Complex Lacrimal Disease


Which patients are more ‘complex’?

Lacrimal symptoms vary from an awareness of excessive tears in the eye, to flooding of the eye with tears, an overflow of tears onto the cheek (referred to as “epiphora”) and / or mucus discharge from the inner corner of the eye. Some patients will respond to simple lubrication of the eye with artificial tears, whilst others may require surgical intervention to restore the drainage of tears from the eyes.

However the causes of the watering may be more complex, and may include the following patients:

(a) Those who have undergone previous surgery for a watery eye, and in whom the symptoms have returned.

(b) Those in whom there has been blockage to the fine canaliculi (tear out-flow channels) in the eyelids.

The causes include:

a. Injuries to the eyelids
b. Previous surgery to the inner corner of the eyelids (the medial canthus)
c. Previous viral infections of the eyes
d. Certain inflammatory diseases
e. A past history of chemotherapy
f. Previous use of certain types of punctal plug
g. Previous operations

How is a patient with complex causes for watering managed?

The key to the successful management of the watering eye in such complex situations requires:

a. Sufficient understanding of the possible background causes
b. The ability to interpret appropriate investigations
c. A logical approach to management
d. A wide practical experience of the appropriate surgery
e. Experience of preventing and managing surigical complications

Depending on the causes of overflow tearing, and the level of lacrimal blockage, treatment may entail the following:

a. Correction of any eyelid malposition

b. Management of conjunctival and / or ocular surface disease
c. Punctal enlargement
d. External dacryocystorhinostomy (DCR) with placement of a stent
e. DCR with removal of a membranous block
f. DCR and canalicular revision (DCR and retro-canaliculostomy)
g. Endonasal revision of previous surgery with placement of a stent
h. Placement of a pyrex lacrimal bypass tube – a Lester Jones tube – (in cases where previous lacrimal surgery has been unsuccessful, and / or where the natural drainage channels are absent or injured)


In these situations, can a watery eye be cured?

A degree of watering of the eye is common in all healthy individuals from time to time. However, where there are different, and / or complex, causes for watering, the outcome of medical and surgical intervention depends on the severity of the underlying cause(s). With appropriate treatment, which in the most challenging cases may even require the placement of a pyrex lacrimal bypass tube – a Lester Jones tube – the great majority of complex patients can expect significant relief from their symptoms.