Epiphora (Watery Eye) & Dacryocystitis

A systematic approach to the watery eye (epiphora)

Epiphora is true tear overflow down the face, pointing to lacrimal outflow obstruction — distinct from tear welling (reflex tear production from ocular surface stimulation).

Differential diagnosis

Category	Causes
Reflex tear production (excess production, usually reactive)	Eyelash malposition (trichiasis/distichiasis), blepharitis/meibomian gland dysfunction (see blepharitis.md), conjunctivitis (allergic/viral/bacterial), foreign body, dry eye (see dry-eye.md), keratitis, uveitis, angle-closure glaucoma (see acute-glaucoma.md)
Reduced tear outflow	Lid malposition — entropion/ectropion (involutional, cicatricial, mechanical/spastic, congenital — see ectropion-entropion.md), floppy eyelid syndrome; punctal stenosis; nasolacrimal duct obstruction (iatrogenic — rhinoplasty/sinus surgery; traumatic — facial fracture, canalicular lid laceration; sinusitis; systemic inflammatory disease; neoplastic)
Paediatric-specific	Ophthalmia neonatorum, congenital glaucoma, punctal atresia, congenital nasolacrimal duct obstruction (the most common cause of watery eye under age 4)

Anatomy

Tears (baseline + reflex secretion via optic/trigeminal nerve stimulation) drain via orbicularis oculi contraction through the upper/lower puncta → canaliculi → common canaliculus → lacrimal sac → nasolacrimal duct → nose (via Hasner’s valve). Obstruction anywhere along this pathway causes epiphora.

History

• Onset, duration, laterality, pattern (constant/intermittent)
• Age: congenital NLD obstruction is the most common cause under age 4; lid malposition/dry eye more likely in older patients
• Chronicity: watering >3 months is chronic and usually implies lacrimal outflow obstruction with an otherwise normal exam
• Diplopia or reduced visual acuity, crusting/discharge, altered tear colour or blood/pus, prior ocular trauma or surgery
• Sinonasal history (rhinorrhoea, obstruction, anosmia, unilateral epistaxis — raises concern for a sinonasal mass, previous sinonasal surgery/trauma)

Examination

• General facial inspection (asymmetry, palsy), lid malposition, ingrown lashes, lid masses, poor lid closure
• Visual acuity, extraocular movements, lid position
• Direct ophthalmoscope with blue filter for corneal pathology if no slit lamp available; tonometry if available (raised IOP suggests intraocular inflammation or angle closure as a cause of reflex tearing)
• Dye disappearance test: instil fluorescein to the inner lower lid, reinspect at 5 minutes — residual dye in the tear film (positive test) suggests nasolacrimal obstruction. Strong blinking/blepharospasm can confound interpretation.
• Sinonasal exam (anterior rhinoscopy via otoscope) if a nasal cause is suspected

Investigations

Not routine — organise on ophthalmology advice. CT orbits for suspected traumatic/ mechanical/sinonasal/neoplastic obstruction; MRI/dacryocystography have limited primary-care role. Blood tests rarely indicated (primary autoimmune/inflammatory epiphora is rare). Conjunctival swab if conjunctivitis is suspected (this usually presents with acute discharge rather than true watering) — include HSV/VZV/adenovirus, plus chlamydia/gonorrhoea if an STI is a concern (→ urgent ophthalmology referral).

