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   Table of Contents      
OPHTHALMOLOGY PRACTICE
Year : 1994  |  Volume : 42  |  Issue : 3  |  Page : 157-161

Practical approach to a patient with epiphora


L.V. Prasad Eye Institute, Hyderabad, India

Correspondence Address:
G Chandra Sekhar
L.V. Prasad Eye Institute, Road No. 2, Banjara Hills, Hyderabad 500 034
India
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Source of Support: None, Conflict of Interest: None


PMID: 7829181

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How to cite this article:
Sekhar G C. Practical approach to a patient with epiphora. Indian J Ophthalmol 1994;42:157-61

How to cite this URL:
Sekhar G C. Practical approach to a patient with epiphora. Indian J Ophthalmol [serial online] 1994 [cited 2020 Oct 26];42:157-61. Available from: https://www.ijo.in/text.asp?1994/42/3/157/25568


  I. INTRODUCTION Top


Epiphora or tearing is an extremely common ocular symptom. A host of disease entities can lead to this symptom. A thorough understanding of these entities with appropriate strategies to identify the causes of tearing in a given patient is the only way to successfully manage this annoying symptom.

The first step in the understanding of epiphora is to differentiate epiphora from lacrimation. Epiphora is watering that occurs secondary to abnormal excretory system in the presence of normal tear secretion. Lacrimation, on the other hand, is watering that occurs secondary to excessive tear production in the presence of a normal excretory system. Failure to differentiate these two conditions can result in unwarranted and improper medication of a large number of patients.


  II. PATHOPHYSIOLOGY Top


A. Secretory System

A.1. Tear Film

Normal tear secretion is necessary to keep the ocular surface moist. The tears form a thin film called the precorneal tear film over the cornea. The integ­rity of this film is crucial for normal corneal physi­ology.

A.2. Tear Composition and Secretion

The tear film is composed of three layers. The mucin layer on the surface of the conjunctiva and cornea is secreted by the goblet cells. This alters the surface tension of the tears and increases its adher­ence to the cornea.

The aqueous layer is secreted by the accessory lacrimal glands in the fornix (Krause) and tarsal conjunctiva (Wolfring). In the presence of ocular irritation the main lacrimal gland acts as the reflex secretor and produces excessive aqueous layer.

The meibomian glands secrete the oily layer which lies on the surface of the tear film and prevents its evaporation.

A.3. Pathology of the Tear Film

Deficiency of the aqueous layer results in kera­toconjunctivitis sicca or dry eye. The eyes are truly dry and there is no watering. On the other hand, deficiency of either mucous or meibomian secretions results in instability of the tear film and inadequate lubrication of the ocular surface. This leads to compensatory excessive aqueous secretion and results in paradoxical watering in the dry eye.

B. Lacrimal Drainage System

B.1. Anatomy of the Lacrimal Drainage System

Anatomically, the lacrimal drainage system con­sists of the puncta, the canaliculi, the lacrimal sac, and the nasolacrimal duct. The canaliculus is approxi­mately 10 mm in the lower lid and 8 mm in the upper lid. The two canaliculi fuse and form the common canaliculus which opens into the lacrimal sac.

B.2. Physiology of the Lacrimal Drainage System

For the normal drainage of tears, the puncta should be open and in firm apposition to the globe. The tears drain into the puncta from the tear menis­cii along the lid margins by capillary action and also due to the negative pressure created by the sac. As the sac is surrounded by the orbicularis muscle, normal blinking movements result in negative pres­sure in the sac when the lids are open and positive pressure when, the lids are closed. The valves at the common canaliculus (Rosen muller) and nasolacrimal duct opening into the nose (Hassner) ensure unidi­rectional flow of tears into the nose. Paralysis of the orbicularis can result in epiphora due to lacrimal pump failure.

The various causes of watering and their identi­fication is presented in the Flowchart. The causes and management of watering in the paediatric age group are different from those of adult patients and hence needs to be considered separately.


