The condition referred to as ‘watering eye’ or ‘watery eye’, or the excessive production of tears to the point where they can overflow down the cheek is known as “epiphora”. It can have many different causes, and the treatment will depend on the cause e.g. if the lower eyelid is sitting away from the eye (an ectropion) the eyelid will need to be repositioned. If the puncta (the little holes in the inner aspect of the eyelids which represent the start of the tear drainage system) are very narrow, these will need to be opened (by means of a punctoplasty). If the tear duct is blocked (a nasolacrimal duct obstruction) an operation will be required to bypass the blockage. In clinic a test referred to as a ‘sac washout’ is performed to see if there is any tear drainage system blockages. This is quick to perform and only requires an anaesthetic drop to numb the surface of the eye for a few minutes. Click here to see how this is done. This is often combined with an examination of the interior of the nose using an endoscope (a small straight telescope). This is referred to as nasal endoscopy.
Occasionally a dry eye can lead to excessive tears when glands in the eyelids do not function properly. This causes the tear film to evaporate quickly, leaving the sensitive cornea exposed. The tear glands then produce an excessive volume of tears. This often leads to confusion with patients finding it difficult to understand why they have been prescribed artificial tears to improve their watering eye symptoms!
Sometimes a special x-ray (a dacryocystogram or DCG) or a radioactive tracing test (a lacrimal scintigram) may be required to identify the cause of the problem. Usually though the condition can be isolated to an abnormality in the tear drainage system caused by scarring due to injury, recurrent infection or just as the result of the ageing process. The most common operation performed for the management of a tear drainage system blockage is a dacryocystorhinostomy (a DCR). Rarely a special bypass tube (a Lester Jones tube) is required for patients with more extensive scarring, usually involving the tear drainage pathway within the eyelids.
A photograph showing the appearance of a silicone stent which is barely visible in the inner corner of the eye.
Lester Jones Tube
A photograph of a Lester Jones tube in place
The inner aspect of each eyelid has a little tear drainage hole (known as a punctum). This can often become narrowed (punctal stenosis). This is a common cause of impaired tear drainage resulting in watering of the eye. Punctal stenosis can be corrected by performing a punctoplasty.
A punctoplasty is a short procedure performed under local anaesthetic. The narrowed punctum is widened using either a “Kelly punch” instrument or with the temporary placement of a perforated punctal plug.
A perforated punctal plug is a tiny specially designed plug with a drainage hole that is inserted into the narrowed punctum for 6 weeks whilst the underlying cause is treated (e.g. simple daily lid hygiene can treat blepharitis or an ectropion repair can correct the eyelid position and return the punctum to it’s normal position). After removal of the perforated plug the enlarged punctum can drain tears more effectively.
A DCR is performed where there is an obstruction in the tear drainage system by making a small incision on the side of the nose, or through the nose with the use of an endoscope (a surgical telescope). The success rate of both approaches when performed by Face & Eye’s surgeons is better than 95%. An endoscopic approach is particularly popular with female patients, young patients and glasses wearers who are inconvenienced by the presence of a tender wound on the side of the nose. During the surgery a fine silicone tube (a stent) is put in place to maintain an opening in the tear drainage system. This is removed later. If this surgery is not totally successful the symptoms may be resolved by the use of a Lester Jones tube.
Conjunctivo-dacryocystorhinostomy (CDCR) and Lester Jones tube
The CDCR operation is performed for patients who have a complete blockage of the tear passages in the eyelids, often following trauma. The operation is very similar to a DCR but instead of a removable silicone stent, a tiny pyrex tube is placed between the inner corner of the eye and the nose which is almost invisible. Unlike a stent, this remains in place indefinitely. This surgery is most often performed endoscopically.
A DCR or CDCR and Lester Jones tube procedure can be performed under local anaesthesia with sedation but most patients prefer a general anaesthetic for this. For this reason this procedure is usually performed at the Manchester Centre for Vision (the private wing of the Manchester Royal Eye Hospital) or at the new Spire Manchester Hospital, usually with an overnight stay. Someone must be available to take you home (and stay with you until the next day if you have had any sedation).
