Watery Eye & the Evaluation of Tearing

Part of our complete guide to Tear-Duct & Lacrimal Surgery — this page covers the watery-eye work-up in depth.

Evaluation of Tearing

A systematic evaluation identifies the site and severity of obstruction before planning treatment.

History

• Duration and laterality of tearing
• Associated discharge, pain, or swelling over the lacrimal sac
• Prior eye surgery, chemotherapy, or topical medication use (especially anti-glaucoma drops)
• History of facial trauma, nasal surgery, or chronic sinusitis
• Prior episodes of dacryocystitis

Clinical Tests

• Dye disappearance test (DDT): fluorescein dye placed in both eyes; persistence of dye on slit lamp after 5 minutes indicates delayed drainage. Quantified by asymmetry between eyes
• Jones I test (primary dye test): cotton swab placed beneath the inferior turbinate; recovery of fluorescein confirms functional patency of the entire system
• Jones II test (secondary dye test): if Jones I is negative, the sac is irrigated with clear saline; recovery of fluorescein-stained fluid from the nose indicates dye reached the sac (functional or partial obstruction at/below the sac), whereas recovery of clear saline only suggests dye never reached the sac (punctal/canalicular dysfunction)
• Lacrimal irrigation / probing: a fine cannula irrigates the system through the punctum. Hard stop (probe reaches the medial wall of the sac against the lacrimal bone) indicates a patent canalicular system up to the sac, localizing any obstruction at or below the sac; soft stop (probe meets spongy resistance before reaching bone) suggests canalicular obstruction proximal to the sac. Reflux of fluid indicates nasolacrimal obstruction
• Regurgitation test: pressure over the lacrimal sac expresses mucoid or purulent material through the punctum — confirms an obstructed, infected sac (dacryocystitis)

Imaging

• CT scan of orbits and sinuses: identifies bony anatomy, nasolacrimal canal dimensions, and sinus pathology; essential before revision DCR surgery
• Dacryocystography (DCG): contrast injected into the system outlines the anatomy and identifies the level of obstruction
• Nasal endoscopy: evaluates the nasal cavity, inferior meatus, and valve of Hasner; identifies intranasal pathology (polyps, deviated septum) that may contribute to obstruction