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Tearing may be caused by excess production or decreased drainage of tears (see Table 3: Approach to the Ophthalmologic Patient: Causes of Tearing and Fig. 2: Approach to the Ophthalmologic Patient: Anatomy of the lacrimal system.).

Table 3
Causes of Tearing Increased production Foreign body (including trichiasis, distichiasis) Allergies Conjunctivitis Reflex tearing from dry eye Keratitis Corneal abrasion Uveitis Decreased drainage Nasolacrimal obstruction Congenital Acquired Idiopathic Sarcoidosis Wegener's granulomatosis Dacryocystitis Canaliculitis Idiopathic Infectious (Staphylococcus aureus, varicella zoster, herpes simplex, Stevens- Johnson syndrome) Drugs ( echothiophate iodide Some Trade Names PHOSPHOLINE IODIDE Click for Drug Monograph , epinephrine Some Trade Names ADRENALIN PRIMATENE MIST Click for Drug Monograph ) Radiation Trauma Foreign body Tumor Eyelid abnormalities Ectropion Entropion Punctal stenosis

Fig. 2
Anatomy of the lacrimal system.

Excess production occurs most commonly with irritation, such as from a foreign body (including inturned eyelashes) or corneal epithelial defect; with allergic rhinitis or conjunctivitis; as a reflex reaction to the sensation of irritation caused by dry eyes; and with the common cold. In newborns, congenital glaucoma and congenital nasolacrimal duct obstruction are causes.

Decreased drainage has multiple causes; primary categories are nasolacrimal obstruction, punctal stenosis, and eyelid abnormalities.

Nasolacrimal obstruction may be congenital or acquired. In congenital obstruction, a membrane at the distal end of the nasolacrimal duct persists, causing tearing and purulent discharge; the condition may present as chronic conjunctivitis.

Acquired nasolacrimal duct obstruction is most often a result of age-related stenosis of the nasolacrimal duct. Other causes include past nasal or facial bone fractures or sinus surgery, which disrupt the nasolacrimal duct; inflammatory diseases (eg, sarcoidosis, Wegener's granulomatosis); and dacryocystitis (see Approach to the Ophthalmologic Patient: Dacryocystitis).

Punctal or canalicular stenosis physically prevents tears from entering the canalicular system, causing tears to drain down the cheek. Causes include chronic conjunctivitis, especially herpetic; certain types of chemotherapy; adverse reactions to eyedrops (especially topical echothiophate iodide Some Trade Names
PHOSPHOLINE IODIDE
Click for Drug Monograph
); and radiation.

Ectropion and entropion are eyelid disorders that cause tearing; with both, the punctum inverts or everts with the eyelid and no longer properly drains tears. In addition, with entropion, the eyelashes rub against the cornea, stimulating excessive tear production. Ectropion and entropion may also cause dry eyes (see Eyelid and Lacrimal Disorders: Entropion and Ectropion).

Symptoms and Signs

Symptoms that accompany tearing may help narrow the differential diagnosis. Itching suggests an allergic cause; nasal pain suggests dacryocystitis; constant foreign body sensation suggests a corneal foreign body, corneal abrasion, corneal ulcer, or trichiasis; intermittent foreign body sensation suggests dry eyes; other symptoms (eg, photophobia) suggest uveitis or keratitis. In newborns, conjunctivitis causes onset of signs and symptoms at a much earlier age (ie, hours to 2 wk old) than does nasolacrimal duct obstruction (ie, > 2 wk old).

Diagnosis

Diagnosis is most often obvious from history and physical examination. The examiner should look for signs of underlying causes, such as foreign bodies, sinus pain, canthal swelling or mass, and eyelid abnormalities. The Schirmer test (see Corneal Disorders: Diagnosis) may be used to quantify tear production. An adjunctive test performed by ophthalmologists that may be indicated to diagnose specific causes of tearing is probing and saline irrigation of the lacrimal drainage system with and without fluorescein dye. Reflux through the opposite punctum/canaliculus signals fixed obstruction; reflux and nasal drainage signify stenosis. Imaging tests and procedures (dacryocystography, CT, nasal endoscopy) are sometimes useful to delineate abnormal anatomy when surgery is being considered or occasionally to detect an abscess when infection is suspected.

Treatment

Foreign bodies should be removed and underlying allergies treated. The use of artificial tears lessens tearing when dry eyes or corneal epithelial defects are the cause. Congenital nasolacrimal duct obstruction often resolves spontaneously; before 1 yr, manual compression of the lacrimal sac 4 or 5 times/day may relieve the distal obstruction. After 1 yr, the nasolacrimal duct may need probing with the patient under general anesthesia; if obstruction is recurrent, a temporary drainage tube may be inserted.

In acquired nasolacrimal duct obstruction, irrigation of the nasolacrimal duct may be therapeutic when underlying causes do not respond to treatment. As a last resort, a passage between the lacrimal sac and the nasal cavity can be created surgically (dacryocystorhinostomy [DCR]).

For the treatment of congenital glaucoma, see Eye Defects and Conditions in Children: Congenital Cataract.

Ectropion and entropion typically require surgery (see Eyelid and Lacrimal Disorders: Entropion and Ectropion). In cases of punctal or canalicular stenosis, dilation is usually curative. If canalicular stenosis is severe and bothersome, a surgical procedure that places a glass tube leading from the caruncle into the nasal cavity can be considered.

Dacryocystitis

Dacryocystitis is infection of the lacrimal sac, usually with staphyloccocal or streptococcal species and usually as a consequence of nasolacrimal duct obstruction.

In acute dacryocystitis, the patient presents with pain, redness, and edema around the lacrimal sac. Diagnosis is suspected on the basis of symptoms and signs and when pressure over the lacrimal sac causes reflux of mucoid material through the puncta. Initial treatment is with warm compresses and either oral antibiotics for mild cases ( cephalexin Some Trade Names
KEFLEX
KEFTAB
Click for Drug Monograph
500 mg q 6 h) or IV antibiotics ( cefazolin Some Trade Names
ANCEF
KEFZOL
Click for Drug Monograph
1 g q 6 h) for more severe cases. The abscess can be drained and the antibiotics changed based on culture results if the initial antibiotic proves ineffective.

Dacryocystitis

Patients with chronic dacryocystitis usually present with a mass under the medial canthal tendon and chronic conjunctivitis. Definitive treatment for a resolved acute dacryocystitis or a chronic conjunctivitis is usually with surgery (DCR).

Canaliculitis

Canaliculitis is infection of the canaliculus (see Fig. 2: Approach to the Ophthalmologic Patient: Anatomy of the lacrimal system.).

The most common cause is infection with Actinomyces israelii, a gram-positive bacillus with fine branching filaments, but other bacteria, fungi (eg, Candida albicans), and viruses (eg, herpes simplex) may be causative. Symptoms and signs are tearing, discharge, red eye (especially nasally), and mild tenderness over the involved side. Diagnosis is suspected on the basis of symptoms and signs, expression of turbid secretions with pressure over the lacrimal sac, and a gritty sensation that can be felt during probing of the lacrimal system caused by necrotic material. Treatment is warm compresses, irrigation of the canaliculus with antibiotic solution, and removal of any concretions, which usually requires surgery. Antibiotic selection is usually empiric but may be guided by irrigation samples.

Last full review/revision November 2005

Content last modified November 2005