Epiphora: Causes and Treatment Options

Educational Objectives

The goal of this program is to improve the management of epiphora. After hearing and assimilating this program, the clinician will be better able to:

1. Review commonly overlooked sources of epiphora.
2. Manage epiphora based on the cause of the excess tearing.

Summary

Sources of epiphora: can be difficult to identify if it is not caused by a nasolacrimal duct obstruction; overproduction of tears — accounts for ≈20% of patients in clinic; many patients have dry eye and reflex tearing, and the problem is multifactorial for many patients; treatment of dry eye can improve epiphora; demodex blepharitis and allergic conjunctivitis can also be causes, and these patients can have chronic tearing even after treatment of underlying pathology; botulinum toxin injection of the lacrimal gland can be an option in these cases but carries risks for dry eye, diplopia, or ptosis; reduced outflow — may be caused by punctal, canalicular, or nasolacrimal stenosis; treatment for each is different; Stevens Johnson syndrome is a common cause of canalicular stenosis, and management can be difficult because patients often have dry eyes with tearing; trauma can cause canalicular issues; probing with a stent placement can be used for canalicular-only issues; monocanalicular stents can be used for congenital nasolacrimal duct obstruction (CNDO) or monocanalicular issues; autostable, bicanalicular, nasolacrimal intubation system (eg, Ritleng stent) can be helpful for pediatric patients with CNDO and bicanalicular stenosis; pushed self-retaining bicanalicular stents can be used for a canalicular issue or nasolacrimal duct stenosis; for severe canalicular stenosis in which a stent cannot be passed, use a Jones tube (generally used as a last resort)

Congenital nasolacrimal duct obstruction: dacryocystitis is rare; Crigler massage is recommended for patients ≤12 mo; surgical intervention is recommended for patients >1 yr of age; monocanalicular stent (Masterka stent) is easy to place and remove; dacryocystocele is rare, but associated respiratory problems can occur due to large nasal cysts and require urgent surgical removal; Tavakoli et al (2018) found that a significantly higher percentage of patients with CNDO were delivered via cesarean delivery; however, Sathiamoorthi et al (2018) did not find an association between mode of delivery and CNDO; lack of hydrostatic pressure on the lacrimal sac during cesarean delivery and birth age may contribute to CNDO; in Tavacoli et al (2018), the association between mode of delivery and CNDO was maintained after removing preterm babies from the analysis

Primary acquired nasolacrimal duct obstruction: commonly seen in middle-aged and older women (anatomic and hormonal factors may contribute); patients often present with persistent, progressive tearing that worsens over time; consider possible secondary causes (eg, neoplasms)

Dacryocystorhinostomy (DCR): approach depends on the patient; recovery tends to be quicker with an endoscopic approach, which may be preferred by younger patients because of the lack of scar and for active dacryocystitis because less bleeding and postoperative edema occur compared with an external approach; endoscopic approach can correct associated intranasal pathology if needed, and perioperative time and postoperative healing are shorter; mitomycin C is often used during nasolacrimal surgery and helps with fibrous tissue formation over the osteotomy site; mitomycin C drops should be used (with caution) only in canalicular stenosis because of the potential toxicity

BLICK mnemonic for other causes of epiphora (Tse et al [2014]): blink dynamics — facial nerve palsy is an obvious cause; lid malposition — lateral canthal tendon disinsertion leads to reduced function of the orbicularis muscle, leading to eyelid mismatch and tearing; if lateral scleral show is not visible, the lateral canthal tendon has disinserted medially; if it is severe or recurrent after standard lateral canthal tendon plication, drillholes can be placed after dissecting the periosteum; ectropion can cause lid malpositioning and needs to be fixed; with entropion, chronic irritation of the eye from the eyelashes leads to primary and secondary epiphora; with an entropion repair, success rate is lower if the lateral canthal tendon is not fixated; imbrication — may originate from floppy eyelid syndrome, subconjunctival fat prolapse, or eyelid disparity; look for blink dynamics and Parkinson signs; conjunctivochalasis — can obstruct the puncta, which causes issues with tear distribution across the cornea and obstructs the drainage of tears into the nasolacrimal drainage apparatus; issues with megalocaruncle can occur; kissing puncta — often underrecognized; can occur from ptosis or lateral canthal tendon disinsertion; pulling the eyelid laterally and raising the eyelid up can restore the normal anatomy to allow the lacrimal pump to work

Readings

Sathiamoorthi S, Frank RD, Mohney BG. Incidence and clinical characteristics of congenital nasolacrimal duct obstruction. Br J Ophthalmol. 2019;103(4):527-529. doi:10.1136/bjophthalmol-2018-312074; Shriver EM, Erickson BP, Kossler AL, et al. Lateral canthal tendon disinsertion: clinical characteristics and anatomical correlates. Ophthalmic Plast Reconstr Surg. 2016;32(5):378-385. doi:10.1097/IOP.0000000000000552; Tavakoli M, Osigian CJ, Saksiriwutto P, et al. Association between congenital nasolacrimal duct obstruction and mode of delivery at birth. J AAPOS. 2018;22(5):381-385. doi:10.1016/j.jaapos.2018.05.016; Tse DT, Erickson BP, Tse BC. The BLICK mnemonic for clinical-anatomical assessment of patients with epiphora. Ophthalmic Plast Reconstr Surg. 2014;30(6):450-458. doi:10.1097/IOP.0000000000000281; Vagge A, Ferro Desideri L, Nucci P, et al. Congenital nasolacrimal duct obstruction (CNLDO): a review. Diseases. 2018 Oct 22;6(4):96. doi: 10.3390/diseases6040096. PMID: 30360371; PMCID: PMC6313586.

Disclosures

For this program, the following relevant financial relationships were disclosed and mitigated to ensure that no commercial bias has been inserted into this content: Dr. Wester has been an advisor for Horizon Therapeutics; a consultant for Immunovant and Sling Therapeutics; and has received research support from Horizon Therapeutics, Immunovant, Larsen Therapeutics, and Sling Therapeutics. Members of the planning committee reported nothing relevant to disclose. Dr. Wester’s lecture includes information related to the off-label or investigational use of a therapy, product, or device.

Acknowledgements

Dr. Wester was recorded at the 22nd Annual Downeast Ophthalmology Symposium, held September 29 to October 1, 2023, in Bar Harbor, ME, and presented by the Maine Society of Eye Physicians and Surgeons. For information on future CME activities from this presenter, please visit www.maineeyemds.com. Audio Digest thanks the speakers and presenters for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0.75 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0.75 CE contact hours.

Lecture ID:

OP620803

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.