Differential Diagnosis of Watering of Eyes

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Differential diagnosis of watering of eyes (epiphora)

Watering may result from either excess tear production or impaired tear drainage. It may be unilateral or bilateral, intermittent or persistent.

1. Excess tear production (reflex tearing)

Ocular surface irritation

Dry eye disease, including evaporative dry eye due to meibomian gland dysfunction
Foreign body, trichiasis, entropion
Corneal abrasion, corneal ulcer, keratitis
Contact lens irritation or overwear
Chemical, smoke, dust, wind, cold, or bright-light exposure

Inflammatory eye disease

Conjunctivitis: viral, bacterial, allergic, toxic, irritative
Blepharitis
Meibomianitis
Episcleritis or scleritis
Anterior uveitis

Allergy

Seasonal/perennial allergic conjunctivitis
Vernal or atopic keratoconjunctivitis

Painful eye disorders

Acute angle-closure glaucoma, typically with severe pain, red eye, blurred vision, headache, nausea
Corneal disease or trauma

2. Defective tear drainage

Punctal abnormalities

Punctal stenosis or occlusion
Punctal eversion
Congenital absence or malposition of punctum

Canalicular disease

Canaliculitis
Canalicular obstruction or scarring, for example after trauma, infection, surgery, radiotherapy, or topical medications

Lacrimal sac or nasolacrimal duct obstruction

Primary acquired nasolacrimal duct obstruction, common in older adults
Chronic dacryocystitis
Acute dacryocystitis
Trauma or fracture involving the lacrimal drainage system
Nasal disease: chronic rhinitis, sinus disease, nasal polyps, deviated septum
Lacrimal sac or sinonasal tumor, especially with unilateral persistent epiphora, bloody tears, or a firm medial canthal mass

Congenital causes

Congenital nasolacrimal duct obstruction, usually due to persistence of the membrane at the valve of Hasner
Presents in infants with watering and sticky discharge, often beginning in the first weeks of life

3. Eyelid and lacrimal-pump failure

Lower-lid laxity and involutional ectropion
Facial nerve palsy causing ectropion and poor blinking
Eyelid retraction or lagophthalmos
Previous eyelid surgery, trauma, or scarring
Floppy eyelid syndrome
Poor orbicularis muscle function or reduced lacrimal pump action

4. Important associated systemic or neurologic causes

Facial palsy
Thyroid eye disease causing exposure and reflex tearing
Parkinsonism or reduced blink rate
Nasal/sinus inflammatory disease
Drug-related punctal/canalicular stenosis, such as some topical glaucoma drugs and systemic chemotherapy agents

Clinical clues

Feature	More suggestive cause
Itching, bilateral redness	Allergy
Grittiness, burning, fluctuating symptoms	Dry eye disease
Purulent/sticky discharge	Conjunctivitis or lacrimal drainage infection
Pain, photophobia, reduced vision	Keratitis, uveitis, glaucoma, corneal ulcer
Medial canthal swelling/tenderness	Dacryocystitis
Watering outdoors in wind/cold	Partial nasolacrimal obstruction or dry eye
Unilateral persistent watering	Lacrimal drainage obstruction until proven otherwise
Infant with tearing and discharge	Congenital nasolacrimal duct obstruction

Red flags requiring urgent ophthalmic assessment

Painful red eye with reduced vision
Photophobia or contact-lens wearer with a red eye
Corneal opacity, suspected foreign body, or trauma
Severe headache, nausea/vomiting, halos around lights
Fever with painful swelling near the medial canthus
Bloody tears, recurrent unilateral epiphora, or a palpable lacrimal sac mass

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Watering of eyes (epiphora) results from either:

Excess tear production (usually reflex tearing from ocular-surface irritation), or
Defective tear drainage through the lacrimal passages.
Kanski’s Clinical Ophthalmology, 10th ed., p. 99.

Differential diagnosis

1. Reflex hypersecretion / ocular-surface irritation

Often associated with redness, discomfort, grittiness, itching, photophobia, or pain.