  III. EVALUATION OF PAEDIATRIC PATIENTS WITH EPIPHORA Top


Though congenital nasolacrimal duct obstruction is the most common cause of epiphora in the pae­diatric age group, other conditions that could lead to watering in a child need to be scrupulously excluded to avoid mismanagement. If watering is intermittent or has started more than a month after birth, it is unlikely to be due to congenital nasolacrimal duct (NLD) obstruction. Presence of long-standing epiphora associated with a quiet eye and mucoid or mucopu­rulent discharge is invariably diagnostic of congeni­tal NLD obstruction.

A. Causes of Pseudoepiphora

A.1. Epiblepharon

Epiblepharon is a fold of skin that pushes the normally directed lashes against the globe. This may not be clear in primary position, but becomes appar­ent in the downward gaze. As the nasal structures develop the fold of skin disappears. The child needs to be treated in the intervening period with an ocular lubricant such as methylcellulose eye drops. If irri­tation is severe, excision of the excess skin and orbicularis muscle provides prompt relief.

A.2. Distichiasis

Distichiasis is the presence of abnormal lashes at the openings of the meibomian gland. The lashes may appear normal, but more often appear as fine lanugo­like hair. Examination under magnification might be necessary to pick up the diagnosis.

A.3. Trichiasis

Trichiasis is misdirection of the normal eye lashes onto the cornea and is relatively uncommon in the paediatric age group.

Trichiasis and distichiasis might be manageable by electrolysis if only a few lashes are abnormal, but surgery is required if the disease is extensive.

A.4. Congenital Glaucoma

Children with watering, photophobia, enlarged hazy cornea are most likely to have congenital glau­coma. While a full-blown clinical picture can be im­mediately diagnosed, incipient cases require careful examination under anaesthesia. Once the causes of pseudoepiphora are excluded, the lacrimal drainage system warrants close attention.

B. Clinical Evaluation of True Epiphora

Examination of the lacus is most essential. If it is filled with tears, it is indicative of outflow obstruction.

Regurgitation of mucoid or mucopurulent material from the punta on pressure over the sac area is indicative of nasolacrimal duct obstruction. At times, a dilated sac may be palpable.

Absence of the puncta can be identified clinically, if the child cooperates, with the help of loupes and bright illumination.

A history of rhinorrhoea or gross pathology in the nose can also explain the symptoms of epiphora.

C. Management of Congenital NLD Block C.1. Medical Management

After the diagnosis has been established, lacrimal massage and instillation off topical antibotic drops are advised three times a day. The key to successful man­agement is proper massage. It helps to show the landmarks of the lacrimal sac on the mother's face. The anterior lacrimal crest which is the continuation of the inferior orbital margin is to be palpated and massage done posterior to it. The initial stroke of massage should be in a downward direction starting from the fundus of the sac. This creates a downward hydrostatic pressure on the obstruction in the NLD and helps to open the block.

If there is no improvement with conservative treatment in 6 to 8 weeks or if the child is nearly one year old, syringing and probing of the lacrimal passages under general anaesthesia should be consid­ered.

C.2. Syringing and Probing the Lacrimal Passage

The success rate for syringing and probing is more than 90%, if it is performed within the first year of the child's life. It subsequently declines to about 50% at 2 years of age.

It is easy and safe to have general anaesthesia by endotracheal intubation. This facilitates mobility and convenient intranasal examination and manipulation, which otherwise would be impossible with facial masks.

Both upper and lower puncta are dilated with a punctum dilator. All the contents of the lacrimal sac are irrigated. Probing is done through the upper punctum. Usually No.0 and No.1 sized Bowman probes are used. While the use of finer probes can lead to false passage, larger probes can cause damage to the puncta.

