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Assessment of the Watery Eye

Editor: Thomas J. Stokkermans Updated: 2/26/2024 11:58:48 PM

Introduction

The human eye, a vital organ for vision, is a complex and sensitive structure that can be affected by various conditions, one of which is the production of excessive tears, medically known as epiphora or watery eyes. This condition, where tears overflow onto the face, can be due to either an overproduction of tears or inadequate drainage. Watery eyes are a common clinical presentation and a symptom that spans all age groups; its implications can range from a mere nuisance to a marker of significant underlying pathology.

The tear film is essential in lubricating and protecting the ocular surface and contributing to vision quality.[1] However, excess tearing is likely to affect patients´ lives negatively, which results in a common complaint encountered in ophthalmology clinics. Problems with increased tear production may cause this excess tearing, often called reflex tearing, poor distribution due to lacrimal pump failure, decreased drainage, or a combination of these factors.[2] Therefore, a thorough history and examination are required to evaluate all the possible factors causing a watery eye and to provide adequate treatment tailored to the underlying specific cause or combination of etiologies.[3] 

Watery eyes can substantially impact the quality of life, as excessive tear production may interfere with vision and daily activities, leading to social embarrassment and functional impairment. Though often considered trivial by the uninformed, persistent watery eyes warrant thorough evaluation due to their potential to signify serious ocular or systemic diseases. The lacrimal apparatus, responsible for the production and drainage of tears, can be affected at various levels, leading to watery eyes. The lacrimal glands produce tears, which then bathe the eye for nourishment and protection. Once used, tears usually drain through a system that includes the puncta, canaliculi, lacrimal sac, and nasolacrimal duct, finally exiting into the nasal cavity. Disruption at any of these points can result in the accumulation of tears and subsequent overflow.[4]

When assessing watery eyes, healthcare professionals must consider a myriad of potential causes. On one end of the spectrum, environmental factors such as wind, smoke, or allergens may irritate the ocular surface, leading to reflex hypersecretion of tears. Conversely, more concerning etiologies such as lacrimal duct obstruction due to infection, inflammation, or neoplastic processes may be at play. Additionally, systemic conditions like rheumatoid arthritis, Sjögren's syndrome, or thyroid eye disease can manifest with watery eyes, making a comprehensive approach to assessment essential.[3]

A systematic evaluation begins with a detailed patient history to elucidate the onset, duration, and severity of symptoms, as well as associated factors such as eye redness, pain, vision changes, or discharge that might suggest conjunctivitis, dacryocystitis, or keratitis. The physical examination is equally crucial and should include inspection of the eyelids, puncta, and ocular surface, as well as assessment of the lacrimal drainage system. Specialized tests, such as the Schirmer test to quantify tear production or diagnostic imaging to evaluate the anatomical patency of the tear drainage system, may also be necessary.[5]

The management of watery eyes is as varied as its causes. Simple cases due to transient irritants may require no more than reassurance and avoidance of triggers. Conversely, persistent or severe cases might necessitate medical interventions ranging from topical medications to address surface inflammation to surgical procedures such as punctoplasty or dacryocystorhinostomy (DCR) for structural blockages. As we consider the multifactorial nature of watery eyes, the significance of a collaborative, interdisciplinary approach becomes clear. Optimal patient outcomes are achieved when primary care physicians, ophthalmologists, and occasionally other specialists, such as rheumatologists or allergists, work together. This collaborative approach ensures that both common and rare causes of watery eyes are considered and that treatment strategies are tailored to the individual's needs.[6] 

In summary, assessing watery eyes is a complex challenge requiring careful and systematic evaluation. With a multitude of potential underlying causes, it is an issue that highlights the importance of a comprehensive, multidisciplinary approach to patient care. The ultimate goal of such an assessment is to alleviate the symptom and address its root cause, thus protecting vision and improving the patient’s quality of life.

Etiology

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Etiology

A watery eye is a complex symptom to tackle, as the following etiologies may be implicated:

Conditions Affecting the Eyelids and Periocular Region

Skin conditions: Rosacea, eczema, actinic keratoses, ichthyosis, zoster, scleroderma, lichen planus, or discoid lupus cause tearing due to stimulating reflex tearing, impairing the tear distribution system or a combination of both.[7][8][9][10]

Facial akinesia: In this condition, blink dynamics are altered, causing reflex tearing due to corneal exposure and negatively affecting the tear-pumping mechanism. 

Brain disorders: Conditions such as Parkinson's disease and progressive supranuclear palsy alter the blink neuronal circuit, which causes decreased blink rate and amplitude, resulting in pumping problems and reflex tearing triggered by desiccation of the ocular surface.

Facial nerve palsy: The facial nerve innervates the orbicularis muscle, so conditions causing facial nerve palsy may result in abnormal lower eyelid position (paralytic ectropion), decreased upper eyelid excursion (causing ocular surface exposure and reflex tearing), and reduced orbicularis contraction affecting the pumping mechanism for tears egress.[9]

Aberrant seventh-nerve regeneration: This can result in tearing while eating or drinking ("crocodile tears") due to abnormal connections with the lacrimal ducts instead of the salivary glands.[11]

Space-occupying lesions or drugs: Cholinergic agents, for example; stimulation of the parasympathetic lacrimal fibers results in an increased production of tears.

Lacrimal gland tumors: Dacryops, for example; these tumors can cause primary tear hypersecretion.[12]

Dacryoadenitis: Inflammation of the lacrimal gland as a result of infection (such as Epstein-Barr, Staphylococcus aureus, or tuberculosis), autoimmune condition (such as Sjögren disease, thyroid eye disease, or immunoglobulin G4–related disease), or idiopathic process (such as nonspecific orbital inflammation or sarcoidosis) can manifest with tearing.[13]

Botulinum toxin: When applied in the periocular area, botulinum toxin can decrease orbicularis muscle function.

Herniation of orbital fat: This causes a watery eye due to displacing the tear meniscus and altering tear flow along the eyelid margin.[9]

Lumps in or around the eyelids: These may irritate the ocular surface, causing reflex tearing. 

Eyelid burns and scars: These may cause lid malposition and alteration of blink dynamics.

Floppy eyelid syndrome: This causes tearing by a combination of reflex hypersecretion, deficient distribution of the tear film, and ineffective lacrimal pump.

Eyelid retraction

  • In exophthalmos: Graves ophthalmopathy, for example; an incomplete blink due to the widened eyelid fissure disrupts proper corneal lubrication. Nocturnal lagophthalmos (incomplete eyelid closure) with an abnormal Bell's phenomenon due to fibrotic inferior recti causes exposure keratopathy and reflex tearing. In addition, associated conjunctival chemosis disrupts tear flow along the lower eyelid.
  • Due to surgery, trauma, or skin conditions: Any of these may trigger reflex tearing. 

Eyelid imbrication syndrome: In this condition, the lax upper lid overrides the lower lid during closure. As a result, the disrupted distribution of the tear film on the ocular surface is combined with reflex tearing due to rubbing the tarsal conjunctiva on the surface. In addition, the punctum is in an abnormal position, which impedes tear outflow.

Eyelid length disparity: This can result in abnormal eyelid closure and subsequent reflex tearing due to corneal exposure. 

Lower lid laxity: This causes pump problems due to poor apposition of the eyelids against the eye. It affects the eyelid's position, which creates an abnormal gradient for the tear to flow toward the punctum with each blink.[9]

Entropion from any cause: In entropion, the eyelashes are directed inward, rubbing the cornea or conjunctiva and causing reflex tearing. In addition, the punctum is in an unfavorable position to receive tears. This condition results from 1 or a combination of the following causes: horizontal eyelid laxity, posterior lamella scar, dehiscence of lower eyelid retractors, and overriding preseptal orbicularis. 

Ectropion from any cause: The ectropic eyelid displaces the tear lake from the eyelid margin and stops tears from reaching the punctum. One or a combination of the following factors may cause this problem: lower eyelid retractor disinsertion, horizontal eyelid laxity, medial canthal tendon laxity, vertical tightness of the skin, orbicularis paresis, and puncta malposition. Clinical examination will help to determine the presence of each factor.[9]

Eyelid notches and tumors: These can alter the tear distribution over the eye surface.

Keratinization of the eyelid margin: The contact between the keratinized margin and the anterior surface causes irritation and reflex tear hypersecretion. This is also called lid-wiper epitheliopathy.[14]

Malpositioned eyelashes: Trichiasis and distichiasis, for example. These rub the cornea or conjunctiva and cause reflex tearing.

Blepharitis or meibomian gland dysfunction: Chronic blepharitis may cause posterior lamellar shortening, resulting in lashes rubbing the eye surface and causing reflex tearing. In meibomian gland dysfunction, a decreased tear film lipid layer increases tear evaporation and may result in compensatory tear hypersecretion.  

Conditions Affecting the Ocular Surface

Dry eyes: This condition has a component of inflammation and tear instability that stimulate corneal and conjunctival neurosensory receptors, resulting in reflex tearing. This is one of the most common causes of excessive tearing and an essential factor to rule out. 

A foreign body: Whether in the cornea or conjunctiva, a foreign body irritates the ocular surface and causes reflex tearing.

Conjunctival inflammation: This causes reflex tearing by stimulating the neurosensory receptors.  

Conjunctivochalasis: The redundant bulbar conjunctiva displaces the normal tear meniscus, impedes tear flow toward the punctum, and interferes with the distribution of the tears present in the tear meniscus by the eyelid during a blink.[9] Moreover, it may mechanically irritate the eye, which causes reflex tearing. It als

Conjunctival symblepharon: This condition can cause eyelid malposition, resulting in lagophthalmos and poor blinking. 

Pinguecula and pterygia: These conditions alter tear distribution over the eye surface.

Corneal pathology: Keratitis and ulcer, for example; corneal pathology stimulates the afferent corneal nerves of the reflex tearing arc. 

Ocular inflammation: Iritis, for example; occular inflammation causes reflex tearing. 

Megalocaruncle: An enlarged caruncle may cover the punctum, which prevents tear drainage.[9]

Conditions Affecting the Lacrimal Drainage System

Conjunctivitis: Various conditions (such as allergy or infection) can trigger the inflammatory response that can lead to obstruction of the punctum and canaliculus. 

Rhinitis or sinusitis: The inflammatory process may lead to acute or chronic nasolacrimal duct blockage.

Punctal apposition syndrome: Opposition of the upper punctum to the lower punctum prevents tear drainage through the puncta.[9]

Malpositioned punctum: The punctum should be opposed to the eyeball correctly. Even subtle eversion may cause tearing, especially in young patients, because tears are prevented from entering the canaliculi.[9]

Punctal stenosis: Medication use (such as glaucoma drops), trauma, or inflammatory diseases may cause punctal stenosis, which makes it difficult to drain tears. 

Absence of puncta: This condition may be congenital or secondary to previous inflammatory disease. 

Accessory punctum: Although most patients with this condition are asymptomatic, some may complain of tearing.[15]

Dacryocystitis: Dacryocystitis consists of inflammation of the lacrimal sac, typically due to nasolacrimal obstruction. In acute cases, it manifests with erythema, swelling, tenderness at the medial canthus, and purulent discharge through the punctum when the sac is manually expressed. 

Mucocele: This is a lacrimal sac full of mucus due to obstruction above or below the lacrimal sac.

Absent or fibrotic sac: The sac's absence or fibrosis may result from prior surgery. 

Canaliculitis: The inflammatory process affecting the canaliculus may impede tear drainage, which causes watery eyes.  

Sinus and nasal surgery: Surgeries performed in nearby structures can lead to inflammation of the lacrimal drainage system. 

Neoplasms: Neoplasms originate from any part of the lacrimal drainage system and can obstruct it due to primary or secondary growth or metastatic spread. 

Trauma: Scars from trauma may cause stenosis or obstruction of the lacrimal drainage system. Trauma can be iatrogenic (after orbital, nasal, paranasal, or craniofacial surgical procedures) or noniatrogenic. 

Intraluminal foreign bodies: Dacryoliths; for example; these may obstruct lacrimal drainage. 

Radiotherapy on the head and neck: Radiation triggers inflammation, which can result in cicatricial nasolacrimal duct obstruction.[16]

Systemic chemotherapy: Some systemic chemotherapeutic agents have been linked to tearing, such as 5-fluorouracil, docetaxel, and, less commonly, radioactive iodine, S-1, capecitabine, topical mitomycin C, and imatinib, which are responsible for punctum, canalicular, and nasolacrimal duct obstruction.[16][17]

Bone marrow transplantation: This procedure can cause graft-versus-host disease, which causes inflammation, resulting in obstruction of the lacrimal drainage system. 

Eye drops: For example, glaucoma drops may irritate ocular and periocular structures, which results in punctal stenosis or eversion. Chronic irritation may also increase any subtle lubrication, pump, or drainage problems.

Endogenous (autoimmune) inflammation: This includes conditions such as sarcoidosis, Wegener granulomatosis, Kawasaki disease, cicatricial pemphigoid, Stevens-Johnson syndrome, sinus histiocytosis, or scleroderma, which may lead to obstruction of the lacrimal drainage system.

Functional Epiphora: Functional epiphora is a common term used in the literature to report epiphora in the presence of an anatomic patent lacrimal drainage system. However, there is no clear consensus about its diagnostic criteria and management.

Functional epiphora is a multifactorial disease whose management depends upon the suspected underlying cause or combination of causes. The suggested etiologies proposed by some authors include stenosis in the drainage system, lacrimal pump failure, edema at the nasolacrimal duct opening, tear hypersecretion, and nasal inflammation.[18] In contrast, other authors view it as a diagnosis of exclusion.[19] 

In addition, the different tests used in various studies to diagnose this condition were often noncomparable due to the absence of standardization. Consequently, different techniques have been used to tackle the problem with variable results, including DCR, silicone intubation, insertion of Lester-Jones tube, injection of botulinum toxin A into the lacrimal gland, and lid tightening.[20][21][22][23]

Epidemiology

Tearing is a symptom that can occur at any age (from several weeks after birth through advanced ages) as a manifestation of different conditions. In children, congenital nasolacrimal duct obstruction at the valve of Hasner is the most common cause of watery eyes.[24] However, the most common etiology of tearing in adults is unclear, as there is significant variability between studies performed in different parts of the world. The top causes cited in the literature are dry eye, lower lacrimal drainage obstruction, punctal stenosis, and lower lid laxity.[3][25][26][27]

Most studies have detected a female preponderance in low lacrimal drainage obstructions.[2] It has been postulated that this could be due to anatomic differences affecting tear drainage and accumulation.[3] Regarding laterality, unilateral tearing is more common in cases of a lacrimal obstruction than other causes, whereas bilateral tearing is more frequent in cases of reflex tearing.[3]

Pathophysiology

The mechanisms that cause watery eyes can be simplified as follows:

  • Overproduction of tears: Due to abnormal stimulation of the lacrimal gland (primary hypersecretion [rare] or reflex tearing)
  • Dysfunctional distribution of tears: Through the ocular surface
  • Inadequate drainage: Caused by an obstruction in any part of the lacrimal drainage system [28]

 The tear film is divided into 3 layers:

  1. Inner mucin: Produced by the conjunctival goblet cells; adheres to the aqueous layer on the eye surface
  2. Middle aqueous: Secreted by the autonomically innervated lacrimal gland and the accessory glands of Krause and Wolfring
  3. Outer lipid layer: Produced by the meibomian and Zeiss glands; it reduces the evaporation of the aqueous layer [29]

Any problems affecting any of these glands alter the correct composition of the tear film, which causes compensatory reflex hypersecretion.

