jordan DR. Etiology of tearing: a retrospective analysis of referrals to a tertiary care oculoplastics practice. Ophthalmic Plast Reconstr Surg. 2011;27:155-157.
2. Ali MJ, Paulsen F. Etiopathogenesis of primary acquired nasolacrimal duct obstruction: what we know and what we need to know. Ophthalmic Plast Reconstr Surg. 2019;35:426-433.
3. Woog JJ. The incidence of symptomatic acquired lacrimal outflow obstruction among residents of Olmsted County, Minnesota, 1976-2000. Trans Am Ophthalmol Soc. 2007;105:649-666.
4. American Academy of Ophthalmology. Basic and Clinical Science Course, Section 7: Oculofacial Plastic and Orbital Surgery. San Francisco: American Academy of Ophthalmology.