Cory Lappin, OD, MS, FAAO of the Dry Eye Center of Ohio, joins host Damon Dierker, OD, FAAO of Eye Surgeons of Indiana in Indianapolis on Dry Eye Fireside Chat to walk through a systematic, three-category approach to epiphora and share a case that ended in the operating room.
Epiphora is one of the more challenging and commonly misunderstood complaints in a dry eye practice. Drs. Lappin and Dierker organize the differential into three categories: dry eye, mechanical causes, and outflow obstruction. Working through these categories, every time, is how you avoid months of chasing the wrong diagnosis.
Fast facts: Sarcoidosis and lacrimal sac obstruction
- Sarcoidosis accounted for 2.1% of granulomatous findings across 377 consecutive dacryocystorhinostomy (DCR) biopsy specimens.1
- Granulomatous inflammation of the lacrimal sac represents 1 to 2% of all DCR specimens; the majority is attributed to systemic sarcoidosis.2
- Sarcoidosis affects Black Americans at approximately 3 times the incidence of white Americans, with rates as high as 35.5 per 100,000.3
- Clinical presentation is indistinguishable from any other nasolacrimal duct obstruction. The diagnosis is made at biopsy, not at the slit lamp.
- Management of the underlying systemic disease runs concurrent with surgical planning. In this case, the second eye DCR was held pending better systemic control.
A surprising diagnosis hiding in the drainage system
The conversation centers on a patient Dr. Lappin had been managing for years: a woman in her 60s with known dry eye disease who suddenly developed bilateral epiphora, and eventually needed a DCR. A careful evaluation of the potential underlying causes led to a definitive, and surprising, diagnosis.
When Dr. Lappin’s patient developed bilateral epiphora, a dry eye flare was a potential explanation, but despite intensified dry eye treatment, her epiphora did not respond. She had no apparent external mechanical causes—no lid malposition or excessive laxity, punctal ectropion, or conjunctivochalasis.
He moved to outflow. Irrigation of the lacrimal drainage system yielded minimal flow and no relief. At this point a more extensive examination of the lacrimal drainage system was warranted, and he referred to oculoplastics.
Dr. Lappin’s patient was found to have a complete obstruction of the lacrimal sac requiring dacryocystorhinostomy. However, this is where the case took an interesting turn. In addition to dry eye disease, his patient also had sarcoidosis. When the tissue was biopsied, the answer was definitive: non-caseating granulomas from her sarcoidosis had infiltrated the lacrimal sac wall.
Clinical considerations for sarcoidosis of the lacrimal sac
Lacrimal sac involvement is not how most clinicians think about sarcoidosis. Its typical anterior segment manifestations are well documented—uveitis, conjunctival nodules, keratoconjunctivitis sicca. The lacrimal drainage system is a different conversation entirely, and rare enough that it stays off the differential until the pathologist puts it in front of you.
There are no external signs that distinguish lacrimal sac sarcoidosis from any other obstruction. The presentation is the same: epiphora, possible dacryocystitis, failed irrigation. The diagnosis is made in the operating room, not at the slit lamp.
In the case of Dr. Lappin’s patient, the co-managing oculoplastics specialist held the second eye surgery pending better systemic control of her sarcoidosis before proceeding, which is the correct sequence: surgical planning does not move ahead of disease management.
For any patient who presents with epiphora, the lacrimal drainage system needs to be methodically evaluated. Do not chase dry eye treatments indefinitely or wait for dacryocystitis to develop before assessing the patency of the system. Dilation and irrigation is the gate. If it fails, oculoplastics is the next call. Dr. Dierker emphasized that he has almost never regretted doing a probe and irrigation because it is both diagnostic and therapeutic.
Key takeaways
- Work through the potential causes of epiphora systemically: identify any mechanical abnormalities, determine if outflow obstruction is present, and rule out dry eye as a causative or contributing factor. Every time.
- Dry eye is a common cause of epiphora, but other causes must be ruled out, especially if it does not respond to traditional dry eye treatment.
- Punctal ectropion and conjunctivochalasis are the two most commonly missed mechanical causes. Look for them deliberately.
- In some cases, dilation and irrigation gives you more clinical information in 5 minutes than any additional dry eye intervention. Do not skip it.
- Epiphora itself can develop for numerous reasons. Whether caused by excessive reflex tear production due to dry eye, nasolacrimal duct obstruction associated with aging, or an incredibly rare finding such formation of granulomas in the lacrimal sac, it is imperative to identify the underlying cause.
Conclusion
Watch the full conversation with Drs. Lappin and Dierker for the complete three-category exam framework, their step-by-step approach to dilation and irrigation technique, and the clinical decision points that led from a suspected dry eye flare to an operating room diagnosis.
For more on building a systematic ocular surface workup, read Dr. Lappin’s guide: The Simple Dry Eye Workup for Primary Care Optometrists.
