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The most common causes are

• Upper respiratory infection

• Allergic rhinitis

• Allergic conjunctivitis

• Dry eyes (reflex tearing produced in response to dryness of the ocular surface)

• Trichiasis

Any disorder causing conjunctival or corneal irritation can increase tear production (see table Some Causes of Tearing). However, most patients with corneal disorders that cause excess tearing (eg, corneal abrasion, corneal ulcer, corneal foreign body, keratitis) or with primary angle-closure glaucoma or anterior uveitis present with eye symptoms other than tearing (eg, eye pain, redness). Most people who have been crying do not present for evaluation of tearing.

The most common causes are

• Idiopathic age-related nasolacrimal duct stenosis

• Dacryocystitis

• Ectropion

Nasolacrimal drainage system obstruction may be caused by strictures, tumors, or foreign bodies (eg, stones, often associated with subclinical infection by Actinomyces). Obstruction can also be a congenital malformation. Many disorders and medications can cause stricture or obstruction of nasolacrimal drainage.

Other causes of nasolacrimal drainage stricture or obstruction include

• Burns

• Chemotherapy drugs

• Eye drops (particularly echothiophate iodide, epinephrine, and pilocarpine)

• Infection, including canaliculitis (eg, caused by Staphylococcus aureus, Actinomyces, Streptococcus, Pseudomonas, herpes zoster virus, herpes simplex conjunctivitis, infectious mononucleosis, human papillomavirus, Ascaris, leprosy, tuberculosis)

• Inflammatory disorders (sarcoidosis, granulomatosis with polyangiitis)

• Injuries (eg, nasoethmoid fractures; nasal, orbital, or endoscopic sinus surgery)

• Obstruction of nasal outlet despite an intact nasolacrimal system (eg, upper respiratory infection, allergic rhinitis, sinusitis)

• Radiation therapy

• Stevens-Johnson syndrome

History of present illness addresses the duration, onset, and severity of symptoms, including whether tears drip down the cheek (true epiphora). The effects of weather, environmental humidity, and cigarette smoke are ascertained.

Review of symptoms should seek symptoms of possible causes, including itching, rhinorrhea, or sneezing, particularly when occurring perennially or after exposure to specific potential allergens (allergic reaction); eye irritation or pain (blepharitis, corneal abrasion, irritant chemicals); and pain near the medial canthus (dacryocystitis). Other symptoms are of lower yield but should be sought; they include positional headache, purulent rhinorrhea, nocturnal cough, and fever (sinusitis, granulomatosis with polyangiitis); rash (Stevens-Johnson syndrome); cough, dyspnea, and chest pain (sarcoidosis); and epistaxis, hemoptysis, polyarthralgias, and myalgias (granulomatosis with polyangiitis).

Past medical history asks about known disorders that can cause tearing, including granulomatosis with polyangiitis, sarcoidosis, and cancer treated with chemotherapy medications; disorders that cause dry eyes (eg, rheumatoid arthritis, sarcoidosis, Sjögren syndrome); and medications, such as echothiophate, epinephrine, and pilocarpine. Previous ocular and nasal history, including infections, injuries, surgical procedures, and radiation exposure, is ascertained.

Examination focuses on the eye and surrounding structures.

The face is inspected; asymmetry suggests congenital or acquired obstruction of nasolacrimal duct drainage. When available, a slit lamp should be used to examine the eyes. The conjunctivae and corneas are inspected for lesions, including punctate spots, and redness. The cornea is stained with fluorescein and examined. The lids are everted to detect hidden foreign bodies. The eyelids, including the lacrimal puncta, are closely inspected for foreign bodies, blepharitis, hordeola, ectropion, entropion, and trichiasis. The lacrimal sac (near the medial canthus) is palpated for warmth, tenderness, and swelling. Any swellings are palpated for consistency and to see whether pus is expressed.

The nose is examined for congestion, purulence, and bleeding.

The following findings are of particular concern:

• Repeated, unexplained episodes of tearing

• Hard mass in or near the nasolacrimal drainage structures

Findings that suggest obstruction of nasolacrimal drainage include:

• Tears running down the cheek (true epiphora)

• Absence of a different specific cause

For a list of common causes that may be evident from the Ophthalmic evaluation, see table Some Causes of Tearing.

Testing is often unnecessary because the cause is usually evident from the examination.

Schirmer test with a large amount of wetting (eg, > 25 mm) suggests an evaporative dry eye as the etiology of tearing. Schirmer test with very little wetting (< 5.5 mm) suggests an aqueous tear-deficient dry eye. Usually, Schirmer test is done by an ophthalmologist to ensure it is done and interpreted correctly.

Probing and saline irrigation of the lacrimal drainage system can help detect anatomic obstruction of drainage, as well as stenosis due to complete obstruction of the nasolacrimal drainage system. Irrigation is done with and without fluorescein dye. Reflux through the opposite punctum (eg, the eye's upper punctum if the lower punctum was irrigated) or canaliculus signals fixed obstruction; reflux and nasal drainage signify stenosis. This test is considered adjunctive and is done by ophthalmologists.

Imaging tests and procedures (dacryocystography, CT, nasal endoscopy) are sometimes useful to delineate abnormal anatomy when surgery is being considered or occasionally to detect an abscess. Recurrent infectious dacryocystitis can progress to more serious disorders such as orbital cellulitis.