BASICS

DESCRIPTION

Epiphora, or tearing, represents an imbalance between tear production and tear drainage. The lacrimal gland and accessory tear glands produce tears while the nasolacrimal drain carries the tears form the ocular surface down into the nose. An overproduction from ocular irritation will cause tearing as will a blockage of the drainage system.

EPIDEMIOLOGY

• This can occur in patients of any age, but there is typically a bimodal distribution, in infancy and late adulthood. In infants, tearing most commonly represents a blocked tear duct, which occurs in about 5% of all babies. Fortunately, 90% of these resolve by age 1.

• In the adult population, tearing is a much more common problem, often from a dry eye. This is more common in women, especially postmenopause.

PATHOPHYSIOLOGY

• In normal patients, aqueous tears are produced by the lacrimal glands, which mix with sebaceous secretions and mucus, to lubricate the eye. The force of blinking, with a negative pressure within the tear drain on opening the lids, pulls the tears off the ocular surface down the drain and into the nose. Any imbalance along this pathway can result in tearing.

• Congenital obstruction occurs from incomplete canalization of the nasolacrimal duct during embryogenesis.

• Adults with tearing most often have a dry eye or an unstable tear film that leads to ocular irritation and secondary reflexive tearing, which is intermittently symptomatic. The imbalance can occur from associated blepharitis with poor sebaceous secretions from the eyelid or decreased aqueous tear production.

• Ocular surface irritation from trichiasis, entropion, a foreign body, keratitis, uveitis, or conjunctivitis can all cause reflexive tearing acutely.

• Lower lid laxity, with or without frank ectropion, can limit the normal tear pump mechanism.

• Acquired obstructions occur from progressive narrowing anywhere along the course of the drain. This usually results secondarily from infection, inflammation, or trauma. These patients typically have constant tearing. Certain chemotherapeutics can also cause stenosis.

ETIOLOGY

Again, a multitude of things can trigger tearing. Over production of tears occurs from irritation of the ocular surface while a blockage of the drain leads to poor drainage.

COMMONLY ASSOCIATED CONDITIONS

Blepharitis, trichiasis, entropion, ectropion, dry eye, tear drain obstruction, ocular surface inflammation, foreign body.

DIAGNOSIS

HISTORY

• Infants most commonly present with constant tearing in 1 or both eyes that starts shortly after birth and continues constantly. They often awake from naps and bedtime, which crusting on the lashes. Finally, symptoms are often worse with nasal congestion.

• In adults with dry eye, the symptoms have an insidious onset with intermittent symptoms. The tearing is typically worse with activities that require more concentration, and thus less blinking, such as reading, watching TV, using a computer, and driving. Cold, windy weather also exacerbates symptoms.

• In the adult patient with a poor tear pump or blocked drain, the symptoms are more constant.

• Patients with acquired obstruction may have a history of eye infection, dacryocystitis, or trauma to the drain system, but not always.

PHYSICAL EXAM

• Examine tear film for quality and quantity.

• Lid anatomy and position, looking specifically for misdirected lashes, entropion, ectropion, lower lid laxity. Also, they may have macerated skin in the lower lid from chronically being moist.

• Ocular surface exam looking for evidence of dry eye, foreign body, conjunctivitis, or keratitis.

• Examine tear drainage both functionally and physically with evaluation of the puncta, canaliculi, and irrigation down the nasolacrimal duct. Palpation of the lacrimal sac is important if a distal obstruction of the drain is suspected.

DIAGNOSTIC TESTS & INTERPRETATION

• Dye disappearance test: Fluorescein is applied to the conjunctival cul de sac, and the patient is observed for 5 min.

– In a negative test (normal), the tear meniscus will become relatively unstained as the tears naturally flow down through the drainage system. Dye can sometimes be found in the nose.

– In a positive test (abnormal), the height of the stained tear meniscus will increase owing to the obstructed lacrimal system.

– No change in the tear meniscus can be encountered with either an obstructed drain or a dry eye where there are not enough tears to wash the dye down the drain.

• Schirmer testing of tear production. This is best done with topical anesthesia of the eye to measure basal tear secretion alone. Less then 5 mm of wetting in 5 min is considered dry. 5–10 mm is borderline and greater then 10 mm is normal.

