Tearing, increased [Epiphora]

Tearing, increased [Epiphora]: Excerpt from Professional Guide to Signs & Symptoms (Fifth Edition)

Tears normally bathe the eyes, keeping the epithelium moist and flushing away foreign bodies. Excessive lacrimation (tear production) usually results from inadequate tear drainage due to obstruction of the lacrimal drainage system or malposition of the lower lid. Reflex tearing occurs with any disturbance of the corneal epithelium.

Lacrimation may be classified as psychic or neurogenic. Psychic lacrimation normally occurs in response to emotional or physical stress, such as pain, and is the most common cause of increased tearing. Neurogenic lacrimation is triggered by reflex stimulation associated with ocular trauma or inflammation or with exposure to environmental irritants, such as strong light, dry or hot wind, or airborne allergens. This type of lacrimation may also accompany eyestrain, yawning, vomiting, and laughing.

Decreased tearing can be caused by aging, vitamin A deficiency, eye trauma, and the use of certain drugs. (See Causes of decreased tearing.)

History and physical examination

If the patient complains of increased tearing, begin by fully exploring this sign. When did it begin? Is it constant or intermittent? Minimal or extensive? Is increased tearing accompanied by pain, irritation, or any other eye drainage or discharge? Next, ask about recent eye trauma and about ocular and systemic disorders. Then record which drugs the patient is taking. Note his occupation and the nature of his work. For example, does he read extensively, look at a computer screen frequently, or work with small or fine objects? Is he exposed to any chemicals or dust in the workplace?

After taking vital signs, examine both eyes—unless the history suggests a perforating or penetrating injury. Carefully inspect the external structures. Do the eyelashes contain debris? Examine the eyelids for lesions and edema. Ask the patient to look straight ahead at a fixed object while you check for ptosis. Are the lid margins turned inward or outward? Examine the eyeballs. Do they appear sunken or bulging? Examine the conjunctivae for redness and abnormal drainage. Also, note the color of the sclera. Hold a flashlight at the side of each eye and examine the cornea and iris for scars, irregularities, and foreign bodies. Evaluate extraocular muscle function by testing the six cardinal fields of gaze. (See Testing extraocular muscles, page 245.) Finally, test the patient’s visual acuity.

Medical causes

Blepharophimosis

Increased tearing and exposure keratitis—corneal inflammation with incomplete lid closure—are common signs of this disorder. Examination also reveals ectropion; a small, expressionless face with deep-set eyes and pursed lips; and a high-arched palate.

Conjunctival foreign body or abrasion

Increased tearing may accompany localized conjunctival injection, severe eye pain, and photophobia. A foreign-body sensation may be present.

Conjunctivitis

Typically, increased tearing is accompanied by conjunctival injection and itching in this disorder. Allergic conjunctivitis also causes a stringy discharge. Bacterial conjunctivitis also causes a copious purulent discharge, burning, a foreign-body sensation and, possibly, eye pain if the cornea is involved. Associated signs of fungal conjunctivitis include lid edema, burning, and a copious thick, purulent discharge that may form sticky crusts on the lids. The patient complains of photophobia and pain if the cornea is involved. Highly contagious viral conjunctivitis also causes a foreign-body sensation, slight exudate, and lid edema.

Corneal abrasion

Marked by severe corneal pain that’s aggravated by blinking, this injury also causes increased tearing. Associated features are a foreign-body sensation, blurred vision, conjunctival injection, and photophobia, which makes opening the lids difficult.

Corneal foreign body

When a foreign body lodges in the cornea, the patient experiences increased tearing, blurred vision, a foreign-body sensation, photophobia, eye pain, miosis, and conjunctival injection. A dark speck may also be visible in the cornea.

Corneal ulcer

In this vision-threatening disorder, increased tearing is accompanied by severe photophobia and eye pain. Typically, the disorder begins with pain that’s aggravated by blinking. Ulcers also cause blurred vision, conjunctival injection, and a white opaque cornea. Bacterial ulcers also produce a copious purulent discharge that may form sticky crusts on the lids.