You will visit the clinic to have a preoperative consultation. This usually lasts 30 minutes. You will be asked to complete a healthcare questionnaire, providing information about your current and past health, about any previous eye, eyelid or facial surgery or treatments including refractive surgery or laser eye surgery. We need to know if you have a past history of any eye problems e.g. dry eyes, or if you use contact lenses. We need to know about any allergies you may have, medications you are taking (including over the counter products e.g. Aspirin, Indomethacin, Nurofen, Diclofenac or vitamin supplements), previous major surgery or illnesses, any past dermatology history and whether or not you smoke. You will have your blood pressure checked by the nurses at the clinic.
If you are unsure of the names of any medications, bring them with you.
You will be told whether or not to stop any medications at this preoperative clinic visit. For example, if you are taking aspirin-containing medicines or anticoagulants, they may need to be temporarily withdrawn or reduced in dose for two weeks before the procedure as long as these are not medically essential. You might need to check this with your GP. Any anti-inflammatory medicines e.g. Ibuprofen, Nurofen should be discontinued at least 2 weeks before surgery. These medicines predispose you to excessive bleeding. You will be given a leaflet advising you on what medications, foods, and vitamin supplements to avoid prior to surgery. Your blood pressure should also be under good control if you take medications for hypertension. This is very important.
Your vision in each eye will be measured. Your eyes will be examined carefully using a slit lamp (a special ophthalmic microscope). Your tear film status is determined and the back of the eyes (called the retina) is examined as well as the eyelids themselves. The rest of your face is then examined.
The risks and potential complications of surgery should be considered but these need to be kept in perspective. Complications in the hands of a trained and experienced oculoplastic surgeon are very rare and all precautions are taken to minimize any risks.
What are the possible complications of lacrimal drainage system surgery?
Most complications of this surgery are amenable to successful treatment.
Complications from tear drainage surgery include:
- Blurred or double vision, lasting mainly for a few hours, and sometimes up to a day or two after surgery. This may occur for several reasons – ointment put in the eyes immediately after the operation, local anaesthetic used in the operation. If blurring persists for longer than 48 hours, it is important to inform your surgeon.
- Injury to the surface of the eyeball (a corneal abrasion) that causes persistent pain. If the pain lasts longer than a few hours after the operation, the surgeon must be informed. Such a problem is extremely rare in the hands of an oculoplastic surgeon. Such a problem is treated with antibiotic ointment. Sometimes a “bandage” contact lens needs to be used.
- Bleeding from the nose. This usually subsides spontaneously but very rarely the bleeding may need to be stopped in the operating theatre.
- Infection. An infection following this surgery is very rare and would be treated with antibiotics.
- Scarring of the new tear drainage pathway. This can lead to failure of the procedure and the need for further surgery.
- A stent prolapse. It is important to avoid rubbing the eye, blowing the nose or holding the nose when sneezing to prevent this. If the stent prolapses it will need to be replaced with an endoscope in clinic or it may need to be removed earlier than planned.
After surgery activity is restricted for a week to prevent bleeding. You may have some minor intermittent nose bleeding which will take 3-4 days to settle. Avoid any activity which can provoke a nose bleed e.g. lifting heavy weights or straining.
You may have difficulty wearing your glasses for a short period after surgery (external DCR only). You may experience nasal stuffiness but this will gradually improve. Avoid blowing your nose or rubbing your eye.
If you have undergone an endoscopic DCR or CDCR you will be instructed to perform regular nasal douching using Sinurinse. You will also be prescribed nasal sprays (Beconase and Otrivine) to use 2-3 times a day for approximately a week after surgery.
Antibiotic ointment should be applied to the site as directed (external DCR only). The sutures are usually dissolvable but can be removed after 3-4 weeks (external DCR only).
The silicone stent may come out as a loop in the inner corner of the eye. If this happens it can be taped it to the side of the nose– this is not an emergency so call us in normal working hours but DO NOT CUT IT OR PULL IT. The stent is usually removed in clinic. This takes less than a minute to do. The stent is cut between the eyelids and then removed from the nose using an endoscope and forceps.
If you have a Lester Jones tube you will be instructed to instil Hypromellose drops (do not use any other more viscous drops) at least twice a day into the eye and to sniff while occluding the opposite nostril. This is a permanent self-treatment which is important.