Lacrimal Disorders & Tearing

The lacrimal system is the network of structures responsible for producing, spreading, and draining tears. It has two parts that work together. The secretory part—made up of the lacrimal gland above the outer corner of the eye and smaller accessory glands on the inner eyelid surface—produces the tears that keep the eye moist and protected. The excretory part—a series of drainage channels including the tiny openings called puncta at the inner corner of each eyelid, narrow tubes called canaliculi, a small sac called the lacrimal sac, and the nasolacrimal duct that empties into the nose—carries used tears away from the eye. Disorders can affect either part of this system. They range from very common, self-resolving infant conditions to chronic adult diseases that require surgery, and they can be present from birth (congenital) or develop over time (acquired).

Lacrimal disorders are a group of conditions that affect the tear-producing glands or the tear-drainage channels. The hallmark symptom is epiphora—an overflow of tears onto the face. Epiphora occurs either because the eye is producing too many tears or because tears cannot drain away fast enough. It is one of the most common complaints in ophthalmology clinics and a leading reason for referral to oculoplastic surgeons—specialists in the tissues around the eye. Importantly, watery eyes are not always caused by a blocked drain. In many cases, the drainage system is entirely open, and the tearing is a reflex response to an irritated or dry eye surface.

Epiphora affects people of all ages but is particularly common in infants and in adults over age 60. In studies of patients referred for tearing, more than half are aged 60 or older, and slightly more women than men are affected. Congenital nasolacrimal duct obstruction—the most common lacrimal disorder in babies—affects an estimated 5–20% of infants under one year of age and resolves on its own in the vast majority of cases by a child’s first birthday.

Tearing from a lacrimal disorder occurs through one of two mechanisms: the eye produces more tears than the drainage system can carry away (hypersecretion), or the drainage system is too narrow, blocked, or weak to drain tears at a normal rate (reduced outflow). In many patients, both factors are present at the same time.

Reflex hypersecretion, where the eye produces extra tears in response to irritation, is one of the most common causes of a watery eye and is frequently overlooked. Dry eye disease, meibomian gland dysfunction, blepharitis, allergic conjunctivitis, an eyelash rubbing against the eye (trichiasis), and environmental irritants such as smoke, wind, and bright light all stimulate the corneal surface nerves and trigger the lacrimal gland to release a flood of tears. 

Specific causes of reduced outflow include:

• Age-related changes: The puncta and canaliculi naturally narrow with aging. The muscle that pumps tears through the drainage system with each blink also weakens over time.
• Chronic eyelid inflammation: Blepharitis and prolonged use of preserved eye drops damage the punctal opening and the inner lining of the drainage channels, causing scarring and narrowing over time.
• Bacterial and fungal infections: Canaliculitis (most often from Actinomyces israelii) and dacryocystitis cause inflammation and scarring within the drainage passages.
• Viral infections: Epstein-Barr virus, mumps, and adenovirus can inflame the lacrimal gland (dacryoadenitis), temporarily reducing its normal function or causing reflex tearing.
• Autoimmune diseases: Sjögren’s syndrome, sarcoidosis, and IgG4-related disease infiltrate and damage the lacrimal gland, reducing tear production and causing gland enlargement.
• Medication toxicity: Certain chemotherapy drugs—particularly docetaxel and 5-fluorouracil—can cause scarring of the canaliculi during treatment, sometimes requiring surgical repair.
• Trauma: Facial fractures, lacerations of the inner corner of the eyelid, or prior nasal or sinus surgery can scar or sever any part of the drainage pathway.
• Congenital membrane: In newborns, an incompletely opened membrane at the lower end of the nasolacrimal duct is the most common structural cause of tearing in the first year of life.
• Tumors: Growths within the lacrimal sac, nasolacrimal duct, nasal cavity, or surrounding sinuses can compress and block the drainage system. A firm mass at the inner corner of the eye that does not respond to antibiotic treatment should be evaluated for a lacrimal sac or nasal tumor.

Lacrimal disorders can affect people at any age, from newborns to the elderly. Certain factors significantly raise the risk of developing specific conditions within this group.

