Watery Eye & the Evaluation of Tearing

Watery Eye & the Evaluation of Tearing | Jon Caster, MD | EyePlastics

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.

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

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)

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

Why does my eye water constantly?: A constantly watering eye (epiphora) usually means tears are either overproduced (often from irritation or dry eye) or, more commonly, not draining — because the tear-drainage pathway is narrowed or blocked.
How is the cause of a watery eye diagnosed?: Through a focused history and exam, the dye-disappearance test, and gentle irrigation/probing of the tear ducts; imaging is added when the level of blockage needs to be confirmed.

Your Surgeon

Jon Caster, MD

🏅 ASOPRS Fellowship Trained