Definition etiology causes clinical features examination diagnosis and management of Epiphora for Ent pg exam
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Here is a comprehensive PG exam-oriented write-up on Epiphora:
EPIPHORA — Complete ENT/Ophthalmology PG Exam Notes
1. DEFINITION
Epiphora is the overflow of tears onto the cheek/face due to either hypersecretion of tears beyond normal drainage capacity, or defective drainage of tears through the lacrimal drainage system.
"Epiphora is the overflow of tears at the eyelid margin." — Kanski's Clinical Ophthalmology, 10th ed.
2. RELEVANT ANATOMY
Fig. 3.1 — Anatomy of the lacrimal drainage system (Kanski's Clinical Ophthalmology)
The lacrimal drainage system:
| Structure | Dimensions |
|---|---|
| Ampulla (vertical canaliculus) | 2 mm |
| Horizontal canaliculus | ~8 mm |
| Common canaliculus | joins lateral wall of lacrimal sac |
| Lacrimal sac | 10–12 mm; lies in lacrimal fossa |
| Nasolacrimal duct | 12–18 mm; opens into inferior meatus |
| Valve of Hasner | mucosal fold at NLD opening |
| Valve of Rosenmüller | at junction of common canaliculus & sac — prevents reflux |
Physiology of tear drainage: Tears flow along the marginal strips → lacus lacrimalis → enter canaliculi by capillarity + suction. On blinking, orbicularis (Horner muscle) compresses the ampullae and forces tears down the nasolacrimal duct. On eye opening, negative pressure draws tears from canaliculi into the sac.
3. ETIOLOGY / CAUSES
Two fundamental mechanisms:
A. Hypersecretion (Lacrimation)
Reflex overproduction exceeds drainage capacity:
- Dry eye ("paradoxical watering" — commonest cause overall)
- Conjunctivitis, keratitis, uveitis
- Entropion / trichiasis / aberrant eyelashes
- Corneal foreign body or ulcer
- Congenital hereditary endothelial dystrophy
- Sclerocornea (in neonates)
- Congenital glaucoma (rare)
B. Defective Drainage
I. Punctal/Lid Malposition
- Ectropion (commonest lid cause) — punctum everts away from globe
- Centurion syndrome — medial lid displaced anteriorly by prominent nasal bridge
- Lower lid laxity
II. Obstruction at any level
| Level | Cause |
|---|---|
| Punctal | Stenosis (chronic blepharitis, herpes, radiation, cicatrising conjunctivitis, 5-FU, topical glaucoma drops); atresia (congenital) |
| Canalicular | Canaliculitis (Actinomyces israelii), trauma, herpes, cicatrising conditions |
| Lacrimal sac | Dacryocystitis, dacryolithiasis, tumour |
| NLD | PANDO (Primary Acquired NLD Obstruction) — commonest acquired cause in adults; congenital NLD obstruction (valve of Hasner failure to canalise); secondary — sinusitis, trauma, tumour |
III. Lacrimal Pump Failure
- Facial nerve palsy (orbicularis weakness)
- Lower lid laxity / involutional change
- Conjunctivochalasis (redundant conjunctival fold blocking punctum)
4. CLINICAL FEATURES
Symptoms
- Tears overflowing onto the cheek (cardinal symptom)
- Worse in cold, windy weather; better in warm, dry room (suggests drainage failure)
- Mucopurulent discharge (especially in NLD obstruction)
- Crusting of lashes on waking
- Skin maceration/excoriation at medial canthus
- Swelling at medial canthus (dacryocystitis, mucocele, dacryocoele)
In Neonates / Congenital NLD Obstruction
- Epiphora present in ~20% of normal babies
- Spontaneous resolution in ~90% by age 1 year
- Mucopurulent discharge (sticky eye)
- Congenital dacryocoele: bluish cystic swelling at/below medial canthus at birth
Fig. 3.18 — (A) Child with watering eye; (B) probing of nasolacrimal duct; (C) congenital dacryocele (Kanski's)
5. EXAMINATION
Step 1 — Slit-lamp Examination (Before any manipulation)
- Marginal tear strip (meniscus): Normal = 0.2–0.4 mm; Elevated ≥0.6 mm = abnormal
- Examine puncta (do this BEFORE cannulation to avoid masking stenosis):
- Punctal stenosis (commonest cause of drainage failure)
- Ectropion / eversion
- Pouting punctum → canaliculitis
- Conjunctivochalasis occluding punctum
- Eyelash in ampulla
Step 2 — Lacrimal Sac Palpation
- Mucocele: Regurgitation of mucopurulent material on pressure → NLD obstruction with patent canaliculi
- Acute dacryocystitis: Tender swelling — do NOT press (or irrigate in acute phase)
- Hard mass → stone or tumour
Step 3 — Fluorescein Disappearance Test (FDT)
- Instil fluorescein 1–2% drops into both conjunctival fornices
- Normal: little/no dye remains at 5–10 minutes under blue light
- Prolonged retention = inadequate lacrimal drainage
Step 4 — Jones Tests (Dye Tests)
- Jones I (Primary Dye Test): Fluorescein instilled; nasal pledget checked at 5 minutes.
