Tearing Disorder

Tears are produced constantly by the lacrimal gland which is located under the upper eyelid. Tears are essential because they form a thin film that coats the front surface of the eye and prevents it from becoming dry. Normally, tears are quickly drained from the eye through a complex system of channels that lead from the inner corner of the eyelids into the nose. This system of channels is called the lacrimal drainage system.

Any emotional stress or eye irritation will cause an overproduction of tears. Blockage of the lacrimal drainage system is an important cause of excessive tearing. This tends to occur in older people and the cause of the blockage is usually believed to be due to involutional changes of the nasolacrimal duct.

If you have an acute infection of the lacrimal drainage system, this must be treated with antibiotics. The next step is to determine the degree of obstruction and the site of blockage. This is simply done in the clinic by flushing the tear ducts with saline. Flushing the system might relieve the symptoms temporarily, but they often recur after some time.

Surgery is necessary to treat those with severe obstruction of the tear ducts, or those who have repeated infections of the system. The operation required is called Dacryocystorhinostomy (DCR), in which a new channel is created to allow tears to drain into the nose again. Specific operations depend on the site of obstruction.

Figure 1 - Severe tear duct infection

DCR is a procedure performed for the treatment of tearing (epiphora) due to blockage of the nasolacrimal duct. It creates an ostium between the tear sac and the nasal cavity by removing the mucosa and bone layers between them.

There are two main approaches to a dacryocystorhinostomy - external and endoscopic. The external approach requires a skin incision. The endoscopic approach creates the ostium from within the nose without the need for a skin incision. Both have similar success rates, with their own advantages and disadvantages.

While external and endoscopic dacryocystorhinostomy (DCR) remain the gold standard for nasolacrimal duct obstruction, today we live in a surgical era that strives towards minimally invasive surgery.

NOTES is an emerging field within other disciplines. Lacrimal surgery has seen this trend with the introduction of the microendoscope. Endoscopic lacrimal duct recanalization (ELDR) provides an alternative approach to the treatment of obstructive epiphora. ELDR is currently the least invasive procedure designed for primary acquired nasolacrimal duct obstruction (pando). It is appealing as it restores integrity of natural lacrimal drainage system, and avoids the necessity of making new bony openings.

A newborn baby may present with a "wet" eye usually at one to two weeks of age. Occasionally, there may be associated mucopurulent discharge. This is due to a membrane blocking the drainage system of tears into the nose. This blockage usually opens spontaneously within four to six weeks after birth. Massaging the inner corner of the eyelids may hasten the opening of the blockage.

However, if the tearing persists despite the massage, flushing and probing of the drainage system can be done to perforate the membranous blockage. This is usually done when the child is less than one year of age. The flushing and probing can be repeated if the tearing persists. Persistent tearing despite all these measures would require surgical procedures to relieve the obstruction.

Tearing disorders may be due to irritation of the eye or disorder of the drainage system. This can be determined by paying a visit to an eye doctor who will perform simple tests to determine the cause.