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Home , Allergic conjunctivitis, Blepharitis, Conjunctivochalasis, Epiphora (medicine), Keratoconjunctivitis

Ophthalmic Pearls

External Disease

The Tearing Patient: Diagnosis and Management

by kristina m. price, md, and michael j. richard, md edited by ingrid u. scott, md, mph, and sharon fekrat, md

xcessive tearing, also known 1 as , is due to a EPIPHORA disruption in the balance between tear production Primary Overproduction Underdrainage Reflexive Tearing Production > Loss Production > Loss (secondary and tear loss. Numerous eti- (uncommon) overproduction) Eologies lead to an excess of , and there are a number of ways to diagnose Irrigate Measure basal tear secretion Can tears enter and treat this condition. (anesthetized Schirmer’s) and lacrimal drainage system? tear breakup time (TBUT) Currently, there is not a firm con- sensus on the best way to evaluate the Neurogenic Idiopathic tearing patient. However, a simple No Yes Tear wetting Tear wetting < 10 mm in > 10 mm in algorithm may aid the general oph- five minutes five minutes thalmologist in the evaluation and TBUT TBUT Evaluate lids management of this common condi- < 10 seconds > 10 seconds tion (see Fig 1).

Where is Lid malposition Loss > Basal Anatomy and Physiology the location Punctal stenosis production of the Lacrimal System of reflux? The main lacrimal gland, the accessory lacrimal glands and the conjunctival Mechanical epithelium are responsible for pro- irritation ducing tears. Tears are spread over Same Opposite punctum punctum Medicamentosa the surface of the by blinking to Ocular cicatricial establish the precorneal tear film. Each Canalicular Distal pemphigoid contraction of the orbicularis muscle obstruction obstruction Stevens-Johnson (e.g., NLDO) helps move the tears across the ocular syndrome Decreased Increased loss surface toward the lacrimal drainage production (i.e., evaporation) system. Tear film instability Ideally, the basal tear secretion rate sicca Lid malposition May equals the rate of tear drainage and overlap evaporation. Basal tear secretion oc- Decreased blink reflex curs at a rate of about 1.2 µl/minute, although reflexive tear secretion can increase this up to 100-fold. Tears but ideally tear evaporation roughly Clinical Causes and enter the puncta at a rate of 0.6 µl/ equals the difference between basal Associated Symptoms min; about 90 percent are reabsorbed secretion and drainage. The ocular The lacrimal system governs a delicate through the mucosa surface (including the lacrimal lakes in balance between tear production and and 10 percent drain into the floor of the conjunctival fornices, the marginal loss with little reserve for disturbance. the nasal cavity. Tears evaporate from tear strip and the precorneal tear film) This balance is complicated by the fact the ocular surface at a variable rate, can hold only 8 µl of tears at any time. that the system is subject to a constant

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the lacrimal drainage pathway can Causes and Treatments for Epiphora result in tearing. Punctal and canali- cular stenosis can result from toxic TreatmentS Causes medications (pilocarpine, epinephrine, Punctal obstruction Dilation, three-snip punctoplasty, sili- phospholine iodide and idoxuridine), cone intubation trauma, prior radiation therapy and Canalicular obstruction chronic inflammation secondary to Canalicular stenosis/constriction Silicone intubation infections (e.g., Actinomyces israelii) or Complete canalicular occlusion Excision of occluded area and plastic autoimmune disorders (e.g., ocular ci- repair of canaliculus catrical pemphigoid, Stevens-Johnson syndrome). The nasolacrimal duct also Canaliculitis , warm compresses, curettage may become obstructed secondary to with canaliculotomy to remove con- involutional stenosis, trauma, prior cretions , post-irradiation, chronic sinus Common canalicular obstruction or Conjunctivodacryocystorhinostomy disease, or granuloma- obstruction of both canaliculi (CJDCR) with Jones tube placement tous disease. In addition, neoplasms Nasolacrimal duct obstruction (NLDO) Silicone intubation with or without can affect and obstruct any portion of (DCR) the nasolacrimal system. With dacryocystitis Antibiotics, allow acute infection to Ocular surface disorders. Ocular resolve, usually necessitates DCR surface dryness or irritation stimulates the reflex arc of the fifth and seventh Recurrent NLDO DCR cranial nerves, producing excessive Poor pump function/lid malposition tear secretion. If the lacrimal drain- Involutional Horizontal tightening with lateral age system is unable to handle the tarsal strip or modified lateral can- transient increase in tear volume, this thopexy results in an overflow of tears. The list Involutional Retractor reinsertion with lateral tarsal of ocular surface disorders is exten- strip or modified lateral canthopexy sive, but some of the more common Punctal ectropion Medial spindle with or without horizontal etiologies include chronic blepharitis, eyelid tightening procedure keratoconjunctivitis sicca, trichiasis, allergic , exposure ker- Ocular surface disorders Correct underlying problem; if dryness atopathy and medicamentosa. is a contributing factor, consider arti- Neurogenic lacrimal hypersecre- ficial tears, punctal plugs, Restasis, tory disorders. Hypersecretion of tears etc. is rare but can occur in certain condi- tions. Compression of the parasym- input of environmental, physical and mal drainage system. The orbicularis pathetic lacrimal fibers from a tumor, biologic factors. An imbalance in the muscle provides the pump mechanism aberrant regeneration of the seventh system in either direction eventually for the excretion of tears. With eyelid cranial nerve secondary to trauma, may lead to epiphora. Tear produc- closure, orbicularis contraction creates or certain medications tion in excess of loss directly leads to a negative pressure within the lacrimal (e.g., cholinergic agonists) can result in tearing, whereas tear loss in excess of drainage system, thus propelling fluid inappropriate lacrimation. production stimulates reflexive tear into the nasolacrimal sac. When the production, which may also lead to eye opens, the muscles relax, creating Examination and Diagnosis epiphora. Most imbalances fall into the positive pressure within the system A pertinent history is essential to pro- categories described below. and forcing tears from the sac into the vide clues to the diagnosis. History of Appositional abnormalities and duct. Any abnormality that affects this sinus disease, sinus surgery, midfacial poor pump function. Close apposition pump mechanism or any condition in or ocular trauma, or history of na- of the lids against the is an inte- which the puncta are not in apposition solacrimal duct probing as a child may gral part of maintaining an adequate to the globe can produce epiphora. all suggest obstructive problems. In tear balance. This apposition prevents The most common examples of this addition, pus or blood in the tear film excessive exposure of the ocular sur- include ectropion, entropion, floppy may indicate infection or malignancy, face and minimizes tear film evapo- eyelid syndrome, punctal eversion and respectively. Associated symptoms ration. Lid-globe apposition is also seventh nerve palsy. such as pain, itching, burning, etc., important for directing tears across Obstructive lacrimal drainage dis- are important to elicit, as they may the ocular surface and into the lacri- orders. Any condition that obstructs provide further insight into the etiol-