Dry eye disease: paradoxical reflex watering, often with burning, fluctuating vision, and symptoms worse with screens, wind, or air-conditioning
Blepharitis / meibomian gland dysfunction
Allergic conjunctivitis: itch is prominent
Viral, bacterial, toxic, or chlamydial conjunctivitis
Foreign body: corneal, conjunctival, or subtarsal
Corneal abrasion, recurrent erosion, ulcer, keratitis, or corneal oedema
Trichiasis, distichiasis, epiblepharon: lashes rubbing on the eye
Entropion
Anterior uveitis / iritis
Contact lens-related irritation
Chemical exposure or trauma

2. Lacrimal drainage obstruction

Typically causes persistent overflow of tears onto the cheek, sometimes worse outdoors in cold or wind.

Punctal stenosis or occlusion
Punctal eversion due to ectropion
Canalicular obstruction, stenosis, or canaliculitis
Common canalicular obstruction
Nasolacrimal duct obstruction: congenital or acquired
Chronic dacryocystitis or lacrimal-sac inflammation
Dacryolith (lacrimal stone)
Lacrimal sac mass or tumour, especially with bloody tears, a medial canthal mass, or recurrent unilateral symptoms
Nasal disease affecting the distal duct: chronic rhinosinusitis, nasal polyps, trauma, or sinonasal mass
Cicatrising disorders: ocular cicatricial pemphigoid, Stevens-Johnson syndrome, chemical burns

3. Lacrimal pump failure

Drainage passages may be anatomically open, but tears are not pumped effectively.

Lower-lid laxity, commonly age-related
Ectropion
Orbicularis weakness due to facial nerve palsy
Previous eyelid surgery, scarring, or trauma
Functional epiphora: symptoms despite a patent system, diagnosed after other causes are excluded

4. Lid and ocular-adnexal abnormalities

Ectropion
Entropion
Floppy eyelid syndrome
Eyelid tumour or scarring
Conjunctivochalasis
Caruncular or conjunctival lesions mechanically blocking a punctum

5. Neurological or unusual causes

Crocodile tears: gustatory lacrimation after facial nerve palsy or aberrant regeneration
Emotional crying
Rare primary lacrimal hypersecretion

In children

Important causes include:

Congenital nasolacrimal duct obstruction: commonest cause
Punctal or canalicular atresia
Epiblepharon and trichiasis
Foreign body, conjunctivitis, keratitis, or corneal abrasion
Congenital glaucoma: tearing with photophobia, corneal haze, enlarged eye, or blepharospasm requires urgent assessment
The Wills Eye Manual, “Tearing,” p. 43.

Practical clinical clues

Finding	More likely diagnosis
Itching, bilateral redness	Allergic conjunctivitis
Grittiness or burning with paradoxical watering	Dry eye / blepharitis
Severe pain, photophobia, reduced vision	Keratitis, corneal ulcer, uveitis, acute glaucoma
Mucopurulent reflux on pressing lacrimal sac	Nasolacrimal duct obstruction / dacryocystitis
Tears running down one cheek without irritation	Drainage obstruction
Worse in wind or cold	Lacrimal drainage failure
Facial weakness with lower-lid laxity	Lacrimal pump failure
Child with tearing and photophobia	Consider congenital glaucoma urgently

Kanski emphasizes that dry ocular surface disease is a common cause of reflex tearing, while drainage failure may reflect punctal malposition, obstruction anywhere from punctum to valve of Hasner, or pump failure from lid laxity or facial palsy. Kanski’s Clinical Ophthalmology, 10th ed., p. 99. This is also consistent with the clinical overview of epiphora and a primary-care approach.

Urgent ophthalmic referral is indicated for painful red eye, photophobia, reduced vision, corneal opacity, trauma or chemical injury, suspected corneal ulcer, acute swelling and tenderness over the lacrimal sac with fever, bloody tears, a lacrimal-sac mass, or a child with tearing plus photophobia/corneal enlargement.

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