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Simple techniques available for tearing patients
Medical history, tests can pinpoint cause of this common complaint.
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Complaints of tearing are common. Symptoms can include a “wet” feeling of the eyes; intermittent tearing in dry, bright or windy conditions; blurred vision; red or macerated eyelids; and chronic discharge. These symptoms can be associated with a history of swelling of the lower lid or medial canthal area. Symptoms can reflect an obstructive process of the lacrimal drainage system, causing overflow tearing known as epiphora. Alternatively, symptoms can reflect excess tearing, or hypersecretion of tears, due to reflex arcs initiated by such processes as keratoconjunctivitis sicca, allergies or uveitis.
Workup for tearing
Most oculoplastic texts elaborate on the workup for tearing patients. The workup begins with the medical history. Determining whether both eyes are affected yields insight into the possible causes of the tearing. Unilateral tearing is suggestive of a lacrimal outflow problem because of either obstruction or poor function of the tear pump due to weakness of the orbicularis muscle, seventh nerve palsy or lower lid laxity. Bilateral tearing is more suggestive of a hypersecretion etiology. However, bilateral outflow abnormalities also can result in bilateral tearing.
The history should include questions about facial trauma, radiation, allergies, coexistent eye disease, sinusitis and nose and sinus surgery. The patient should also be questioned about medication use. Topical medications such as echothiophate iodide can cause scarring of the outflow system. Obstruction of the outflow system can also result from systemic chemotherapeutics such as 5-fluorouracil and docetaxel.
The examination of the tearing patient begins with inspection of the ocular adnexa. In the most severe cases, tears may be visible on the cheek and can be associated with macerated skin. Inspection of the eyelids and lashes may show signs of blepharitis, ectropion, entropion, trichiasis, lagophthalmos, poor blinking mechanism secondary to seventh nerve palsy and overriding upper and lower lids. Punctal size, position, movement and obstruction by conjunctiva or plica semilunaris should be noted. The slit lamp exam also allows inspection of the tear meniscus and tear breakup time, which can indicate aqueous and lipid deficiencies as causes of tearing. Conjunctivitis and conjunctival lesions, which may cause irritation (eg, chalazion, concretions), can also be at the root of a tearing problem. Examination should include tonometry since elevated IOP can cause irritation and tearing.
Examination of the nose is necessary to rule out nasal tumors, polyposis or turbinate obstruction of the distal end of the nasolacrimal duct. A self-illuminating nasal speculum is helpful for this aspect of the examination.
Any history suggesting dacryocystitis should lead to palpation of the lacrimal sac. A purulent discharge refluxing back through the puncta when the sac is palpated with a cotton tip applicator indicates nasolacrimal duct obstruction and is an indication for dacryocystorhinostomy. Palpation of the eyelids that leads to thick discharge from the meibomian glands is suggestive of lipid insufficiency and dry eye as a cause of the tearing problem.
Tests
Several tests help to better determine the cause of tearing. The dye disappearance test is useful in the assessment of functional lacrimal outflow. Fluorescein 2% solution or a fluorescein strip is placed in both eyes. After 2 minutes, the amount of fluorescein in each tear meniscus is compared and graded on a 4+ scale. Asymmetry of the fluorescein levels signifies loss of lacrimal excretion on the side with the greatest fluorescein.
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| (Images courtesy of Marc Shields, MD.) | |
The Schirmer 1 test and basic secretion test assess aqueous tear production. The Schirmer 1 test is performed without topical anesthetic and measures basic and reflex secretions, although the existence of basic secretors has been disputed. A filter paper test strip (Whatman No. 41 filter paper) is folded at the notch and placed behind the lateral lower lid. This is best done before any stimulation of the eye or eyelids, including refraction and instillation of drops. The test strip is left in place for 5 minutes with the eyes open in a slight upgaze with the room lights dimmed. Ten millimeters or greater of wetting is consistent with normal tear secretion, hypersecretion and pseudoepiphora. Less than 10 mm of wetting indicates hyposecretion of tears. (Testing can occur for 1 minute with the amount of secretion multiplied by three to approximate a 5-minute test.)