34 june 2009 Ophthalmic Pearls ogy. A full ocular examination is war- five minutes is considered subnormal, to localize the obstruction. Reflux ranted to pinpoint the cause of tearing. while less than 5 mm is pathologic. through the same punctum suggests Inspection. The ophthalmologist • Assessing for lacrimal obstruction. canalicular obstruction, whereas re- should look for facial and periorbital While there is no consensus re­garding flux through the opposite punctum asymmetry, eyelid malposition and the best way to assess for lacri­mal ob- suggests distal obstruction. midface . Any inflammation, struction, we present our method. The discharge or fistulas should be noted. dye disappearance test (DDT) can help Management It is also necessary to evaluate the cor- determine whether a lacrimal outflow Successful management of the tear- neal surface, assess the blink reflex and obstruction is present, especially in ing patient requires the clinician to check for lagophthalmos. A simple but unilateral cases. is instilled determine the underlying cause of the very effective way to assess for nasolac- into the conjunctival cul-de-sac bilat- epiphora. Unfortunately, this can be rimal duct obstruction is to evaluate erally. Persistence of significant dye difficult to discern, at least in part be- the size of the tear meniscus. Burkat and asymmetric clearance of the dye cause the causes are often multifacto- and Lucarelli1 demonstrated that the from the tear lake over five minutes rial. We begin all epiphora evaluations height of the tear meniscus, measured indicates a relative obstruction on the by explaining the normal tear balance by slit-lamp examination, was a sta- side with the retained dye. We do not to patients and pointing out that any tistically useful indicator for nasolac- routinely perform the Jones I and II disruption to one part of the system rimal duct obstruction. They found tests when evaluating the patency of can cause changes in other parts of the that the median tear level in with the lacrimal system. Instead, we irri- system. The “art” of the evaluation of obstructed nasolacrimal ducts was 0.6 gate the lacrimal system to determine the tearing patient is to try to deter- mm compared with 0.2 mm in eyes the level of the obstruction. A 27-gauge mine what processes are contributing with unobstructed ducts. anterior chamber cannula on a 3-cc most to the tearing and then direct Palpation. Fullness over the lacri- syringe with normal saline allows the treatment accordingly (see “Causes mal sac region and/or reflux of mu- ophthalmologist to irrigate without and Treatments for Epiphora”). copurulent drainage upon palpation of having to dilate the puncta. After ir- the lacrimal sac may indicate dacryo- rigant is introduced into the lacrimal 1 Burkat, C. N. and M. J. Lucarelli. Ophthal- cystitis. Nodules or firmness superior system, resistance, reflux and delay or mology 2005;112:344–348. to the medial canthal tendon may sug- lack of clearance into the nasopharynx gest neoplasm. suggests the presence of obstruction. Dr. Price is a fellow in and Dr. Functional testing. Functional The degree of resistance and reflux Richard is an assistant professor of ophthal- tests include: suggests the severity of obstruction, mology, specializing in oculoplastics. Both are • Assessing lid laxity. Horizontal whereas the location of reflux helps at Duke University. lid laxity is assessed by pulling the lid down or away from the globe. If the lid can be stretched more than 8 mm, How to Write a Pearls Article this is considered to be excessively lax. Ophthalmic Pearls articles reflect main- The lid is also considered lax if it takes stream practice and provide readers with A more than 8 seconds for the lid to re- tips on procedures in widespread use or turn to its normal position. The laxity provide a review of disease management. B is severe if the lid does not appose the All articles are doctor-written and are drawn D C globe before the first blink. from clinical experience. • Assessing for dry eyes and other tear film abnormalities. Evaluate tear What To Do: A. Come up with a topic and clear it with breakup time (TBUT) by having the E patient refrain from blinking after EyeNet’s medical editors* before you start. placing fluorescein in the conjunctival B. Medical students, residents and fellows cul-de-sac. If TBUT is less than 10 should team with a faculty member who can F seconds, there may be a problem with provide pearls from experience. tear film stability. There is some debate C. Send at least one photo or illustration. about the reliability of testing to evalu- D. Write an introduction letting readers ate tear production, but we find it use- know why this topic is relevant. ful to assess the basal tear secretion. E. Use subheadings to help readers easily navigate the 1,500-word article. This is done by placing a strip of filter F. Keep references to five or fewer if possible. paper in the conjunctival fornix after *Send topics to Pearls Editors Ingrid U. Scott, MD, MPH, [email protected], or administering topical anesthetic drops. Sharon Fekrat, MD, [email protected]. Less than 10 mm of tear wetting in

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