Tearing Evaluation

History of symptoms

A tearing evaluation of begins with the determination of unilateral vs. bilateral tears, but also:

  • Nasal/sinus/facial fracture or surgery
  • Bloody tears/pain without inflammation (rule out tumor)
  • Nasal polyps, sinusitis
  • Hay fever
  • External ocular irritation
  • Bell’s palsy
  • Epinephrine
  • Phospholine iodide

Etiologies of Epiphora

Causes of excessive watering of the eye (epiphora) may include:

  • Surface irritation/reactive hypersecretion
  • Outflow obstruction
  • First degree idiopathic hyper-secretion
  • 5th nerve stimulation: external/corneal disease pseudoepiphora
    • dry eye syndrome
    • conjunctivitis
    • blepharitis
    • uveitis
    • entropion
    • trichiasis
    • thyroid eye disease
    • sinusitis
    • hay fever
    • dental problems (6th nerve aberrant regeneration, post-Bell’s palsy; crocodile tears)
  • Central nervous system issues
  • Inadequate drainage
    • Stiff lid
    • From burn, scar tissue, scleroderma
    • Lacrimal pump dysfunction, punctal displacement
    • Punctal problems
      • genesis (probe membranes, and if none seen cut down and over probe, inject methylene blue inferior to medial canthal tendon)
      • stenosis (treat with dilation, ampulotomy, may possibly need silicone intubation, eversion/malpositions, rx with internal vertical shortening, may possibly need horizontal lid shortening for laxity, transconjunctival cautery inferior to punch in bedridden patients)
    • Conjunctivochalasis
      • can occlude punctum
      • rx: vasoconstrictor (Visine, etc.) course then PF may possibly be helpful
    • Canalicular problems
      • common canaliculus occlusion
      • trauma
      • meds: 5-FU, IDU, PI, eserine
      • viral infection
      • autoimmune (pemphigoid, Stevens-Johnson)
    • Canaliculitis
      • mostly actinomyces israelii, gm filamentous rod, yellow concretions (sulfur), other bact & fungi
      • rx: compresses, antibiotics, curretage, canaliculotomy to remove concretions
    • Functional Occlusion
      • may possibly be total occlusion if poor pump function
      • repeat probings
      • NLD obstruction
    • Congenital

Examination of the Lacrimal System

In examining the lacrimal system for problems:

  • Check puncta for stenosis, position
  • Conjunctivochalasis – is excess conjunctiva obstructing puncta opening
  • Conjunctival injection
  • Trichiasis
  • Entropion
  • Pseudoepiphora: tear evaluation (meniscus, tear break up time)
  • Keratopathy
  • Lid stiffness
  • Lid laxity
  • Pump function Lagophthalmos
  • Check VII nerve
  • Look up nose
  • Schirmer 1
  • Push on sac, look for discharge
  • Basic Tear Secretion (BST) (tear strips after anesthesia)
  • Dye Disappearance Test (DDT) (fluorescein to both fornices, look with blue light for asymmetry after 5 minutes)

Primary Dye Test

  • Fluorescein to eyes, blow nose, dye present or absent

Irrigation (JONES I)

  • Estimate flow through system
  • Topical anesthesia
  • Lower punctal dilation and irrigation, noting stenosis
  • Drawing amount of flow 0-100%:
  • Reflux around canula or out superior punctum without lacrimal sac distension = common canaliculus block, if same lacrimal sac distension likely complete nasolacrimal duct obstruction
  • If no reflux but w/pain lacrimal sac distention = nasolacrimal duct obstruction w with patent valve of Rosenmuller
  • If reflux and drainage to nose = partial nasolacrimal duct obstruction

Secondary Dye Test = Informal Jones II

  • Irrigate, dye present in nose = functional nasolacrimal duct obstruction, patent canalicular system, functional pump; or absent


  • Diagnostic probing of adult upper system (puncta, canaliculi, lac sac) ok to find level of obstruction, not to probe NLD

Dacryocystogram (DCG)

  • Good for anatomy, not physiology evaluation



Epiphora: Patients with epiphora complain of watery eyes; it is when there is an imbalance between production and drainage of tears. Visit the Lacrimal page for more details.


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