• Older age: Age-related narrowing of the puncta and canaliculi, eyelid laxity, and declining orbicularis muscle strength all reduce tear drainage efficiency. Primary acquired nasolacrimal duct obstruction is most common in women over age 50.
• Female sex: Women are more frequently affected by primary acquired nasolacrimal duct obstruction, likely related to a naturally narrower bony nasolacrimal canal. Women are also more commonly affected by autoimmune conditions, such as Sjögren’s syndrome, that damage the lacrimal gland.
• Chronic eyelid disease: Blepharitis, meibomian gland dysfunction, and rosacea promote punctal scarring and are among the most common modifiable risk factors for drainage-related tearing.
• Long-term use of preserved glaucoma eye drops: Benzalkonium chloride and other preservatives in these drops cause progressive punctal stenosis with prolonged use.
• Chemotherapy: Certain drugs, particularly docetaxel (Taxotere®) and 5-fluorouracil, are toxic to the lining of the canaliculi and can cause permanent canalicular scarring during or after cancer treatment.
• Autoimmune disease: Sjögren’s syndrome, sarcoidosis, IgG4-related disease, and granulomatosis with polyangiitis can all affect the lacrimal gland or drainage system.
• Prior facial trauma, surgery, or radiation: Any procedure or injury involving the nose, sinuses, or inner corner of the eyelid can damage the drainage anatomy.
• Neonatal period: Failure of the nasolacrimal duct membrane to open at birth is the primary risk for lacrimal disease in infants. Premature birth may be associated with a higher rate of persistent congenital obstruction.

There is no population-wide screening program for lacrimal disorders. In newborns, the presence of sticky or watery eyes in the first days or weeks of life is routinely noted by parents and pediatricians and should prompt early evaluation to distinguish infectious conjunctivitis—which requires treatment—from congenital nasolacrimal duct obstruction, which usually resolves on its own. In adults, tearing that is persistent, worsening, or associated with discharge, pain, or swelling at the inner corner of the eye warrants evaluation by an ophthalmologist or oculoplastic specialist. Most lacrimal disorders are identified when a patient presents with symptoms rather than through screening.

Many lacrimal disorders, particularly those related to aging, genetics, or autoimmune disease, cannot be fully prevented. However, several practical steps can reduce the risk of acquired drainage problems and reflex tearing:

• Treat blepharitis and meibomian gland dysfunction consistently: Keeping eyelid margins clean through daily warm compresses and lid hygiene reduces the chronic inflammation that scars the puncta and canaliculi over time.
• Use preservative-free eye drops when possible: For patients on long-term glaucoma therapy or other topical eye drops, asking about preservative-free formulations can reduce the progressive damage to the punctal openings.
• Manage dry eye disease proactively: Treating dry eye before it triggers persistent reflex tearing avoids the cycle of surface irritation and excessive lacrimal gland stimulation.
• Notify your oncologist if tearing develops during chemotherapy: For patients receiving docetaxel or 5-fluorouracil, early reporting of watery eyes allows for protective measures and earlier intervention before permanent canalicular damage occurs.
• Perform nasolacrimal massage in affected infants: Parents of infants with congenital nasolacrimal duct obstruction are taught a gentle massage technique that applies pressure over the lacrimal sac to help open the duct membrane. Performed several times daily, this technique can speed resolution and reduce the risk of dacryocystitis.

The hallmark symptom of all lacrimal disorders is epiphora—tears spilling over the lower eyelid and running down the cheek. This can range from occasional mild dampness to a constant flow of tears that blurs vision and irritates the skin below the eye. The pattern of tearing and what accompanies it helps the doctor identify the underlying cause. Reflex tearing from dry eye or surface irritation is often worse in wind, cold air, or bright sunlight and may come and go. Tearing from a blocked drain is usually constant, often associated with discharge, and may be worse on waking.

Signs and symptoms associated with lacrimal disorders include:

