Management of Watery Eyes

Diagnostic Considerations

• The American Academy of Ophthalmology suggests assessing for symptoms of dry eye including irritation, itching, soreness, burning, or intermittent blurred vision that may accompany the watering 1, 2
• Evaluate for meibomian gland dysfunction, which is extremely common in dry eye disease and contributes to tear film instability 3, 2
• Differentiate between aqueous tear deficiency and evaporative dry eye, noting that these conditions frequently coexist in the majority of patients 2, 4

First-Line Management

• The American Academy of Ophthalmology recommends patient education about the paradoxical nature of watery eyes often being caused by underlying dry eye syndrome 1, 2
• Identify and modify environmental factors that may exacerbate symptoms, such as reducing exposure to air drafts, low humidity environments, and cigarette smoke 5
• Consider lipid-containing supplements if meibomian gland dysfunction is present 1, 4
• Implement eyelid hygiene and warm compresses to improve meibomian gland function 1, 4

Second-Line Management

• Switch to preservative-free ocular lubricants to minimize preservative-induced toxicity, especially if using more than four times daily 4, 5
• Consider tear conservation strategies, such as punctal occlusion (temporary or permanent) and moisture chamber spectacles/goggles 4
• Implement overnight treatments such as lubricating ointments 4
• Consider in-office physical heating and expression of meibomian glands 4

Advanced Management Options

• Prescription medications may be considered, such as topical anti-inflammatory agents (limited-duration corticosteroids) 4
• Topical immunomodulatory drugs (cyclosporine) may be used 5
• Topical LFA-1 antagonists (lifitegrast) may be considered 4
• Oral macrolide or tetracycline antibiotics may be used for meibomian gland dysfunction 4

Special Considerations

• Be aware that some medications (antihistamines, diuretics, antidepressants) can exacerbate dry eye symptoms 3, 5
• For severe cases unresponsive to treatment, referral to an ophthalmologist is recommended 6

Common Pitfalls to Avoid

• Avoid indiscriminate use of antibiotics or corticosteroids without clear indication 7
• Do not overlook the importance of treating underlying blepharitis or meibomitis which can contribute to symptoms 5
• Recognize that tear replacement alone may be unsuccessful if additional causative factors are not addressed 1, 2