In cases where the neurosensory receptors from the trigeminal nerve in the cornea and conjunctiva are stimulated (eg, neuralgia, conjunctival disease, corneal disease, ocular inflammation, or eyelid inflammation), there is increased lacrimal gland secretion (reflex tearing). In addition, mechanical wiping of the tears can irritate the conjunctiva further, which causes reflex tearing and perpetuates the cycle.

Eyelid movement must also be normal to facilitate proper tear film circulation across the conjunctiva and corneal surface. Thus, the upper eyelid should move downwards, touching the inferior eyelid with each blink and consequently picking up the tear meniscus for its distribution vertically. Moreover, the orbicularis muscle (pretarsal and preseptal segments) should contract its fibers narrowing the palpebral fissure to spread the tear film toward the punctum. As a result, this blink circle facilitates tears circulation from the punctum through the lacrimal sac and down to the nasolacrimal duct.[9] Therefore, a healthy seventh cranial nerve-orbicular muscle unit, good eyelid position, and tone are required to complete tear film distribution across the ocular surface and down to the drainage path.

Once the tears enter the upper and lower puncta, they flow into a vertical portion before entering the horizontal part of the canaliculi that ends at the lacrimal sac in the lacrimal fossa. The tears then flow down the nasolacrimal duct to end at the inferior meatus of the nose. An abnormality that partially or completely blocks any part of this path usually causes watery eyes. This epiphora not only depends on how complete the obstruction is but also on how many tears are produced. Therefore, younger patients may be more symptomatic than older patients as tear production decreases with age.

History and Physical

Clinical History

A thorough diagnostic workup is needed to identify the cause or combination of causes responsible for watery eyes. Clinical history is one of the most important aspects of assessing a patient with a watery eye as it provides clues to identify the possible cause of this symptom. The clinical history should include the following:

Symptom Onset

In children, tearing since birth is often caused by an obstructive valve of Hasner; however, tearing onset in an older child suggests a different etiology, such as an obstruction in the canaliculus. 

Laterality

Unilateral tearing often indicates obstruction; in contrast, bilateral tearing mainly suggests reflex tearing. Some exceptions exist, such as bilateral puncta or canaliculi obstruction secondary to a viral infection or unilateral reflex tearing secondary to facial nerve palsy.  

Intermittent or continuous course

Intermittent tearing in adults usually results from partial stenosis, dacryolithiasis, or reflex tearing. Persistent symptoms are usually due to complete outflow obstruction.

Tear location

Whether tears appear on the cheek or remain in the eyes is a helpful indicator, as true epiphora manifests with tears overflowing onto the cheek due to lacrimal drainage duct obstruction.

Exacerbating or provoking factors

Worse tearing in cold air or wind may be caused by dry eye or partial lacrimal obstruction.

Association with eating or chewing

This association suggests aberrant facial nerve regeneration ("crocodile tears").

Associated ophthalmic symptoms

  • Itching: This suggests an allergic phenomenon.
  • Grittiness and burning: These sensations may suggest tear film instability (dry eye).
  • Pain in the eye: Conditions such as keratitis, iritis, ulcers, or foreign bodies must be ruled out when there is pain in the eye. 
  • Pain at the site of the lacrimal sac: Acute dacryocystitis should be ruled out.
  • Photophobia: Corneal damage should be suspected.

Additionally, constant tearing without foreign body sensation, grittiness, or pain suggests watery eyes.

  • Associated signs:
    • Mucous discharge: This suggests nasolacrimal duct obstruction, particularly when it occurs in the morning 
    • Bloody tears: These may be due to malignancy.
  • Associated nasal symptoms
  • Use of ophthalmic medications

Several tools, including the ocular surface disease index (OSDI) and standard patient evaluation of eye dryness (SPEED) questionnaires, are specifically designed to quantify dry eye disease as a cause of excessive tearing.[30]

Medical and Surgical History

  • Systemic conditions such as craniofacial syndromes
  • Lacrimal probing during childhood
  • Past ophthalmic diseases or symptoms
  • Prior surgical history:
    • Lid or lacrimal surgery
    • Sinus surgery
  • Lid, facial, or orbital trauma
  • History of facial palsy
  • History of dacryocystitis (prior episodes indicate a nasolacrimal duct obstruction)
  • History of chemotherapy or orbital radiotherapy

Physical Examination

Physical examination focuses on demonstrating the patency of the drainage system and ruling out causes of reflex tearing.

Examination of the face and periocular area

  • Inspect the patient's face for signs of skin diseases (such as rosacea, acne, eczema, ichthyosis, and scleroderma) or facial asymmetry (indicative of facial nerve palsy).
  • Examine the superolateral orbit for clues of lacrimal gland disease (enlargement, tenderness, erythema, or induration. 
  • Exclude orbital fat prolapse.
  • Check for spillage of the tears onto the cheek (medial spillage indicates impaired drainage, lateral spillage suggests lower lid laxity).[8]
  • Assess for leakage from a dimple in the eyelid suggesting a congenital fistula.

Examination of the eyelids

  • Contour: Any lump, cyst, or notch may irritate the ocular surface, causing reflex tearing. 
  • Laxity: This affects the pumping mechanism of the eyelids; check for lid laxity with the lid snap test and lid distraction test.[31][32] 
  • Position:
    • Entropion (lid turns inward): Contact between the entropic eyelid and the ocular surface can result in ocular irritation and subsequent reflex tearing. 
    • Ectropion (lid turns outward): The ectropic eyelid can cause watery eyes due to corneal exposure.
    • Ptosis: Increased ptosis during cheek puffing indicates aberrant facial nerve regeneration.[33]
    • Retraction: Upper or lower eyelid retraction may cause unsuccessful tear pumping and increase the ocular surface, which favors tear evaporation. 
    • Imbrication: Lid laxity causes the upper lid to override the lower, causing the lower eyelid margin to chronically irritate the upper lid tarsal conjunctiva.
  • Closure of the eyes: Incomplete or defective eyelid closure (lagophthalmos) can cause tearing due to corneal exposure. 
  • Blink: Check for blink frequency and the proper touch between the upper and lower eyelid with each blink.
  • Associated diseases: Assess the lids for signs of blepharitis.
  • Eversion: Evert the eyelids to rule out any foreign body irritating the eye or scars that indicate previous surgery, trauma, or trachoma. 
  • Signs of previous eyelid surgery: Skin color changes or scars may indicate previous eyelid surgery contributing to tearing. 

Examination of the eyelashes

Examine the eyelashes for signs of blepharitis, meibomian gland dysfunction, or eyelashes turning in.

Examination of the medial canthus

Compare both sides for symmetry and check for fistulas, lumps (look for visual clues and palpate) or scars (indication of prior surgery).

  • Dacryocystitis: Acute dacryocystitis presents with erythema, swelling, and tenderness at the medial canthus, with discharge through the punctum when the sac is manually expressed. No further testing is necessary to diagnose nasolacrimal duct obstruction in this case.
  • Mucocele: In the case of a mucocele, palpation is necessary as many mucoceles are not visible.
  • Malignancies: Any malignancies in this region may mechanically obstruct the drainage system. 

Examination of the conjunctiva

Examine the conjunctiva for evidence of conjunctivochalasis, symblepharon, redness, follicles, papillae, foreign body, scars, or secretions.

Examination of the cornea

Examine the cornea to rule out any noticeable corneal pathologic changes, for example, the presence of punctate epithelial erosions in dry eyes or a corneal ulcer. Assess how much of the cornea is covered when the patient blinks spontaneously or closes her eyes.

Examination of the tear film

Two crucial aspects of the tear film need to be assessed:

  • Quantity: Examine the tear film lake before placing any drops. If the tear film lake is high, obstruction is usually present. The lacrimal lake, also called the tear meniscus, is an average of 0.22 mm and is depleted in cases of dry eye.[34]
  • Quality: Look for the existence of a foamy tear film, debris, and mucous. Debris floating in the tear meniscus suggests obstruction of the nasolacrimal duct. Conversely, high tear meniscus without debris indicates blocked puncta or canaliculi. 

Examination of the punctum 

  • Check for its presence, size, number, and position during all stages of the blink cycle. Physical eversion of the eyelid is necessary to visualize the punctum on slit lamp examination. If the punctum is visible with no eversion of the eyelid, its position is abnormal.
  • Examine it for evidence of inflammation or stenosis.
  • Look for the presence of discharge, granules (suggesting canaliculitis or dacryocystitis), or bleeding (alerting to the possibility of malignancy).

Examination of the canaliculi 

  • Check for signs of inflammation.
  • Palpation may reveal any localized problems or the level of obstruction.
  • Additional tests may help assess the patency of the canaliculi. 

Examination of the nose

Rhinoscopy helps rule out malignancy, hypertrophic mucosa, or nasal polyps that can obstruct the nasolacrimal ostium.[35]

The BLICK mnemonic stands for blink dynamics, lid malposition, imbrication, conjunctivochalasis, and kissing puncta, and was developed for clinicians to easily remember important causes of excessive tearing that are often overlooked.[9]

Evaluation

When a physical examination does not determine the origin of the tearing clearly, different tests can help assess the watery eye. A thorough understanding of the elements that contribute to the dry eye vicious circle helps guide the process.[36]

Secretory Tests

These tests help evaluate the increased tear production in reflex tearing or primary hypersecretion cases.

Schirmer test

A Whatman filter paper (35 mm x 5 mm) strip is placed between the middle and lateral third of the lower lid, and the patient is instructed to keep the eyes open, blinking normally, for five minutes. The distance that is wetted in five minutes is recorded.[37]

  • Schirmer I: Performed without a topical anesthetic to assess basal and reflex tear production 
  • Schirmer II: Performed with a topical anesthetic to assess basal tear production 
  • Schirmer III: Used to measure reflex secretion
    • In this test, a topical anesthetic is not applied to the ocular surface. A cotton applicator is then applied to the nasal mucosa and used to stimulate the trigeminal nerve. Some literature sources list this as the Schirmer II test, whereas the Schirmer I and II are listed as IA and IB.[38]

Fluorescein tear break-up time  

This test assesses the tear film's stability, as an unstable tear film can trigger reflex tearing.[39] The inferior temporal bulbar conjunctiva is touched with a wet fluorescein staining strip for 1 to 2 seconds. The patient is subsequently asked to blink 2 to 3 times naturally to spread the fluorescein uniformly on the ocular surface. The tear film is examined from the last blink to the first dry spot using a cobalt-blue filter of a slit-lamp with 10x magnification; the average time of 2 or 3 consecutive readings is recorded as fluorescein tear break-up time in seconds. The fluorescein tear break-up time is abnormal if it is less than 10 seconds. Although this is an easy test to perform, it has low reliability due to different operational and environmental factors.

Corneal and conjunctival vital dye staining

Staining of the cornea with fluorescein sodium (most common) and rose bengal (less common) and the conjunctiva with lissamine green allows the clinician to detect the presence of devitalized and damaged cells on the ocular surface. Different scales can be used, such as the National Eye Institute scale, to determine the level of drying and damage to the surface of the eye.[40][41]

  • MMP-9 testing: Allows the clinician to determine whether this dry eye-specific inflammatory marker is present.[42]
  • Tear film osmolarity: Elevated tear film salt concentrations over 308 mOsm/L are an indication of dry eye as a cause of reflex tearing.[43][44]
  • Tear film lipid layer thickness: Measurements taken utilizing tear film interferometry allow the detection of evaporative dry eye.[45]
  • Blink dynamics: These detect the number and extent of blinks and can be measured using the LipiView®II diagnostic system (Johnson & Johnson Vision Care).[46] Blinks should be complete and average 15 times per minute. Studies have shown that concentrated near tasks such as digital device use can reduce the blink rate by over 50 percent.[47]
  • Meibomian gland loss and morphological changes: These can be detected with transillumination and infrared reflection devices. Scales such as the Pult scale can be used to quantify the degree of loss of the oil-producing meibomian glands.[48]

Excretory Tests 

These tests are used to report the lacrimal system patency and drainage function.

Fluorescein dye disappearance test 

This physiologic test consists of staining the tear film using a fluorescein strip or instilling a drop of 2% fluorescein in the lower fornix. Observations of the residual fluorescence of the tear meniscus are made at 5 minutes, and the thickness of the tear meniscus is measured and graded on a scale that can be used to quantify the thickness subjectively. The scale range is 0 to 4+, with 0 representing no fluorescein dye remaining and +4 representing all the fluorescein dye remaining.

A thin or no fluorescein remaining indicates a positive test and probable normal drainage outflow. This test is most valuable when both sides are compared simultaneously, which results in an asymmetric tear meniscus.[8] However, this test does not differentiate between anatomic and functional defects and gives no information on the site of the obstruction.[49] This rapid, simple, painless, and highly specific test can assist in assessing nasolacrimal duct obstruction, especially in children.[50]

Jones dye test 1 

In this physiologic test, a drop of fluorescein 2% is instilled in the lower conjunctiva. The patient is asked to blow each nostril separately in a tissue. Alternatively, a swab is inserted into the nose after 2 and 5 minutes. If the tissue or swab is not stained with fluorescein, the test is considered negative and likely to have an impaired drainage system. If fluorescein is obtained, the test is positive and may suggest there is no anatomic or functional blockage.[51] However, this test has a high rate of false-positive and false-negative results. The fluorescein passage into the nose varies from person to person and may take more time than expected despite the patent drainage system, which gives false-negative results. At the same time, a false-positive result can be obtained despite a mild anatomic obstruction.

