Tearing Evaluation
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History of symptoms
A tearing evaluation of begins with the determination of unilateral vs. bilateral tears, but also:
- Nasal/sinus/facial fracture or surgery
- Bloody tears/pain without inflammation (rule out tumor)
- Nasal polyps, sinusitis
- Hay fever
- External ocular irritation
- Bell’s palsy
- Epinephrine
- Phospholine iodide
Etiologies of Epiphora
Causes of excessive watering of the eye (epiphora) may include:
- Surface irritation/reactive hypersecretion
- Outflow obstruction
- First degree idiopathic hyper-secretion
- 5th nerve stimulation: external/corneal disease pseudoepiphora
- dry eye syndrome
- conjunctivitis
- blepharitis
- uveitis
- entropion
- trichiasis
- thyroid eye disease
- sinusitis
- hay fever
- dental problems (6th nerve aberrant regeneration, post-Bell’s palsy; crocodile tears)
- Central nervous system issues
- Inadequate drainage
- Stiff lid
- From burn, scar tissue, scleroderma
- Lacrimal pump dysfunction, punctal displacement
- Punctal problems
- genesis (probe membranes, and if none seen cut down and over probe, inject methylene blue inferior to medial canthal tendon)
- stenosis (treat with dilation, ampulotomy, may possibly need silicone intubation, eversion/malpositions, rx with internal vertical shortening, may possibly need horizontal lid shortening for laxity, transconjunctival cautery inferior to punch in bedridden patients)
- Conjunctivochalasis
- can occlude punctum
- rx: vasoconstrictor (Visine, etc.) course then PF may possibly be helpful
- Canalicular problems
- common canaliculus occlusion
- trauma
- meds: 5-FU, IDU, PI, eserine
- viral infection
- autoimmune (pemphigoid, Stevens-Johnson)
- Canaliculitis
- mostly actinomyces israelii, gm filamentous rod, yellow concretions (sulfur), other bact & fungi
- rx: compresses, antibiotics, curretage, canaliculotomy to remove concretions
- Functional Occlusion
- may possibly be total occlusion if poor pump function
- repeat probings
- NLD obstruction
- Congenital
Examination of the Lacrimal System
In examining the lacrimal system for problems:
- Check puncta for stenosis, position
- Conjunctivochalasis – is excess conjunctiva obstructing puncta opening
- Conjunctival injection
- Trichiasis
- Entropion
- Pseudoepiphora: tear evaluation (meniscus, tear break up time)
- Keratopathy
- Lid stiffness
- Lid laxity
- Pump function Lagophthalmos
- Check VII nerve
- Look up nose
- Schirmer 1
- Push on sac, look for discharge
- Basic Tear Secretion (BST) (tear strips after anesthesia)
- Dye Disappearance Test (DDT) (fluorescein to both fornices, look with blue light for asymmetry after 5 minutes)
Primary Dye Test
- Fluorescein to eyes, blow nose, dye present or absent
Irrigation (JONES I)
- Estimate flow through system
- Topical anesthesia
- Lower punctal dilation and irrigation, noting stenosis
- Drawing amount of flow 0-100%:
- Reflux around canula or out superior punctum without lacrimal sac distension = common canaliculus block, if same lacrimal sac distension likely complete nasolacrimal duct obstruction
- If no reflux but w/pain lacrimal sac distention = nasolacrimal duct obstruction w with patent valve of Rosenmuller
- If reflux and drainage to nose = partial nasolacrimal duct obstruction
Secondary Dye Test = Informal Jones II
- Irrigate, dye present in nose = functional nasolacrimal duct obstruction, patent canalicular system, functional pump; or absent
Probing
- Diagnostic probing of adult upper system (puncta, canaliculi, lac sac) ok to find level of obstruction, not to probe NLD
Dacryocystogram (DCG)
- Good for anatomy, not physiology evaluation
CT
Terms
Epiphora: Patients with epiphora complain of watery eyes; it is when there is an imbalance between production and drainage of tears. Visit the Lacrimal page for more details.