• Persistent watery eyes (epiphora): Tears overflow onto the face, either intermittently or continuously. The eye itself may not feel dry or irritated—some patients with a blocked nasolacrimal duct have no surface discomfort at all.
• Sticky discharge in the inner corner of the eye: Yellow-white discharge, particularly noticeable on waking, suggests dacryocystitis or a chronically infected, blocked lacrimal sac.
• Painful swelling at the inner corner of the eye: A red, tender, swollen lump at the base of the nose beside the eye is the hallmark of acute dacryocystitis. It can become an abscess requiring urgent treatment.
• Blurred vision: Excess tears on the corneal surface can temporarily blur vision, especially when reading or looking at a screen. Blurring clears briefly with blinking.
• Mucus or pus that can be expressed from the corner of the eye: Gentle pressure over the lacrimal sac in a patient with a blocked duct often causes a small amount of mucus or pus to reflux back through the punctum. This is a characteristic sign of chronic dacryocystitis or lacrimal sac distension.
• Swelling of the upper outer eyelid: A smooth, firm or rubbery swelling under the outer third of the upper eyelid suggests lacrimal gland enlargement from dacryoadenitis or a gland tumor.
• Recurrent eye infections or conjunctivitis: Repeated episodes of a red, sticky eye—particularly in an infant or young child—may be caused by chronic stasis of fluid in a blocked lacrimal system rather than a new infection each time.
• Skin irritation below the eye: Chronic overflow of tears causes redness, scaling, and skin breakdown on the cheek below the affected eye, particularly in infants and elderly patients.
• Symptoms in infants: Watery, sticky eyes and crusty lashes beginning in the first weeks of life, often with visible mucous discharge at the inner corner of one or both eyes, are the typical presentation of congenital nasolacrimal duct obstruction. Fever or significant swelling around the eye in an infant requires urgent evaluation to rule out dacryocystitis.

An ophthalmologist, or more specifically, an oculoplastic surgeon for complex cases, diagnoses lacrimal disorders. Because many different conditions can cause a watery eye, the evaluation involves a systematic process to distinguish between surface-related reflex tearing, anatomical drainage obstruction, and less common causes such as lacrimal gland disease or tumors. The history of when tearing began, whether it is constant or intermittent, which environmental conditions make it worse, and whether discharge or pain are present gives important clues before any testing begins.

• Slit-lamp examination: a magnified examination of the entire anterior eye, eyelid margins, puncta, and conjunctival surface. The doctor assesses the tear film, looks for surface disease, blepharitis, or misdirected eyelashes, and examines the punctal openings for stenosis or abnormal position.
• Fluorescein dye disappearance test (DDT): A drop of fluorescein dye is placed in each eye. Under blue light, the doctor observes how quickly the dye drains from the eye over five minutes. Dye that remains in one eye longer than the other suggests impaired drainage on that side. This is a quick, noninvasive, and reliable first-line test.
• Lacrimal irrigation (syringing): A fine cannula is inserted into the punctum and saline is gently flushed through the drainage system. The doctor can determine whether the system is fully open, partially blocked, or completely obstructed, and at what level the obstruction lies. This is the primary diagnostic test for nasolacrimal duct obstruction.
• Probing: A thin metal probe is passed through the punctum and canaliculus to confirm patency (openness) of the upper drainage channels and to identify the site and nature of any blockage. In infants, probing under anesthesia serves as both a diagnostic and therapeutic maneuver.
• Dacryocystography (DCG): A contrast dye is injected into the drainage system, and X-rays or computed tomography (CT) images are taken to map the anatomy and locate blockages. This is used when the level of obstruction is unclear from clinical examination alone, or when a lacrimal sac or ductal tumor is suspected.
• Lacrimal scintigraphy: A tiny amount of a radioactive tracer is placed in the eye, and its movement through the drainage system is tracked with a gamma camera over time. This test is particularly useful for diagnosing functional epiphora—cases where the drainage channels are open on syringing but drain too slowly in real life.
• Nasal endoscopy: A small camera is passed into the nose to examine the nasal opening of the nasolacrimal duct and surrounding structures. This is done when surgery is being planned, when secondary causes such as nasal polyps, tumors, or previous nasal surgery are suspected, or when endoscopic tear duct surgery is the preferred approach.
• Imaging (CT or magnetic resonance imaging (MRI) of orbits and sinuses): ordered when a lacrimal gland mass, lacrimal sac tumor, nasal or sinus pathology, or orbital disease is suspected. CT is preferred for evaluating bony anatomy; MRI provides better soft tissue detail.

Treatment for lacrimal disorders is matched to the underlying cause. Tearing caused by dry eye or eyelid disease is treated by addressing those surface conditions—with lubricating drops, prescription anti-inflammatory eye drops, lid hygiene, and treatment of blepharitis—rather than by operating on the drainage system. When the tearing is caused by a structural blockage in the drainage channels, the goal of treatment is to re-establish a clear pathway for tears to drain. The type and location of the blockage determine whether this is accomplished medically, with a minor office procedure, or with surgery. In infants with congenital nasolacrimal duct obstruction, the standard first approach is watchful waiting combined with nasolacrimal massage, because the great majority of cases resolve spontaneously before the child’s first birthday.