Jones dye test 2 

This nonphysiological test is performed in patients with negative Jones dye test 1. A small syringe is used to inject 1 mL of normal saline gently through a lacrimal cannula situated at the punctum. The test is positive if the fluid from the nose is deeply stained with fluorescein. A positive test indicates an incomplete obstruction in the nasolacrimal duct. In this situation, the patent lacrimal puncta and canaliculi enable the lacrimal sac to be filled with fluorescein, which flows down to the incomplete obstructed nasolacrimal duct. When the canaliculus is open but not functioning, the fluid obtained from the nose is clear (negative test) because the fluorescein has not reached the lacrimal sac. Failure to get fluid out of the nose indicates a complete obstruction in the lacrimal drainage system.[51]

Lacrimal probing test

After topical anesthesia of the conjunctival sac, the lid is distracted laterally and kept under tension. At the same time, a Bowman probe is inserted gently vertically through the punctum and then horizontally through the canaliculus until a hard (lacrimal bone) or soft stop (tissue) is felt by the examiner. Bone is contacted when the probe passes through the lacrimal sac, which indicates a patent lacrimal system up to the lacrimal sac. Alternatively, when the probe's progress is impeded by soft tissue, stenosis or obstruction of the canalicular system is present. When there is a stop, the probe is clamped at the punctum. Then the distance to the clamp is measured to determine the length to the site of obstruction or stenosis. A calibrated Bowman probe may help to localize the site of obstruction more easily and accurately.[52] 

It is essential to keep the lid under lateral traction, which stabilizes the eyelid and stretches the canaliculus to facilitate passage of the lacrimal probe and avoid "soft stops" due to kinking of the canaliculus. Failure to recognize resistance to passing or incorrect technique can lead to trauma to the canaliculi resulting in a false passage or stenosis due to scarring in the injury area. In cases of acute dacryocystitis and acute canaliculitis, probing should be avoided. Active infection can hinder the passage of a probe, which increases the risk of iatrogenic trauma.

Lacrimal syringing test 

After topical anesthesia of the conjunctival sac, the lid is distracted laterally and kept under tension. At the same time, a lacrimal cannula on a saline-filled 5-mL syringe is inserted gently vertically through the punctum and then horizontally through the canaliculus until a hard or soft stop. The plunger is then gently pushed down to flush the nasolacrimal duct with saline, and the degree and localization of reflux are recorded. The duct is anatomically patent if the saline flows into the nose or throat. Reflux via the same or contralateral punctum suggests stenosis or obstruction.

While regurgitation through the opposite punctum means a block of the common canaliculus or more distal structures, reflux through the same punctum indicates obstruction of the ipsilateral canaliculus, and syringing must be repeated through the opposite canaliculus. Distension of the lacrimal sac suggests a nasolacrimal duct obstruction.[53] The lacrimal syringing test is commonly used in the clinic due to its simplicity and immediate results. However, the greater than normal positive hydrostatic pressure makes it unreliable for diagnosing nasolacrimal duct stenosis or functional delay. In addition, it has limited value in distinguishing the exact site of obstruction.[54]

Optical coherence tomography

This test uses the principle of low coherence interferometry and is gaining popularity in obtaining images from the punctum and canaliculus due to its noninvasive nature. However, its use is limited due to the lack of guidelines about standard terminologies, measurements, and image capture techniques. New modalities such as dynamic optical coherence tomography and optical coherence DCG will play an essential role in the future as they provide more extensive information about the anatomy, physiology, and pathophysiology of punctal and canalicular disorders.[55][56]

Dacryoendoscopy

A dacryoendoscope is inserted through the lower or upper punctum. This leads to a detailed and direct visualization of the proximal lacrimal drainage system (punctum and canaliculus).[57] It enables precisely locating pathologic changes affecting these structures and can be used simultaneously to perform surgical repair under direct visualization.[58]

Nasal endoscopy

A rhinoscope is used to examine the nasal space to assess anatomic variations and to rule out nasal pathologies such as inflammation, polyps, and tumors.

Dacryoscintigragphy

A 10-mL drop of technetium-99m radiotracer is instilled into the conjunctiva's lower fornix, and images are taken every minute for 45 minutes with a gamma camera. Dacryoscintigragphy (DSG) is a noninvasive helpful technique to assess the functional patency of the lacrimal drainage system.[54] However, its limitations include its cost, long acquisition time, the low resolution to show the precise anatomic location, and the need for confirmatory procedures in the event it is abnormal.[59]

Conventional dacryocystography 

This technique requires the injection of contrast media (lipoidal, iohexol, iopamidol) in the superior or inferior canaliculus to obtain posterior and lateral radiographs. Conventional dacryocystography (DCG) provides more extended information about the anatomy of the lacrimal drainage system, which helps localize the site of obstruction. Currently, its use is limited to atypical cases. Disadvantages of this technique include the use of ionizing radiation and contrast media, lack of information about the surrounding bony structures, inability to assess the tear flow dynamics, and a limited view of the proximal lacrimal system.[60]

Digitally subtracted DCG 

This technique leads to bone-free images of the lacrimal drainage system after injecting contrast media (iohexol, iopamidol, sinograffin) in the superior or inferior canaliculus; it is indicated in complex lacrimal disorders. Disadvantages of this technique include the use of ionizing radiation and contrast media, lack of information about the surrounding bony structures, inability to assess the tear flow dynamics, and a limited view of the proximal lacrimal system.[60] Despite these limitations, it is considered the gold standard for evaluating obstruction of the lacrimal drainage system.

Computed tomographic DCG

This technique involves obtaining axial and coronal (1–2-mm thickness) computed tomographic images after using contrast media. The contrast media (iohexol, iopamidol) could be injected in the inferior or superior canaliculus or applied topically every minute for 5 minutes or 3 times at 0, 5, and 10 minutes. The main advantage is the information about the surrounding bony structures, which is relevant in assessing nasolacrimal obstructions in cases of maxillofacial trauma, congenital craniofacial deformities, previous surgery, lacrimal drainage tumors, and associated sinus disease. 

Computed tomographic DCG is the technique of choice when the bony anatomy is vital for pre-operative planning. Limitations include higher ionizing radiation exposure than DCG, contrast use, poor visualization of the common canaliculus, and inability to assess the dynamic tear flow. Currently, a reduction in ionizing radiation exposure could be attained using cone-beam computed tomographic-DCG with similar good images of the lacrimal drainage system.[60]

Magnetic resonance DCG

This technique uses fast sequence techniques and fat suppression to obtain high-quality images of the lacrimal drainage system. Gadolinium contrast is used by cannulation or topical instillation (1 drop every minute for 5 minutes or 1 drop every 3 minutes for 15 to 20 minutes). Alternatively, normal saline or normal saline mixed with 0.5% lidocaine and a balanced salt solution can be used.[60] 

Advantages include acquiring a series of images and no radiation exposure. In contrast, the main limitations are poor bone visualization, long acquisition time, motion artifact, difficult visualization in case of mucosal and paranasal sinus disease, and high cost. Dynamic magnetic resonance DCG can capture the passage of contrast media across the lacrimal drainage system, which makes it helpful in evaluating functional epiphora.[55]

Treatment / Management

Specific treatment will vary according to the etiology of the watery eye and coexisting exacerbating factors. In general, when there is a problem with one of the tear film layers or in the distribution of the tears through the ocular surface, the condition may improve with medical management. These treatments are extensive and include the following categories:

  • Tear supplementation: Using artificial tears, gels, ointments, and tear suppository inserts [61]
  • Immunosuppressants: Including steroid drops and ointments and calcineurin T-cell inhibitors [62] 
  • Tear production–enhancing nasal sprays and drugs: Those containing cholinergic agonists [63]
  • Environmental modifications: Including humidifiers [64]
  • Tear film lipid layer enhancers: Perfluorohexyloctane, for example [65]
  • Eyelid treatments: Including massage and heating devices, antimicrobial eye drops, ointments and foams, oral antibiotics, meibomian gland probing, and eyelid margin cleansers, all of which can enhance meibum production and reduce inflammation of the eyelid [66]
  • Autologous serum tears [67][68]
  • Scleral contact lenses [69]
  • Diet modifications: Including the addition of foods containing omega-3 fatty acids [70]
  • Lifestyle changes: Including the elimination of drugs and habits that are known to cause dry eye [71][72][73]
  • Contact lens changes: Adjusting contact lens types and wearing habits [74]
  • (A1)

Treatment with steroid eyedrops or ointments can distinguish whether inflammation of the ocular surface and the lacrimal drainage system is the immediate cause of the watery eye or whether an anatomical noninflammatory etiology is present requiring surgery.[75][76](A1)

Treatment Based on Etiology

Following, in order of preference, are treatments for conditions affecting the eyelids and periocular region.

Skin conditions

  • (Including rosacea, eczema, actinic keratoses, ichthyosis, zoster, scleroderma, lichen planus, discoid lupus)
  • Treatment may include topical or oral medications to reduce inflammation, moisturizers for skin care, and avoidance of triggers that worsen the condition. In some cases, light therapy or laser treatment may be beneficial.[77]

Facial akinesia

  • Artificial tears and lubricating ointments to protect the corneal surface
  • Eyelid taping or a moisture chamber at night to prevent exposure
  • In severe cases, surgical interventions such as tarsorrhaphy may be considered.[78]

Brain disorders

  • Optimizing systemic medications to improve motor function (in the case of Parkinson's disease and progressive supranuclear palsy)
  • Use of artificial tears and ointments to maintain ocular surface moisture [79]

Facial nerve palsy

  • Lubrication with artificial tears and ointments
  • Eye patch or taping for eyelid closure at night
  • Surgical procedures to correct ectropion or for eyelid weight implantation to improve closure [80]

Aberrant seventh-nerve regeneration

  • Botulinum toxin injections to reduce aberrant tear production
  • Symptomatic treatment with artificial tears [33]
  • (B2)

Space-occupying lesions or drugs

  • Interventions that address the underlying cause, such as reducing or stopping medication causing tear overproduction.
  • Surgical intervention [81]
  • (B3)

Lacrimal gland tumors

  • Surgical removal of the tumor
  • Regular monitoring for any changes in the size or behavior of the gland [82]

Dacryoadenitis

  • Treatment of the underlying infectious or inflammatory condition with antibiotics, steroids, or immunosuppressive drugs
  • Warm compresses and massage to facilitate drainage [83]

Botulinum toxin

  • Time, as the effects of botulinum toxin are temporary
  • Symptomatic treatment with tears and ointments [84]

Herniation of orbital fat

  • Surgical correction to reposition displaced fat and restore normal tear flow [85]
  • (B3)

Lumps, burns, and scars on eyelids

  • Surgical removal or reconstruction to restore normal eyelid function
  • Lubrication to protect the ocular surface [86]

Floppy eyelid syndrome

  • Eyelid surgery to correct the laxity
  • Protective measures during sleep, such as a sleep mask or taping eyelids shut [87]
  • (B3)

Eyelid retraction in exophthalmos

  • Treat underlying thyroid disease
  • Surgical correction of eyelid retraction
  • Lubrication to prevent exposure keratopathy [88]

Eyelid imbrication syndrome

  • Surgical correction of eyelid position
  • Lubrication to manage symptoms of exposure.[89]
  • (B3)

Eyelid length disparity

  • Surgical intervention to correct the disparity
  • Use of lubricating drops or ointments to protect the cornea [90]

Lower lid laxity

  • Surgical tightening of the lower eyelid
  • Punctal plugs to improve tear retention [91]

Entropion and ectropion

  • Surgical correction of eyelid malposition
  • Lubrication to protect the ocular surface from irritation by eyelashes [92]

Eyelid notches and tumors

  • Removal or biopsy of tumors
  • Reconstruction to restore normal lid anatomy and function [93]

Keratinization of the eyelid margin

  • Topical retinoids or lubrication to manage lid-wiper epitheliopathy
  • Surgical intervention in severe cases [94]
  • (B2)

Malpositioned eyelashes

  • Epilation, electrolysis, or cryotherapy to remove misdirected lashes
  • Regular monitoring and maintenance treatment [95]

Blepharitis or meibomian gland dysfunction

  • Warm compresses and eyelid hygiene
  • Topical antibiotics or steroid drops
  • Omega-3 supplementation to improve gland function [96]

Treatments for conditions affecting the ocular surface include:

Dry eyes

  • Artificial tears and lubricating ointments to stabilize the tear film
  • Prescription eye drops like cyclosporine or lifitegrast to reduce inflammation
  • Punctal plugs to prevent tear drainage and maintain moisture
  • Lifestyle changes, including reducing screen time and improving the humidity of the environment
  • Omega-3 fatty acid supplements to improve tear quality [97]

Foreign body in the cornea or conjunctiva

  • Removal of the foreign body by a healthcare professional
  • Antibiotic drops to prevent infection following removal
  • Analgesic drops to reduce pain if needed [98]

Conjunctival inflammation

  • Anti-inflammatory eye drops, such as steroid drops, reduce inflammation
  • Cool compresses and artificial tears for symptomatic relief
  • Treating underlying causes, such as allergies, with an antihistamine or mast-cell stabilizer drops [99]

Conjunctivochalasis

  • Lubricating drops and ointments to relieve mechanical irritation
  • Surgical intervention to remove excess conjunctival tissue if severe and symptomatic [100]

Conjunctival symblepharon

  • Surgical separation of the adhesions may be necessary.
  • Management of the underlying condition causing the symblepharon, such as treating ocular cicatricial pemphigoid with immunosuppressants [101]
  • (B3)

Pinguecula and pterygia

  • Lubricating eye drops and sunglasses for protection from UV light
  • Surgical removal if the pterygium significantly disrupts vision or tear distribution [102]
  • (B3)

Corneal pathology

  • (Keratitis and ulcer)
  • Antibiotic or antifungal eye drops for infectious keratitis
  • Steroid eye drops to reduce inflammation if noninfectious
  • Proper corneal care and monitoring by an eye care professional [103]

Ocular inflammation

  • (Iritis, for example)
  • Steroid eye drops to reduce inflammation
  • Cycloplegic drops to prevent the iris from sticking to the lens and to relieve pain
  • Treatment of the underlying systemic condition if present [104]

Megalocaruncle:

  • Surgical reduction of the caruncle if it is obstructing the punctum
  • Monitoring for changes in size and symptoms [105]

Treatments for conditions affecting the lacrimal drainage system include:

Conjunctivitis

  • Allergic conjunctivitis: Antihistamine or mast cell stabilizer eye drops
  • Bacterial conjunctivitis: Antibiotic eye drops
  • Viral conjunctivitis: Supportive care with cool compresses and lubrication [106]
  • (A1)

Rhinitis or sinusitis

  • Nasal decongestants and saline sprays
  • Antihistamines for allergic rhinitis
  • Antibiotics for bacterial sinusitis [107]

Punctal apposition syndrome

  • Punctoplasty to correct the apposition
  • Use of punctal plugs if necessary [106]
  • (A1)

Malpositioned punctum

  • A surgical procedure (punctoplasty) to correct the position
  • Artificial tears to manage symptoms if surgery is not indicated [108]

Punctal stenosis

  • Punctal dilation and possible placement of punctal plugs
  • Surgical intervention for severe cases (eg, punctoplasty).[109]

