Use drops, irrigation to treat patients with epiphora
An oculoplastic surgeon shares tips on the evaluation and management of multifactorial epiphora.
Epiphora is one of the more common complaints in an ophthalmology practice. Defined as abnormal excessive tearing, epiphora can have a social impact, cause blur and be associated with infections, as shown in Figure 1. Knowing how to distinguish and assess the many causes of epiphora is essential to guiding successful treatment. This article will focus on the more common causes of epiphora, with emphasis on in-office treatment and topical therapy.
Adult epiphora is most commonly due to a combination of factors involving the eyelid, ocular surface and lacrimal excretory system. The history will be able to generate significant clues before the exam. Duration of tearing, unilateral vs. bilateral, constant vs. intermittent, presence of irritation and prior intervention, including medication or surgery, should all be recorded. For example, if tearing is unilateral and constant, this may indicate primarily a lacrimal problem. Conversely, tearing that is bilateral and intermittent could represent an ocular surface problem.
The examination of the tearing patient begins with an external exam looking at the eyelid for malpositions including ectropion, entropion and horizontal laxity. Digital pressure is placed on the lacrimal sac to see if there is discharge from the punctum. Presence of discharge can indicate a nasolacrimal duct obstruction. Slit lamp examination is then performed, specifically looking at the ocular surface for causes of irritation and reflex tearing including allergy, dry eye, meibomian gland disease, rosacea and trichiasis. Special attention is given to the punctum, noting its position and caliber. A normal punctum should be in apposition to the globe and have an open aperture. Punctal stenosis is one of the main factors contributing to epiphora in an adult, but it must be looked for (Figure 2).
Lacrimal testing begins with a dye disappearance test. A drop of fluorescein is placed in the eye and observed for clearance within a few minutes. Retention of the dye could indicate a lacrimal drainage problem. A basic secretor test is used to assess for dry eye. This is done with topical anesthetic, and the test strips are measured after 1 minute. Wetting less than 3 mm is indicative of dry eye.
Nasolacrimal probing and irrigation is the gold standard of lacrimal diagnosis and in select cases can be used for treatment. The punctum is dilated after two drops of anesthetic. A lacrimal cannula on a 3 cc syringe is advanced smoothly into the canaliculus. Resistance to advancement in the canaliculus or a soft stop indicates a canalicular stricture. A small amount of water is gently injected, and if the system is patent, the patient should feel the water in the nose (Figure 3A and 3B). Attention is paid to the puncta as the water is injected. If there is a nasolacrimal duct obstruction, there will be reflux from the puncta.
A nasolacrimal duct obstruction does not have to be an all-or-nothing phenomenon. Degrees of partial obstruction can be assessed by the experienced examiner by judging the amount of reflux encountered vs. the amount injected and the amount flowing thorough into the nose. For example, if 0.5 cc of water is injected and about half of the amount is reflux but the patient feels the water in the nose, there is about a 50% obstruction. This assessment is readily gained through proper technique and experience.
In lieu of frank pathology such as entropion or a complete nasolacrimal duct obstruction, epiphora in the adult patient is almost always a combination of eyelid, ocular surface and lacrimal factors. The typical patient will have a mix of causes including dry eye, meibomian gland disease, allergy and trichiasis combined with varying degrees of punctal stenosis and nasolacrimal duct obstruction. Clinical judgment and experience are used to determine the causative factors and treatment.
Treatment begins with nasolacrimal dilation and irrigation with initiation of topical therapy. Choice of drops depends upon severity, symptoms and findings. For example, a patient with mild symptoms and allergy as a prominent component may be started on Patanol (olopatadine HCl, Alcon). I have found the antihistamine portion of Patanol to be slightly drying and thus a beneficial side effect for the purposes of treating epiphora. A patient with more severe symptomatology may benefit from steroids such as Alrex (loteprednol etabonate 0.2%, Bausch & Lomb) or Lotemax (loteprednol etabonate 0.5%, B&L). Restasis (cyclosporine ophthalmic emulsion 0.05%, Allergan) has also been useful since conditions such as dry eye, meibomian gland disease, allergy and rosacea all have inflammation as an underlying component of reflex tearing. Restasis may also be combined with Alrex or Lotemax for more rapid relief. A healthy ocular surface simply tears less.
Patients are reassessed after 1 month. If the patient with lacrimal and ocular surface pathology shows some improvement, the nasolacrimal system is dilated and irrigated and the drops continued. If initiated, steroids are tapered in favor of Patanol or Restasis for longer-term treatment. Patients then return in 3 months. If the patient shows no improvement after 1 month, stronger drops such as Lotemax and Restasis are initiated or increased in dosing. The lacrimal system is also dilated and irrigated. If the patient returns again after 1 month and has no improvement, then a surgical correction of eyelid or lacrimal factors can be considered. Let the patient’s symptoms guide treatment and follow-up. Multifactorial epiphora can be a challenging problem; however, many of these patients can be controlled with conservative therapy consisting of drops and irrigation.
For Your Information:
- Michael L. Glassman, MD, FACS, can be reached at 115 E. 57th St., 10th Floor, New York, NY 10022; 212-832-2020; fax: 212-832-9739. Dr. Glassman is a paid consultant for Allergan.