Epiphora secondary to frequent wiping can be easily treated

A practitioner explains why patients who have this condition should stop wiping their eyes.

Issue: July 10, 2012

ByAbdul Khaliq, MD, FRCS

Chronic epiphora can have a dramatic effect on a patient’s quality of life, to the point of dysfunction.

Although epiphora is strictly due to an obstruction of the lacrimal drainage system (except for lacrimal functional block), there has been an overlap between lacrimation and epiphora. For example, tearing due to entropion is considered epiphora when the lacrimal passages are open. Epiphora secondary to frequent wiping is primarily due to lacrimal gland hypertrophy in the presence of patent lacrimal passages. Hypertrophy of the lacrimal gland also occurs in the presence of lacrimal drainage system obstruction, in which wiping is even more frequent than in nonobstructive epiphora. The condition is chronic and has raised little concern, mainly because there is no threat of vision loss.

Epiphora secondary to wiping

Because wiping is even more frequent in obstruction of lacrimal passages, it causes hypertrophy of the lacrimal gland and makes the condition worse. Abstinence from eye wiping is not a substitute for surgery and its benefits are limited, but it can be helpful for those patients for whom surgery is contraindicated. These patients should wipe their eyes only when they are completely closed.

Some patients have no obvious cause for their epiphora. If these patients frequently wipe their eyes, they fall into the category of epiphora secondary to wiping.

Cases

In one case, a 66-year-old woman complained that watering in both eyes was interfering with her ability to work. Her vision was 20/20 in both eyes with correction, and she had no abnormality in either punctum, both upper and lower. Both corneas were clear, anterior chambers were normal, and pupils were equal and reactive. The patient was pseudophakic with IOLs in perfect placement bilaterally. Vitreous was clear, and the optic discs, macula and peripheral retina were all normal. IOP was 16 mm Hg in the right eye and 17 mm Hg in the left. Tear film was high at 3+ in both eyes, and the lacrimal and nasal passages were clear.

The patient was advised to stop wiping her eyes immediately and to squeeze her eyes tightly three or four times instead of wiping every time she felt the urge. When she was seen in the office 2 weeks later, she was asymptomatic.

In another case of chronic epiphora secondary to wiping with a duration of 7 years, the patient was similarly told to stop wiping her eyes and to squeeze her eyes tightly three or four times rather than wiping. At 3-month follow-up, her left eye was asymptomatic, while the right eye was much improved, becoming asymptomatic at 5 months.

Physiology of tearing, squeezing

The sensation of dryness is received by the brain from the cornea and then transmitted to the lacrimal gland, which supplies tears to the cornea. In epiphora secondary to frequent wiping, the cornea becomes dry each time the tissue touches the tear film due to capillary action. The tear gland must replace the tear film. Because this process is repeated frequently over an extended period of time, the lacrimal gland becomes hypertrophied and the cycle continues. When wiping is stopped, the cycle is broken, the lacrimal gland returns to normal size, and the patient becomes asymptomatic.

When the eye is squeezed (orbicularis contraction), three things happen: The puncta become opposed, the canaliculi are compressed horizontally, and the lacrimal sac is compressed, forcing tears to flow into the nose. Forceful squeezing increases the flow of tears from the eye to the nose, and the tear film regains its normal level. The eye is not dry after squeezing, as it would be if a tissue were used to wipe the eye dry. The decrease in the tear film when the eye is squeezed can be observed under the slit lamp. When the basal tear film level is maintained, the epiphora cycle is broken.

Epiphora secondary to frequent wiping is an easily treatable condition. If not treated, it can have a great impact on a patient’s quality of life. Discontinuation of wiping helps not only nonobstructive but also obstructive disease of the lacrimal passages. It should be considered in all cases of epiphora.

References:

Adler FH, Moses RA, ed. Physiology of the Eye. 7th ed. St. Louis: Mosby; 1981:21.
Jones LT. The cure of epiphora due to canalicular disorders, trauma and surgical failures on the lacrimal passages. Trans Am Acad Ophthalmol Otolaryngol. 1962;66:506-524.
Mackie IA, Seal DV. Beta-blockers, eye complaints, and tear secretion. Lancet. 1977;2(8046):1027.
Murube J. On gravity as one of the impelling forces of lacrimal flow. In: Yamaguchi M, ed. Recent Advances on the Lacrimal System. Tokyo: Asaki Press; 1978:51-61.
Raflo GT, Chart P, Hurwitz JJ. Thermographic evaluation of the human lacrimal drainage system. Ophthalmic Surg. 1982;13(2):119-124.
Zappia RJ, Milder B. Lacrimal drainage function. 1. The Jones fluorescein test. Am J Ophthalmol. 1972;74(1):154-159.

For more information:

Abdul Khaliq, MD, FRCS, can be reached at 45 S. Main St., West Hartford, CT 06107; 860-233-7210; fax: 860-233-7724; email: khaliq42@hotmail.com.
Disclosure: No products or companies are mentioned that would require financial disclosure.