Watery Eye and DCR Surgery in London

What is a watery eye (epiphora)?

 

An apparent excess of tears on the eye causing the tears to blur the vision or overflow onto the cheek is known as a watery eye. It may also lead to a runny nose and the excessive tearing can be intermittent or continuous depending on the cause. The medial term is epiphora for watering. DCR surgery is the operation to treat a blocked tear duct. 

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What causes it?

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Interestingly, the most common cause is having a dry eye. The lacrimal gland that controls tear production is triggered by the eye being dry and produces excess tears when the eye is dry. This is why artificial tears are often advised as a first line measure to treat the problem.

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Other common causes include:

 

Blepharitis of the eyelids

The eyelids contain multiple oil glands known as meibomian glands. These secrete oils that form an important part of your tears. If the oils do not come out properly a dry eye can develop and watering occurs

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Allergic conjunctivitis

A reaction to an allergy is to develop a watery discharge and itchy eyes. The allergic reaction results in increased tear production as the eye remains irritated. Allergy sufferers such as those who have hay fever, can say that their eyes tend to water when their symptoms are bad and less so when the allergy symptoms are under control. Then the eyes water there may be vision changes die to the teary eyes.

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An eye infection

An infective conjunctivitis (known as pink eye) or more urgently, a contact lens related injection causes irritation to the eye surface. This results in extra tears to try and remove the cause of the irritation. It is important to see your eye doctor urgently if you wear contact lenses and have an eye infection.

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The eyelids being too lax with entropion or ectropion

The lids form part of the a mechanism known as the tear pump. As you blink the act as a pump to push excess tears into the tear duct. If the eyelids become too loose this no longer happens effectively. It tends to happen in older adults. With the increased laxity of the lower eyelid the eyelid position can turn outwards (ectropion) or inwards (entropion). This can result in further irritation, tear drainage problems and watering.

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A blocked tear duct

The tears naturally come from the tear gland and create a tear filler that then drain into the tear sac and into lacrimal duct. This constitutes normal tear drainage. If the nasolacrimal duct is blocked the tears are unable to drain effectively and watering can occur.

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An injury to the eye like a scratch or corneal abrasion

An eye injury like a corneal abrasion can lead to watering. The reflex tearing that occurs result in excess tears. This usually settles as the eye heals but it may require the eye being checked by your doctor to make sure there are no other injuries. They may also provide you with an ointment to use.

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How do you stop a watery eye?

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To stop the symptoms the underlying cause needs to be addressed. If is it due to dryness or blepharitis then warm compresses to the eyelids regularly all well as dry eye drops may be all that is required. Compresses help improve the quality of the tear film and dry eye syndrome. Some recommend baby shampoo in water being applied to the eyelid margin and this may be of benefit but can be irritated if the shampoo is too concentrated.

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Anti-allergy drops or over the counter anti-histamines can be used if the watering is due to hay fever or allergy

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Any eye infection can be treated with eye drops or an ointment. It is important to seek an urgent option if you have an infection are wear contact lenses. Conjunctivitis from a common cold viral infection tends to settle on its own without treatment. It can however cause eye irritation.

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Eyelid laxity tends to require surgery to tighten the lower lid and correct any changes to its position if they are present. This is known as an entropion or ectropion repair.

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If the opening to the tear duct is too small this can be widened with a simple procedure. It is known as a punctoplasty or 3 snip and is done under local anesthesia.

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For a tear duct blockage, dacryocystorhinostomy surgery is required. This creates a bypass to the blockage allowing the tears to drain.

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What does it mean if one eye keeps watering?

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One eye watering tends to suggest a narrowed or blocked tear duct. This would require an assessment in the clinic. Mr Ahmad Aziz in his London clinic is able to assess your eyes and the drainage ducts to see if one or both are blocked or narrowed.

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In children the most common cause of one eye watering is a blockage to the tear duct which has not yet fully developed. With time and massage this can settle by the age of 2 years.

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What does it mean when a baby eye keeps watering?

