December 2020 - Armadale Eye Clinic

What is Epiphora?

Epiphora is the medical term for watery eyes and the excessive production of tears. Epiphora can occur in one eye (unilateral) or both (bilateral), and often is asymmetrical, being worse in one eye than the other.

Watery eyes can be a reflexive reaction to some sort of temporary irritation to the eye, such as exposure to chemical fumes or a speck of dust. The rapid production of tears aims to flush away the irritant and protect the delicate surface of the eye.

However, some people suffer from persistently watery eyes, which makes it more likely they may require the attention of an oculoplastic surgery specialist.

What is Epiphora Caused By?

Watery eyes can be caused by a number of factors, though not all will require referral for oculoplastic surgery.

Causes of epiphora can include:

Conjunctivitis: Conjunctivitis refers to an inflammatory condition of the conjunctiva, the translucent membrane that covers the whites of the eye. You may be familiar with infective conjunctivitis causes, such as a bacterial or viral conjunctivitis. Viral conjunctivitis often presents with watering and epiphora of the eye, accompanied by redness and itching or soreness. Allergic conjunctivitis is also commonly associated with epiphora, along with the hallmark itching and puffiness. You may also experience other symptoms of allergy, such as nasal symptoms.

Trauma: If you’ve ever accidentally been poked in the eye, you’ll know that in addition to some significant pain and discomfort, your eye is likely to water profusely. As the surface of the eye is highly sensitive, it doesn’t take much to cause this reflexive reaction – even just brushing a finger against the cornea can trigger a watery eye.

Dry eye: When discussing what is epiphora, it may be unexpected to encounter dry eye disease as a possible underlying cause. However, because the eye’s surface requires constant moisture and lubrication for good health, it makes sense for the body to have a reflexive mechanism to produce more tears when the cornea becomes dry. This results in a release of more fluid from the lacrimal gland, which can then end up overflowing. Treating the watery eye is then – counterintuitively – a matter of actually treating dry eyes, such as with artificial tear lubricants or warm compresses.

Poor structure and/or function of the nasolacrimal system and eyelids: Epiphora due to changes to the tear duct (nasolacrimal) system and eyelids can be one of the more difficult causes to identify. If your optometrist or GP suspects issues along the nasolacrimal system as a contributing factor then you may be referred to a specialist in oculoplastic surgery.

Oculoplastic Surgery for Epiphora

The nasolacrimal system is involved in the production of tears as well as its drainage from the surface of the eye. There are multiple components of a healthy tear film, produced by various glands in different locations around the eyes. As all these components are secreted onto the surface of the eye, together they form the tear film, which aims to protect and lubricate the eye. Eventually, this tear film gathers along the lower eyelid due to gravity. From there, the blinking motion of our eyelids pushes what’s known as the tear prism, or tear lake, towards the inner corners of the eyes, where two tiny openings sit on the eyelid margins, known as puncta. Tears then drain through the puncta and, via a system of ducts and channels, through the nose and down the throat.

Issues with the nasolacrimal system and eyelids can contribute to epiphora, including:

Weak or incomplete blinking: If the eyelids do not blink well, whether due to a disease such as Bell’s palsy that causes weakness of the facial nerves, or simply from lazy blinking, the tear lake is less efficiently drained through the puncta, leading to overflow of tears from the eye.

Loose lower eyelids: With age, our skin loosens and can sag; the eyelids are no exception. If the lower eyelid does not sit well-positioned against the surface of the eye, it will have difficulty holding up the tear lake, resulting in these tears running down the cheek due to gravity. Additionally, a sagging lower eyelid, known as an ectropion, may result in the puncta also sitting away from the eye’s surface, making it difficult for tears to efficiently drain through it.

Narrowing of the puncta: This can often occur due to age-related changes to our skin, where the opening of the puncta becomes smaller with time, impeding the drainage of tears.

Narrowing or obstruction of the ducts: There are various locations where the nasolacrimal drainage channels may become narrowed or blocked, hindering the proper flow of tears through to the throat and resulting in a backlog and overflow of tears from the eye. These obstructions, whether full or partial, can be due to age, trauma, or even a growth or tumour.

An ophthalmologist experienced in oculoplastics is able to perform a thorough examination to determine what is your epiphora caused by and advise whether your condition is suitable for surgery.

Note: Any surgical or invasive procedure carries risks. Before proceeding, you should seek a second opinion from an appropriately qualified health practitioner.

The retina is the paper-thin tissue lining the inside of the back of the eye. It’s made up of several layers of cells that work together to sense light and images entering the eye before sending along neural impulses to the brain for the perception of vision. Disease or damage to the retina, such as a significant retinal tear or retinal detachment, can result in permanent vision loss.

