Watery Eye

Question 1

What are the two types of watery eye?

Answer 1

hyperlacrimation (reflex epiphora)
impaired drainage (epiphora)

Question 2

What can cause hyperlacrimation?

Answer 2

• Trauma/inflammation caused by conj. or corneal FB
• Trichiasis (in grown eyelashes)
• Emotional states
• Conjunctivitis
• Corneal ulcers
• Dry eye
• Blepharitis

Question 3

Symptoms of Dry Eye?

Answer 3

• Watering
• Ocular irritation
• FB sensation
• Burning
• Photophobia
• Symptoms worse while reading, watching TV etc (reduced blink reflex)
• Rarely complain of dry eyes

Question 4

Signs of Dry Eye?

Answer 4

• Small marginal tear meniscus
  o Stain tears with NaFL and use SL- height of tear film on lower lid margin measured- normal height is 1-1.5mm
• Mucous strands in conj.
• Corneal filaments in severe cases
• Corneal punctate staining with fluorescein- usually inferior
• Use Tear film break up time test and Schirmer test

Question 5

Describe TBUT & results expected for normal, mild dry eye and severe dry eye

Answer 5

• Drop of fluorescein
• On SL with blue light
• Blink a few times then stop
• Timer started
• Observe development of first dry spot on cornea
• Time taken for first dry spot to appear is then recorded
• Normal TBUT is >10 seconds after px stops blinking
• 5-10 seconds = mild dry eye (may or may not be symptomatic)
• TBUT <5seconds is significant dry eye

Question 6

Describe Shirmer test & results expected for normal, borderline dry eye and significant dry eye

Answer 6

• Used when other signs of dry eye are absent or equivocal (uncertain) but you suspect it
• Special paper strip used
• Gently dry the eye- place filter paper folded at 5mm mark into lower fornix at junction of inner 2/3 and outer 1/3 of eyelid
• Measure wetting of paper at 5mins
• Normal: wetting of 15mm or more
• 5-10mm wetting – borderline
• <5mm significant dry eye

Question 7

What causes corneal punctate staining?

Answer 7

Caused by micro abrasions on corneal surface caused due to lack of wetting on the epithelial cells causing microtrauma

Question 8

What is filamentary keratitis and what causes it?

Answer 8

• Formation of thread-like strands on cornea
• Formed by degenerated epithelial cells and mucus on corneal surface
• Significant pain, photophobia, and FB sensation

Question 9

Management of dry eye?

Answer 9

• Often chronic, have to learn to manage rather than cure it completely
• General advice- avoid low humidity (air conditioning, warm room with too much heating etc)- use of humidifiers can alleviate dry eye symptoms
• Tear substitutes (px should try a drop from each category and whichever one alleviates symptoms most- carry that on long term):
  o Hypromellose, carmellose (celluvisc)
  o Polyvinyl alcohol (liquifilm tears)
  o Carbomer gels (viscotears, gel tears)
  o Sodium hyaluronate based (hylo tears)
  o Petrolatum based ointments (lacrilube)
• Acetylcysteine for corneal filaments (ilube)- hospital
• Ciclosporin eye drops (ikervis)- hospital
• Punctal occlusion- silicone plugs to block upper and lower lacrimal puncta which stops drainage of (low level of) tears, allowing them to wet the ocular surface better and help improve the symptoms of dry eyes

Question 10

What causes reduced tear drainage (epiphora)?

Answer 10

• Obstruction to drainage:
  -Can be caused by canalicular obstruction/inflammation
  -Nasolacrimal duct blockage
  -Lacrimal sac tumours
• Physiological dysfunction:
  -Eyelid malpositions (ectropion/entropion)
  -Lacrimal pump failure (orbicularis weakness/lid laxity)
  -Nasal pathology with normal lacrimal pathway but opening of tear duct into nose is blocked. Seen in pxs with chronic allergic rhinitis or nasal polyps

Question 11

Questions asked when evaluating watery eye?

Answer 11

• Onset- chronic- had for years, acute- more inflammatory/traumatic causes
• Any associated symptoms- red eye, photophobia, blurring, discharge, FB sensation, itchy eyes
• Lacrimal sac swelling- blocked nasolacrimal duct
• Hx of medication- pilocarpine, chemo or radiotherapy (canalicular obstruction)
• Worse indoors or outdoors? Dry eyes: worse in windy or outdoors. Blocked lacrimal system: won’t matter, will be both
• Where does the water leak from? Inner (nasolacrimal duct obstruction) or outer (eyelid malpositions) corner of eye

Question 12

Tests carried out for examination of a watery eye?

