It seems counterintuitive, a dry eye causing a watery eye. Yet this is one of the most common causes of epiphora, and one of the most frequently misunderstood. Understanding why it happens is the first step towards treating it effectively.
The surface of the eye is kept moist and stable by the tear film, a thin, three-layered structure of oils, water, and mucus. When the tear film becomes unstable or breaks down too quickly, the cornea, the clear window at the front of the eye, becomes exposed and irritated. This irritation triggers a reflex response in the brain, which instructs the lacrimal gland to release a sudden flood of watery tears.
These reflex tears are quite different from the steady, balanced tears that normally keep the eye comfortable. They are thin and watery, and because they arrive in large quantity rather than at a steady rate, the drainage system cannot keep pace. The result is overflow, tears running down the cheek, despite the underlying problem being insufficient lubrication.
This is known as reflex tearing or reflex epiphora, and it accounts for a very significant proportion of patients attending eye clinics with watery eyes.
Dry eye disease is extremely common. It becomes more prevalent with age, affects women more than men, particularly around and after the menopause, and is made worse by several modern lifestyle factors.
Common contributors include prolonged screen use, air conditioning and central heating, contact lens wear, certain medications (including antihistamines, antidepressants, and some blood pressure drugs), and systemic conditions such as rheumatoid arthritis and Sjögren’s syndrome.
A common pattern is a patient who spends long hours at a screen and notices their eyes watering later in the day, or when going outside into cold or windy weather. This is classic reflex tearing from dry eye, and it responds well to treatment.
The first-line treatment for dry eye disease is regular use of lubricating eye drops. These are available over the counter from pharmacies without a prescription. They come in many formulations, drops, gels, and ointments, and choosing the right one depends on the severity of symptoms and personal preference.
Preservative-free drops are preferable for regular use, as preservatives in multi-dose bottles can themselves irritate the eye surface over time. Drops containing hyaluronic acid are generally well tolerated and effective for mild to moderate symptoms.
The oily outer layer of the tear film is produced by meibomian glands, which sit along the margins of the eyelids. When these glands become blocked or dysfunctional, a very common condition called meibomian gland dysfunction, the tear film evaporates too quickly, driving dry eye and reflex tearing.
Treatment involves warm compresses applied to closed eyelids for several minutes daily, followed by gentle massage of the lid margins. This softens the oils within the glands and helps them flow more freely. Heated eye masks are a convenient way to do this.
For patients with moderate to severe dry eye that does not respond to lubricating drops and lifestyle measures, further options include prescription anti-inflammatory drops, punctal plugs (tiny silicone inserts that slow tear drainage to keep the eye surface more moist), or specialist treatments such as intense pulsed light therapy for meibomian gland dysfunction.
If lubricating drops used regularly for four to six weeks do not improve your symptoms, if your vision is affected, or if you experience persistent discomfort or light sensitivity, it is worth seeking assessment from your optometrist or GP. They can examine the tear film directly and advise on further management.
This guide is covered in depth in Chris Matthews’ patient book on watery eyes, including how each condition is investigated, what to expect at a clinic appointment, and the full range of treatment options explained in plain English.