Absence of puncta

  • Surgical creation of a new punctum if necessary
  • Lubrication to manage symptoms [110]

Accessory punctum

  • Observation if asymptomatic
  • Surgical closure if symptomatic [15]
  • (B2)

Dacryocystitis

  • Warm compresses and massage to reduce inflammation
  • Oral antibiotics for infection
  • Dacryocystorhinostomy surgery to bypass the obstruction [111]

Mucocele

  • Surgical drainage
  • Dacryocystorhinostomy surgery if there is an underlying nasolacrimal duct obstruction [112]

Absent or fibrotic sac

  • Dacryocystorhinostomy surgery to create a new drainage pathway [113]

Canaliculitis

  • Canaliculotomy to remove the infectious material
  • Topical and/or systemic antibiotics [114]

Sinus and nasal surgery

  • Postoperative care to reduce inflammation
  • Monitoring for potential complications affecting lacrimal drainage [115]
  • (B3)

Neoplasms

  • Surgical excision of the tumor
  • Additional therapy based on the type of neoplasm (eg, chemotherapy, radiotherapy) [116]

Trauma

  • Reconstruction surgery to repair the lacrimal drainage system
  • Use of stents or tubes to maintain patency during healing [117]

Intraluminal foreign bodies

  • Removal of the foreign body
  • Dilation of the duct if needed [118]

Radiotherapy

  • Conservative management with lubricants
  • Surgical intervention (eg, dacryocystorhinostomy) for severe obstruction [119]

Systemic chemotherapy

  • Symptomatic treatment with lubricants
  • Stent placement if obstruction is significant [120]

Bone marrow transplantation

  • Treatment of graft-versus-host disease with immunosuppressants
  • Lubrication to manage symptoms [121]

Eye drops

  • Consultation with a physician to change or adjust any medication causing irritation
  • Punctoplasty or punctal plugs for stenosis [122]
  • (B3)

Endogenous inflammation

  • Systemic immunosuppressive therapy for autoimmune conditions
  • Surgical interventions for structural complications [123]

Surgical Management

In cases of tearing due to eyelid laxity, lower eyelid tightening surgery is useful, although the effect does not always last.[124] When eyelid retraction or incomplete blink amplitude is the problem, options include placing a gold weight on the upper eyelid and aggressive lubrication.[9] Cases of a patent lacrimal system and well-positioned puncta have been managed with lower eyelid tightening and dacryocystorhinostomy with variable results.[125](B2)

Based on the obstruction site

In the case of true epiphora, when the obstruction is a cause, surgical treatment is often required to restore drainage. The appropriate procedure is chosen based on the specific site of obstruction.

  • Punctal stenosis: Managed with perforated punctal plugs, punctoplasty or punctum dilatation, and positioning of a monocanalicular or bicanalicular stent [126] 
  • Proximal and midcanalicular obstruction: Dacryocystorhinostomy with retrograde intubation is the technique of choice
  • Distal canalicular obstructions: Bypass surgery is advised
  • Common canalicular obstructions: 
    • Proximal obstruction: Canaliculodacryocystorhinostomy
    • Distal obstruction: Dacryocystorhinostomy with membranectomy and intubation 
    • No patency: Bypass surgery with a Lester Jones tube [126]
    • Obstruction in the nasolacrimal duct: Dacryocystorhinostomy will offer the best results

Procedures

Surgical management of a watery eye is tailored to address the underlying cause, which often involves the lacrimal drainage system. The goal is to restore proper drainage of tears into the nasal cavity. Several surgical options are available, and the choice of procedure depends on the specific site and cause of obstruction. 

Punctoplasty

Punctoplasty is a procedure aimed at correcting punctal stenosis, which is the narrowing of the lacrimal punctum, the entry point of the lacrimal drainage system. This simple procedure involves making a slit-like incision to enlarge the punctum and is often done under local anesthesia. There are various techniques, such as the 3-snip punctoplasty, 4-snip punctoplasty, or the 1-snip procedure. The choice of technique depends on the surgeon's preference and the extent of the stenosis.[127]

DCR

DCR is the most commonly performed procedure for the surgical management of nasolacrimal duct obstruction. It creates a new pathway between the lacrimal sac and the nasal cavity, bypassing the obstructed nasolacrimal duct. DCR can be performed via an external approach (external DCR) or endoscopically (endonasal DCR).[128]

External DCR

This traditional approach involves a skin incision and is notable for its high success rate.[129]

Endonasal DCR

This is a less invasive procedure performed entirely within the nasal cavity using endoscopic techniques. It has the advantage of no external scarring and a quicker recovery time.[130]

Conjunctivodacryocystorhinostomy 

Conjunctivodacryocystorhinostomy (CDRC) is indicated when there is a need to bypass the entire lacrimal drainage system. This is usually the case when there is an obstruction at the level of the canaliculi or when there has been a failure of previous DCR surgeries. In CDCR, a glass tube known as the Jones tube is inserted to connect the conjunctival sac directly to the nasal cavity.[131](A1)

Lacrimal intubation

In cases of partial obstruction or functional epiphora, silicone tubes may be inserted to open the lacrimal drainage system. This can be a temporary or sometimes a long-term solution.[132]

  • Lacrimal tubes: Used in various procedures to facilitate the creation of a new tear drainage pathway or to keep a new or existing pathway open [133]
  • Crawford tube: A silicone tube that is passed through the punctum, into the lacrimal sac, and then through the nasolacrimal duct into the nose; used primarily in pediatric cases or when a canalicular obstruction is present [134]
  • Jones tube: A glass tube used in CDCR procedures for cases of canalicular damage or after failed dacryocystorhinostomy; serves as a permanent conduit for tears from the eye to the nasal cavity [135]
  • Masterka tube: A variation of the Jones tube that is self-retaining and does not require a suture for fixation; has a larger internal opening to reduce the risk of blockage [136]
  • Mini-Monoka tube: A monocanalicular stent that is secured in place without the need for sutures, as it has a plug that anchors it to the punctum; used for canalicular obstructions [137]
  • (B2)

The surgical management of a watery eye is complex and should be personalized based on the patient's specific anatomy and pathology. Postoperative care is critical and includes monitoring for infection, tube patency, and proper positioning of the tubes. Long-term follow-up is necessary to ensure the continued function of the surgical intervention and to manage any complications or recurrences.

Differential Diagnosis

In patients with a complaint of tearing, a detailed differential diagnosis should be made of the possible causes or combination of causes of a watery eye mentioned above.

The differential diagnosis consists of disorders summarized within the following main categories:[138]

  • Eyelid appositional disorders and impaired tear pump function
  • Lacrimal drainage obstruction
  • Ocular surface disease
  • Neurogenic lacrimal hypersecretion [4] 
  • Conjunctivitis: Inflammation of the conjunctiva often leads to tearing. It can be allergic, bacterial, or viral in origin.
  • Dry eye syndrome: Ironically, one of the reflex responses to dry eyes is increased tearing. This occurs as the eye tries to compensate for the underlying dryness.
  • Blepharitis: Inflammation of the eyelids, particularly at the base of the eyelashes, can lead to blockage of the meibomian glands and secondary watery eyes.
  • Corneal disorders: Any irritation to the cornea, including abrasions, ulcers, or foreign bodies, can stimulate excessive tear production.
  • Dacryocystitis: Infection of the lacrimal sac can cause tearing due to blockage of the nasolacrimal duct.
  • Canaliculitis: Infection of the canaliculus can lead to watery eyes due to obstruction of the tear drainage pathway.
  • Nasolacrimal duct obstruction: Blockage of the tear drainage duct, whether due to congenital reasons, infection, inflammation, or trauma, can cause persistent watery eyes.
  • Ectropion: This is where the lower eyelid turns outwards, failing to contain tears within the ocular surface effectively.
  • Entropion: An inward turning of the eyelid can cause irritation from the eyelashes rubbing against the cornea, leading to excessive tearing.
  • Bell's Palsy or facial nerve palsy: This condition can lead to poor eyelid function, which can cause the eyes to water.
  • Trachoma: This infection can cause scarring of the conjunctiva and secondary tearing.
  • Foreign body sensation: The presence of a foreign body in the eye can stimulate tear production.[4]
  • Glaucoma: Acute angle-closure glaucoma can present with tearing, though it is usually accompanied by severe eye pain and vision changes.
  • Allergic eye disease: Eye allergies can cause significant tearing, itching, and redness.
  • Tumors or masses: Any mass in the tear drainage system or in the vicinity that causes compression can lead to epiphora.
  • Systemic conditions: Rheumatoid arthritis, sarcoidosis, and other systemic conditions can affect the eyes and lead to tearing.
  • Medications: Certain medications can cause or exacerbate watery eyes as a side effect.
  • Refractive errors: Uncorrected vision problems can lead to eye strain and reflex tearing.
  • Contact lens complications: Overwear or poorly fitting contact lenses can cause irritation, leading to excessive tearing.[4]

In each case of watery eyes, a thorough patient history and clinical examination are required to narrow down the differential diagnosis. Additional diagnostic tests, such as Schirmer's test for tear production, slit-lamp examination, fluorescein staining, and imaging studies, may be necessary to establish the correct diagnosis and guide appropriate management.

Some authors differentiate between "true epiphora" (obstruction of the lacrimal drainage system) and a watery eye (caused by tear film or blinking problems) to make this differential diagnosis easier by dividing the possible causes under these 2 possible results. In a child with a tearing eye, one should consider the possibility of congenital glaucoma in addition to the etiologies mentioned above. The elevated intraocular pressure in this condition causes tearing, redness, photophobia, and enlargement of the eyes (buphthalmos).[4]

Treatment Planning

The treatment planning for watery eyes is typically a stepwise approach that often starts with conservative management and progresses to surgical intervention if necessary. Radiation therapy is not a standard treatment for watery eyes; it is usually reserved for severe ocular conditions or tumors.

Initial assessment: A thorough clinical evaluation to determine the cause of watery eyes. Examination may include slit-lamp examination, evaluation of lacrimal drainage patency, and possibly imaging studies.[113]

Conservative management: Treatment of underlying conditions such as infection or inflammation with appropriate medications. Addressing dry eye syndrome with artificial tears or punctal plugs to manage reflex tearing. Eyelid hygiene for conditions like blepharitis.[139]

Surgical management: If conservative measures fail or if anatomical blockages are identified, surgical options are considered.

Punctoplasty: For punctal stenosis, punctoplasty may be performed to enlarge the punctal opening and facilitate tear drainage.[140]

DCR: External DCR or endonasal DCR to create a new drainage pathway between the lacrimal sac and the nasal cavity.[128]

Lacrimal intubation: Insertion of silicone tubes to maintain patency of the nasolacrimal system.[141]

CDCR: In cases of complete lacrimal system obstruction, a Jones tube may be placed to directly shunt tears from the eye to the nasal cavity.[131]

Surgical interventions for eyelid malposition: Correction of ectropion or entropion if malposition is contributing to the watery eye.[142]

Postoperative care: Follow-up is crucial to ensure the success of surgical intervention. Management may include topical antibiotics, steroids, and nasal decongestants.[143]

Special cases: In rare cases where a tumor is causing secondary epiphora, treatment planning would involve a multidisciplinary approach, including oncology, radiology, and ophthalmology. Only in these specific cases would radiation therapy potentially be a part of the treatment plan, and it would be tailored to the individual case, considering the type, location, and size of the tumor, as well as the preservation of ocular function.[144]

For each patient, treatment should be individualized based on the underlying cause, the patient's health status, and the patient's response to initial therapies. Regular monitoring and adjustments to the treatment plan are often needed to manage watery eyes effectively.

Prognosis

Watery eyes may significantly affect patients' quality of life, as the condition may cause social embarrassment and interfere with daily activities such as reading and driving.[145] It may also cause chronic irritation of the periorbital skin due to repeated wiping away of the tears and the interaction of the salty tears on the skin. For most patients, symptoms improve after the appropriate diagnosis and treatment.

The prognosis for watery eyes is generally good, especially when the underlying cause can be identified and properly treated. The outlook depends on a variety of factors, including the etiology, the patient's overall health, the presence of any comorbid conditions, and the response to treatment.[146]

For cases of watery eyes due to temporary conditions such as conjunctivitis or environmental irritants, the prognosis is excellent, with symptoms typically resolving with appropriate treatment or removal of the irritant. In cases due to chronic conditions like dry eye syndrome, the prognosis is also good, although management may be ongoing. Treatment such as artificial tears, punctal plugs, or anti-inflammatory medications can control symptoms effectively.[4]

If watery eyes are caused by obstructions within the lacrimal drainage system, such as with nasolacrimal duct obstruction, the prognosis varies. Infants with congenital nasolacrimal duct obstruction often experience spontaneous resolution within the first year of life. Adults with acquired nasolacrimal duct obstruction may require procedural intervention, like DCR, which has high success rates.[147]

Surgical correction typically provides very good outcomes for epiphora due to eyelid malpositions such as ectropion or entropion. In the case of tumors or growths causing secondary epiphora, the prognosis would depend on the type, location, and extent of the tumor, as well as the success of the treatment, which may include surgery, chemotherapy, or radiation therapy.[148]

Inflammatory and systemic conditions that manifest with watery eyes, such as rheumatoid arthritis or sarcoidosis, may have a variable prognosis based on the response to systemic treatment of the underlying disease. Although the symptom of watery eyes has a generally favorable outlook when treated appropriately, the prognosis for the underlying cause of watery eyes can be quite variable. Patients need to follow up with their healthcare provider to monitor their condition and adjust treatment as needed.[149]

Complications

It should be noted that a watery eye is not always only a discomforting symptom as it can be the manifestation of pathologies that can cause permanent ocular damage or complicate intraocular surgeries if left untreated.[26] Watery eyes can lead to several complications if not properly managed:

  • Chronic discomfort: Constant tearing can cause discomfort and interfere with daily activities, including reading and driving.
  • Vision impairment: Excessive tearing may lead to blurred vision and can reduce quality of life.
  • Skin irritation: Chronic wetness around the eyes can lead to irritation, dermatitis, and skin breakdown on the eyelids and surrounding skin.
  • Infection: Persistent moisture can create a breeding ground for bacteria, potentially leading to infections such as conjunctivitis or dacryocystitis.
  • Corneal problems: In severe cases, excessive tear production can overflow onto the cornea, leading to exposure keratopathy, corneal ulceration, or infection.
  • Social and psychological impact: The constant tearing and associated symptoms can be cosmetically unappealing and socially embarrassing, potentially impacting mental health.
  • Chronic inflammation: In cases where watery eyes are due to chronic conditions like ocular surface disease, it can lead to persistent inflammation, further damaging eye tissues.
  • Secondary vision problems: If watery eyes result from another ocular condition, such as conjunctivitis or blepharitis, failing to address the primary issue could lead to more serious secondary vision problems.

