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Watery eye — epiphora


Publications by Mr Malhotra on watery eyes and lacrimal surgery include:

Litwin A, Malhotra R. The Great Debate: External versus Endonasal Dacryocystorhinostomy.  In “Principles and Practice of Lacrimal Surgery”, Ali MJ (ed). Springer, New Delhi, 2015, pp 351–358.

"Selective serotonin reuptake inhibitors and perioperative bleeding in endoscopic dacryocystorhinostomy" 
J Saad, K Ziahosseini, G Wearne, S Ali, R Malhotra (Accepted EYE 2014)

"Endonasal Dacryocystorhinostomy for nasolacrimal duct obstruction in patients with sarcoidosis" I Avisar, JL deSousa, PJ Dolman, AA McNab, BCK Patel, D Selva, R Malhotra Orbit. 2013 Aug;32(4):225-30. 

"Lacrimal sac mucocele" S Sagili, C Thaung, R Malhotra (Accepted Br J Ophthalmol)

"Management and outcomes of patients with epiphora referred to a specialist ophthalmic plastic unit". D Sibley, JH Norris, R Malhotra. Clin Experiment Ophthalmol. 2012 Sep 7. doi: 10.1111/j.1442-9071.2012.02866.x. [Epub ahead of print]

"The upper eyelid wick syndrome: association of upper eyelid dermatochalasis and tearing" I Avisar, JH Norris, D Selva, R Malhotra Arch Ophthalmol. 2012 Aug 1;130(8):1007-12.

Lacrimal scintigraphy: “interpretation more art than science” S Sagili, D Selva, R Malhotra Orbit. 2012 Apr;31(2):77-85. Review.

"Perspective: what does the term functional mean in the context of epiphora?" W Chan, R Malhotra, H Kakizaki, I Leibovitch, D Selva.
Clin Experiment Ophthalmol. 2012 Mar 19. doi: 10.1111/j.1442-9071.2012.02791.x.

Marsupialization for lacrimal ductal cysts (dacryops): a case series A Salam, AW Barrett, R Malhotra, JM Olver Ophthal Plast Reconstr Surg. 2011 Sep 27. 

Endoscopic dacryocystorhinostomy in acute dacryocystitis: a multicenter case series SN Madge, WO Chan, R Malhotra, R Ghabrial, S Floreani, PJ Wormald, A Tsirbas, D Selva Orbit. 2011 Jan;30(1):1-6.
 
Early experience using a new modified bone-nibbler for superior superior osteotomy during endonasal dacryocystorhinostomy V Patel, JJ Ross, R Malhotra
Ophthal Plast Reconstr Surg. 2010 Oct 11. [Epub ahead of print]
 
Evolution and changing paradigms in Dacryocystorhinostomy (review) Part I V Patel, J Ross, R Malhotra EYE NEWS (non-peer reviewed publication), October 2009 vol16(3): p52-56
 
Evolution and changing paradigms in Dacryocystorhinostomy (review) Part II V Patel, J Ross, R Malhotra EYE NEWS (non-peer reviewed publication), December 2009 vol16(4):6-10.

The lacrimal bypass tube for lacrimal pump failure due to facial palsy SN Madge, R Malhotra, JL DeSousa, A McNab, B O’Donnell, P Dolman, D Selva American Journal of Ophthalmology, November 5, 2009 Epub ahead of print

Retained silicone sleeve as a cause of dacryocystorhinostomy failure SY Then, A O'Donnell, B Beigi, R Malhotra Ophthalmic Plastic and Reconstructive Surgery, November/December 2007 23(6):492-493

An endoscopic endonasal approach for replacing Lester-Jones tubes I Leibovitch, I Sheikh, D Selva, G Davis, PJ Wormald, R Malhotra Orbit, September 2005 24(3):191-4
 
A consideration of the time taken to do dacryocystorhinostomy (DCR) surgery R Malhotra, M Wright, JM Olver Authors reply R Malhotra, J Olver Eye, 2003 ; Eye 2004 17(6):691-696


A diagrammatic record of the lacrimal system assessment R Malhotra, JM Olver Eye, 2000 14:358-363

Mr Malhotra has developed:
The Malhotra endonasal DCR nibbler
The Malhotra endonasal DCR punches

A surgical video of Mr Malhotra's technique (for the purposes of teaching) is available on youtube.
 