The basic secretion test is performed immediately after the Schirmer 1 test. Local anesthetic is instilled into each eye and the lower fornices are dried carefully with a cotton tip applicator. The test strip is then placed behind the lower lids of each eye, as with the Schirmer 1 test. The test strip is left in place for 5 minutes. Less than 10 mm of wetting indicates hyposecretion of tears and is consistent with pseudoepiphora.
More screenings
The Jones I test assesses nasolacrimal drainage under physiologic conditions. Fluorescein 2% is placed in the tear meniscus. A cotton tip applicator is then placed under the anterior half of the inferior turbinate. After 5 minutes, the applicator is removed. If dye is present, there is at least some flow of tears through the lacrimal system. If no dye is present, a functional obstruction of the lacrimal drainage apparatus is suggested. However, up to one-third of patients with unobstructed lacrimal systems may have a false-negative result.
The Jones II test assesses nasolacrimal drainage under nonphysiologic conditions. In the Jones II test, the remaining fluorescein is flushed from the conjunctival sac. Clear, sterile irrigation fluid (balance salt solution, saline) is placed in a 3-mL syringe with a lacrimal irrigation cannula. The cannula is inserted through the inferior punctum and canaliculus. Irrigation occurs with the patient’s head held over a white basin. If dye is retrieved in the basin with no reflux, a partial nasolacrimal duct obstruction is suggested since dye can be irrigated through under nonphysiologic conditions. If the irrigant retrieved is clear, no dye reached the lacrimal sac, and a punctal or canalicular obstruction is suspected. If there is reflux from the upper punctum, there is an obstruction at or below the sac. If there is reflux around the irrigating cannula, the obstruction is likely at the level of the common canaliculus. By noting the size of the puncta, stenotic areas of the canaliculus and reflux patterns, the clinician can find much of the same information using simple irrigation without collection of the fluorescein dye.
Finally, function of the lacrimal drainage system can be assessed with a dacryocystogram (DCG), in which a radiopaque dye is injected into the lacrimal sac. A DCG can help to better delineate lacrimal sac stones and tumors as well as partial and complete nasolacrimal duct obstructions.
If the above tests demonstrate an abnormality of the canaliculi, lacrimal sac or nasolacrimal duct, a conjunctivodacryocystorhinostomy or dacryocystorhinostomy may be necessary. If a functional obstruction of the lacrimal drainage system exists proximal to these areas, simpler procedures may suffice. Many of the patients with epiphora that we have treated have one or a combination of three problems: punctal and/or vertical canalicular stenosis, punctal ectropion or conjunctivochalasis.
Stenosis
Punctal and/or vertical canalicular stenosis is a common cause of tearing. The punctual opening is 0.3 mm in diameter. This opens into a 2-mm-long vertical canaliculus and ampulla, which is 2.5 mm in diameter. Stenosis of these structures can be caused by a variety of reasons, including inflammatory conditions, topical medications, systemic chemotherapeutic medications and masses in the area of the punctum.
Many techniques have been devised to open the punctum and canaliculi. Jones and Wobig popularized the one-snip procedure in which one blade of a pair of scissors is inserted into the punctum and vertical canaliculus, and the posterior aspect of each is opened. However, the cut edges can reapproximate and scar, causing exacerbation of the tearing. A two-snip procedure in which a triangular wedge of tissue is removed has also been advocated, as has a three-snip procedure. In the latter procedure, two parallel vertical snips are joined at the base with a third snip, thus removing the entire posterior wall of the punctum and vertical canaliculus. Laser and electrocautery punctoplasties have been used. Offutt and Cowen even have described excision and reconstruction of the stenotic punctum with externalization of the vertical canaliculus.
We approach punctal and vertical canalicular stenosis in a manner similar to that described by Edelstein and Reiss. Instead of using a Reiss punch, we use a Kelly punch. While the eyelid is everted with a pair of forceps, the punch is used to remove the posterior aspect of the punctum and vertical canaliculus. (Figure 1). No cautery is used. If the proximal horizontal canaliculus is stenotic, it can be dilated.
