Common Eye Conditions • Lacrimal apparatus • Watering eye and dacryocystitis
Disorders of the Lacrimal Apparatus: Watering Eye, Obstruction and Dacryocystitis
The lacrimal apparatus produces, spreads and drains the tear film. Disorders may present with watering, discharge, recurrent conjunctivitis, medial canthal swelling or painful infection. The emergency clinician must distinguish reflex tearing from drainage obstruction and identify dacryocystitis that has extended to preseptal/orbital cellulitis.
Emergency warning: Fever with medial-canthal swelling, proptosis, painful/restricted eye movements, reduced vision, RAPD, severe headache, vomiting, altered consciousness, rapidly spreading facial swelling or neonatal dacryocele requires urgent hospital/ophthalmic assessment.
Learning objectives
- Describe the lacrimal glands, puncta, canaliculi, lacrimal sac and nasolacrimal duct.
- Explain epiphora and differentiate overproduction from drainage failure.
- Recognise congenital/acquired nasolacrimal obstruction, canaliculitis, dacryocystitis and dacryoadenitis.
- Perform a safe history and examination, including medial-canthus and nasal assessment.
- Describe first aid, medical treatment, investigations, definitive procedures and prevention.
- Recognise complications requiring admission and urgent specialist referral.
1. Anatomy and physiology of tears
| Structure | Role | Clinical relevance |
|---|---|---|
| Main lacrimal gland | Produces the aqueous component of the tear film; located superotemporally in the orbit. | Inflammation causes painful superotemporal swelling and reduced tear production. |
| Accessory lacrimal glands | Contribute baseline aqueous secretion. | Support continuous surface lubrication. |
| Conjunctival goblet cells | Produce mucin that helps tears spread over epithelium. | Surface disease can cause unstable tears and reflex watering. |
| Meibomian glands | Produce lipid layer that reduces evaporation. | Dysfunction causes evaporative dry eye and reflex tearing. |
| Upper/lower puncta | Small openings at the medial lid margins that collect tears. | Ectropion, scarring or stenosis causes epiphora. |
| Canaliculi | Short channels from puncta to the lacrimal sac; common canaliculus may join before the sac. | Canaliculitis, concretions and trauma can obstruct flow. |
| Lacrimal sac | Reservoir in the lacrimal fossa between the medial canthal tendon and nasal bone. | Stasis and infection cause dacryocystitis and medial-canthal swelling. |
| Nasolacrimal duct | Carries tears through the bony canal to the inferior nasal meatus. | Congenital membrane or acquired stenosis causes chronic watering/infection. |
Blinking creates a lacrimal pump: orbicularis contraction compresses the canaliculi and sac, while lid apposition directs tears toward the puncta. A normal tear system therefore depends on secretion, a smooth ocular surface, correct lid position, patent drainage and nasal anatomy.
2. Watering eye (epiphora)
Epiphora means tears overflow onto the cheek. It may be caused by excessive reflex production, failure of drainage or both. Ask whether the eye is truly watering or feels dry with intermittent reflex tearing.
| Mechanism | Examples | Clues |
|---|---|---|
| Reflex overproduction | Dry eye, blepharitis, allergy, foreign body, corneal abrasion/ulcer, keratitis, smoke/wind/chemical irritation. | Burning, gritty sensation, redness, photophobia or pain. |
| Punctal problem | Punctal stenosis/atresia, ectropion, scarring or inflammation. | Overflow with abnormal punctum position or lid malposition. |
| Canalicular obstruction | Canaliculitis, concretions, trauma, surgery, inflammation. | Medial lid tenderness, pouting punctum, discharge or recurrent unilateral symptoms. |
| Sac/duct obstruction | Primary acquired NLDO, congenital obstruction, tumour, trauma, chronic inflammation. | Persistent unilateral watering, reflux from punctum or recurrent dacryocystitis. |
| Nasal cause | Rhinitis, inferior-meatus obstruction, polyps, sinus disease or fracture. | Nasal congestion, discharge, bleeding or prior nasal trauma/surgery. |
3. History and examination
- Record onset, laterality, constant/intermittent pattern and whether tears run down the cheek.