Healthy eyes need to be moist, so the lacrimal gland — a specialised gland located under the outer one-third of the upper eyelid — makes tears. Each time you blink, the eyelid spreads the tears over the surface of the eye and pumps excess tears into a duct that drains the tears into your nose. That is why your nose runs when you cry.

 

Watery eye or watering eye, where the patient produces excessive tears or tears flow down the cheek when they are not supposed to, is known as epiphora.

 

It is very rare not to be able to overcome the problem of a watery eye caused by a blockage of the tear drainage pathway. Depending on the nature of the obstruction, the chance of success varies from 80 to 95 per cent. Most patients are completely free from watering or only experience watering in specific situations such as cold wind.

 

Watery eye treatment should be covered by health insurance — you will need to check with your insurance company.

 

Causes

 

There are many possible reasons for watery eyes. Among them are:

 
  • Evaporative dry eye, or reflex tearing — perhaps the most common cause. This is set off by malfunctioning glands in the eyelids (the Meibomian glands), which normally secrete an oily material that forms part of our tears. This secretion helps retard the evaporation of tear water between blinks. When the glands are not functioning properly, the tear water evaporates quickly and leaves the sensitive cornea exposed. The tear glands then produce an excessive volume of tears as a reflex. That overwhelms the tear drainage system, just as it does when you cry.
  • The lower eyelid sagging away from the eye (ectropion).
  • Narrowing of the tear drain (stenosis). The drain,sometimes known as the naso-lacrimal duct, may also be completely blocked or non-functioning. If it is blocked, it can lead to a painful swelling in the inner corner of the eyelids (dacryocystitis).
  • Children born with blocked tear ducts — they have watery eyes and infection in their tears, causing a discharge to collect between the eyelids. These obstructions often resolve themselves without treatment within a few months.
  • Pump failure, where the action of the eyelids and tear drainage system is reduced. This is often because weak or lax eyelids are incapable of forcing tears to the draining duct in the inner corner of the eye.
 

Treatment

 

Treatment depends on the cause of watery eyes. Occasionally, a special form of X-ray examination of the tear drainage pathway (a dacryocystogram) or a test using a radiolabelled tracer (dacryoscintillography or lacrimal scintigraphy) is needed during assessment.

 

DCR — dacryocystorhinostomy

 

Unblocking the tear duct is called dacryocystorhinostomy (DCR) and is usually carried out under a general anaesthetic. In selected cases, when patients are unfit for general anaesthesia, it can be performed under local anaesthesia with intravenous sedation by an anaesthetist.

 

The surgery creates a new pathway between the lacrimal sac and the inside of the nose by removing a thin bone between them. Mr Malhotra may insert small silicone tubes temporarily to keep the new tear duct open while healing takes place. A DCR has traditionally been performed through a small skin incision at the side of the nose (external DCR). Nowadays, it is preferable to carry this out through the nose (endonasally).


DCR description
diagram courtesy of JL deSousa


inner lining of the nose during endonasal DCR
 
View of the inner lining of the nose during an endonasal DCR. The lacrimal sac has been opened to drain directly into the nose. Temporary tubes are also passed through this opening.
 

Endonasal DCR avoids a skin incision and the results are pretty much equal to external DCR. Mr Malhotra has designed specific pieces of equipment for this operation, the Malhotra endonasal DCR punch and the Malhotra endonasal nibbler.


Malhotra endonasal DCR punch
The Malhotra endonasal DCR punch

Malhotra endonasal nibbler
The Malhotra endonasal nibbler
 

Endonasal DCR may not be a suitable procedure if the obstruction is not in an appropriate location or there is a problem within the nose. Mr Malhotra carries out both external and endonasal DCRs and will recommend the best approach.

