In case of a lacrimal obstruction, lacrimal massage and topical antibiotics as needed are indicated. If no improvement occurs with age, refer to an ophthalmologist.

If corneal problems or glaucoma are suspected, refer immediately to an ophthalmologist.

What Shouldn’t Be Missed

Glaucoma should not be missed. Early treatment of glaucoma is critical to optimizing vision. If a child with excess tearing has corneal clouding or eye size asymmetry, immediate referral to an ophthalmologist is indicated.

Excess tearing in infants is one of the most common eye problems that pediatricians encounter. Approximately 6% of infants have some symptoms of excess tearing. Most of these spontaneously improve. Because this symptom is so common, however, it is possible to overlook much rarer but potentially serious disorders that present with the same clinical picture.

• 1. Nasolacrimal duct obstruction (NLDO). This is by far the most common cause of excess tearing in infants. It results from incomplete opening of the tear ducts, with symptoms of overflow tearing (epiphora), periocular crusting, or both (Figure 7–1). Most symptoms of NLDO resolve within the first 1 to 2 months of life.
  
• 2. Other anatomic abnormalities of the lacrimal system.
  
  
  
  • a. Absent lacrimal puncta. Much less frequently, infants are born with absent or imperforate lacrimal puncta (the site on the eyelid where the tears enter the lacrimal system) (Figure 7–2A and B). These children present with overflow tearing only. Unlike most children with NLDO, these patients do not get periocular crusts or other symptoms of infection.
    
  • b. Lacrimal fistula. This is a rare anatomic abnormality in which an accessory lacrimal duct extends to the skin, usually nasal and inferior to the eye (Figure 7–3). If the fistula is patent, patients may present with symptoms of excess tearing.
  
  
• 3. Misdirected eyelashes. If the eyelashes are pointed toward the cornea, they may produce chronic irritation, with symptoms of excess tearing and mucoid discharge. These symptoms are similar to those of NLDO. The most common cause of misdirected eyelashes is epiblepharon, an extra fold of skin on the lower eyelid, which causes the eyelashes to turn in toward the cornea (Figure 7–4).
  
• 4. Other corneal problems. Corneal abnormalities are uncommon in infants. Potential etiologies include inherited disorders, infection, foreign bodies, and dry eyes.
  
• 5. Glaucoma. Glaucoma results from increased pressure in the eye. In many infants the cornea enlarges and becomes edematous, which causes ocular irritation and light sensitivity. Many affected infants therefore have symptoms of excess tearing (Figure 7–5).
  
• 6. Retinal dystrophies. Increased light sensitivity occurs in some inherited retinal dystrophies, which may result in excess tearing, particularly in bright light. Most of these disorders have profound effects on vision, and concern about the abnormal vision is usually what brings these patients to medical attention.