Epiphora Caused by Upper Lacrimal Drainage System Problems

Byoung Jin Kim, Md; Angelo Tsirbas, Md, Franzco

In This Article

The Excretory Apparatus: Upper Versus Lower Lacrimal Drainage System

One can think of this apparatus as having both functional and anatomical (structural) components.

The first component is functional and consists of the lacrimal pump. During blinking, the contraction of deep heads of pretarsal and preseptal orbicularis leads to a suction effect that draws the tear film into the lacrimal apparatus. A classic case of problems with this functional component is seen in facial nerve palsy: The power of the blink reflex (orbicularis muscle) is decreased, and tearing occurs without obvious anatomical obstruction.

The anatomical component of the excretory apparatus can be divided into the upper and lower lacrimal drainage systems.[1] The upper lacrimal drainage system starts at the puncta, canaliculi, and the common internal puncta (opening of common canaliculus) and drains into the lacrimal sac. The lower lacrimal drainage system consists of the lacrimal sac and the nasolacrimal duct; the nasolacrimal duct drains below into the inferior meatus of the nose.

The various valves and sinuses in the lacrimal system are not functionally important, but anatomically, the area of the common internal punctum, the lacrimal sac-duct junction, and the nasolacrimal duct orifice (valve of Hasner) has some role in determining treatment and designing surgery.

Proper evaluation of epiphora begins with defining the condition (tearing). A useful clinical definition can be based on the patient's symptomatology and complaints. For example, patients often complain that "tears overflow onto the cheek." This symptom complex suggests some obstruction of the lacrimal drainage system. One can also consider definitions for the "watery eye"; in this situation, the tears do not overflow onto the cheek but instead well up in the lacrimal lake and inferior fornix. This problem may be more commonly related to poor tear quality or poor tear distribution. When evaluating a patient for epiphora, careful examination of the ocular and periocular structures is vital, as most causes of epiphora, especially in the elderly, are due to a combination of factors rather than simply anatomical obstruction of the drainage system. Evaluating the cause of epiphora prior to treatment is imperative to a successful outcome (Figures 1 and 2).

Fluorescein tear strip.

Punctal apposition to lacrimal lake.

The history of the patient's problem may help to explain the cause of epiphora. Often, watery eyes are related to poor tear film, which causes ocular irritation (or reflex tearing). Tearing that is worse in wind or in cold air may be caused mostly by dry eye (keratoconjunctivitis sicca), and partial lacrimal obstruction. Tears that flow down onto the cheek, especially at rest in indoor environments, are usually caused by lacrimal obstruction. It is important to note that upper lacrimal system obstruction causes clear tearing only. Obstruction of the lower system (usually of the nasolacrimal duct) causes tearing often with mucopurulent discharge. Unilateral symptoms are often due to the use of local agents, such as antiglaucoma drops used in only one eye. A history of allergic conjunctivitis, rhinitis, or sinusitis can also lead to acute or chronic blockage of the puncta or opening of the nasolacrimal duct and may cause secondary epiphora. A history of nasal surgery or facial fracture is also related to epiphora.

Inspection of the eyelid for anatomical abnormalities (e.g., ectropion, entropion, lower lid laxity, and lacrimal pump weakness due to Bell palsy) that may lead to structural and functional problems in the distribution and drainage of the tears is also important.

Palpation of the outflow system may demonstrate the level of obstruction or any localized problems. One may see or feel a mass, and the patient may complain of tenderness. Any mucopurulent or bloody discharge elicited by compression of the sac may signify problems distally or a lesion in the sac itself that needs investigation (lower lacrimal system obstruction).

Finally, slit-lamp examination will help to check for punctal stenosis or malposition; it can also show any conjunctival problems, such as conjunctivochalasis, which manifests as swollen or redundant conjunctiva over the puncta. An evaluation for dry eye is also vital, as this may lead to pseudoepiphora (reflex tearing). On slit-lamp examination one may see an abnormal tear meniscus, punctuate erosions, prolonged tear break-up time, or an abnormally poor Schirmer test. Local mechanical causes of epiphora, such as trichiasis, distichiasis, conjunctivitis, keratitis, and uveitis are also obvious on slit-lamp examinations.