Common Eyelid problems related to dry eye disease: Part 6b: When tears run over the eyelids (visibly crying when you don’t mean to, Part 2)

 In the last post, I discussed the many, common causes of tearing when you don’t need to, try to, or mean to - best described as “reflex tearing” (apart from the babies born with teary eyes). That post includes a diagram of the anatomy, which I recommend you review if terms I use in this post are unfamiliar.

The problem when simple, reflex tearing is not the problem, usually relates to internal blockages of the plumbing itself. Of interest is the fact that in treating dry eye, we sometimes will intentionally block the plumbing with plugs (“Punctal plugs” – see my earlier post on this here: https://www.eyethera.com/blog/what-about-punctal-plugs-or-why-not-dam-up-those-damn-tears). The larger problem with a tear duct that blocks deeper in the plumbing (other than on the surface, like these plugs), is that the blockage, or “dam,” creates a pool of tears trapped in the dark recesses of that plumbing can act as food for germs – creating colonies of these microscopic critters that can back up and infect eyes, or can ooze through the plumbing and into the skin, creating infections that can be hard to treat and even life threatening, as this can function like an abscess. Antibiotics can contain some of these infections, but to get permanently rid of them, we need to fix the plumbing to “open the dam.” In the short term, this may mean an incision to drain the “abscess,” but in the longer term, it will depend on where in the system the dam occurs (and the cause of that dam).

A common cause of blockage is a “stone” – an accumulation of mucus, salts, inflammatory and infectious debris – that block the internal passages (a bit like a nose “booger” can clog up a nose). Blepharitis (especially chronic, low-grade infections), allergies and any form of dry eye disease appear to be common culprits in putting mucus, germs and inflammatory debris into tears and then into the tear ducts draining those tears. When this happens in the canaliculi (the narrow, internal passageways closest to the eyes), then even little stones can cause big troubles and may require surgical opening and removing that material with little spoons (curettes). Adding a course of antibiotics is common, as germs are often found in that mix and can be a primary cause of the stony material, as well as to complicate healing. Flushing the ducts with saline and/or cleaning solutions or antibiotics can also be helpful.

https://eyewiki.aao.org/Dacryocystorhinostomy

Example of an infected tear sac from a blocked tear duct – called dacryocystitis.

When blockages from stones, inflammation, injuries, or infections (like the dacryocystitis photo above) occur deeper in the passageways, then larger surgeries are often required – though similar flushing - as used for superficial blockages, can sometimes be helpful or even curative. When fluid “back-flushes” from the lower punctum to the upper, then we know the blockage is deeper than the “common canaliculus,” (where the two small passages come together), which means unclogging or bypassing the deeper blockage can be curative. The common non-surgical way to do this, is to either vigorously flush or probe (if possible) from the punctum to the nose, and in some cases, leave a tiny, thin, silicone tube in place to allow healing of the probed passageway to occur without healing it closed (the tube helps keep it open until it heals – typically over a few months) – or if flushing or probing is not possible due to big stones, heavy scarring or strictures – then surgery with a so called “Dacryocystorhinostomy” – or “DCR” is performed.

 

A DCR bypasses the blockage in the sac or duct by making a small hole in the nasal bone and connecting the tear plumbing to the nose more directly. This can be done from the outside-in (the external approach) or from the inside-out (the endoscopic, internal approach). Both approaches offer high levels of success, and the principal advantage of the internal approach is the lack of a visible scar alongside the nose. This is mostly done under general anesthesia and requires extra tools and training that is common among Ear Nose and Throat (ENT) doctors and some oculoplastic surgeons. Modern techniques rival success rates of the external approach. The external approach can sometimes offer better visibility and help in diagnosing rare causes of blockage, as from internal tumors or cysts. The external approach can be done under local anesthesia and may take a bit less time to perform. Discussion about which technique is best for an individual case is best left up to the surgeon and the patient. My personal preference is to work alongside an ENT surgeon, as I find the ENT group I work with excels at the internal approach. My years of doing external DCRs can offer some advantages in terms of probing and instilling the silicone tubing we find helps ensure best results.

 

More complex, is the case where the common canaliculus is blocked. This usually requires a permanent (Jones) tube be installed, to take the place of the internal natural plumbing – and this can be coupled with the DCR approach (a so-called Conjunctivo-DCR or CDCR). Oculoplastic surgeons are trained in this less common realm of subspecialty care.

 

So, what to do when your eyes want to cry when you don’t need or want them to? First, take care of your eyes and eyelids along the recommendations I’ve given, and most dry eye specialists agree on – and that is prevention using good lid hygiene and making your best tears. Treat infections and allergies with the help of those specialists and if common treatments for dry eye are insufficient, or tearing is frequent, then have that specialist irrigate your tear ducts to flush out debris that can contribute to clogging and to prove that your tear drainage plumbing can work properly. If there is a deeper clog, have them help you clear it without surgery, if possible, but don’t hesitate to have the surgery if your surgeon says it is indicated. Untreated, these blockages amplify reflex tearing “spill over” - which is annoying - but can lead to increasing rates and degrees of infections and antibiotic treatments can select for resistant germs over multiple recurrences. This can be a bad combination - leading to hospitalization, increasing difficulty in future surgical success and in extreme cases, risk death from aggressive, antibiotic-resistant germs.

To schedule an appointment with Dr. Jaccoma, call Excellent Vision at either of these two dry eye offices:

(1) 155 Griffin Rd, Portsmouth, NH 03801 (603) 574-2020

(2) 3 Woodland Rd, STE 112 Stoneham, MA 02180 (near Boston) (781) 321-6463

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When tears don’t drain properly you get “Toxic Soup.” (and the “Toxic Soup Syndrome!”)

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Common Eyelid problems related to dry eye disease: Part 6a: When tears run over the eyelids (visibly crying when you don’t mean to, Part 1 of 2)