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Infants can have a blocked tear duct which can settle on its own or with massage. By the age of 2 years if the tearing is persistent then this have be probed under a general anaesthetic to assess the tear drainage and see if there is a membrane than can be unblocked without the need for bypass surgery. Less commonly a child will need bypass surgery or a dacryocystorhinostomy (DCR) if the symptoms persist.

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Which eye drop is best for watery eyes?

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Eye drops are recommended depending on the cause. In infants if the epiphora is due to allergy then Alomide is advised. Older children and adults can use Opatanol eye drops. Both these drops are part of the antihistamine family to calm and settle any allergic component that may be causing watering.

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Dry eye drops are multiple and there are a range of options available. Sodium hyaluronate is one of the first line drops given to help treat the dryness and encourage the reservation of the outer surface of the eye. Other drops include Carmellose, Hypromellose and Carbomer gel in different strengths and some of these work better in some patients. Less commonly steroid eye drops are used if there is evidence of inflammation. In severe dry eye Cyclosporin is a medication in drop form that can be applied once daily to help treat the symptoms.

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What home remedy can I use for watery eyes?

 

Home remedies include hot flannels regularly to the eyelids to try and improve the tear quality. Some people are not comfortable using a hot flannels and a heat eye mask can be used instead. Other options which have less evidence from clinical trials include increasing your Omega 3 intake and the use of diluted tree tee oil on the eyelid margin.

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Can eye drops help watery eyes?

 

Drops can help if the watering is due to infection, dryness or allergy. Drops tend to only improve the comfort if it due to eyelid laxity. Interestingly them can sometimes help in a tear duct blockage as watering tends to be due to multiple factors and not just one.

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Does glaucoma cause watery eyes?

 

Glaucoma can cause watering. This is because some glaucoma medications contain a preservative that can irritate the eye resulting in tearing. The eye needs to be assessed to ensure there is no other cause. If it seems that it may be due to the glaucoma medication, the treatment is to change the medication to formulations without the preservative.

Rarely watering can be a sign of acute angle glaucoma and so if the watering is associated with redness of the eye, pain, halos in the vision and blurred vision this requires urgent attention.

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What is a Dacryocystorhinostomy (DCR) operation?

 

DCR surgery is used to treat blocked tear ducts. A blocked duct is called nasolacrimal duct obstruction. The operation allows the tears to drain normally by creating a new passage for the tears to drain from the tear sac and the nose. It is performed under a general anaesthetic with you asleep during the operation and typically takes 1 hour to complete. In cases where having a general anaesthetic may be less safe, an external DCR can be performed under local anaesthetic if you are not able to be put to sleep. This will be discussed with you prior to the procedure.

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There are two approaches to DCR surgery. An external approach and an endonasal approach. Most people prefer to go for an endonasal approach because it avoids a scar on the side of the nose. An external approach is used in people who are unable to have a general anaesthetic and in cases where going through the nose is not possible. This will be discussed with you during your consultation.

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Is DCR surgery painful?

 

The surgical procedure can feel sore for a day or two and this can be treated with simple painkillers. Most people do not suffer from significant pain. The endoscopic approach may have less pain due to there being no scar.

 

How long is the recovery from the surgery?

 

The bruising and swelling noticeably settle within 2 weeks resorting a more natural look giving you confidence in going out publicly and subtle swelling that the patient may notice will generally resolve over a period of 2 months in the majority of cases. 

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There may also be some spotting or bleeding from the nasal cavity following the procedure. Usually people can return to their normal activities after a week.

 

To encourage success of your DCR:

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• Try to sit up and sleep on 1 or 2 extra pillows at night

• Avoid blowing or picking your nose for one week after having had you surgery.

• Use paracetamol painkillers for any discomfort but avoid taking aspirin and ibuprofen which can encourage bleeding.

• Try to avoid any strenuous exercise or activity for two weeks after you procedure

• Also avoid exercise especially swimming for two weeks after surgery.

• Try to avoid travelling by plane for seven days after your operation. ​

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How is tear duct surgery performed?

