History

A child with excessive tearing can cause parents and primary care doctors concern. Build-up of mucus in the tear film causes “stickiness” and constant spillage of tears causes redness and irritation of the lower lid skin. The lids may be stuck together on waking and require frequent cleaning. Parents may complain that the appearance “ruins” childhood photographs and they may feel the child’s appearance reflects poorly on them as a parent. The primary care physician may feel compelled to prescribe repeated courses of topical antibiotics, to no lasting effect.

Try and establish whether the watering had its onset soon after birth, or if it is recent. Photophobia must specifically be asked about, as it is common in congenital glaucoma. The typical presentation is a child who avoids opening their eyes in normal daylight, often burying the eyes behind an arm or hand. Photophobia is also a symptom of corneal disease (such as cystinosis; see Chapter 33), uveitis, and a foreign body in the conjunctival sac. The possibility of trauma needs to be kept in mind, as children cannot always give a detailed history. The child with excessive lacrimation, rather than blocked tear drainage, may have a watery nose on the same side as the watery eye. A history of eye rubbing or poking and concerns about whether the child can see suggests a retinal dystrophy, such as Leber’s congenital amaurosis (see Chapter 44).

External inspection

Tearing, red macerated skin, and stickiness may be seen. In nasolacrimal duct obstruction, the tear lake is thickened, brimming the lower lid margin. Normally, the tear film is virtually invisible, and, with fluorescein staining of the tear film, measures less than 1 mm. With obstruction, it typically measures 2 mm or more. Secondary bacterial conjunctivitis can occur, causing generalized conjunctival redness, whereas perilimbal injection may be more specific for keratitis or uveitis. Generalized corneal haze with secondary corneal epithelial edema may be a sign of glaucoma. An estimate should be made of horizontal corneal diameters using a ruler held close to the lid. A congenital swelling over the nasolacrimal sac is probably a dacryocystocele.

Slit-lamp examination

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