The probe is lubricated with sterile ophthalmic ointment and passed into the upper canaliculus. It is useful to remember that the first 2 mm of the canaliculus is vertically oriented. Hence, this should be the initial direction of the probe. Later, the probe is passed horizontally along the canaliculus as far as the medial wall of the lacrimal sac in order to touch the bone. The probe is then directed downward, backward and laterally towards the upper second molar tooth. It is useful to remember to pass the probe along the bony resistance. A membranous or fibrous obstruction will be felt to give way. The intranasal portion of the probe can be palpated with the largest sized Bowman probe passed along the lateral wall of the nose in the inferior meatus. The same probe can be used to infracture the inferior turbinate, which should form an integral part of the syringing and probing.

Following syringing and probing topical antibiotic drops and sac massage are continued for 2 to 3 months even if the symptoms subside.

Failure of syringing and probing is not uncom­mon. In such situations a second probing and syr­inging can be attempted. Failure of two probings is an indication for silicone tube intubation of the lacri­mal passages. Retrieval of the silicone tube in the inferior meatus is technically difficult. If silicone tube incubation is not possible, a dacryocystorhinostomy should be performed after the age of 3 years.

D. Atresia of the Lacrimal Drainage System

Absence of canaliculi and puncta is more diffi­cult to manage and calls for conjunctivo da­cryocystorhinostomy when the child grows to an age to cooperate during the difficult postoperative man­agement required for such a procedure.


  IV. EVALUATION OF AN ADULT PATIENT WITH EPIPHORA Top


A. Pseudoepiphora

As in the paediatric patient, in the adult patient too pseudoepiphora needs to be excluded first. In the presence of pseudoepiphora, the lacus is dry and syr­inging is patent. Lacrimation secondary to corneal disorders or conjunctivitis is obvious due to associ­ated symptomatology or on examination. Two con­ditions which can be mistaken for true epiphora are dry eye syndrome and blepharitis.

A.1. Dry Eye

Dry eye secondary to deficiency of mucous or meibomian secretions can have paradoxical watering as discussed in pathophysiology of tear film. A detailed discussion on dry eye is beyond the purview of this article. A diagnosis of dry eye is usually based on reduced lower tear meniscus, and increased debris in tear film on slit-lamp examination. Increased tear break-up time (BUT) and reduced Schirnmer's strip wetting corroborate the diagnosis. Treatment consists of topical lubricants.

A.2. Blepharitis

Blepharitis is another underdiagnosed entity that can lead to tearing. The diagnosis is based on thick­ened, hyperaemic lid margins with scales deposited on the lashes. Blocked meibomian openings, exces­sive abnormal meibomian secretions, and frothy discharge on the lid margins are the other diagnos­tic features. Treatment consists of lid scrubs, oral tetracycline and topical lubricants.

B. True Epiphora

True epiphora is secondary to either an anatomi­cal obstruction of the lacrimal drainage system or functional deficiency like ectropion or lacrimal pump failure. These two groups are differentiated easily on the basis of syringing.

B.1. Patent Syringing

If the lacus is wet and syringing is patent, the patient is asked to keep his neck flexed and look upwards; normally the lower punctum should not be visible unless the lid is everted. If the punctum is visible without touching the lid, ectropion is diag­nosed. This minimal ectropion can be idiopathic or senile. Lacrimal irrigation is performed to rule out obstructed passage. Conjunctivoplasty gives reward­ing results.

More extensive ectropion can occur secondary to senility or VII N paralysis. In either of these condi­tions the orbicularis is weak and the lacrimal pump is ineffective. Lid tightening procedures are described for both these conditions, which give satisfactory results only in the case of involutional ectropion.

B.2. Syringing Blocked

Lacrimal drainage obstructions could be at vari­ous sites and the management for each is different.

B.3. Technique of Lacrimal Irrigation

Punctal dilatation is the first step. If the punctum is stenosed or attretic, it may be difficult to visual­ize the punctum. A useful clue is the presence of the punctum at the apex of the lacrimal papilla. The landmark for lacrimal papilla is the junction of the medial canalicular part of the lid margin and the lateral ciliary part of the lid margin along the line of the meibomian gland openings. Slit-lamp or operating microscope magnification is occasionally needed to locate the lacrimal papilla and the punc­tum. Usually the lower canaliculus is used for the irrigation. When irrigation is necessary through the upper canaliculus, it is useful to remember that the upper punctum is located about 2 mm medial to the lower punctum.