Early diagnosis and appropriate treatment of the underlying cause of epiphora are essential to prevent these complications and preserve ocular health and quality of life.[150]

Postoperative and Rehabilitation Care

Postoperative care following a procedure for a watery eye, such as DCR or punctoplasty, is crucial for ensuring proper healing and the best possible outcome. This care typically includes:

  • Monitoring: Close observation for any signs of infection or complications
  • Medications: Use of prescribed antibiotics and/or steroid eye drops to prevent infection and reduce inflammation
  • Pain management: Pain is usually minimal; if necessary, appropriate analgesics can be prescribed.
  • Activity restrictions: Patients may be advised to avoid strenuous activities or heavy lifting for a brief period postsurgery
  • Eye protection: Shielding the eye from potential irritants and trauma, especially in the first few days following surgery
  • Rehabilitation care: Focuses on the recovery and functional improvement of the eye after surgery or other treatments
  • Lacrimal system massage: Patients may be instructed on how to perform lacrimal sac massage to promote drainage through the newly created pathway.
  • Lid hygiene: Maintaining clean eyelids to prevent meibomian gland dysfunction, which can affect the tear film and contribute to watery eyes
  • Follow-up appointments: Regular check-ups to assess the patency of the lacrimal drainage system and to ensure that the postoperative course is progressing as expected
  • Adjustment of medications: Based on the recovery and any ongoing symptoms, adjustments to medications may be made.
  • Tear management: Use of artificial tears or punctal plugs to manage tear film if dry eye is a contributing factor to the watery eye condition [151]

Consultations

Primary care physician or general practitioner: They conduct initial evaluation and referral to specialists if necessary. Management of systemic conditions that might contribute to a watery eye, such as allergies or infections[152]

Ophthalmologist

  • Comprehensive eye examination, including assessment of the lacrimal system
  • Specialized tests such as Schirmer's test for tear production, tear break-up time, and ocular surface staining
  • Imaging studies like DCG or a CT scan to evaluate the lacrimal drainage system[113]

Oculoplastic Surgeon

  • Evaluation for surgical intervention if there is a structural problem with the eyelids or lacrimal system
  • Management of eyelid malpositions such as entropion or ectropion that can cause watery eyes [153]

Neurologist: Consultation may be needed if there is a suspicion of a neurological cause affecting the eyelids or tear drainage system [154]

Rheumatologist: In cases where a systemic autoimmune condition is suspected to be causing ocular surface inflammation leading to watery eyes [155]

Allergist/immunologist: Evaluation for allergies that may contribute to chronic conjunctivitis and watery eyes [156]

Dermatologist: If skin conditions around the eyes are thought to contribute to the watery eye, such as atopic dermatitis or rosacea [157]

ENT Specialist (Otorhinolaryngologist)

  • Assessment of the nasal and sinus passages, which can impact the lacrimal drainage system
  • Management of any sinus conditions or nasal obstructions that may affect tear drainage [157]

A multidisciplinary approach may be necessary to thoroughly assess a watery eye, especially if the initial treatments do not resolve the issue or if complex underlying conditions are suspected. The specific specialists involved may vary depending on the underlying cause of the watery eye and the patient's overall health status.

Deterrence and Patient Education

Understanding the condition: Educate patients about the possible causes of a watery eye, which could range from dry eye syndrome and allergies to blockages in the tear drainage system.[158]

Importance of follow-up: Stress the importance of follow-up appointments to monitor the condition and response to treatment. Explain the potential need for further testing or referral to a specialist if the condition persists.[159]

Self-care strategies: Provide instructions on eyelid hygiene, especially for those with blepharitis or meibomian gland dysfunction. Discuss the role of environmental factors such as wind, smoke, and air conditioning in exacerbating symptoms and how to mitigate these.[160]

Proper use of medications: Instruct patients on correctly using any prescribed medications, such as eye drops or ointments. Emphasize the importance of completing the full course of any antibiotic treatment if prescribed.[161]

Recognizing complications: Educate patients on the signs of complications that should prompt immediate medical attention, such as increased redness, swelling, pain, or vision changes.[99]

Preventive measures: For those with allergies, discuss ways to reduce exposure to allergens. Suggest the use of protective eyewear in environments that could lead to eye irritation or injury.[162]

Lifestyle modifications: Advise on dietary changes or supplements that may benefit those with dry eyes, such as increasing omega-3 fatty acids. Discuss the importance of taking breaks during activities that require prolonged focus, like computer work, to reduce eye strain and encourage regular blinking.[163]

Surgical interventions: If surgery is a treatment option, provide detailed information about the procedure, potential risks, benefits, and the postoperative care required.[164]

Long-term management: Educate patients with chronic conditions on the importance of long-term management to control symptoms and prevent complications.[165]

Emotional support: Acknowledge the frustration and discomfort that can come with chronic watery eyes and offer support or referral to a counselor if needed.[166]

Patient education should be tailored to the individual, considering their specific diagnosis, treatment plan, and personal circumstances. Ensuring that patients have a clear understanding of their condition and how to manage it can lead to better outcomes and patient satisfaction.

Pearls and Other Issues

When assessing a patient with a watery eye, several key "pearls" can guide clinicians to an accurate diagnosis and effective management plan.[91]

  • Comprehensive history-taking: Always start with a detailed history that includes onset, duration, associated symptoms (like discharge, pain, vision changes), and any aggravating or relieving factors.[91]
  • Systemic considerations: Be aware of systemic diseases such as rheumatoid arthritis, Sjögren's syndrome, or thyroid disease that can present with ocular symptoms, including a watery eye.[167]
  • Medication review: A thorough review of the patient's medications is essential, as certain drugs, including chemotherapy agents, can cause or exacerbate tearing.[168]
  • Environmental factors: Consider occupational and environmental factors that may contribute to eye irritation and excessive tearing, such as exposure to chemicals, pollutants, or wind.[169]
  • Physical examination: A meticulous eyelid, lacrimal apparatus, and ocular surface exam is crucial. Look for signs of ectropion, entropion, blepharitis, conjunctivitis, or punctal anomalies.
  • Diagnostic tests: Utilize diagnostic tests judiciously. When used appropriately, Schirmer's test, fluorescein dye disappearance test, and imaging studies can be very informative.[91]
  • Patient education: Educate patients about their condition and the importance of compliance with treatment and follow-up visits. This education can improve outcomes and patient satisfaction.

Other Issues in the Assessment of a Watery Eye

While "pearls" are valuable tips, there are also other issues to consider during the assessment:

  • Differentiating causes: Differentiating between the overproduction of tears and inadequate drainage can be challenging but is essential for proper management.
  • Age-related changes: Consider age-related changes in the lacrimal system, as conditions like dry eye and lacrimal duct obstruction increase with age.
  • Referral when necessary: Know when to refer to an ophthalmologist or oculoplastic specialist, especially if surgical intervention is indicated or if the diagnosis is uncertain.[91]
  • Chronicity and severity: Assess the chronicity and severity of symptoms to prioritize treatment options and anticipate the need for more aggressive interventions.[168]
  • Cost-effectiveness: Be mindful of the cost-effectiveness of diagnostic tests and treatments, and consider the patient's financial constraints when making recommendations. By keeping these pearls and other issues in mind, clinicians can navigate the complex presentation of a watery eye with a greater chance of achieving a successful patient outcome. Watery eyes may have a marked adverse impact on patients' quality of life. A thorough clinical history is essential in assessing watery eyes, as it provides clues about the possible etiology and enables selecting the proper test for confirmation. A systematic physical examination is recommended, as a combination of different factors may cause watery eyes.  Before treating an obstruction surgically, it is advisable to address hypersecretion and distribution problems first.[168]

Enhancing Healthcare Team Outcomes

Although optometrists and ophthalmologists are almost always involved in caring for patients with watery eyes, consulting with an interprofessional team of specialists is essential for the effective management of a patient with a watery eye.

  • Radiologist: Plays a vital role in interpreting the radiologic images
  • Otolaryngologist: Crucial in diagnosing nasal pathology as the cause of watery eyes and contributes to the surgical management of lacrimal drainage obstructions
  • Family physicians and nurses: Have an essential role in assessing this pathology, as they are often the first port of call for patients complaining of watery eyes.

Strategies to Enhance Outcomes

Interdisciplinary collaboration: Encourage regular communication between primary care providers, ophthalmologists, optometrists, nurses, and ancillary staff to ensure a cohesive management plan.[145]

Role clarification: Clearly define the roles and responsibilities of each team member to streamline the care process, reduce redundancy, and ensure that all aspects of patient care are covered.

Continuing education: Provide ongoing education and training opportunities for healthcare team members to stay updated on the latest diagnostic and therapeutic advances related to eye conditions.[91]

Standardized protocols: Implement standardized assessment and treatment protocols for common causes of a watery eye to minimize variability in care and improve patient outcomes.

Patient-centered care: Focus on patient-centered care by involving patients in decision-making, addressing their concerns, and providing personalized education.[167]

Utilization of technology: Use electronic medical records effectively for documentation and to facilitate easy access to patient information for all team members.

Quality improvement: Regularly review outcomes and processes for the assessment and management of watery eyes. Use this data to identify areas for improvement and implement changes.

Efficient referral systems: Establish efficient referral systems to ensure timely consultations with specialists when advanced care is needed.[145]

Multimodal communication: Utilize various modes of communication, such as meetings, email updates, and shared electronic health records, to keep all team members informed about patient progress.

Supportive environment: Foster a supportive work environment that encourages teamwork, open communication, and mutual respect among all healthcare providers.

Patient feedback: Incorporate patient feedback into the healthcare team's evaluation to understand patient satisfaction and improvement areas.[91]

By implementing these strategies, healthcare teams can provide high-quality, coordinated care for patients presenting with a watery eye, ultimately leading to better clinical outcomes, enhanced patient satisfaction, and more efficient use of healthcare resources.

References


[1]

Arbabi EM, Arshad FA, Holden K, Carrim ZI. The watery eye. BMJ (Clinical research ed.). 2011 Jul 19:343():d4029. doi: 10.1136/bmj.d4029. Epub 2011 Jul 19     [PubMed PMID: 21771824]


[2]

Nemet AY. The Etiology of Epiphora: A Multifactorial Issue. Seminars in ophthalmology. 2016:31(3):275-9. doi: 10.3109/08820538.2014.962163. Epub 2014 Nov 6     [PubMed PMID: 25375763]

Level 2 (mid-level) evidence

[3]

Shen GL, Ng JD, Ma XP. Etiology, diagnosis, management and outcomes of epiphora referrals to an oculoplastic practice. International journal of ophthalmology. 2016:9(12):1751-1755. doi: 10.18240/ijo.2016.12.08. Epub 2016 Dec 18     [PubMed PMID: 28003974]


[4]

Patel J,Levin A,Patel BC, Epiphora 2020 Jan;     [PubMed PMID: 32491381]


[5]

Gurnani B, Kaur K. Bacterial Keratitis. StatPearls. 2023 Jan:():     [PubMed PMID: 34662023]


[6]

Basu S. Seeing through tears: Understanding and managing dry eye disease. Indian journal of ophthalmology. 2023 Apr:71(4):1065-1066. doi: 10.4103/IJO.IJO_642_23. Epub     [PubMed PMID: 37026232]

Level 3 (low-level) evidence

[7]

Icasiano E, Latkany R, Speaker M. Chronic epiphora secondary to ocular rosacea. Ophthalmic plastic and reconstructive surgery. 2008 May-Jun:24(3):249. doi: 10.1097/IOP.0b013e318172b4ca. Epub     [PubMed PMID: 18520861]

Level 3 (low-level) evidence

[8]

Swampillai AJ, McMullan TF. Epiphora. British journal of hospital medicine (London, England : 2005). 2012 Nov:73(11):C162-5     [PubMed PMID: 23147256]


[9]

Tse DT, Erickson BP, Tse BC. The BLICK mnemonic for clinical-anatomical assessment of patients with epiphora. Ophthalmic plastic and reconstructive surgery. 2014 Nov-Dec:30(6):450-8. doi: 10.1097/IOP.0000000000000281. Epub     [PubMed PMID: 25216202]


[10]

Webber NK, Setterfield JF, Lewis FM, Neill SM. Lacrimal canalicular duct scarring in patients with lichen planus. Archives of dermatology. 2012 Feb:148(2):224-7. doi: 10.1001/archdermatol.2011.580. Epub     [PubMed PMID: 22351823]


[11]

Portelinha J, Passarinho MP, Costa JM. Neuro-ophthalmological approach to facial nerve palsy. Saudi journal of ophthalmology : official journal of the Saudi Ophthalmological Society. 2015 Jan-Mar:29(1):39-47. doi: 10.1016/j.sjopt.2014.09.009. Epub 2014 Sep 28     [PubMed PMID: 25859138]


[12]

Zhang Y, Zeng C, Chen N, Liu C. Lacrimal ductal cyst of the medial orbit: a case report. BMC ophthalmology. 2020 Sep 24:20(1):380. doi: 10.1186/s12886-020-01636-1. Epub 2020 Sep 24     [PubMed PMID: 32972388]

Level 3 (low-level) evidence

[13]

Kim JS, Liss J. Masses of the Lacrimal Gland: Evaluation and Treatment. Journal of neurological surgery. Part B, Skull base. 2021 Feb:82(1):100-106. doi: 10.1055/s-0040-1722700. Epub 2021 Feb 18     [PubMed PMID: 33777623]


[14]

Lievens CW, Rayborn E. Tribology and the Ocular Surface. Clinical ophthalmology (Auckland, N.Z.). 2022:16():973-980. doi: 10.2147/OPTH.S360293. Epub 2022 Mar 30     [PubMed PMID: 35386611]


[15]

Al Saleh A, Vargas JM, Al Saleh AS. Supernumerary lacrimal puncta: Case series. Saudi journal of ophthalmology : official journal of the Saudi Ophthalmological Society. 2020 Oct-Dec:34(4):328-330. doi: 10.4103/1319-4534.322615. Epub 2021 Jul 29     [PubMed PMID: 34527885]

Level 2 (mid-level) evidence

[16]

Kang S, Seo JW, Sa HS. Cancer-associated epiphora: a retrospective analysis of referrals to a tertiary oculoplastic practice. The British journal of ophthalmology. 2017 Nov:101(11):1566-1569. doi: 10.1136/bjophthalmol-2016-309774. Epub 2017 Mar 23     [PubMed PMID: 28341695]

Level 2 (mid-level) evidence

[17]

Esmaeli B, Hidaji L, Adinin RB, Faustina M, Coats C, Arbuckle R, Rivera E, Valero V, Tu SM, Ahmadi MA. Blockage of the lacrimal drainage apparatus as a side effect of docetaxel therapy. Cancer. 2003 Aug 1:98(3):504-7     [PubMed PMID: 12879466]


