Evaluation of Epiphora

Abstract

Epiphora or watering is one of the most common symptoms of any ocular pathology. Though most cases of watering are due to non-patency in the lacrimal outflow pathway, others like eyelid and adnexal disorders and corneal and ocular surface pathology can also manifest as watering. In this context, it is important to distinguish between the terms epiphora and pseudoepiphora or hyperlacrimation [1–3]. True epiphora refers to watering due to obstruction in the lacrimal outflow pathway, while hyperlacrimation refers to excessive watering due to reflex irritation of the corneal and conjunctival surface as in cases of dry eye, corneal abrasion, corneal foreign body, etc. It is also important to differentiate between anatomical and functional lacrimal pathway obstruction. Anatomical obstruction refers to any structural pathology in the lacrimal outflow pathway which hinders tear drainage. Conditions like punctal and canalicular stenosis and block, nasolacrimal duct obstruction (NLDO), etc. are the causes of anatomical obstruction. In functional dysfunctions, the lacrimal outflow pathway is anatomically patent, but there is a failure of lacrimal pump mechanisms. This could also be due to pathologies outside the lacrimal pathway like facial palsy, eyelid laxity, and ectropion. Hence, a detailed and comprehensive evaluation is needed to identify the cause of watering and initiate appropriate management. The goal of the evaluation is to differentiate true epiphora from hyperlacrimation, differentiate obstructive cause of epiphora from non-obstructive cause and to localize the site of pathology in cases of obstructive epiphora. The evaluation can be divided into history taking, local examination, lacrimal system irrigation and probing, ancillary investigations, and nasal evaluation. The lacrimal system irrigation and probing can be schematically represented as has been shown in this chapter, which is a partial adaptation of Jane Olver’s methodology.