Answer 12

Unless cause of watery eye is v evident e.g. FB or corneal ulcer
* Eyelid position
* Dynamic eyelid closure
* Evaluate puncta
* Evaluate lacrimal sac
* Tear meniscus (marginal tear strip)
* Fluorescein dye disappearance test

Question 13

Lid Laxity: Describe lid distaction test and results expected if the lid is lax

Answer 13

• Lid laxity in absence of ectropion/entropion can also cause epiphora by interfering with lacrimal pump mechanism
• Horizontal lid laxity is presumed if eyelid can be pulled >8mm from cornea- lacrimal pump failure- don’t actually measure in practice but with experience will know

Question 14

Lid Laxity: Describe the snap-back test & the lid laxity depending on how the lid returned to its original position

Answer 14

• Pull lower lid down w/ finger on centre of orbital rim & release to observe return of eyelid
• Spontaneous return:
  o Quick – normal
  o Slow – mild lid laxity
• Return with blink – moderate lid laxity
• Incomplete return – severe lid laxity

Question 15

What is normal eyelid closure and what is abnormal eyelid closure in terms of puncta position?

Answer 15

Normal – puncta well apposed when eyelids closed
Abnormal – over riding of eyelid margins in lid laxity
Abnormal – punctal eversion on eyelid closure

Question 16

What are you looking for when you examine the puncta?

Answer 16

• SL examination
• Normal – puncta directed posteriorly in contact with globe
• Look for punctal eversion, stenosis (narrowing), absence of puncta or FB
• Canaliculitis – inflammation of puncta w/ discharge

Question 17

What happens when there is swelling of lacrimal sac?

Answer 17

Some pxs present with swelling in the area of lacrimal sac just below medial canthus. Typically seen in nasolacrimal duct blockage. In some cases, pressure on sac area can cause thick purulent stuff to be expressed from lacrimal puncta. Typically seen in chronic Dacryocystitis secondary to nasolacrimal duct obstruction.

Question 18

Describe inflammations of the lacrimal system?

Answer 18

• Dacryoadenitis:
  o Idiopathic or due to viral (e.g. mumps, Epstein-Barr, cytomegalovirus) or rarely bacterial infection (e.g. sarcoidosis, Sjogren syndrome, thyroid disease)
  o Rapid onset of discomfort in region of lacrimal gland
  o Lacrimal secretion may be ↓ or ↑ & discharge may be reported
  o Swelling of lateral aspect of eyelid overlying palpebral lobe leads to characteristic S-shaped ptosis
  o Enlargement on orbital lobe may give slight downward & inward dystopia & occasionally proptosis & other signs of orbital disease
  o Tenderness over lacrimal gland & injection of conjunctiva overlying palpebral lobe may be seen on upper lid eversion
  o Chemosis may be present & there may be local (e.g. pre-auricular) lymph node enlargement
• Canaliculitis: inflammation of puncta w/ discharge
• Dacryocystitis:
  o Lacrimal Sac Blockage/Infection
  o Red, tender swelling over lacrimal sac

Question 19

What is the fluorescein dye dissapearance test (FDDT) and what are normal and abnormal results?

Answer 19

• Check for drainage mechanism of tears
• Instil a drop of fluorescein into patients both eyes and then take hx and further exam
• After ~5mins, fluorescein should start disappearing from the eye as it drains into nasolacrimal duct
• If eye still full of fluorescein and some has leaked onto cheek – indicates tears are not gaining access into nasolacrimal system meaning, there is lacrimal pump failure or blocked nasolacrimal duct causing epiphora

Question 20

Examination for someone with obstructive epiphora secondary to blocked lacrimal drainage pathway

Answer 20

• High tear meniscus – on lower lid with NaFl
• Delayed FDDT
• Rule out lid position abnormalities – ectropion/ entropion
• Examine lacrimal puncta (stenosis (narrowing), occlusion)
• Lacrimal sac syringing – hospital to confirm diagnosis
  -Instil proxymetacaine to ocular surface
  -Small cannula mounted on syringe filled with saline is inserted into the lower canaliculus. Saline injected.
  -In px with normally functioning nasal lacrimal system, fluid drains through nasolacrimal sac, nasolacrimal duct into the nose and px feels the salty water coming down back of throat- tells you lacrimal sac is patent
  -Tells surgeon where blockage in nasolacrimal system is, could be a hard stop or soft stop – allows them to target surgery to correct epiphora. If blocked, saline will be regurgitated onto ocular surface through upper puncta

Question 21

What would the px complain of in H&S for obstructive epiphora (blocked NLD)?

Answer 21

Commonest form of lacrimal drainage pathway obstruction is nasal lacrimal duct blockage
* Watering – constant – both indoors and outdoors – slightly worse outdoors
* Tears run down inner corner of eye
* Lower lid skin changes – irritation and redness as tears are salty – eczema type changes

Question 22

What is the imaging technique for blocked NLD and how does it work?

Answer 22

Radiopic dye injected into the lacrimal system then x-rays of eyes taken to show where the dye has drained or where has been blocked.

Question 23

Management for blocked NLD

Answer 23

• Dacryocystorhinostomy (DCR)– surgery
  o Operation usually done under General Anaesthetic
  o Lacrimal sac exposed
  o Lacrimal sac connected to nasal mucosa via bony ostium created on lateral wall of nose to create alternate pathway for tear drainage into nose
  o Silicone intubation kept in place for ~3 months following surgery to allow passage to develop permanently