Lab

Follow-up & special considerations

Sjögren antibodies—if the patient is a young adult or is middle aged and has a dry mouth or other rheumatologic symptoms.

Diagnostic Procedures/Other

• Dacryocystogram can be helpful in differentiating between poor tear pumping versus obstruction of the tear drain.

• Lacrimal scintigraphy can also be performed on occasion to evaluate drainage form the eye into the nose, but is rarely done in children.

• CT scan be obtained if there is a concern of a nasolacrimal cyst or dacryocele, or tumor in the lacrimal sac.

• In teenagers and adults, in office irrigation of lacrimal system at the level of the canaliculus can be used diagnostically to evaluate for obstruction within the drain system.

Pathological Findings

• Intrapalpebral punctuate staining of the cornea and conjunctiva is seen with moderate-to-severe dry eye.

• A distended lacrimal sac, which extrudes purulent debris from the puncta with manual pressure, is indicative of a chronic dacryocystitis and blocked nasolacrimal duct.

DIFFERENTIAL DIAGNOSIS

• Children (chronic) congenital obstruction of nasolacrimal duct, congenital glaucoma, epiblepharon.

• Children (acute) conjunctivitis foreign body, keratitis.

• Adult (chronic) dry eye, acquired nasolacrimal duct obstruction, ectropion, entropion, trichiasis, old facial palsy.

• Adult (acute) conjunctivitis, keratitis, uveitis, foreign body, cranial nerve 7 palsy.

Geriatric Considerations

Tearing in this age group is usually intermittent and often represents a dry eye that becomes irritated and secondarily waters.

Pediatric Considerations

In this age group, the most common diagnoses are a congenitally blocked tear duct and infection. Don’t overlook infantile glaucoma, but this is relatively uncommon by comparison.

TREATMENT

MEDICATION

First Line

• Pediatric (chronic)—topical antibiotic ointment (erythromycin, bacitracin, polysporin) PRN if significant discharge and crusting.

• Adult (chronic)-–artificial tears drops.

• Acute pediatric and adult epiphora-–treat underlying issue such as removal of foreign body, topical antibiotics for bacterial conjunctivitis or keratitis, removal of irritating lashes with trichiasis.

Second Line

Adult (chronic)—topical cyclosporin eyedrops b.i.d., topical steroid eyedrops for short-term treatment of chronic ocular inflammation.

ADDITIONAL TREATMENT

General Measures

• Punctal occlusion if dry eye present.

• Punctoplasty for punctual stenosis.

Issues for Referral

Acute dacryocystitis, especially in infants.

COMPLEMENTARY & ALTERNATIVE THERAPIES

Pediatric tearing from congenital obstruction can be treated with daily massage over the lacrimal sac, hoping to help open the obstruction distally.

SURGERY/OTHER PROCEDURES

• Pediatric—probing and irrigation, P & I with stenting of tear drain, balloon dacryoplasty, dacryocystorhinostomy, conjunctivodacryocystorhinostomy.

• Adult (blocked tear drain)—Punctoplasty, P & I with stenting or balloon dacryoplasty, dacryocystorhinostomy, conjunctivodacryocystorhinostomy.

• Adult (lid malposition)–-entropion repair, ectropion repair, horizontal lid tightening for pump failure.

ONGOING CARE

FOLLOW-UP RECOMMENDATIONS

• Infants can be followed conservatively during the 1st year of life. If they fail to resolve by age 1 year, surgery should be scheduled at this time.

• Adults can be followed as needed depending on the severity of their symptoms. Chronic dry eye and blepharitis patients can be seen with their routine care. Lid malposition and nasolacrimal obstruction patients should be scheduled for surgery and seen postoperatively to ensure resolution.

DIET

Fish oil, flax seed, and other sources of omega-3 fatty acids can improve tear film stability in adult patients with dry eyes.

PATIENT EDUCATION

• For pediatric patients, instruct parents on proper nasolacrimal massaging technique.

• For adult patients with chronic blepharitis, daily lid scrub can be helpful usinga warm wash cloth.

PROGNOSIS

• Pediatric cases-–excellent.

• Adult cases–-mixed depending on underlying etiology. Chronic dry eye and blepharitis patients will tend to have intermittent chronic symptoms. Patients with nasolacrimal duct obstruction do well after DCR surgery.

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