- Ask about pain, redness, discharge, fever, trauma, surgery, nasal disease, contact lenses and systemic inflammatory disease.
- Check vision, pupils/RAPD, cornea, conjunctiva, eyelid position and ocular motility.
- Inspect the puncta for position, stenosis, pouting, concretions and discharge.
- Palpate gently over the lacrimal sac, noting tenderness, swelling and reflux; do not force pressure in acute infection.
- Examine the nose for congestion, purulence, bleeding, mass, septal disease and inferior-meatus obstruction.
- Assess the medial canthus and orbit for proptosis, spread, skin necrosis or painful movements.
4. Nasolacrimal duct obstruction (NLDO)
Congenital obstruction
Congenital NLDO commonly results from persistence of a distal membranous barrier near the inferior nasal meatus. Infants present with persistent tearing and mucous mattering despite otherwise healthy eyes. Complications include recurrent infection, dacryocele and rarely orbital/airway problems.
- Check the red reflex, cornea, pupil and visual behaviour so congenital glaucoma, cataract and corneal disease are not missed.
- Clean discharge with sterile saline/gauze; avoid sharing towels.
- In uncomplicated infants, clinicians may teach gentle lacrimal-sac massage and monitor. Recurrent infection, dacryocele, fever or corneal/visual abnormality requires paediatric ophthalmology.
- Persistent obstruction may require probing or other lacrimal intervention by an ophthalmologist; acute infection is treated first.
Acquired obstruction
| Cause | Examples | Clinical clues |
|---|---|---|
| Primary acquired stenosis | Inflammatory/fibrotic narrowing, often in older adults. | Chronic unilateral epiphora, recurrent discharge or dacryocystitis. |
| Traumatic/iatrogenic | Medial eyelid injury, facial fracture, nasal/ocular surgery. | Onset after trauma/procedure; canalicular or punctal injury. |
| Infectious/inflammatory | Chronic conjunctivitis, canaliculitis, sarcoidosis, granulomatosis or autoimmune disease. | Recurrent inflammation, bloody reflux or systemic symptoms. |
| Neoplastic | Lacrimal sac/nasal tumour. | Blood-stained tears, firm mass, unilateral persistent symptoms or failure of usual treatment. |
| Medication/radiation | Chronic topical toxicity, chemotherapy or radiotherapy. | Dry eye plus stenosis or history of treatment. |
5. Dacryocystitis
Dacryocystitis is infection and inflammation of the lacrimal sac, usually because nasolacrimal obstruction causes tear stasis. It may be acute, chronic or recurrent.
| Type | Features | Risks |
|---|---|---|
| Acute | Rapid painful erythema, warmth and swelling over the inferomedial canthus; tearing, discharge and tenderness. | Abscess, preseptal/orbital cellulitis, fistula, sepsis and intracranial spread. |
| Chronic | Persistent watering, mucous discharge, medial swelling and reflux with pressure. | Recurrent conjunctivitis, corneal contamination and acute flares. |
| Congenital/neonatal | Dacryocele or medial canthal swelling with tearing/discharge. | Rapid infection, orbital cellulitis, meningitis or airway compromise in severe cases. |
Clinical distinction
- In dacryocystitis, the maximal tenderness is over the lacrimal sac below/near the medial canthus; the punctum may look relatively normal.
- In canaliculitis, the punctum/canaliculus is pouting, red and tender, and concretions or discharge may express.
- In orbital cellulitis, proptosis, painful restricted motility, diplopia, reduced vision or RAPD indicate postseptal spread.
Management principles
- Assess severity: vitals, vision, pupils, motility, proptosis, fever, neurological status and immunocompromise.
- Uncomplicated acute disease: warm compresses and clinician-directed systemic antimicrobial treatment with close review; culture purulent material when appropriate.
- Abscess: urgent ophthalmic drainage may be required. Avoid forceful massage or probing through friable infected tissue.
- Complicated disease: admission, IV antibiotics, imaging and surgical consultation if orbital signs, systemic toxicity, immunosuppression, rapid progression or failure of oral therapy.