- Positive (normal): fluorescein recovered from nose → drainage intact
- Negative: proceed to Jones II
- Jones II (Secondary Dye Test): Irrigate canaliculus with saline after prior fluorescein instillation:
- Fluorescein-stained saline from nose → partial NLD obstruction (fluorescein entered sac)
- Unstained saline from nose → upper lacrimal (punctal/canalicular) dysfunction or pump failure
Step 5 — Lacrimal Syringing (Irrigation)
- Dilate punctum → insert blunt 26/27G lacrimal cannula into lower punctum
- Hard stop (cannula hits medial lacrimal bone) = canalicular system patent to sac level
- Soft stop (cannula meets soft resistance before hard stop) = canalicular obstruction
- Gently irrigate:
- Free flow to nasopharynx = patent NLD
- Regurgitation from same punctum = complete canalicular block
- Regurgitation from opposite punctum = NLD obstruction (common canaliculus patent)
- Partial flow with resistance = partial NLD obstruction (functional block)
6. INVESTIGATIONS / DIAGNOSIS
| Investigation | Purpose |
|---|---|
| Fluorescein disappearance test | Screening; highly specific for congenital NLD obstruction |
| Jones I & II tests | Localise level of obstruction |
| Lacrimal syringing | Confirm and localise obstruction; gold standard for functional test |
| Probing | Diagnose + treat congenital NLD obstruction |
| Dacryocystography (DCG) | Radio-opaque contrast injected into canaliculi; shows anatomy, site of block, diverticula, filling defects (stones, tumours); digital subtraction DCG is most detailed |
| Nuclear lacrimal scintigraphy | Physiological assessment with radiolabelled tears; identifies partial or functional blocks; less anatomical detail than DCG |
| CT/MRI | Paranasal sinus disease, lacrimal sac tumour |
| Nasal endoscopy | Polyps, deviated septum, intranasal pathology |
| Microbiological swab | Discharge in canaliculitis/dacryocystitis |
7. MANAGEMENT
Management is directed at the underlying cause and level of obstruction.
