Epiphora is one of the most common complaints of patients consulting ophthalmology clinics. It causes much discomfort for patients in their daily lives and also puts the safety of several intraocular surgeries and surgical attempts at risk [
The primary cause of epiphora is an obstruction that prevents the drainage at any level of the nasolacrimal system or even the lack of drainage related to eyelid diseases. Another cause may be the reflex hypersecretion related to ocular surface diseases such as dry eye or the combination of all these situations [
In this study, we aimed to retrospectively investigate the etiologies, duration, and treatment modalities for epiphora in patients who consulted our clinic about eye watering complaints.
A retrospective analysis of the records of patients who consulted our clinic about eye watering complaints from June 2013 to January 2014 was conducted. The following data were collected from the patients: duration of complaints, whether they were previously treated, and the treatments they received.
The patients included in our study were divided into four primary categories based on the etiology: (1) ocular surface diseases (dry eye, blepharitis, etc.), (2) lacrimal system diseases (chronic dacryocystitis, congenital dacryostenosis, punctal stenosis, etc.), (3) eyelid anomalies (entropion, ectropion, etc.), and (4) others. All the patients underwent complete ophthalmologic examination. Lid position anomalies were evaluated; entropion, ectropion and the accompanying punctal stenosis, and additional pathologies were recorded. Punctual openings, eyelash anomalies (trichiasis and distichiasis), blepharitis, and presence of additional problems were investigated by biomicroscopic examination. The diagnosis related to dry eye was made based on the presence of at least two of the following symptoms: hypersecretion, presence of corneal fluorescein staining, tear break-up time ≤ 10-s, and Schirmer’s test performed under anesthesia under 10 mm. Children examined for congenital dacryostenosis were asked to wait for 5 min after the administration of eye drops containing fluorescein and the diagnosis was made after the fluorescein disappearance test. Patients who were suspected of having chronic dacryocystitis underwent nasolacrimal duct irrigation and the diagnosis was confirmed by contrast dacryocystography. In addition to the basic above-mentioned diagnoses, punctum anomalies such as the mass closing off the punctum, conjunctivochalasis, inflamed pterygium, and double punctum, likely to cause epiphora, were grouped separately as other causes of epiphora.
Patients were excluded if they had a concurrent ocular infection, a history of facial palsy, ocular or periocular trauma, facial radiotherapy, and ocular medication except that given for epiphora.
This study adhered to the tenets of the Declaration of Helsinki to review the patients’ data.
Data were analyzed using SPSS 21 (SPSS, Inc., Chicago, IL, USA). The correlation among the variables was evaluated using Pearson’s chi-square test. The group averages were compared using the one way analysis of variance test and post hoc evaluation was performed using Tukey’s test. A
The average age of the 163 patients included in this study was
Causes of epiphora, duration of complaints, and relationship with gender.
Patients ( |
Duration of complaints ( |
Sex (%) |
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<1 month | 1 month–1 year | 1–5 years | >5 years | ||||
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(a) Dry eye/blepharitis | 63 (38.7) | 8 (4.9%) | 42 (25.7%) | 13 (7.9%) | F (57.1 |
0.083 | |
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(a) Chronic dacryocystitis | 36 (22.1) | 15 (9.2%) | 15 (9.2%) | 6 (3.6%) | F (69.4) | 0.052 | |
(b) Congenital lacrimal stenosis | 5 (3.06) | 5 (3.06%) | M (60) | 0.042 | |||
(c) Punctum stenosis | 42 (25.8) | 13 (7.9%) | 29 (17.7%) | M (66.6) | 0.233 | ||
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(a) Ectropion | 27 (16.6) | 5 (3.06%) | 21 (12.8%) | 1 (0.6%) | M (59.2) | 0.151 | |
(b) Entropion | 5 (3.06) | 1 (0.6%) | 4 (2.4%) | M (60) | 0.044 | ||
(c) Trichiasis/distichiasis | 6 (3.6) | 2 (1.2%) | 4 (2.4%) | F (50) | 0.083 | ||
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When the epiphora groups were examined, lacrimal system diseases were present in 48.4% (79/163) of the patients. But when we considered the diseases individually, ocular surface disease (dry eye/blepharitis) was the topmost with a rate of 38.7% (63/163). Table
Causes of epiphora and the relationship with treatment methods and treatment rates.
