Evaluation of Tearing
History of symptoms
unilateral vs. bilateral
- nasal/sinus/facial fracture or surgery
- bloody tears/pain w/o inflammation: rule out tumor
- nasal polyps, sinusitis
- hay fever
- external ocular irritation
- Bells palsy
- epinephrine
- phospholine iodide
Etiologies of Epiphora
- surface irritation/reactive hypersecretion
- outflow obstrutionn
- 1o idiopathic hypersecretion
- inadequate Drainage
- Vth nerve stimulation: external/corneal disease pseudoepiphora
- dry eye syndrome
- conjunctivitis
- blepharitis
- uveitis
- entropion
- trichiasis
- thyroid eye disease
- sinusitis
- hay fever
- dental problems
- VII nerve aberrant regeneration
- post-Bell’s palsy; crocodile tears
- central nervous system
- Inadequate Drainage
- Stiff Lid
- from burn, scar tissue, scleroderma
- lacrimal pump dysfunction, punctal displacement
- Punctal Problems
- Agenesis
- probe membranes, if none seen, do cut down (over probe)
- can inject methylene blue inferior to medial canthal tendon
- Stenosis
- treat with dilation, ampullotomy (one-snip), could need silicone intubation
- Eversion / Malpositions
- rx with internal vertical shortening, could need horizontal lid shortening for laxity
- transconjunctival cautery inferior to puncta in bedridden pt
- Conjunctivochalasis
- can occlude punctum
- Rx: vasoconstrictor (Visine, etc) course then PF could 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
- could be total occlusion if poor pump function
- repeat probings
- NLD Obstruction
- Congenital
Examination of the Lacrimal System
- check puncta for stenosis, position
- conjunctivochalasis - is excess conjunctiva obstructing puncta opening
- conjunctival injection
- trichiasis
- entropion
- pseudoepiphora: tear evalaution (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 min.

- 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 imabance between production and drainage of tears. Visit the Lacrimal page for more details.