Punctal ectropion
Punctal ectropion can be seen with ectropion of the entire lower eyelid. In this case, a tarsal strip or Smith lazy-T procedure can be used to place the lid and punctum in a normal position. In localized punctal ectropion or medial lid ectropion, a less invasive procedure will often suffice. A Bowman probe is placed in the canalicular system. The lid is everted over a cotton tip applicator. Using the probe as a guide, a small wedge or diamond of conjunctiva and lower lid retractors is removed from the area just below the canalicular system. (Figure 2A) The defect is closed with a dissolvable suture, which can be brought out through an incision in the skin and tied down (Figure 2B). The skin can then be closed over the knot.
Conjunctivochalasis
Conjunctivochalasis, excess conjunctiva that drapes over the lower lid and puncta, is often overlooked as a cause of tearing (Figure 3). Conjunctivochalasis can cause tearing in mild cases due to tear film instability, in moderate cases due to obstruction of the puncta and in severe cases due to foreign body sensation and irritation resulting from ocular surface exposure. Medical treatment such as lubricants can be used to address some of the symptoms. If this is unsuccessful, we have found that a limited excision of the conjunctiva in the area of the chalasis is often beneficial. Under sterile conditions, a topical anesthetic is given, and the conjunctiva is injected with a local anesthetic. The area of conjunctivochalasis is then excised, and hemostasis is achieved with light cautery. Meller et al have shown that more aggressive excisions and subsequent reconstructions of the conjunctival surface with amniotic membrane are beneficial.
In summary, tearing is a common complaint. A complete workup is multifaceted and requires a thorough medical history as well as a comprehensive anterior segment and lacrimal system exam. Many of the causes of tearing can be controlled with simple procedures.
For Your Information:References:
- Marc Shields, MD, and Allen M. Putterman, MD, SC, FACS can be reached at 111 North Wabash, Suite 1722, Chicago, IL 60602; 312-372-2256; fax: 312-372-1762.
- Putterman AM. Evaluation of the lacrimal system. Eye Ear Nose Throat Monthly. 1972;51:212-216.
- Tanenbaum M. Lacrimal drainage system disorder: diagnosis and treatment. In: McCord CD, Tanenbaum M, Nunery WR, eds. Oculoplastic Surgery. 3rd ed. New York, NY: Raven Press; 1995:341-377.
- Homblass A, Herschom BJ. Lacrimal Diagnosis. In: Nesi FA, Lisman RD, Levine MR, eds. Smith’s Ophthalmic Plastic and Reconstructive Surgery. 2nd ed. St Louis, Mo: Mosby; 1998:643-669.
- Fezza JP, Wesley RE, Klippenstein KA. The treatment of punctal and canalicular stenosis of patients on systemic 5-FU. Ophthalmic Surg Lasers. 1999;30:105-108.
- Esmaeli B. Valero V, Ahmadi MA, et al. Canalicular stenosis secondary to docetaxel (Taxotere): a newly recognized side effect. Ophthalmology. 2001;108:994-995.
- Jordan A, Baum J. Basic tear flow: does it exist? Ophthalmology. 1980;87:920-930.
- Jones LT, Wobig JL. Surgery of the canaliculi. In: Surgery of the Eyelids and Lacrimal System. New York, NY: Aesculapius Publishers Inc; 1976:175-176.
- Offutt WN, Cowen DE. Stenotic puncta: microsurgical punctoplasty. Ophthal Plast Reconstr Surg. 1993;9:201-205.
- Edelstein JP, Reiss G. Introducing the Reiss punctal punch. Arch Opthalmol. 1991;109:1310.
- Smith B. The lazy-T correction of ectropion of the lower punctum. Arch Ophthalmol. 1976;94:1149.
- Meller D, Tseng SC. Conjunctivochalasis: literature review and possible pathophysiology. Surv Ophthalmol. 1998;43:225-232.
- Meller D, Maskin SL, Pires RT, Tseng SC. Amniotic membrane transplantation for symptomatic conjunctivochalasis refractory to medical treatments. Cornea. 2000;19(6):796-803.