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The tear film consists of three layers: an oily layer from the meibomian glands on the edge of the eyelid, which slows evaporation, a watery layer from the tear gland, and a mucous layer that makes everything stick to the cornea. With every blink, the eyelids pump used fluid into two tiny openings at the inner corner of the eye, the tear points (puncta). From there it flows through the tear canals and the tear sac and down the tear duct into the nose — which is why your nose runs when you cry. Watery eyes (epiphora) therefore come about either because too much fluid is produced or because too little drains away.
This article looks at the watering itself. If burning and a feeling of dryness without tears are the main problem, the article on dry eyes will help; inflammation of the conjunctiva is described in detail in the article on conjunctivitis.
In dry eye (sicca syndrome), the tear film is too thin or breaks up too quickly — often because the oily layer is missing when the meibomian glands are blocked, less often because too few watery tears are produced. Dry spots on the cornea are reported as irritation, and the tear gland sends a flood of reflex tears. These are watery, contain hardly any oil, and evaporate quickly or run over: the eye waters and still feels dry.
Typically both eyes are affected, with burning, a gritty feeling, eyes that tire quickly and blurred vision that improves after blinking hard. The symptoms get worse with screen work, because you blink less often, and also in heated or air-conditioned air, in wind, with contact lenses and towards the evening. The risk rises with age, during the menopause, with rosacea affecting the eyes and with autoimmune diseases such as Sjögren's syndrome, which also dries out the mouth. First step: reduce the triggers, use artificial tears without preservatives and care for the edges of the eyelids with warmth.
In adults, the tear duct (nasolacrimal duct) often narrows for no obvious reason, probably as a result of slowly scarring inflammation; women from middle age onwards are affected more often. Chronic inflammation of the nose and sinuses, injuries to the middle of the face, previous operations in this area, certain medicines and, very rarely, tumours can also be responsible. Typical is an eye that constantly "swims" and runs over onto the cheek, worse outdoors in cold and wind, along with slightly blurred vision, lashes stuck together with mucus in the morning and recurring irritation of the conjunctiva on one side.
If secretions build up in the tear sac, it can become inflamed (dacryocystitis): a painful, red swelling develops below the inner corner of the eye, sometimes with a fever — a case for the eye specialist the same day. Whether the passage is open is shown by flushing (irrigating) the tear ducts. If the blockage is complete, an operation creates a new drainage route from the tear sac into the nose (dacryocystorhinostomy), either from the outside or through the nose.
In newborns, a tear duct that has not yet opened is common: one eye waters and gets sticky in the first weeks of life. The duct usually opens by itself during the first year of life; your paediatric practice will show you a gentle massage over the tear sac. If the watering persists, the duct can be probed by an eye specialist.
In ectropion, the lower eyelid turns outwards, usually because the tissue slackens with age. The tear point then no longer dips into the small pool of tears along the lid margin, and the tears run over — and the exposed conjunctiva dries out, which triggers additional reflex tears. After facial palsy, too, the lower lid sags and the eye no longer closes fully. In entropion, the edge of the eyelid turns inwards and the lashes rub against the cornea; individual misdirected eyelashes (trichiasis) have a similar effect. In both cases, a minor eyelid operation is usually the only lasting solution; until then, artificial tears or ointments protect the cornea. A special feature after facial palsy is "crocodile tears": the eye waters while eating because regrowing nerve fibres have been misrouted.
In allergic conjunctivitis, itching is the key symptom. Both eyes water and are red, the eyelids swell, and sneezing and a runny nose are often added — typical of hay fever (allergic rhinitis) in the pollen season, or all year round with a dust mite or pet allergy. Rubbing makes the cycle worse. Cool compresses, avoiding the allergen and anti-allergy eye drops usually help well.
Viral conjunctivitis causes watery tears, redness and a foreign body sensation, often starts in one eye, spreads to the other and can be very contagious. A bacterial infection tends to show up with yellowish pus and eyelids stuck together in the morning. Thorough hand washing and your own towels protect others. With pus, pain, worsening vision or contact lenses, the eye needs to be seen by an eye specialist.
A speck of dust, an eyelash, a scratch on the cornea (erosion) or an inflammation of the cornea (keratitis) trigger heavy watering — usually on one side, with pain, sensitivity to light and the urge to squeeze the eye shut. With contact lenses, a corneal infection caused by bacteria or amoebae is particularly feared: take the lens out immediately and have the eye examined by an eye specialist the same day. What to watch out for with lenses and medicines is explained in the guide Medications and contact lenses. Blisters on the forehead or the tip of the nose with a red, watering eye can point to shingles affecting the eye — also a case for the same day.
With an overactive thyroid of the Graves' disease type, the tissue in the eye socket can swell (endocrine orbitopathy, also called thyroid eye disease): the eyes bulge, water, burn and are sensitive to light, and double vision may follow later. Watering on one side with extremely severe pain around one eye in recurring attacks, often with a runny nose on the same side, fits a rare form of headache, cluster headache. Bloody tears or a hard, painless swelling at the inner corner of the eye are very rare but should be checked promptly by an eye specialist.
These observations do not replace a diagnosis or an examination with a slit lamp. But they help you recognise the pattern and report it precisely at your appointment.
Many medicines reduce tear production. These include antihistamines such as cetirizine or desloratadine — paradoxically, since they are taken for allergic watery eyes — as well as medicines with anticholinergic effects such as tricyclic antidepressants, for example amitriptyline, and bladder medicines such as oxybutynin. Beta blockers, diuretics (water tablets) and some hormonal products are also associated with dry eyes. Isotretinoin dampens the meibomian glands; contact lenses are often tolerated less well while taking it. The guide Medications and the eyes gives an overview of side effects affecting the eyes.
The preservative benzalkonium chloride can irritate the surface of the eye when used for years — a well-known problem with long-term drops, for example in glaucoma treatment. Preservative-free alternatives are often available; ask your eye specialist about them. But never stop glaucoma drops on your own initiative, because the pressure in the eye then rises without you noticing. Important for your medication plan: beta-blocker eye drops such as timolol reach the bloodstream and can slow the pulse or make asthma worse.
Docetaxel and fluoropyrimidines such as capecitabine or 5-fluorouracil can cause scarring of the tear points and tear canals — constant watering is the result. If it is recognised early, a permanent blockage can often be prevented by treatment from an eye specialist, for example silicone tubes inserted temporarily. So if new watering starts during chemotherapy, raise it promptly with the oncology team. In rare cases, narrowing of the tear duct is also seen after radioiodine therapy of the thyroid.
Active substances with cholinergic effects — such as pilocarpine tablets for dry mouth in Sjögren's syndrome or pyridostigmine for myasthenia gravis — can directly stimulate the flow of tears and saliva. If the watering starts with one of these medicines, the connection is obvious.
A painful eye is not a case for prolonged self-treatment. Without medical advice, according to the package leaflet, you should usually take over-the-counter painkillers such as ibuprofen or paracetamol for no longer than three to four days — and they can mask an inflammation of the cornea. There is a good reason why anaesthetic eye drops are not available for self-treatment: used repeatedly, they damage the cornea. More in the painkiller comparison.
Symptoms and doses over time make the timing visible.
Glaucoma drops, artificial tears and tablets in one place — with dose reminders and an interaction check.
This article is for general information and does not replace medical advice, diagnosis or treatment. The self-tests described — including the pressure test at the corner of the eye and the eyelid check — are a guide and not a diagnosis. If you have a suddenly red, painful eye with worsening vision, a chemical burn or an injury, a painful swelling at the inner corner of the eye with fever, or pain while wearing contact lenses, please contact a doctor or the emergency services without delay.