[18]

Chan W, Malhotra R, Kakizaki H, Leibovitch I, Selva D. Perspective: what does the term functional mean in the context of epiphora? Clinical & experimental ophthalmology. 2012 Sep-Oct:40(7):749-54. doi: 10.1111/j.1442-9071.2012.02791.x. Epub 2012 May 25     [PubMed PMID: 22429759]

Level 3 (low-level) evidence

[19]

Perry JD. Dysfunctional epiphora: a critique of our current construct of "functional epiphora". American journal of ophthalmology. 2012 Jul:154(1):3-5. doi: 10.1016/j.ajo.2012.02.034. Epub     [PubMed PMID: 22709832]


[20]

Maroto Rodríguez B, Stoica BTL, Toledano Fernández N, Genol Saavedra I. Treatment for functional epiphora with botulinum toxin-A versus lateral tarsal strip in a randomized trial. Archivos de la Sociedad Espanola de Oftalmologia. 2022 Oct:97(10):549-557. doi: 10.1016/j.oftale.2022.06.011. Epub 2022 Jul 22     [PubMed PMID: 35879178]

Level 1 (high-level) evidence

[21]

Ozturker C, Purevdorj B, Karabulut GO, Seif G, Fazil K, Khan YA, Kaynak P. A Comparison of Transcanalicular, Endonasal, and External Dacryocystorhinostomy in Functional Epiphora: A Minimum Two-Year Follow-Up Study. Journal of ophthalmology. 2022:2022():3996854. doi: 10.1155/2022/3996854. Epub 2022 Mar 23     [PubMed PMID: 35369002]


[22]

Lee MJ, Park J, Yang MK, Choi YJ, Kim N, Choung HK, Khwarg SI. Long-term results of maintenance of lacrimal silicone stent in patients with functional epiphora after external dacryocystorhinostomy. Eye (London, England). 2020 Apr:34(4):669-674. doi: 10.1038/s41433-019-0572-2. Epub 2019 Sep 16     [PubMed PMID: 31527764]


[23]

Shams PN, Chen PG, Wormald PJ, Sloan B, Wilcsek G, McNab A, Selva D. Management of functional epiphora in patients with an anatomically patent dacryocystorhinostomy. JAMA ophthalmology. 2014 Sep:132(9):1127-32. doi: 10.1001/jamaophthalmol.2014.1093. Epub     [PubMed PMID: 24903661]

Level 2 (mid-level) evidence

[24]

Vagge A, Ferro Desideri L, Nucci P, Serafino M, Giannaccare G, Lembo A, Traverso CE. Congenital Nasolacrimal Duct Obstruction (CNLDO): A Review. Diseases (Basel, Switzerland). 2018 Oct 22:6(4):. doi: 10.3390/diseases6040096. Epub 2018 Oct 22     [PubMed PMID: 30360371]


[25]

Mainville N, Jordan DR. Etiology of tearing: a retrospective analysis of referrals to a tertiary care oculoplastics practice. Ophthalmic plastic and reconstructive surgery. 2011 May-Jun:27(3):155-7. doi: 10.1097/IOP.0b013e3181ef728d. Epub     [PubMed PMID: 20940663]

Level 2 (mid-level) evidence

[26]

Ulusoy MO, Kıvanç SA, Atakan M, Akova-Budak B. How Important Is the Etiology in the Treatment of Epiphora? Journal of ophthalmology. 2016:2016():1438376. doi: 10.1155/2016/1438376. Epub 2016 Aug 10     [PubMed PMID: 27595013]


[27]

Ishikawa S, Murayama K, Kato N. The proportion of ocular surface diseases in untreated patients with epiphora. Clinical ophthalmology (Auckland, N.Z.). 2018:12():1769-1773. doi: 10.2147/OPTH.S172503. Epub 2018 Sep 11     [PubMed PMID: 30254415]


[28]

Qian L, Wei W. Identified risk factors for dry eye syndrome: A systematic review and meta-analysis. PloS one. 2022:17(8):e0271267. doi: 10.1371/journal.pone.0271267. Epub 2022 Aug 19     [PubMed PMID: 35984830]

Level 2 (mid-level) evidence

[29]

Cher I. Fluids of the ocular surface: concepts, functions and physics. Clinical & experimental ophthalmology. 2012 Aug:40(6):634-43. doi: 10.1111/j.1442-9071.2012.02758.x. Epub 2012 Mar 21     [PubMed PMID: 22300341]

Level 3 (low-level) evidence

[30]

Martin R, Emo Research Group. Comparison of the Ocular Surface Disease Index and the Symptom Assessment in Dry Eye Questionnaires for Dry Eye Symptom Assessment. Life (Basel, Switzerland). 2023 Sep 21:13(9):. doi: 10.3390/life13091941. Epub 2023 Sep 21     [PubMed PMID: 37763343]


[31]

Kinoshita S, Ukyo H, Masuda N, Osawa S. Comparison of the Postoperative Outcomes of Posterior Layer Advancement and Modified Iliff Suturing to Correct Involutional Lower Lid Entropion. The Journal of craniofacial surgery. 2021 May 1:32(3):1143-1146. doi: 10.1097/SCS.0000000000007303. Epub     [PubMed PMID: 33278253]


[32]

Milbratz-Moré GH, Pauli MP, Lohn CLB, Pereira FJ, Grumann AJ. Lower Eyelid Distraction Test: New Insights on the Reference Value. Ophthalmic plastic and reconstructive surgery. 2019 Nov/Dec:35(6):574-577. doi: 10.1097/IOP.0000000000001392. Epub     [PubMed PMID: 30969191]


[33]

Chen C, Malhotra R, Muecke J, Davis G, Selva D. Aberrant facial nerve regeneration (AFR): an under-recognized cause of ptosis. Eye (London, England). 2004 Feb:18(2):159-62     [PubMed PMID: 14762408]

Level 2 (mid-level) evidence

[34]

Zhang YH, Feng J, Yi CY, Deng XY, Zhou YJ, Tian L, Jie Y. Dynamic tear meniscus parameters in complete blinking: insights into dry eye assessment. International journal of ophthalmology. 2023:16(12):1911-1918. doi: 10.18240/ijo.2023.12.01. Epub 2023 Dec 18     [PubMed PMID: 38111923]


[35]

Abraham ZS, Bukanu F, Kahinga AA. A missed giant rhinolith retained for a decade in a paediatric patient at a zonal referral hospital in Central Tanzania: Case report and literature review. International journal of surgery case reports. 2022 Oct:99():107622. doi: 10.1016/j.ijscr.2022.107622. Epub 2022 Sep 9     [PubMed PMID: 36099770]

Level 3 (low-level) evidence

[36]

Bron AJ, de Paiva CS, Chauhan SK, Bonini S, Gabison EE, Jain S, Knop E, Markoulli M, Ogawa Y, Perez V, Uchino Y, Yokoi N, Zoukhri D, Sullivan DA. TFOS DEWS II pathophysiology report. The ocular surface. 2017 Jul:15(3):438-510. doi: 10.1016/j.jtos.2017.05.011. Epub 2017 Jul 20     [PubMed PMID: 28736340]


[37]

Singh Bhinder G, Singh Bhinder H. Reflex epiphora in patients with dry eye symptoms: role of variable time Schirmer-1 test. European journal of ophthalmology. 2005 Jul-Aug:15(4):429-33     [PubMed PMID: 16001372]


[38]

Li N, Deng XG, He MF. Comparison of the Schirmer I test with and without topical anesthesia for diagnosing dry eye. International journal of ophthalmology. 2012:5(4):478-81. doi: 10.3980/j.issn.2222-3959.2012.04.14. Epub 2012 Aug 18     [PubMed PMID: 22937509]


[39]

Mou Y, Xiang H, Lin L, Yuan K, Wang X, Wu Y, Min J, Jin X. Reliability and efficacy of maximum fluorescein tear break-up time in diagnosing dry eye disease. Scientific reports. 2021 Jun 1:11(1):11517. doi: 10.1038/s41598-021-91110-9. Epub 2021 Jun 1     [PubMed PMID: 34075199]


[40]

Sall K, Foulks GN, Pucker AD, Ice KL, Zink RC, Magrath G. Validation of a Modified National Eye Institute Grading Scale for Corneal Fluorescein Staining. Clinical ophthalmology (Auckland, N.Z.). 2023:17():757-767. doi: 10.2147/OPTH.S398843. Epub 2023 Mar 7     [PubMed PMID: 36915716]

Level 1 (high-level) evidence

[41]

Bunya VY, Chen M, Zheng Y, Massaro-Giordano M, Gee J, Daniel E, O'Sullivan R, Smith E, Stone RA, Maguire MG. Development and Evaluation of Semiautomated Quantification of Lissamine Green Staining of the Bulbar Conjunctiva From Digital Images. JAMA ophthalmology. 2017 Oct 1:135(10):1078-1085. doi: 10.1001/jamaophthalmol.2017.3346. Epub     [PubMed PMID: 28910455]


[42]

Jamerson EC, Elhusseiny AM, ElSheikh RH, Eleiwa TK, El Sayed YM. Role of Matrix Metalloproteinase 9 in Ocular Surface Disorders. Eye & contact lens. 2020 Mar:46 Suppl 2():S57-S63. doi: 10.1097/ICL.0000000000000668. Epub     [PubMed PMID: 32068662]


[43]

Papas EB. Diagnosing dry-eye: Which tests are most accurate? Contact lens & anterior eye : the journal of the British Contact Lens Association. 2023 Oct:46(5):102048. doi: 10.1016/j.clae.2023.102048. Epub 2023 Aug 4     [PubMed PMID: 37544866]


[44]

Wolffsohn JS, Arita R, Chalmers R, Djalilian A, Dogru M, Dumbleton K, Gupta PK, Karpecki P, Lazreg S, Pult H, Sullivan BD, Tomlinson A, Tong L, Villani E, Yoon KC, Jones L, Craig JP. TFOS DEWS II Diagnostic Methodology report. The ocular surface. 2017 Jul:15(3):539-574. doi: 10.1016/j.jtos.2017.05.001. Epub 2017 Jul 20     [PubMed PMID: 28736342]


[45]

Singh S, Donthineni PR, Srivastav S, Jacobi C, Basu S, Paulsen F. Lacrimal and meibomian gland evaluation in dry eye disease: A mini-review. Indian journal of ophthalmology. 2023 Apr:71(4):1090-1098. doi: 10.4103/IJO.IJO_2622_22. Epub     [PubMed PMID: 37026239]


[46]

Wong S, Srinivasan S, Murphy PJ, Jones L. Comparison of meibomian gland dropout using two infrared imaging devices. Contact lens & anterior eye : the journal of the British Contact Lens Association. 2019 Jun:42(3):311-317. doi: 10.1016/j.clae.2018.10.014. Epub 2018 Nov 7     [PubMed PMID: 30413376]


[47]

Chidi-Egboka NC, Jalbert I, Chen J, Briggs NE, Golebiowski B. Blink Rate Measured In Situ Decreases While Reading From Printed Text or Digital Devices, Regardless of Task Duration, Difficulty, or Viewing Distance. Investigative ophthalmology & visual science. 2023 Feb 1:64(2):14. doi: 10.1167/iovs.64.2.14. Epub     [PubMed PMID: 36763349]


[48]

Pult H, Riede-Pult B. Comparison of subjective grading and objective assessment in meibography. Contact lens & anterior eye : the journal of the British Contact Lens Association. 2013 Feb:36(1):22-7. doi: 10.1016/j.clae.2012.10.074. Epub 2012 Oct 27     [PubMed PMID: 23108007]


[49]

Kashkouli MB, Mirzajani H, Jamshidian-Tehrani M, Pakdel F, Nojomi M, Aghaei GH. Reliability of fluorescein dye disappearance test in assessment of adults with nasolacrimal duct obstruction. Ophthalmic plastic and reconstructive surgery. 2013 May-Jun:29(3):167-9. doi: 10.1097/IOP.0b013e3182873b40. Epub     [PubMed PMID: 23503058]

Level 2 (mid-level) evidence

[50]

Bowyer JD, Holroyd C, Chandna A. The use of the fluorescein disappearance test in the management of childhood epiphora. Orbit (Amsterdam, Netherlands). 2001 Sep:20(3):181-187     [PubMed PMID: 12045910]


[51]

Paramanathan N, Nemet A, Lee SE, Benger RS. A modified Jones test: lacrimal scintigram correlation. Ophthalmic plastic and reconstructive surgery. 2011 Mar-Apr:27(2):81-6. doi: 10.1097/IOP.0b013e3181c8ab70. Epub     [PubMed PMID: 20683280]


[52]

Pujari A, Bajaj MS, Sharma P. Calibrated Bowman's lacrimal probe. Indian journal of ophthalmology. 2018 Mar:66(3):478. doi: 10.4103/ijo.IJO_1063_17. Epub     [PubMed PMID: 29480277]


[53]

Shapira Y, Juniat V, Macri C, Selva D. Syringing has limited reliability in differentiating nasolacrimal duct stenosis from functional delay. Graefe's archive for clinical and experimental ophthalmology = Albrecht von Graefes Archiv fur klinische und experimentelle Ophthalmologie. 2022 Sep:260(9):3037-3042. doi: 10.1007/s00417-022-05654-1. Epub 2022 Apr 23     [PubMed PMID: 35460361]


[54]

Kim S, Yang S, Park J, Lee H, Baek S. Correlation Between Lacrimal Syringing Test and Dacryoscintigraphy in Patients With Epiphora. The Journal of craniofacial surgery. 2020 Jul-Aug:31(5):e442-e445. doi: 10.1097/SCS.0000000000006389. Epub     [PubMed PMID: 32282674]


[55]

Singla A, Ballal S, Guruvaiah N, Ponnatapura J. Evaluation of epiphora by topical contrast-enhanced CT and MR dacryocystography: which one to choose? Acta radiologica (Stockholm, Sweden : 1987). 2023 Mar:64(3):1056-1061. doi: 10.1177/02841851221111888. Epub 2022 Jul 11     [PubMed PMID: 35815704]


[56]

Timlin HM, Keane PA, Ezra DG. Characterizing Congenital Double Punctum Anomalies: Clinical, Endoscopic, and Imaging Findings. Ophthalmic plastic and reconstructive surgery. 2019 Nov/Dec:35(6):549-552. doi: 10.1097/IOP.0000000000001368. Epub     [PubMed PMID: 30865065]


[57]

Zheng Q, Shen T, Luo H, Hong C, He J, Gong J, Jiang J. Application of lacrimal endoscopy in the diagnosis and treatment of primary canaliculitis: Practical technique and graphic presentation. Medicine. 2019 Aug:98(33):e16789. doi: 10.1097/MD.0000000000016789. Epub     [PubMed PMID: 31415384]