A. Treat Hypersecretion (Medical)
- Artificial tears/lubricants for dry eye paradoxical watering
- Anti-inflammatory drops (ciclosporin, steroids) for blepharitis/dry eye
- Treat underlying conjunctivitis, trichiasis, entropion
B. Congenital NLD Obstruction
- Conservative (first-line, <12 months): Crigler massage (Lacrimal sac massage) — index finger over common canaliculus, roll downwards over sac to create hydrostatic pressure rupturing the Hasner membrane
- Probing (definitive treatment): Fine wire via canalicular system → NLD → disrupts obstructing membrane at valve of Hasner; can be repeated if first attempt fails
- Delayed until 12–18 months (may delay to 24 months if mild)
- Under GA; topical anaesthesia for very young infants in outpatient setting
- Follow with irrigation to confirm patency
- If probing fails: Silicone tube intubation ± balloon dilatation of NLD; endoscopic procedures; dacryocystorhinostomy (DCR)
- Congenital dacryocoele: Conservative first; probing if fails
C. Acquired Punctal/Canalicular Obstruction
- Punctal stenosis:
- Punctal dilatation ± mini-Monoka stent (removed at 1 month)
- Punctoplasty (one-, two- or three-snip procedure) if dilation fails
- Ectropion: Lid tightening procedures (lateral tarsal strip, medial canthoplasty)
- Conjunctivochalasis: Topical lubricants/anti-inflammatories; surgical excision/conjunctival suturing
- Canaliculitis (Actinomyces): Canaliculotomy + curettage + topical penicillin/cefuroxime
D. Lacrimal Sac / NLD Obstruction (Acquired / PANDO)
Dacryocystorhinostomy (DCR) — definitive operation:
- Creates anastomosis between lacrimal sac and nasal mucosa, bypassing NLD obstruction
- External DCR (standard):
- Vertical skin incision 10 mm medial to inner canthus
- Periosteum elevated; anterior lacrimal crest and lacrimal fossa bone removed
- Lacrimal sac opened with H-shaped incision → anterior and posterior flaps
- Nasal mucosa opened → flaps sutured (posterior then anterior)
- Success rate ~90%
- Endoscopic (endonasal) DCR: No skin incision; good for functional failures; comparable success rates
- Silicone tube intubation often placed at time of DCR; removed at 3–6 months
E. Dacryocystitis
- Acute: Systemic antibiotics (IV in severe cases: amoxicillin-clavulanate or cephalosporins); warm compresses; DCR after infection resolves
- Chronic: DCR is the definitive treatment
- Mucocele: Pressure test confirms diagnosis; DCR required
F. Lacrimal Pump Failure (Facial Nerve Palsy)
- Treat the underlying cause
- Lubricating eye drops/ointment to protect cornea
- Lateral tarsorrhaphy or lower lid tightening if laxity contributes
8. SUMMARY MNEMONIC — Causes of Epiphora
"PECK DFL"
- P — Punctal stenosis / malposition (ectropion)
- E — Evaporation/dry eye (paradoxical hypersecretion)
- C — Canalicular obstruction (trauma, canaliculitis)
- K — Keratoconjunctivitis / surface disease
- D — Dacryocystitis / NLD obstruction (PANDO)
- F — Facial nerve palsy (pump failure)
- L — Lid laxity / conjunctivochalasis
9. KEY EXAM POINTS
| Fact | Detail |
|---|---|
| Commonest cause of watering eye | Paradoxical dry eye (hypersecretion) |
| Commonest acquired NLD obstruction in adults | PANDO (Primary Acquired NLD Obstruction) |
| Congenital NLD obstruction spontaneous resolution | ~90% by age 1 year |
| Site of congenital obstruction | Valve of Hasner (lower end NLD) |
| First-line treatment congenital NLD obstruction | Crigler massage |
| Definitive Rx congenital NLD obstruction | Probing |
| Definitive Rx acquired NLD obstruction / PANDO | DCR (Dacryocystorhinostomy) |
| Jones II positive (fluorescein-stained saline) | Partial NLD obstruction — fluorescein entered sac |
| Jones II negative (unstained saline from nose) | Upper lacrimal (punctal/canalicular) block or pump failure |
| Hard stop on syringing | Canalicular system patent to sac |
| Soft stop on syringing | Canalicular obstruction |
| Causative organism in canaliculitis | Actinomyces israelii |
| NLD drains into | Inferior nasal meatus (below inferior turbinate) |
| DCR: anastomosis between | Lacrimal sac and nasal mucosa |
| Congenital dacryocoele is NOT confused with | Encephalocoele (which is pulsatile, above medial canthal ligament) |
Sources: Kanski's Clinical Ophthalmology: A Systematic Approach, 10th Ed. (ISBN 9780443110993); K.J. Lee's Essential Otolaryngology; Goldman-Cecil Medicine
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Epiphora PG Exam Notes
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What's included in the PDF:
- Dark blue section banners for each heading (Definition → Key Exam Points)
- Lacrimal anatomy diagram + clinical photo of epiphora/dacryocoele
- Colour-coded tables for anatomy, causes by level, investigations, DCR types, and key exam points
- PECK DFL mnemonic in a styled table
- Jones test interpretation, syringing findings, and full management algorithm
- Source citations at the footer
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