For infants whose congenital obstruction has not resolved by 12 months, or for children who develop dacryocystitis (a lacrimal sac infection), probing of the nasolacrimal duct under a brief general anesthesia is the standard treatment. A thin metal probe is passed through the punctum, canaliculus, and nasolacrimal duct to break through the residual membrane and open the passage. Success rates for a single probing are high—typically 70–90% in children under 18 months. If probing fails or the child is older, a silicone tube may be placed temporarily through the drainage system to keep it open while scar tissue matures, or a balloon dilation catheter may be used to widen the narrowed segment. Acute dacryocystitis in infants or adults requires prompt antibiotic treatment—oral antibiotics for milder cases, intravenous antibiotics for severe or spreading infection. When an abscess has formed, drainage of the abscess and subsequent surgical tear duct repair are needed.

For adults with primary acquired nasolacrimal duct obstruction—the most common indication for tear duct surgery—the definitive treatment is dacryocystorhinostomy (DCR). In this procedure, the surgeon creates a new drainage channel directly from the lacrimal sac into the nasal cavity, bypassing the blocked nasolacrimal duct entirely. DCR can be performed through a small incision in the skin beside the nose (external DCR) or entirely through the nose using an endoscope and no external incision (endoscopic or endonasal DCR). Success rates for both approaches are high—typically 80–95%. A silicone tube is often placed through the new opening for several months during healing and then removed in the office. For punctal stenosis—a narrowed or closed punctal opening—a minor office procedure called punctoplasty widens the opening, sometimes combined with placing a small silicone plug or tube to maintain the new size. Canalicular obstruction from infection or medication toxicity may require a more complex reconstruction called a conjunctivodacryocystorhinostomy (CDCR), in which a small glass or silicone tube called a Jones tube is surgically implanted to create an entirely new drainage pathway from the inner corner of the eye into the nasal cavity, bypassing the damaged canaliculi entirely. Dacryoadenitis caused by viral infection is managed with supportive care and rest; bacterial dacryoadenitis requires antibiotics; autoimmune forms are treated with steroids or immunosuppressive medicines in coordination with a rheumatologist. Lacrimal gland tumors are managed according to their type and malignancy—benign tumors are surgically removed; malignant tumors may require combined surgery and radiation therapy.

For most people, lacrimal disorders are manageable conditions that respond well to treatment. Infants with congenital nasolacrimal duct obstruction almost always achieve fully normal tear drainage—either spontaneously in the first year of life or with a brief, straightforward procedure. Adults who undergo DCR surgery for a blocked nasolacrimal duct have high rates of successful long-term drainage, with most patients experiencing complete resolution of tearing and discharge. For those whose tearing is caused by dry eye or eyelid disease rather than a blocked drain, consistent management of those underlying conditions is what makes the greatest long-term difference. Living with chronic tearing, particularly in colder months or windy conditions—can be frustrating, and the skin below the eye can become sore from constant moisture. Barrier creams and gentle skincare can help protect the skin while the underlying condition is treated. If you develop sudden, painful swelling at the inner corner of the eye, a rapid increase in discharge, fever, or restricted eye movement, contact your doctor promptly, as these may indicate acute dacryocystitis or orbital cellulitis requiring urgent treatment.

To further your understanding of your diagnosis and to contribute to cutting-edge research, consider participating in a clinical trial so clinicians and scientists can learn more about causes, symptoms, treatment, and prevention of lacrimal disorders, tearing, and related conditions. Clinical research uses human volunteers to help researchers learn more about a disorder and perhaps find better ways to safely detect, treat, or prevent disease.

All types of volunteers are needed—those who are healthy or may have an illness or disease of all different ages, sexes, races, and ethnicities to ensure that study results apply to as many people as possible, and that treatments will be safe and effective for everyone who will use them.

To learn more about clinical trials and find studies that may be right for you, visit National Institutes of Health (NIH) Clinical Research Trials and You and ClinicalTrials.gov to search active studies by condition, location, and age group.