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Excessive Eye Tearing (Epiphora): Causes, Evaluation, and Management

Epiphora—overflow tearing—results from imbalance between tear production and drainage. It is a symptom, not a diagnosis, with distinct mechanistic categories.

Causes by Mechanism

MechanismCauses
Overproduction (reflex)Dry eye (paradoxical), blepharitis, ocular surface disease, allergy, foreign body, corneal abrasion, trichiasis, entropion
Drainage obstructionPunctal stenosis, canalicular obstruction, nasolacrimal duct obstruction (NLDO), dacryocystitis, trauma, tumors, medications (docetaxel)
Pump failureFacial nerve palsy (orbicularis oculi), ectropion, floppy eyelid syndrome

Diagnostic Workup

  1. History: laterality, timing, triggers, eye symptoms, sinus/nasal issues.
  2. Exam: tear meniscus height, punctal position/size, expressibility, slit lamp (TBUT, staining), nasal endoscopy.
  3. Dye disappearance test (fluorescein).
  4. Irrigation/probing (office or OR).
  5. Dacryocystography / CT / MRI if mass suspected.

Treatment by Etiology

  • Dry eye: Artificial tears, cyclosporine, lifitegrast, punctal plugs.
  • Blepharitis: Lid hygiene, warm compresses, azithromycin/doxycycline.
  • NLDO: Probing ± intubation (infants); DCR (dacryocystorhinostomy) for adults.
  • Punctal stenosis: Snip punctoplasty.
  • Ectropion/entropion: Surgical repair.
  • Facial palsy: Tarsorrhaphy, gold weight, botox to antagonist.

Ophthalmology or oculoplastics referral for persistent epiphora.

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