- Definitive treatment: after acute inflammation settles, address obstruction—often with dacryocystorhinostomy (DCR) or another specialist procedure.
6. Canaliculitis
Canaliculitis is infection/inflammation of a canaliculus, often associated with concretions (canaliculiths) and chronic unilateral symptoms. Patients may be repeatedly treated for conjunctivitis without improvement.
- Symptoms: unilateral watering, mucopurulent discharge, medial red eye, pouting punctum, mild local tenderness and recurrent “conjunctivitis.”
- Possible organisms include Actinomyces and other bacteria; concretions may harbour infection.
- Management often requires warm compresses, canalicular irrigation and removal of concretions/foreign bodies, frequently by canaliculotomy or another specialist procedure. Topical/systemic antimicrobial treatment is adjunctive and protocol-directed.
7. Dacryoadenitis
Dacryoadenitis is inflammation of the lacrimal gland in the superotemporal orbit, unlike dacryocystitis, which affects the inferomedial lacrimal sac.
| Cause | Clues | Management direction |
|---|---|---|
| Viral | Acute tender superotemporal swelling, often with systemic viral symptoms. | Supportive care and assessment for bacterial complication. |
| Bacterial | Fever, marked tenderness, erythema, purulent infection. | Urgent antimicrobial treatment and orbital assessment. |
| Inflammatory/autoimmune | Chronic or recurrent swelling, bilateral disease, systemic features. | Specialist work-up, imaging and directed immunologic treatment. |
| Neoplastic | Firm, persistent, painless or progressive mass. | Imaging and specialist biopsy pathway. |
8. Investigations
| Investigation | Purpose | Interpretation/caution |
|---|---|---|
| Visual acuity, pupils and motility | Detect sight-threatening ocular/orbital spread. | Abnormal findings require urgent escalation. |
| Slit-lamp examination | Assess surface, puncta, conjunctiva and cornea. | Look for ulcer, infiltrate, inflammation and discharge source. |
| Fluorescein dye disappearance | Screen tear clearance over several minutes. | Persistent dye suggests reduced drainage but is not definitive alone. |
| Regurgitation test | Gentle pressure over sac may express reflux through punctum. | Avoid force in acute infection; pus supports sac involvement. |
| Probing and irrigation | Assess punctal/canalicular/duct patency and reflux pattern. | Performed by trained clinicians; avoid acute friable infection unless specialist-directed. |
| Nasal examination/endoscopy | Assess inferior meatus, rhinitis, polyps, mass, trauma or postoperative anatomy. | Helps plan definitive surgery. |
| Culture/NAAT | Identify organisms in severe/recurrent purulence, neonatal disease or treatment failure. | Collect appropriately without delaying urgent treatment. |
| CT/MRI orbit/sinuses | Assess abscess, orbital/intracranial spread, tumour, fracture or sinus disease. | Urgent when vision, motility, proptosis or systemic status is abnormal. |
9. First aid, medical and surgical management
- Immediate protection: clean discharge with sterile saline/gauze, hand hygiene and avoid sharing towels. Do not rub or forcefully massage a painful swelling.
- Warm compress: may relieve uncomplicated obstruction/canaliculitis or chronic symptoms; avoid burns and avoid pressure in acute severe infection.
- Antimicrobial therapy: selection, route and duration depend on age, severity, allergy, local resistance and complications; use current facility/ophthalmology protocols.
- Abscess drainage: required when fluctuance, persistent collection or progression occurs; specialist drainage prevents rupture and spread.
- DCR: creates a new drainage pathway between lacrimal sac and nasal cavity, bypassing an obstructed duct; external or endonasal approaches may be used.
- Children: urgent paediatric/ophthalmic review for dacryocele, fever, respiratory difficulty or suspected congenital infection.
- Follow-up: treat the obstruction after acute inflammation settles; recurrent attacks without definitive correction are common.
10. Emergency complications
Orbital cellulitis
Spread beyond the orbital septum causes fever, proptosis, painful/restricted movements, diplopia, reduced vision or RAPD. Admit urgently for imaging, IV treatment and surgical review when indicated.