B.4. Stepwise Approach to the Diagnosis of the Site of Lacrimal Obstruction

1. Lacrimal irrigation is not required if reflux of mucoid or mucopurulent material is pres­ent on pressure over the sac, which is indicative of chronic dacryocytisis and in such a case dacryocystorhinostomy will be required.

2. If irrigation is done through lower punctum and mucoid reflux is present through the upper punctum, chronic dacryocystitis is once again the diagnosis.

3. If clear fluid regurgitates through the up­per punctum, there are two possibilities: (1) In common canalicular (CC) block, the reflux comes immediately with certain amount of force. Following irrigation if pressure is applied over the sac, there is no reflux. (2) In NLD block without infection, the regurgitation could be clear but post­irrigation pressure on the sac would result in regurgitation of clear fluid and as syr­inging is being done, the sac might be seen to fill up.

4. A fibrosed and small lacrimal sac cannot be differentiated from CC block by syringing alone. On probing the lacrimal passage with a 00 Bowman probe, the obstruction is beyond 10 mm, the probe meets a bony resistance and on moving it against the obstruction, there is no movement of tissues at the medial canthus.

5. In CC block, the obstruction is 10 mm or less and on moving the probe against the obstruction, tissues at the medial canthus will be seen to move.

6. In case irrigation through lower canaliculus is not possible either because the punctum is absent or because the canaliculus is fibrosed, irrigation through the upper punctum can be performed. Occasionally both canaliculi are cicatrised and the site of obstruction can be documented according to the distance from the punctum on probing.

7. Patency of syringing and absence of ectro­pion with true epiphora is indicative of atonic sac or pump failure. This could be diagnosed by fluorescein dye disappearance test (FDDT), which is the best physiologi­cal way of assessing the lacrimal drainage system. After the tears are stained with fluo­rescein, the patient is instructed not to wipe the eyes and to blink at the normal rate. After 5 minutes the amount of dye remain­ing is measured subjectively on a 1 to 4+ scale. The remaining dye is an indication of ineffective lacrimal drainage system.

The management of lacrimal drainage obstruction at the NLD requires a dacryocystorhinostomy (DCR). In the presence of partial obstruction, DCR can be advised depending on the results of FDDT. Obstruc­tion at common canaliculus or within each canalicu­lus requires conjunctivodacryocystorhinostomy.


  Outline Top


I.INTRODUCTION

II. PATHOPHYSIOLOGY

A. Secretory System

A.1. Tear Film

A.2. Tear Composition and Secretion A.3. Pathology of the Tear Film

B. Lacrimal Drainage System

B.1. Anatomy of the Lacrimal Drainage

System

B.2. Physiology of the Lacrimal Drainage

System

III. EVALUATION OF A PAEDIATRIC PATIENT WITH EPIPHORA

A. Cause of Pseudoepiphora A.1. Epiblepharon A.2. Distichiasis A.3. Trichiasis

A.4. Congenital Glaucoma

B. Clinical Evaluation of True Epiphora

C. Management of NLD Block

C.1. Medical Management

C.2. Syringing and Probing of the Lacrimal

Passage

D. Atresia of the Lacrimal Drainage System

IV. EVALUATION OF AN ADULT PATIENT WITH EPIPHORA

A. Pseudoepiphora

A.1. Dry Eye

A.2. Blepharitis

B. True Epiphora

B.1. Patent Syringing B.2. Syringing Blocked

B.3. Technique of Lacrimal Irrigation

B.4. Stepwise Approach to the Diagnosis of

the Site of Lacrimal Obstruction.


    Figures

  [Figure - 1]



 

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  In this article
I. INTRODUCTION
II. PATHOPHYSIOLOGY
III. EVALUATION ...
IV. EVALUATION O...
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