A retinal tear occurs when the tissue of the retina forms a break or rip. This is different from a detachment when part of the retina lifts away completely from the rest of the eye, though a retinal tear may risk deteriorating into a detachment, which must be then referred for urgent retinal surgery.

Symptoms of a retinal tear include:

Floaters – appearing as tiny black specks, dots, or sometimes described as cobwebs, that float around the vision in the affected eye. These floaters can come in and out of view and persist for some time.
Flashing lights – also called photopsia, sudden flashes in the vision from a retinal tear occurring may appear like a lightning strike or glint out of the corner of your eye.

Occasionally, a retinal tear may also result in an area of blurred vision if the tear caused some damage and bleeding from the tiny capillaries of the retina. There is never any pain or discomfort from a tear, or even a detachment, as the retina contains no pain receptors.

Most retinal tears occur spontaneously with no cause, though there are several risk factors that are associated with the likelihood of developing a tear. These include a family history of retinal tears or detachments, certain eye operations such as cataract surgery, or conditions which cause a thinned retina, such as high myopia (short-sightedness) or the presence of a peripheral retinal abnormality known as lattice degeneration. Advancing age and trauma to the eye area can also put a person at higher risk of forming a retinal tear.

Retinal Tear Treatment

Not all retinal tears need treatment. Some are safe to simply monitor with regular eye exams, and in fact, some will self-heal by naturally scarring and sealing themselves back against the eye.

When deciding if a retinal tear needs treatment, such as retinal surgery, the eye doctor will consider several factors based mainly around the risk of the tear deteriorating into a detachment. Any predisposing risk factors you have, such as the presence of high myopia or whether you’ve previously had a retinal tear or detachment in either eye, will be taken into account, as well as the location, size, and shape of the tear. Retinal tears that are small, peripheral (that is, far out to the edges of the retina, away from the central vision), and asymptomatic (not presenting with any flashes or floaters or disturbances to the vision), may be monitored by an experienced eyecare provider without needing referral for retinal surgery. The type of tear may also be taken into consideration as research has found that certain types of retinal tears and holes are more likely to deteriorate into a detachment.

If your eye doctor finds that your retinal tear is at a significant risk of becoming a sight-threatening retinal detachment, he or she will recommend retinal tear treatment as a preventative measure.

Depending on the facilities available to your local eye doctor, retinal surgery for tears is typically provided as an in-office treatment under local anaesthesia, meaning the ophthalmologist can perform it in the consulting room without needing to send you to an operating theatre or hospital. There are two types of retinal surgery procedures to treat a tear – laser photocoagulation or cryopexy.

Both photocoagulation and cryopexy aim to create controlled scarring around the edges of the retinal tear, thereby sealing the break and re-adhering the torn tissue back to the underlying structures of the eye. Photocoagulation utilises a laser device carefully aimed through the pupil of the eye to create this scarring while cryopexy is performed by placing a probe against the outside of the eye to essentially freeze the edges of the torn retina and induce scarring and reattachment. Depending on the experience and expertise of the ophthalmologist, both procedures take roughly 10 to 15 minutes to complete.

While there is minimal discomfort experienced during either procedure, the recovery time for photocoagulation tends to be much shorter than for cryopexy. Many patients are able to return to their normal routine immediately after a laser photocoagulation procedure with little to no disturbance to their vision post-treatment, though many surgeons will recommend avoiding any activities that risk traumatising the eye while the scarring forms for a couple of weeks. Conversely, an eye having undergone a cryopexy procedure may take up to 2 weeks to fully heal and settle, with the vision being temporarily blurred and the eye slightly red and swollen.

As with many medical procedures, there is a small chance of an adverse effect from either photocoagulation or cryopexy, such as permanent vision loss from the small areas of necessary scarring during treatment. However, because retinal tears tend to occur in the periphery away from the central vision and the treatment areas are quite small, it is very rare that the area of vision loss is significant enough to be noticeable or impact on normal activities.

It is important to remember to maintain regular eye examinations with your eyecare practitioner even after having successful retinal tear treatment as the tear may reoccur or a new tear may form in the same or opposite eye.

Note: Any surgical or invasive procedure carries risks. Before proceeding, you should seek a second opinion from an appropriately qualified health practitioner.

What Is Epiphora and What Causes It?

What is Epiphora?

What is Epiphora Caused By?

Oculoplastic Surgery for Epiphora

Symptoms of Retinal Tear & Treatment

Retinal Tear Treatment