[58]

Bae SH, Park J, Lee JK. Comparison of digital subtraction dacryocystography and dacryoendoscopy in patients with epiphora. Eye (London, England). 2021 Mar:35(3):877-882. doi: 10.1038/s41433-020-0990-1. Epub 2020 May 28     [PubMed PMID: 32467631]


[59]

Mirshahvalad SA, Chavoshi M, Bahmani Kashkouli M, Fallahi B, Emami-Ardakani A, Manafi-Farid R. Diagnostic value of lacrimal scintigraphy in the evaluation of lacrimal drainage system obstruction: a systematic review and meta-analysis. Nuclear medicine communications. 2022 Aug 1:43(8):860-868. doi: 10.1097/MNM.0000000000001578. Epub 2022 May 4     [PubMed PMID: 35506272]

Level 1 (high-level) evidence

[60]

Singh S, Ali MJ, Paulsen F. Dacryocystography: From theory to current practice. Annals of anatomy = Anatomischer Anzeiger : official organ of the Anatomische Gesellschaft. 2019 Jul:224():33-40. doi: 10.1016/j.aanat.2019.03.009. Epub 2019 Apr 4     [PubMed PMID: 30954539]


[61]

Semp DA, Beeson D, Sheppard AL, Dutta D, Wolffsohn JS. Artificial Tears: A Systematic Review. Clinical optometry. 2023:15():9-27. doi: 10.2147/OPTO.S350185. Epub 2023 Jan 10     [PubMed PMID: 36647552]

Level 1 (high-level) evidence

[62]

Karpecki P, Barghout V, Schenkel B, Huynh L, Khanal A, Mitchell B, Yenikomshian M, Zanardo E, Matossian C. Real-world treatment patterns of OTX-101 ophthalmic solution, cyclosporine ophthalmic emulsion, and lifitegrast ophthalmic solution in patients with dry eye disease: a retrospective analysis. BMC ophthalmology. 2023 Nov 2:23(1):443. doi: 10.1186/s12886-023-03174-y. Epub 2023 Nov 2     [PubMed PMID: 37919692]

Level 2 (mid-level) evidence

[63]

Hauswirth SG, Kabat AG, Hemphill M, Somaiya K, Hendrix LH, Gibson AA. Safety, adherence and discontinuation in varenicline solution nasal spray clinical trials for dry eye disease. Journal of comparative effectiveness research. 2023 Jun:12(6):e220215. doi: 10.57264/cer-2022-0215. Epub 2023 Apr 25     [PubMed PMID: 37096956]

Level 2 (mid-level) evidence

[64]

Song MS, Lee Y, Paik HJ, Kim DH. A Comprehensive Analysis of the Influence of Temperature and Humidity on Dry Eye Disease. Korean journal of ophthalmology : KJO. 2023 Dec:37(6):501-509. doi: 10.3341/kjo.2023.0077. Epub 2023 Oct 25     [PubMed PMID: 37899282]


[65]

. Perfluorohexyloctane ophthalmic solution (Miebo) for dry eye disease. The Medical letter on drugs and therapeutics. 2024 Jan 22:66(1694):13-14. doi: 10.58347/tml.2024.1694c. Epub     [PubMed PMID: 38212258]

Level 3 (low-level) evidence

[66]

Villani E, Marelli L, Dellavalle A, Serafino M, Nucci P. Latest evidences on meibomian gland dysfunction diagnosis and management. The ocular surface. 2020 Oct:18(4):871-892. doi: 10.1016/j.jtos.2020.09.001. Epub 2020 Sep 12     [PubMed PMID: 32927081]


[67]

Quan NG, Leslie L, Li T. Autologous Serum Eye Drops for Dry Eye: Systematic Review. Optometry and vision science : official publication of the American Academy of Optometry. 2023 Aug 1:100(8):564-571. doi: 10.1097/OPX.0000000000002042. Epub 2023 Jul 13     [PubMed PMID: 37410855]

Level 1 (high-level) evidence

[68]

Zheng N, Zhu SQ. Randomized controlled trial on the efficacy and safety of autologous serum eye drops in dry eye syndrome. World journal of clinical cases. 2023 Oct 6:11(28):6774-6781. doi: 10.12998/wjcc.v11.i28.6774. Epub     [PubMed PMID: 37901024]

Level 1 (high-level) evidence

[69]

Shorter E, Nau CB, Fogt JS, Nau A, Schornack M, Harthan J. Patient Experiences With Therapeutic Contact Lenses and Dry Eye Disease. Eye & contact lens. 2024 Feb 1:50(2):59-64. doi: 10.1097/ICL.0000000000001051. Epub 2023 Nov 1     [PubMed PMID: 37910817]


[70]

Hussain M, Shtein RM, Pistilli M, Maguire MG, Oydanich M, Asbell PA, DREAM Study Research Group. The Dry Eye Assessment and Management (DREAM) extension study - A randomized clinical trial of withdrawal of supplementation with omega-3 fatty acid in patients with dry eye disease. The ocular surface. 2020 Jan:18(1):47-55. doi: 10.1016/j.jtos.2019.08.002. Epub 2019 Aug 16     [PubMed PMID: 31425752]

Level 1 (high-level) evidence

[71]

Kulkarni A, Banait S. Through the Smoke: An In-Depth Review on Cigarette Smoking and Its Impact on Ocular Health. Cureus. 2023 Oct:15(10):e47779. doi: 10.7759/cureus.47779. Epub 2023 Oct 27     [PubMed PMID: 38021969]


[72]

Nagstrup AH. The use of benzalkonium chloride in topical glaucoma treatment: An investigation of the efficacy and safety of benzalkonium chloride-preserved intraocular pressure-lowering eye drops and their effect on conjunctival goblet cells. Acta ophthalmologica. 2023 Dec:101 Suppl 278():3-21. doi: 10.1111/aos.15808. Epub     [PubMed PMID: 38037546]


[73]

Li Y, Xie L, Song W, Chen S, Cheng Y, Gao Y, Huang M, Yan X, Yang S. Association between dyslipidaemia and dry eye disease: a systematic review and meta-analysis. BMJ open. 2023 Nov 21:13(11):e069283. doi: 10.1136/bmjopen-2022-069283. Epub 2023 Nov 21     [PubMed PMID: 37989379]

Level 1 (high-level) evidence

[74]

Haworth K, Travis D, Leslie L, Fuller D, Pucker AD. Silicone hydrogel versus hydrogel soft contact lenses for differences in patient-reported eye comfort and safety. The Cochrane database of systematic reviews. 2023 Sep 19:9(9):CD014791. doi: 10.1002/14651858.CD014791.pub2. Epub 2023 Sep 19     [PubMed PMID: 37724689]

Level 1 (high-level) evidence

[75]

Liu SH, Saldanha IJ, Abraham AG, Rittiphairoj T, Hauswirth S, Gregory D, Ifantides C, Li T. Topical corticosteroids for dry eye. The Cochrane database of systematic reviews. 2022 Oct 21:10(10):CD015070. doi: 10.1002/14651858.CD015070.pub2. Epub 2022 Oct 21     [PubMed PMID: 36269562]

Level 1 (high-level) evidence

[76]

Awny I, Mossa EAM, Bakheet TM, Mahmoud H, Mounir A. Changes of Lacrimal Puncta by Anterior Segment Optical Coherence Tomography after Topical Combined Antibiotic and Steroid Treatment in Cases of Inflammatory Punctual Stenosis. Journal of ophthalmology. 2022:2022():7988091. doi: 10.1155/2022/7988091. Epub 2022 Jan 24     [PubMed PMID: 35111339]

Level 3 (low-level) evidence

[77]

Gorouhi F, Davari P, Fazel N. Cutaneous and mucosal lichen planus: a comprehensive review of clinical subtypes, risk factors, diagnosis, and prognosis. TheScientificWorldJournal. 2014:2014():742826. doi: 10.1155/2014/742826. Epub 2014 Jan 30     [PubMed PMID: 24672362]


[78]

Ramakrishnan S, De Jesus O. Akinesia. StatPearls. 2024 Jan:():     [PubMed PMID: 32965848]


[79]

Patel V, Chisholm D, Dua T, Laxminarayan R, Medina-Mora ME, Thakur KT, Albanese E, Giannakopoulos P, Jette N, Linde M, Prince MJ, Steiner TJ, Dua T. Neurological Disorders. Mental, Neurological, and Substance Use Disorders: Disease Control Priorities, Third Edition (Volume 4). 2016 Mar 14:():     [PubMed PMID: 27227247]


[80]

Heckmann JG, Urban PP, Pitz S, Guntinas-Lichius O, Gágyor I. The Diagnosis and Treatment of Idiopathic Facial Paresis (Bell's Palsy). Deutsches Arzteblatt international. 2019 Oct 11:116(41):692-702. doi: 10.3238/arztebl.2019.0692. Epub     [PubMed PMID: 31709978]


[81]

AlHarmi RA, Henari DF, Jadah RHS, AlKhayyat HM. A brain populated with space-occupying lesions: identifying the culprit. BMJ case reports. 2018 Apr 24:2018():. pii: bcr-2018-224286. doi: 10.1136/bcr-2018-224286. Epub 2018 Apr 24     [PubMed PMID: 29691273]

Level 3 (low-level) evidence

[82]

Mueller AJ, Czyz CN. Benign Lacrimal Gland Tumors. StatPearls. 2024 Jan:():     [PubMed PMID: 35201723]


[83]

Patel R, Patel BC. Dacryoadenitis. StatPearls. 2024 Jan:():     [PubMed PMID: 30571005]


[84]

Padda IS, Tadi P. Botulinum Toxin. StatPearls. 2024 Jan:():     [PubMed PMID: 32491319]


[85]

Carpenter K, Lockwood J, Iwanaga J, Dumont AS, Bui CJ, Tubbs RS. Herniation of orbital fat through the inferior orbital fissure and into the infratemporal fossa: a cadaveric case report and review. Surgical and radiologic anatomy : SRA. 2020 Sep:42(9):1119-1121. doi: 10.1007/s00276-020-02504-9. Epub 2020 May 29     [PubMed PMID: 32472182]

Level 3 (low-level) evidence

[86]

Pratt DV, Pelton RW, Patel BC, Anderson RL. Burn scar malignancies of the eyelids. Ophthalmic plastic and reconstructive surgery. 2000 Nov:16(6):432-7     [PubMed PMID: 11106187]


[87]

De Gregorio A, Cerini A, Scala A, Lambiase A, Pedrotti E, Morselli S. Floppy eyelid, an under-diagnosed syndrome: a review of demographics, pathogenesis, and treatment. Therapeutic advances in ophthalmology. 2021 Jan-Dec:13():25158414211059247. doi: 10.1177/25158414211059247. Epub 2021 Dec 5     [PubMed PMID: 35187400]

Level 3 (low-level) evidence

[88]

Baldeschi L. Correction of lid retraction and exophthalmos. Developments in ophthalmology. 2008:41():103-126. doi: 10.1159/000131084. Epub     [PubMed PMID: 18453764]


[89]

Chandravanshi SL, Rathore MK, Tirkey ER. Congenital combined eyelid imbrication and floppy eyelid syndrome: case report and review of literature. Indian journal of ophthalmology. 2013 Oct:61(10):593-6. doi: 10.4103/0301-4738.121086. Epub     [PubMed PMID: 24212313]

Level 3 (low-level) evidence

[90]

Mehta MP, Lewis CD, Perry JD. Internal cantholysis for full thickness eyelid defects. Saudi journal of ophthalmology : official journal of the Saudi Ophthalmological Society. 2011 Jan:25(1):31-6. doi: 10.1016/j.sjopt.2010.10.007. Epub 2010 Oct 13     [PubMed PMID: 23960900]


[91]

Labib A, Patel BC, Milroy C. Lower Eyelid Laxity Examination. StatPearls. 2024 Jan:():     [PubMed PMID: 35015428]


[92]

Piskiniene R. Eyelid malposition: lower lid entropion and ectropion. Medicina (Kaunas, Lithuania). 2006:42(11):881-4     [PubMed PMID: 17172788]


[93]

Pe'er J. Pathology of eyelid tumors. Indian journal of ophthalmology. 2016 Mar:64(3):177-90. doi: 10.4103/0301-4738.181752. Epub     [PubMed PMID: 27146927]


[94]

Shanbhag SS, Singh S, Koshy PG, Donthineni PR, Basu S. A beginner's guide to mucous membrane grafting for lid margin keratinization: Review of indications, surgical technique and clinical outcomes. Indian journal of ophthalmology. 2021 Apr:69(4):794-805. doi: 10.4103/ijo.IJO_1273_20. Epub 2021 Jan 28     [PubMed PMID: 33727438]

Level 2 (mid-level) evidence

[95]

Patel BC, Joos ZP. Diseases of the Eyelashes. StatPearls. 2024 Jan:():     [PubMed PMID: 30725785]


[96]

Gurnani B, Kaur K. Meibomian Gland Disease. StatPearls. 2024 Jan:():     [PubMed PMID: 35593799]


[97]

Messmer EM. The pathophysiology, diagnosis, and treatment of dry eye disease. Deutsches Arzteblatt international. 2015 Jan 30:112(5):71-81; quiz 82. doi: 10.3238/arztebl.2015.0071. Epub     [PubMed PMID: 25686388]


[98]

Guier CP, Stokkermans TJ. Corneal Foreign Body Removal. StatPearls. 2024 Jan:():     [PubMed PMID: 32119365]


[99]

Hashmi MF, Gurnani B, Benson S. Conjunctivitis. StatPearls. 2024 Jan:():     [PubMed PMID: 31082078]


[100]

Yvon C, Patel BC, Malhotra R. Conjunctivochalasis. StatPearls. 2024 Jan:():     [PubMed PMID: 35015435]


[101]

Swarup A, Ta CN, Wu AY. Molecular mechanisms and treatments for ocular symblephara. Survey of ophthalmology. 2022 Jan-Feb:67(1):19-30. doi: 10.1016/j.survophthal.2021.04.008. Epub 2021 Apr 29     [PubMed PMID: 33932469]

Level 3 (low-level) evidence

[102]

Jaros PA, DeLuise VP. Pingueculae and pterygia. Survey of ophthalmology. 1988 Jul-Aug:33(1):41-9     [PubMed PMID: 3051468]

Level 3 (low-level) evidence

[103]

Zemba M, Dumitrescu OM, Dimirache AE, Branisteanu DC, Balta F, Burcea M, Moraru AD, Gradinaru S. Diagnostic methods for the etiological assessment of infectious corneal pathology (Review). Experimental and therapeutic medicine. 2022 Feb:23(2):137. doi: 10.3892/etm.2021.11060. Epub 2021 Dec 13     [PubMed PMID: 35069818]


[104]

