The watering eye (epiphora)
- Clinical approach
A watery eye makes too many tears or drains them poorly. In babies it is usually a blocked duct that opens alone; with photophobia it can be glaucoma.
See it in 3D: Tear drainage · Lacrimal gland · Eyelids
What it is
Epiphora is tears spilling over the lid. Either too many tears are made, often as a reflex to irritation (dry eye, blepharitis, an inturned lid or lash), or drainage fails: a narrow punctum, an outturned or lax lower lid, or a blocked nasolacrimal duct. In infants, congenital nasolacrimal duct obstruction is common and usually resolves in the first year. Congenital glaucoma is the rare cause that must not be missed.
Red flags
- An infant with tearing, light sensitivity and a large or cloudy cornea: congenital glaucoma.
- A red, painful swelling below the inner corner of the eye: acute dacryocystitis.
- Bloody tears or a firm mass at the inner corner: lacrimal sac tumour.
- A red, sticky eye in a newborn in the first weeks: neonatal conjunctivitis.
- Tearing with reduced vision or pain.
Step-by-step approach
- Ask about onset (birth or later), one or both eyes, discharge, itch and grittiness.
- Look at the lids: position (entropion, ectropion), laxity, the punctum, lashes touching the eye.
- Look for dry eye and blepharitis: paradoxically, dry eyes water.
- Press over the lacrimal sac: reflux of mucus or pus means a blocked duct.
- In infants, look at the corneal size and clarity and ask about light sensitivity.
Causes of a watering eye
| Cause | Mechanism | Clue |
|---|---|---|
| Congenital nasolacrimal duct obstruction | Drainage | From the first weeks, sticky lashes, white eye |
| Acquired nasolacrimal duct obstruction | Drainage | Older adult, mucus on pressing the sac |
| Ectropion or lid laxity | Drainage | Lower lid turned out or loose |
| Dry eye or blepharitis | Reflex | Grittiness, worse with reading or screens |
| Entropion or trichiasis | Reflex | Lashes rubbing the cornea |
| Congenital glaucoma | Reflex | Light sensitivity, large cloudy cornea |
Keys to the differential
- Most congenital duct obstructions open alone by the age of one year.
- Trachoma scarring turns the lashes in (trichiasis) and still causes blindness in parts of Latin America.
- Acute dacryocystitis can spread to orbital cellulitis.
Next step / Initial management
- Congenital duct obstruction with a white eye: lacrimal sac massage and lid hygiene; refer for probing if it persists beyond about 12 months.
- Infant with tearing, light sensitivity or a large cloudy cornea: urgent paediatric ophthalmology for congenital glaucoma.
- Acute dacryocystitis: systemic antibiotics, warm compresses and ophthalmology; dacryocystorhinostomy once the infection settles.
- Adult: treat dry eye and blepharitis; refer lid malposition and persistent duct obstruction routinely, and bloody tears or a mass urgently.
Test yourself
Think of the answer, then tap the question to see it.
What is the usual course of congenital nasolacrimal duct obstruction?
Most cases open spontaneously in the first year of life; probing is offered if it persists.
Which signs in a tearing infant suggest congenital glaucoma?
Light sensitivity, a large cornea and a cloudy cornea; it needs urgent ophthalmology.
Why can a dry eye water?
Because irritation of the dry surface triggers reflex tearing of poor-quality tears.
Connections
See it in 3D3
The structures of Durgical's 3D anatomy where it is found.
Educational content; not a clinical guideline and no substitute for assessment by a health professional. For sudden visual loss, severe eye pain, a chemical burn or an eye injury, go to an emergency department at once.
Sources: Epiphora (StatPearls Publishing (NCBI Bookshelf), 2023); Congenital Nasolacrimal Duct Obstruction (StatPearls Publishing (NCBI Bookshelf), 2026); Dacryocystitis (StatPearls Publishing (NCBI Bookshelf), 2025).
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Representative model, for educational purposes only.