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
  • 1o 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), might possibly need silicone intubation
        • Eversion / Malpositions
        • rx with internal vertical shortening, might possibly 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 might possibly 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
      • might possibly 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.

      shows excess dye

  • 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

Irrigation (JONES I)

  • 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


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.






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