The Problem of Too Many Tears (Epiphora)
by Thomas Fitzsimmons, MD, MPH
Q. Tears are always running down my face right after I wake up, or when I go outside, or when it is cold. Sometimes it is constant. What is going on?
A. More than likely, you are producing the normal volume of tears, but the drainage of tears away from the eye is being blocked. When that happens, tears can overflow and drain down the side of your nose or from of the outer corner of the eye.
Q. My eye is not leaking?
Actual leakage from the eyeball is fortunately a rare occurrence, and usually preceded by serious trauma to the eye or recent intraocular surgery.
Q. What causes of excessive tears?
Excessive tearing can occur when tears are prevented from draining normally, or you are actually producing an abnormally high volume of tears. In my experience, it is the first scenario that is more common. Tears are made in a gland under the upper eyelid, and then flow over the eye. They drain through small canals in the inner corner of the eyelids and then into the nose. This is why you often see people blowing their noses if they have been crying — it is a demonstration of how tears normally flow into the nose.
Q. Why do we need tears, anyway?
A. To keep the cornea clear, to achieve good vision, and to moisturize delicate structures around the eye.
Q. So, what do I do if I have excessive tears?
A. Your eye doctor will be able to examine for possible reasons that you might be producing too many tears, such as having eyelashes rubbing in the wrong direction against the eye, or tiny crystal particles called concretions that can develop on inside of the eyelids and scratch the eye. If the tear drainage holes (puncta) are not touching the eye because of the eyelids are too loose, tears can overflow.
Q. My eyes are always watering, but my doctor said that I have dry eyes and told me to use artificial tears. This does not make sense.
A. It does seem paradoxical, but some people speculate that when the eyes sense that they are too dry, they send a signal to the brain, which then sends a signal back to the tear gland to produce more tears. I have found that this situation is relatively uncommon, and that the more likely case is that you are producing a normal volume of tears but they simply are not draining properly –a plumbing problem, if you will.
Q. My doctor said that my eyelids are in good position. What else could be happening?
A. An office procedure called nasolacrimal irrigation can often determine if there is an obstruction to outflow. It is a quick procedure, but your insurance company might require preauthorization to do it.
Q. What happens when you find out that there is a blockage in the duct… Can I just take a pill or use some drops to unblock things?
A. Unfortunately, we do not have any medicines that will unclog the drain, so to speak. There are surgical procedures, however, that can create a new passageway between your tear drainage system and the nose.
Q. Do have to stay in the hospital if I have the operation?
A. In the vast majority of cases, you are able to go home the same day, without any patches.
Q. What happens if I have tearing and there is a blockage of the nasolacrimal duct, but I do not want surgery?
A. Your main risk is that because tears are not flowing the way they are supposed to, bacteria can collect and grow in the area of blockage and cause a serious infection. You can recognize it as an area of redness and painful swelling in the corner of the eye near the nose — it is not subtle. I often tell people at risk for this condition to seek medical help promptly if it occurs, rather than waiting a day or two to see if it gets better on its own, because it usually responds to antibiotics.
Q. My child has been having excessive tearing problems since birth. Are things the same as with adults?
A. In many children, a valve in the tear drainage system fails to open which prevents the normal flow of tears. They will often literally outgrow the problem and open up the lacrimal passageway with time. If that does not happen, a probe can be passed through their natural drainage system and open up the passageway. It is a fairly quick procedure, typically done in the operating room, and quite successful in children under the age of two years. Unfortunately, the effectiveness of the procedure decreases over time and is not usually as successful in adults.
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