Lacrimal abscess/fistula
Persistent tender fluctuant medial swelling may rupture through skin or posteriorly. Avoid squeezing; arrange urgent drainage and specialist care.
Intracranial spread
Severe headache, vomiting, altered mental status, meningism, seizures or neurological deficits suggest deeper spread and require emergency imaging and multidisciplinary management.
Neonatal dacryocele
Blue medial canthal swelling, respiratory distress or infection in a newborn requires urgent paediatric ophthalmic evaluation; do not treat as simple watering.
11. Nursing and patient education
- Record laterality, onset, fever, pain, swelling size, discharge and visual function; repeat observations to detect spread.
- Administer prescribed antibiotics/analgesia and monitor allergy, response and gastrointestinal/systemic effects.
- Use warm compresses correctly and keep the skin clean/dry; discard gauze after one use.
- Teach parents safe infant lacrimal massage only when instructed; do not press an acutely inflamed sac.
- Explain that chronic watering may require a procedure even after infection improves.
- Return immediately for fever, increasing redness/swelling, proptosis, pain on movement, blurred vision, vomiting or reduced responsiveness.
12. Applied cases
Case 1: Chronic unilateral watering
An older adult has months of unilateral epiphora and occasional mucous reflux but no pain. Assess lid position, puncta, cornea and nasal disease; refer for lacrimal irrigation/imaging and definitive obstruction management. Persistent blood-stained reflux or a firm mass needs urgent exclusion of tumour.
Case 2: Acute medial-canthal swelling
A patient develops painful red swelling below the medial canthus and purulent reflux. Acute dacryocystitis is likely. Check vision, pupils, motility and fever; start protocol-based treatment and urgent review, avoiding forceful probing in acute infection.
Case 3: Lacrimal infection with proptosis
A child with dacryocystitis develops fever, proptosis and painful restricted movements. This suggests orbital cellulitis, requiring emergency admission, imaging and IV therapy—not outpatient drops alone.
Case 4: Pouting punctum
A patient has recurrent unilateral conjunctivitis, a swollen pouting punctum and small concretions. Canaliculitis is more likely than dacryocystitis; specialist canalicular exploration/removal is often needed.
13. Self-test
- What is epiphora?
- Trace the normal pathway of tear drainage.
- Differentiate reflex tearing from drainage obstruction.
- Where is dacryocystitis located compared with canaliculitis?
- List four red flags suggesting orbital spread.
- Why should acute dacryocystitis not be forcefully probed?
- What is the purpose of dacryocystorhinostomy?
- What are common presentations of congenital NLDO?
- Which lacrimal mass may suggest tumour?
- What findings require hospital admission?
Answers
- Overflow of tears onto the cheek.
- Main/accessory lacrimal glands → ocular surface → puncta → canaliculi → lacrimal sac → nasolacrimal duct → inferior nasal meatus.
- Reflex tearing follows irritation/inflammation; obstruction causes overflow despite a normal or dry surface and often persistent unilateral symptoms.
- Proptosis, painful/restricted movements, reduced VA/RAPD, diplopia, fever/systemic toxicity, severe headache or neurological signs.
- Friable infected tissue can create false passages, spread infection or injure the system; specialist management is safer.
- To bypass an obstructed duct by creating a drainage connection between lacrimal sac and nasal cavity.
- Persistent tearing/mattering from congenital distal duct obstruction, sometimes with dacryocele.
- Persistent unilateral watering, blood-stained reflux, firm swelling, recurrent “dacryocystitis” or failure to respond to usual treatment.
- Orbital signs, systemic toxicity, rapidly progressive infection, abscess, neonatal dacryocele with infection/airway concern or intracranial symptoms.
Key takeaways
- Watering may reflect overproduction, poor drainage or both; examine the surface, lids, puncta, sac and nose.
- Dacryocystitis is usually infection behind nasolacrimal obstruction and can spread to the orbit.
- Canaliculitis causes a pouting punctum and recurrent unilateral discharge; it often needs removal of concretions.
- Proptosis, painful movements, visual loss or systemic toxicity transform lacrimal disease into an emergency.
- Definitive treatment addresses the obstruction after acute infection is controlled.