Gurnani B, Kim J, Tripathy K, Mahabadi N, Edens MA. Iritis. StatPearls. 2024 Jan:():     [PubMed PMID: 28613659]


[105]

Mombaerts I, Colla B. Partial lacrimal carunculectomy: a simple procedure for epiphora. Ophthalmology. 2001 Apr:108(4):793-7     [PubMed PMID: 11297500]


[106]

Azari AA, Arabi A. Conjunctivitis: A Systematic Review. Journal of ophthalmic & vision research. 2020 Jul-Sep:15(3):372-395. doi: 10.18502/jovr.v15i3.7456. Epub 2020 Aug 6     [PubMed PMID: 32864068]

Level 1 (high-level) evidence

[107]

Dykewicz MS, Hamilos DL. Rhinitis and sinusitis. The Journal of allergy and clinical immunology. 2010 Feb:125(2 Suppl 2):S103-15. doi: 10.1016/j.jaci.2009.12.989. Epub     [PubMed PMID: 20176255]


[108]

Alam MS, Jayshree, Ali MJ. Primary anterior punctal malposition presenting as Centurion syndrome. Saudi journal of ophthalmology : official journal of the Saudi Ophthalmological Society. 2017 Jul-Sep:31(3):206-207. doi: 10.1016/j.sjopt.2017.05.011. Epub 2017 May 24     [PubMed PMID: 28860928]


[109]

Nadeem N, Patel BC. Punctal Stenosis. StatPearls. 2024 Jan:():     [PubMed PMID: 32809413]


[110]

Boerner M, Seiff SR, Arroyo J. Congenital absence of the lacrimal puncta. Ophthalmic surgery. 1995 Jan-Feb:26(1):53-6     [PubMed PMID: 7746626]


[111]

Taylor RS, Ashurst JV. Dacryocystitis. StatPearls. 2024 Jan:():     [PubMed PMID: 29261989]


[112]

Huzaifa M, Soni A. Mucocele and Ranula. StatPearls. 2024 Jan:():     [PubMed PMID: 32809690]


[113]

Patel J, Levin A, Patel BC. Epiphora Clinical Testing. StatPearls. 2024 Jan:():     [PubMed PMID: 32491356]


[114]

Feroze KB, Patel BC. Canaliculitis. StatPearls. 2024 Jan:():     [PubMed PMID: 28722951]


[115]

Zhao XY, Chen M, Cheng L. Current and Emerging Treatment Options in Sinus and Nasal Diseases: Surgical Challenges and Therapeutic Perspectives. Journal of clinical medicine. 2023 Feb 13:12(4):. doi: 10.3390/jcm12041485. Epub 2023 Feb 13     [PubMed PMID: 36836019]

Level 3 (low-level) evidence

[116]

Berman J. Modern classification of neoplasms: reconciling differences between morphologic and molecular approaches. BMC cancer. 2005 Aug 10:5():100     [PubMed PMID: 16092965]


[117]

Kostiuk M, Burns B. Trauma Assessment. StatPearls. 2024 Jan:():     [PubMed PMID: 32310373]


[118]

Gupta A, Tripathy K. Intraocular Foreign Body. StatPearls. 2024 Jan:():     [PubMed PMID: 35015440]


[119]

Maani EV, Maani CV. Radiation Therapy. StatPearls. 2024 Jan:():     [PubMed PMID: 30725721]


[120]

Balamurugan S, Kaur K, Gurnani B, Agrawal A. Bilateral acute vision loss as the initial presentation of chronic myeloid leukemia in a young female. Indian journal of cancer. 2023 Oct 1:60(4):578-582. doi: 10.4103/ijc.ijc_573_21. Epub 2024 Jan 9     [PubMed PMID: 38206079]


[121]

Khaddour K, Hana CK, Mewawalla P. Hematopoietic Stem Cell Transplantation. StatPearls. 2024 Jan:():     [PubMed PMID: 30725636]


[122]

Farkouh A, Frigo P, Czejka M. Systemic side effects of eye drops: a pharmacokinetic perspective. Clinical ophthalmology (Auckland, N.Z.). 2016:10():2433-2441     [PubMed PMID: 27994437]

Level 3 (low-level) evidence

[123]

Gurnani B, Kaur K. Endogenous Endophthalmitis. StatPearls. 2024 Jan:():     [PubMed PMID: 35015416]


[124]

Narayanan K, Barnes EA. Epiphora with eyelid laxity. Orbit (Amsterdam, Netherlands). 2005 Sep:24(3):201-3     [PubMed PMID: 16169807]

Level 2 (mid-level) evidence

[125]

Guercio B, Keyhani K, Weinberg DA. Snip punctoplasty offers little additive benefit to lower eyelid tightening in the treatment of pure lacrimal pump failure. Orbit (Amsterdam, Netherlands). 2007 Mar:26(1):15-8     [PubMed PMID: 17510865]

Level 2 (mid-level) evidence

[126]

Fiorino MG, Quaranta-Leoni C, Quaranta-Leoni FM. Proximal lacrimal obstructions: a review. Acta ophthalmologica. 2021 Nov:99(7):701-711. doi: 10.1111/aos.14762. Epub 2021 Jan 17     [PubMed PMID: 33455087]


[127]

Soiberman U, Kakizaki H, Selva D, Leibovitch I. Punctal stenosis: definition, diagnosis, and treatment. Clinical ophthalmology (Auckland, N.Z.). 2012:6():1011-8. doi: 10.2147/OPTH.S31904. Epub 2012 Jul 3     [PubMed PMID: 22848141]


[128]

Ullrich K, Malhotra R, Patel BC. Dacryocystorhinostomy. StatPearls. 2024 Jan:():     [PubMed PMID: 32496731]


[129]

Ali MJ, Naik MN, Honavar SG. External dacryocystorhinostomy: Tips and tricks. Oman journal of ophthalmology. 2012 Sep:5(3):191-5. doi: 10.4103/0974-620X.106106. Epub     [PubMed PMID: 23440476]


[130]

Bharangar S, Singh N, Lal V. Endoscopic Endonasal Dacryocystorhinostomy: Best Surgical Management for DCR. Indian journal of otolaryngology and head and neck surgery : official publication of the Association of Otolaryngologists of India. 2012 Dec:64(4):366-9. doi: 10.1007/s12070-011-0345-0. Epub 2011 Nov 30     [PubMed PMID: 24294581]


[131]

Eisenbach N, Karni O, Sela E, Nemet A, Dror A, Levy E, Kassif Y, Ovadya R, Ronen O, Marshak T. Conjunctivodacryocystorhinostomy (CDCR) success rates and complications in endoscopic vs non-endoscopic approaches: a systematic review. International forum of allergy & rhinology. 2021 Feb:11(2):174-194. doi: 10.1002/alr.22668. Epub 2020 Aug 6     [PubMed PMID: 32761875]

Level 1 (high-level) evidence

[132]

Spinelli HM, Shapiro MD, Wei LL, Elahi E, Hirmand H. The role of lacrimal intubation in the management of facial trauma and tumor resection. Plastic and reconstructive surgery. 2005 Jun:115(7):1871-6     [PubMed PMID: 15923831]


[133]

Li L, Lai Z, Huang W, Xu F, Wu Y. Dacryocystitis secondary to neglected silicone tube in lacrimal duct for 10 years: A case report. Medicine. 2020 Nov 6:99(45):e23073. doi: 10.1097/MD.0000000000023073. Epub     [PubMed PMID: 33157970]

Level 3 (low-level) evidence

[134]

Tong NX, Zhao YY, Jin XM. Use of the Crawford tube for symptomatic epiphora without nasolacrimal obstruction. International journal of ophthalmology. 2016:9(2):282-5. doi: 10.18240/ijo.2016.02.20. Epub 2016 Feb 18     [PubMed PMID: 26949652]


[135]

Steele EA. Conjunctivodacryocystorhinostomy with Jones tube: a history and update. Current opinion in ophthalmology. 2016 Sep:27(5):439-42. doi: 10.1097/ICU.0000000000000287. Epub     [PubMed PMID: 27253607]

Level 3 (low-level) evidence

[136]

Fayet B, Racy E, Katowitz WR, Katowitz JA, Ruban JM, Brémond-Gignac D. Intralacrimal migration of Masterka(®) stents. Journal francais d'ophtalmologie. 2018 Mar:41(3):206-211. doi: 10.1016/j.jfo.2017.11.009. Epub 2018 Mar 23     [PubMed PMID: 29576330]


[137]

Hussain RN, Kanani H, McMullan T. Use of mini-monoka stents for punctal/canalicular stenosis. The British journal of ophthalmology. 2012 May:96(5):671-3. doi: 10.1136/bjophthalmol-2011-300670. Epub 2012 Jan 12     [PubMed PMID: 22241928]

Level 2 (mid-level) evidence

[138]

Burkat CN, Lucarelli MJ. Tear meniscus level as an indicator of nasolacrimal obstruction. Ophthalmology. 2005 Feb:112(2):344-8     [PubMed PMID: 15691573]


[139]

Findlay Q, Reid K. Dry eye disease: when to treat and when to refer. Australian prescriber. 2018 Oct:41(5):160-163. doi: 10.18773/austprescr.2018.048. Epub 2018 Oct 1     [PubMed PMID: 30410213]


[140]

Wong ES, Li EY, Yuen HK. Long-term outcomes of punch punctoplasty with Kelly punch and review of literature. Eye (London, England). 2017 Apr:31(4):560-565. doi: 10.1038/eye.2016.271. Epub 2016 Dec 2     [PubMed PMID: 27911445]


[141]

Okumuş S, Öner V, Durucu C, Coşkun E, Aksoy Ü, Durucu E, Şahin L, Erbağcı I. Nasolacrimal duct intubation in the treatment of congenital nasolacrimal duct obstruction in older children. Eye (London, England). 2016 Jan:30(1):85-8. doi: 10.1038/eye.2015.189. Epub 2015 Oct 9     [PubMed PMID: 26449195]


[142]

Guthrie AJ, Kadakia P, Rosenberg J. Eyelid Malposition Repair: A Review of the Literature and Current Techniques. Seminars in plastic surgery. 2019 May:33(2):92-102. doi: 10.1055/s-0039-1685473. Epub 2019 Apr 26     [PubMed PMID: 31037045]


[143]

Horn R, Hendrix JM, Kramer J. Postoperative Pain Control. StatPearls. 2024 Jan:():     [PubMed PMID: 31335018]


[144]

Valentini V, Boldrini L, Mariani S, Massaccesi M. Role of radiation oncology in modern multidisciplinary cancer treatment. Molecular oncology. 2020 Jul:14(7):1431-1441. doi: 10.1002/1878-0261.12712. Epub 2020 Jun 22     [PubMed PMID: 32418368]


[145]

Bukhari A. Etiology of tearing in patients seen in an oculoplastic clinic in Saudi Arabia. Middle East African journal of ophthalmology. 2013 Jul-Sep:20(3):198-200. doi: 10.4103/0974-9233.114790. Epub     [PubMed PMID: 24014980]


[146]

Golden MI, Meyer JJ, Patel BC. Dry Eye Syndrome. StatPearls. 2024 Jan:():     [PubMed PMID: 29262012]


[147]

Perez Y, Patel BC, Mendez MD. Nasolacrimal Duct Obstruction. StatPearls. 2024 Jan:():     [PubMed PMID: 30422468]


[148]

Ceylanoglu KS, Acar A, Sen E. Overview of Epiphora Referred to Oculoplastic Surgery Clinic in Adults. Beyoglu eye journal. 2023:8(1):45-49. doi: 10.14744/bej.2023.38980. Epub 2023 Mar 1     [PubMed PMID: 36911222]

Level 3 (low-level) evidence

[149]

Kobak Ş, Karaarslan AA, Yilmaz H, Sever F. Co-occurrence of rheumatoid arthritis and sarcoidosis. BMJ case reports. 2015 Jul 6:2015():. doi: 10.1136/bcr-2014-208803. Epub 2015 Jul 6     [PubMed PMID: 26150618]

Level 3 (low-level) evidence

[150]

Guo OD LW, Akpek E. The negative effects of dry eye disease on quality of life and visual function. Turkish journal of medical sciences. 2020 Nov 3:50(SI-2):1611-1615. doi: 10.3906/sag-2002-143. Epub 2020 Nov 3     [PubMed PMID: 32283910]

Level 2 (mid-level) evidence

[151]

Gokhale NS, Medical management approach to infectious keratitis. Indian journal of ophthalmology. 2008 May-Jun;     [PubMed PMID: 18417822]


[152]

Baab S, Le PH, Gurnani B, Kinzer EE. Allergic Conjunctivitis. StatPearls. 2024 Jan:():     [PubMed PMID: 28846256]


[153]

Bergstrom R, Czyz CN. Entropion Eyelid Reconstruction. StatPearls. 2023 Jan:():     [PubMed PMID: 29262117]


[154]

Hamedani AG, Gold DR. Eyelid Dysfunction in Neurodegenerative, Neurogenetic, and Neurometabolic Disease. Frontiers in neurology. 2017:8():329. doi: 10.3389/fneur.2017.00329. Epub 2017 Jul 18     [PubMed PMID: 28769865]


[155]

Ziaragkali S, Kotsalidou A, Trakos N. Dry Eye Disease in Routine Rheumatology Practice. Mediterranean journal of rheumatology. 2018 Sep:29(3):127-139. doi: 10.31138/mjr.29.3.127. Epub 2018 Sep 27     [PubMed PMID: 32185314]


[156]

Metcalfe DD. Future role of the allergist-immunologist. Primary care. 1998 Dec:25(4):885-90     [PubMed PMID: 9735125]


[157]

Jawaheer L, MacEwen CJ, Anijeet D. Endonasal versus external dacryocystorhinostomy for nasolacrimal duct obstruction. The Cochrane database of systematic reviews. 2017 Feb 24:2(2):CD007097. doi: 10.1002/14651858.CD007097.pub3. Epub 2017 Feb 24     [PubMed PMID: 28231605]

Level 1 (high-level) evidence

[158]

Morris DA, Johnson KS, Ammarell N, Arnold RM, Tulsky JA, Steinhauser KE. What is your understanding of your illness? A communication tool to explore patients' perspectives of living with advanced illness. Journal of general internal medicine. 2012 Nov:27(11):1460-6. doi: 10.1007/s11606-012-2109-2. Epub 2012 May 26     [PubMed PMID: 22638605]

Level 3 (low-level) evidence

[159]

Dineen-Griffin S, Garcia-Cardenas V, Williams K, Benrimoj SI. Helping patients help themselves: A systematic review of self-management support strategies in primary health care practice. PloS one. 2019:14(8):e0220116. doi: 10.1371/journal.pone.0220116. Epub 2019 Aug 1     [PubMed PMID: 31369582]

Level 1 (high-level) evidence