First-line management (while awaiting definitive cause)

• Reactive/ocular-surface-disease cause: preservative-free lubricants QID ± chloramphenicol ointment; refer to optometry for ongoing management
• Suspected blepharitis/MGD: warm compress, gentle lid massage, lid hygiene (dilute baby shampoo on a cotton bud/pad, twice daily)
• Suspected rhinosinusitis/allergy: intranasal corticosteroid ± oral/combined antihistamine
• Escalate to ENT for sinonasal symptoms, or to ophthalmology otherwise

Paediatric epiphora — red flags needing urgent ophthalmology discussion

• Neonates <1 month: urgent same-service discussion given the sight/life-threatening potential of ophthalmia neonatorum (chlamydial/gonococcal)
• Buphthalmos (bulging eye) or photophobia: urgent discussion — suspected congenital glaucoma
• Congenital NLD obstruction without red flags: lacrimal massage + lid care while awaiting non-urgent review — the majority resolve spontaneously

Surgical management

Ectropion/entropion repair, or dacryocystorhinostomy (DCR — fistula from lacrimal sac to nasal mucosa, external or endoscopic approach with ENT). Refer eyelid malposition, punctal ectropion or lid laxity to oculoplastics.

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Dacryocystitis (lacrimal sac infection)

Inflammation of the lacrimal sac, usually infective, acute or chronic. More common on the left side (anatomical reasons) and in females; peaks in adults over 40 (peak 60–70 years) — uncommon in infants. An ocular origin of inflammation is less common than a nasal origin.

Congenital dacryocystitis is rare (birth prevalence ~1 in 3,884) but serious — the infant orbital septum is poorly formed, carrying a significant risk of spread to orbital cellulitis.

Acute dacryocystitis

Presentation: epiphora (almost invariable), pain, redness, swelling just lateral and below the nasal bridge (may spread to the nose/face, sometimes with tooth pain). Reduced visual acuity may occur from excess/abnormal tears. Examination shows a tender, tense, red swelling ± preseptal cellulitis in severe cases; mucopurulent discharge can be expressed from the punctum; ± fever/leukocytosis.

Management:

• Swab for MC&S to guide therapy
• Oral antibiotics + analgesia — children: co-amoxiclav or cefaclor; adults: co-amoxiclav or cefalexin (S. aureus remains the main cause, but Gram-negative organisms are increasingly isolated — be guided by microbiology). Typical course 10–14 days.
• If immediate severe/non-severe penicillin reaction, or MRSA suspected → seek expert advice
• Incision and drainage if infection extends beyond the sac to a superficial abscess (risk of fistula formation)
• Refer to ophthalmology for consideration of surgical drainage if significant pain
• Once settled, and in chronic cases: dacryocystorhinostomy (DCR)

Chronic dacryocystitis

Chronic/recurring epiphora, persistent medial canthus redness, ± painless or recurring lacrimal sac swelling; pressure over the sac refluxes mucopurulent material through the lower punctum.

Management: no role for antibiotics; surgical management usually necessary.

• Non-surgical first: warm compresses, massage, nasolacrimal duct probing (a fine metal probe via the punctum/canalicular system past the obstruction — often without general anaesthetic; defer if acutely infected until antibiotics have taken effect)
• If ineffective: DCR
• Balloon dacryoplasty — increasingly used but may have lower long-term success; suited to focal nasolacrimal duct stenosis/occlusion

Differential diagnosis

Orbital/facial cellulitis (no punctal discharge expressible), acute ethmoid/frontal sinusitis, dacryocystocele (mild non-inflamed lacrimal sac enlargement in an infant).

Associated conditions

Most commonly nasolacrimal duct obstruction (stasis of sac contents); less commonly anatomical lacrimal sac abnormalities or nasal/sinus surgery. Nasal disease (rhinitis, trauma, foreign body) is found in some patients. Rarely, a lacrimal sac tumour.

Dacryocystocele and dacryostenosis

An obstructed nasolacrimal duct can form a dacryocystocele behind it. Dacryostenosis (an abnormally narrow duct) predisposes to this. Congenital dacryocystocele generally responds to conservative management (gentle lacrimal sac massage, warm compresses ± topical/systemic antibiotics) — probing and irrigation can resolve the obstruction if needed, though serious infection can develop rapidly so monitor closely. Dacryostenosis causing chronic dacryocystitis may need surgical stenting/dilation.

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Additional source: https://patient.info/doctor/dacryocystitis-and-canaliculitis