Patients ( |
Treatment modality (med/sur) | Untreated patients (%) |
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Med | 65.07 | 0.000 |
(a) Dry eye/blepharitis | 63 (38.7) | Med | 65.07 | 0.000 |
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0.000 | ||
(a) Chronic dacryocystitis | 36 (22.1) | Surg | 88.8 | 0.000 |
(b) Congenital lacrimal stenosis | 5 (3.06) | Surg | 100 | 0.000 |
(c) Punctum stenosis | 42 (25.8) | Surg | 69.04 | 0.000 |
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0.000 | ||
(a) Ectropion | 27 (16.6) | Surg | 70.3 | 0.000 |
(b) Entropion | 5 (3.06) | Surg | 80 | 0.000 |
(c) Trichiasis/distichiasis | 6 (3.6) | — | — | 0.000 |
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Med/Surg | 25 | 0.000 |
Concerning the etiologies, the average age of patients with the pathologies was significantly different between each other (
Etiology distribution in different age groups.
While 69.3% (113/163) of the patients included in this study had never received any treatment, 28.8% (47/163) of them had received medical treatment and only 1.8% (3/163) of them had received surgical treatment. Overall, 65.1% (41/63) of the patients with ocular surface disease (dry eye/blepharitis) had never received any treatment, and 70.7% of those without any treatment had complaint periods between 1 month and 1 year: the complaints of 9.7% of them had a duration varying from 1 to 5 years (
Treatment situation in different etiologies.
Epiphora is one of the most common complaints of patients consulting ophthalmology clinics, which has been described since ancient times in Egyptian papyrus artifacts and during the era of Hippocrates [
To the best of our knowledge, there are only few studies in the literature that have investigated the etiology of epiphora. One of the first studies found on this subject was performed by Mainville and Jordan, which revealed that the lacrimal passage obstruction related to epiphora is found in 48.7% of the cases, followed by dry-eye-related reflex tear secretion in 40% [
Generally, when clinicians see patients with epiphora, the first thing that occurs to their mind is lacrimal system diseases. Lacrimal canal is a long passage that starts at eyelid puncta and ends at inferior nasal meatus. Therefore, the obstruction can be seen at different levels of this passage. Although nasolacrimal duct obstruction can be congenital, it can also develop later in a patient’s life. Most of the acquired cases may develop as a result of chronic dacryocystitis that emerges after an inflammatory process in the lacrimal sac [
Punctum stenosis is known to develop due to chronic blepharitis, eyelid ectropion, side effects caused by topical or systemic medicine use, or just senility [
Another common cause of epiphora is eyelid disorders. This group includes entropion, ectropion, trichiasis/distichiasis, and other less common problems which were reported by Tse et al. [
The above-mentioned discussion is so far related to the cases in which the lacrimal drainage is obstructed. However, dry-eye related hypersecretion may surpass the rates of all the cases we discussed above. Dry eye and/or chronic blepharitis may affect the corneal and conjunctival neurosensorial receptors and cause reflex hypersecretion of the lacrimal gland [
In addition to the frequently found pathologies, there are also some pathologies that are rare but can cause epiphora. In our study, such pathologies included mass closing punctum, conjunctivochalasis, inflamed pterygium, and double punctum anomalies, all of which had a 2.4% (4/163) rate. Conjunctivochalasis is an interesting condition that causes epiphora by mechanically displacing the normal tear meniscus and impeding the flow along the eyelid margin toward the punctum [
Epiphora became chronic in patients who did not receive any treatment. In one study, the average duration of the complaint was 41.1 months. When the pathologies were examined individually, it was found that the longest duration of 61.9 months was related to eyelid problems and the shortest duration of 28.5 months was related to dry eye [
As long as chronic dacryocystitis patients did not undergo surgical intervention, the duration and intensity of complaints may be longer in these patients compared with others as there is no chance of healing. Moreover, every chronic dacryocystitis patient had a risk of infection for possible intraocular surgery. In a recent study, the majority of the microbiologic spectrum of chronic dacryocystitis was Gram (+) which was compatible with the microbiologic spectrum of endophthalmitis, the most feared infection [
Eye lid malpositions such as entropion and ectropion also require surgery. However, as we observed in our study, 78.1% of the eyelid patients who had complaints between 1 and 5 years received medical treatment, despite the lack of medical treatment regimen for these situations, and only 1 (2.4%) entropion patient received surgical treatment. The possible reasons why patients with this particular pathology do not receive surgical treatment can be lack of information and guidance given to the patients by their doctors and lack of etiological evaluation of epiphora.
In conclusion, it should be noted that a complaint of epiphora is not only a discomforting pathology for the patient but can also generate situations that may result in permanent blindness. Moreover, given the fact that older patients are natural candidates for various intraocular surgeries, it should be remembered that nontreatment of these types of pathologies may cause serious complications [
The authors declare no conflict of interests.