 

DCR removes the risk of an infection in the tear sac, known as dacryocystitis, This can develop when tears stagnate in the tear sac because of a blockage of the nasolacrimal duct. It is a painful condition that requires antibiotic tablets and sometimes injections and drainage of the tear sac. After DCR surgery, tears can no longer stagnate so the risk of infection of the sac is removed.

 

Septoplasty

 

If the nasal passage is too narrow to allow Mr Malhotra safely to carry out the procedure through an endonasal approach, he may carry out a small septoplasty to provide more space and access within your nasal passage.

 

A septoplasty straightens the partition between the two nasal passages (the nasal septum). Ideally, the septum should run down the centre of the nose. When it deviates into one of the cavities, it narrows that cavity and impedes airflow.

 

Because the deviation is a result of a cartilage and/or bone surplus, the procedure usually involves removing a portion of any of these tissues. Under general or local anesthesia, Mr Malhotra works through the nostrils, making an incision in the lining of the septum to reach the cartilage targeted in the operation.

 

Mr Malhotra takes care to preserve an L-shaped strut of cartilage of at least 1cm along the tip of the nose to maintain structural support and the overall shape and appearance of the nose. The procedure may increase your potential for a small nose bleed after surgery but only for the first day or so.

 

You are advised to carry out saline irrigations of the nasal passage and use an antibiotic ointment on the lining of the septum. You can blow your nose normally after a week.

 

Jones tube

 

This is an artificial tear duct made of Pyrex glass that remains in place permanently. This operation is usually performed under general anaesthesia, although it can be performed under local anaesthesia with intravenous sedation by an anaesthetist for patients unfit for general anaesthesia.

 

A Jones tube can be used when DCR surgery has failed and for patients who have a blockage of the duct between the eye socket and nose caused by scars, recurrent infections or ageing.

 

Unblocking the tear duct

 

A minor probing of the tear duct will usually fix matters if a baby is born with the condition and it does not heal itself without intervention. More specialist surgery may be needed if this is not successful.

 

Eyelid tightening

 

This can help when pump failure has taken place. The operation is usually performed under local anaesthetic.

 

Positioning the eyelid

 

For patients suffering from outward turning of the lower eyelid (ectropion).

 

Artificial tears

 

These prevent drying of the eyes that leads to excessive production of real tears. There are a variety of artificial tear preparations available. Some patients prefer one over another for their own reasons, so it is a good idea to try different preparations.

 

If the tears need to be used more frequently than four times a day it is better to choose a preparation that is free of preservatives. Mr Malhotra can advise which preparations to try and often carries out a lubricant trial when identifying the main cause for a watery eye.

 

Closing the openings of the tear drainage system

 

If artificial tears do not adequately relieve the discomfort of dry eyes, closing the openings of the tear drainage system can help to keep more moisture on the eye, making it feel less sore and gritty.

 

The closure can be performed temporarily, with the insertion of silicone plugs, or more permanently, with surgery. In either case, the procedure is carried out under local anaesthetic. In extreme cases, other eyelid procedures may be required to control the drying.

 

What to expect

 
  • You will normally be a day patient. After recovery time, you will be moved to a ward. Many people stay overnight but you may go home the same day if all is well.
  • You will generally be able to fly after two days but should check with your doctor.
  • Your eye may still be watery while the silicone tubes are in place — if you need to wipe your eye, do it towards your nose to avoid catching the tubes.
  • You should consider resting for two or three days but can drive and return to normal, gentle activities the next day, if necessary.
  • You should avoid blowing your nose for the first week after surgery.
  • At the first appointment, the tubes are checked and, with external DCRs, the stitches removed.
  • At the second, the drainage site is examined in the clinic and the silicone tubes are removed.
 

All procedures begin with a consultation. For full information about what to do before and after surgery, see Patient information.



 

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