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
• 1^o 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.