 

The essence of the lacrimal surgery it bypass the tear duct and create a new passage for the tears to pass from the lacrimal punctum on the eyelid margin to the lacrimal sac and into the nasal cavity at a level of the nose on the nasal mucosa called the middle meatus. The dcr procedure effectively creates a new lacrimal drainage system. It can be done with an endoscopic dacryocystorhinostomy or externally with a small scar.

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Is tear duct surgery necessary?

 

The tears in the eye usually drain through the tear duct the starts from the corner of the eye by the nose and ends inside the nose itself. When the tear duct becomes blocked the tears are unable to drain resulting in watering of the eye and the risk of infections in the tear duct. An infection in the tear duct is known as dacryocystitis.

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To assess if your tear duct is blocked your Oculoplastic surgeon may use a dye test to see if it drains. This test takes 5 minutes to perform. They may then try to flush the tear duct to see if there is an obstruction. If there is no obstruction you will taste the water down your throat during the test. If the tear duct is blocked you will not taste the water in your throat and it will reflux back and create a watery eye.

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Is the surgery safe?

 

The surgery is generally considered safe. The risk factors to the operation include

 

• Anaesthetic risks and this is assessed at your preoperative assessment.

• Failure of the procedure in approximately 5% of patients. The risk is higher if it is a repeat procedure or you have inflammatory medical conditions that can cause excessive scarring. In these cases a medication known as mitomycin C may also be applied at the time of the operation.

• Persistent watery eye even if there is anatomic latency as watery eye is usually multifactoral

• A small scar on the side of the nose if an external procedure has been performed

• Some bleeding from the nose

• A risk of infection which is small

 

 

 

 

What is endonasal dacryocystorhinostomy?

 

Endoscopic DCR 

Under general anesthesia a telescope is used up the nose to access the tear sac and bypass the blockage site. The telescope used is known as a nasal endoscope. The tear sac is then opened and allowed to drain through a new passage. A flexible tube is inserted to keep the passage open as the nose heals. This small tube is colourless and is hardly noticeable to most people. The tune is then removed about 6 weeks later once the nose as healed. The advantage of this procedure is that is leaves no scar on the side of the nose and is usually entirely scar-less. The success rate for this is about 90%. This is the advantage of an endoscopic DCR. Younger patients and increasingly elderly patients tend to prefer this approach.

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External DCR

Is the most common operation done for blocked tear ducts although endonasal DCR is gaining in popularity for its advantages. It has a success rate of over 90%. With an external dacryocystorhinostomy a small incision is made on the side of the nose to access the tear sac which sits behind a small tendon known as the medial canthal tendon in a small cavity known as the lacrimal fossa. A small amount of bone at a landmark known as the anterior lacrimal crest is removed. This part of bone removed forms part of the lacrimal bone. The nasolacrimal sac is opened forming a posterior flap and an anterior flap and a new passage is made for the tears to drain. A flexible silicone tube is then passed to keep the new passage open as the nose heals. The tubes are removed 6 weeks later. The incision is sutured with stitches which are removed 2 weeks after the procedure.

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Your surgeon will discuss both options and which is most suitable for you.

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How do you remove a DCR tube?

 

The tube is usually kept in for a period of 6 weeks and is removed in clinic in the majority of cases. It is usually a simple and painless procedure. The tube is removed from the inner aspect of the eyelid near the lower punctum. The tube is retained for 6 weeks to try to improve the anatomic success and prevent the new passage closing as it heals. Functional success is the improvement of the systems once the surgery is full healed.

 

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What is the success rate for DCR surgery?

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90% of people have resolution or improvement of their watery eye following DCR surgery and are satisfied with the results They notice a significant difference following the procedure. The surgical outcome usually last a lifetime but in 10% of people the surgery may not help and they may require another procedure.

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Any bruising usually settles within 2 weeks giving you confidence to go out in public. If you have had an endonasal DCR you will have no scar. An external DCR does have a small 1 cm scar on the side of the nose by the area known as the medial canthus that usually fades with time. You should protect the scar site from sun exposure as you do for the rest of your skin.

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