Dacryocystitis

Increased tearing and a purulent discharge are the chief complaints in this disorder, which usually affects only one eye. Associated signs and symptoms include pain and tenderness around the tear sac with marked eyelid edema and redness near the lacrimal punctum. Pressure on the tear sac expresses a thick, purulent discharge or, in chronic cases, a mucoid discharge.

Dry eye syndrome

Excessive dryness of the cornea and conjunctiva can cause reflex stimulation of the lacrimal gland and excess tearing.

Episcleritis

Commonly unilateral, this disorder causes increased tearing, photophobia, and—if the sclera is inflamed—eye pain and tenderness on palpation. Inspection reveals conjunctival injection and edema, a purplish pink sclera, and episcleral edema.

Eyelid contractions

In this disorder, increased tearing usually results from stricture of the canaliculi. Because eyelid contractions are caused by burns or chemical or mechanical trauma, eyelid scars are also commonly visible.

Herpes zoster

Increased tearing usually occurs when herpes zoster affects the trigeminal nerve. It’s accompanied by severe unilateral facial and eye pain that’s followed in several days by the eruption of vesicles. The patient’s eyelids are red and swollen with scanty serous discharge. Other common findings include a white, cloudy cornea and conjunctival injection.

Psoriasis vulgaris

When these psoriatic lesions affect the eyelids and extend into the conjunctivae, they may cause irritation, increased tearing, and a foreign-body sensation. The lesions are typically preceded by signs of chronic conjunctivitis, such as a copious mucoid discharge and conjunctival injection.

Punctum misplacement

Increased tearing is characteristic when ectropion involves the punctum, causing misplacement. It may be accompanied by exposure keratitis.

Raeder’s syndrome

This syndrome is characterized by periodic attacks of unilateral paroxysmal neuralgic pain in the face lasting 5 minutes or longer. The patient may exhibit increased tearing, ptosis, diplopia, enophthalmos, abnormal pupillary response, ipsilateral headache, and anhidrosis of the face and neck.

Scleritis

This rare chronic disorder causes increased tearing, photophobia, and severe eye pain with tenderness on palpation. Examination reveals conjunctival injection and a bluish purple sclera.

Thyrotoxicosis

This disorder may cause increased tearing, usually in both eyes. Other ocular effects include ptosis, lid edema, photophobia, a foreign-body sensation, conjunctival injection, chemosis, diplopia and, at times, exophthalmos. Common associated features are heat intolerance, weight loss despite increased appetite, nervousness, diaphoresis, diarrhea, tremors, tachycardia, palpitations, and an enlarged thyroid gland.

Trachoma

An early sign of trachoma, increased tearing is accompanied by visible conjunctival follicles, red and edematous eyelids, pain, photophobia, and exudation. If the infection is untreated, conjunctival follicles enlarge into inflamed papillae that later become yellow or gray and small blood vessels invade the cornea under the upper lid.

Other causes

Cholinergics

Miotics, such as pilocarpine, may increase tearing.

Special considerations

Obtain a tear specimen for culture, and isolate the patient until a definitive diagnosis is made. Also, prepare him for irrigation of the lacrimal drainage system and for Schirmer’s test to measure tear production and secretion.

Pediatric pointers

The most common causes of increased tearing in children are allergies, conjunctivitis, and the common cold.

Patient counseling

Instruct the patient not to touch the unaffected eye to avoid possible cross-contamination. Teach the patient not to share eye makeup or pillowcases and to practice good hand-washing techniques.

Pictures

Book Source Details

• Book Title: Professional Guide to Signs & Symptoms (Fifth Edition)
• Author(s): Springhouse
• Year of Publication: 2006
• Copyright Details: Professional Guide to Signs & Symptoms (Fifth Edition), Copyright © 2006 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: Professional Guide to Signs & Symptoms (Fifth Edition) Authors: Springhouse Publisher: Lippincott Williams & Wilkins Copyright: 2006 ISBN: 1-58255-510-9

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