The tearing patient is often seen by oculoplastic surgeons. The evaluation and treatment of this condition can be both extremely satisfying and equally frustrating. The underlying cause of tearing can be divided into two broad categories. For patients who fall in the first category, tearing is present because the tear drainage system is plugged, and tears cannot drain down the nasolacrimal duct into the nose. An obstructed nasolacrimal duct is analogous to a sink with a plug in the drain. Water flows into the sink until the sink overflows. The treatment for this type of tearing is directed at repairing the outflow tract or "unclogging the drain".

In the second category, tearing is caused by some sort of ocular irritation. Tearing in this category is more commonly seen and may be due to a variety of conditions such as dry eyes, allergic conjunctivitis, contact lens use, and eyelid malposition. A good example of tearing caused by irritation is the tearing that develops when peeling an onion. The treatment for irritated tearing is directed at removing or ameliorating the underlying cause. The most common cause of irritated tearing is the common dry eye.

The diagnosis of dry eyes is made by clinical history and a few simple tests in the doctor's office. A history of a "gritty sensation" accompanied by intermittent tearing and ocular redness is suggestive of dry eyes. Simple office tests can often confirm a deficiency of tear production. The treatment of dry eyes is primarily designed to increase the lubrication of the cornea with artificial tears or ointment. In a vast majority of patients, this simple and effective treatment regimen improves symptoms significantly.

Punctal occlusion is a treatment option for many dry eye patients. Punctal plugs function by preventing the tears from draining away from the eyeballs. A variety of products are commercially available to temporarily or permanently occlude the tear duct drain. Punctal plugs are always used with caution, since the major complication of punctal occlusion is excess tearing.

Permanent punctal occlusion is a good option for the severe dry eye patient. Prior to permanent punctal occlusion, a trial of temporary punctal occlusion must be completed. Permanent punctal occlusion is achieved in the office quite easily, and it effectively prevents tears from draining away from the eyeball.

Dacryocystitis is a painful infection and abscess of the lacrimal sac. The infection causes tearing by blocking the tear duct drain. The usual cause of dacryocystitis is chronic infection and inflammation. Lacrimal stones, trauma, and cancer can also lead to dacryocystitis if the tear duct drains are blocked.

The diagnosis of dacryocystitis is made by observing a painful swelling in the region of the lacrimal sac and excess tearing. This obstruction can be confirmed by simple office testing. The treatment of dacryocystitis is initiated with topical and systemic antibiotic therapy. Definitive treatment of dacryocystitis requires a dacryocystorhinostomy (DCR). This operation creates a new passageway for the tears to drain into the nose. This surgery is highly successful, with at least 95% of patients cured of dacryocystitis and tearing. The surgery requires approximately 30 minutes of general anesthesia and an overnight stay in the hospital. A half-inch incision is made on the side of the nose at the time of surgery. The scar usually disappears three months after surgery. Patients can expect to return to work several days after the operation.

copyright 1998 John A. Long, M. D., F.A.C.S.