The definition of true epiphora—“tears on the cheek”

As you have seen earlier, I try to divide the patient’s complaint into the watery eye or the tearing eye. The watery eye does not spill tears onto the cheek. The tearing eye has true epiphora, meaning that tears overflow onto the cheek. Make sure that you understand this difference. When your patient tells you the eye waters, ask “Do the tears flow down your cheek or do they stay in your eye?” You will be surprised how many patients tell you that they have tearing, but no tears overflow.

What do the answers to these questions mean? The watery eye can be caused by a number of problems. Most of these problems are related to poor tear film, causing ocular irritation (or reflex tearing). There may be a subtle problem with one of the layers of the tears or the distribution of the tears, as we said above. These conditions improve with medical management such as lid hygiene and use of artificial tears and lubricating ointments. Watery eyes caused by an abnormal lid position or a poorly functioning pump are usually easy to diagnose on physical exam. The tearing eye (true epiphora) is usually caused by poor drainage of tears though the lacrimal system. There are exceptions to this but, in the absence of other obvious problems causing reflex tearing (an inflamed eye or trichiasis, etc.) or a lacrimal pump problem (ectropion or a facial nerve palsy), epiphora means obstruction and an operation will be required to eliminate the tearing. I’ll repeat this concept because it is important: in the absence of a cause of reflex tearing or obvious lacrimal pump problem, epiphora means obstruction of the lacrimal drainage system.

The presence of epiphora depends on how complete the obstruction is and how many tears are being made. If the tears flow down your patient’s cheek, ask “Do the tears flow down your cheek inside when you are resting or mainly when you are outside in cold and wind?” Everyone’s system makes more tears in the wind or cold (a tear drainage stress test of sorts). If tearing is present only in the wind and cold, the obstruction is more likely “partial” or not complete. Remember that young patients’ systems make more tears than those of older patients, so tear overflow will be seen more readily in younger patients than in older patients with the same anatomic problem. In fact, the lacrimal gland of many older adults makes so few tears that epiphora will not be present despite a complete blockage of lacrimal drainage. With nasolacrimal duct obstruction, these patients may exhibit signs of chronic dacryocystitis (mucopurulent drainage) or acute dacryocystitis (painful swelling of the medial canthus), but have no tearing. On the other hand, a young patient may have bothersome epiphora with only slight eversion of one punctum. An older patient with the same punctal eversion will not notice any epiphora.

Children

A child who is seen with a tearing eye, often associated with mattering, has a congenital nasolacrimal duct obstruction until proven otherwise. This obstruction presents in the first month or two of life. Sometimes the mattering is present throughout the day. In other children, the mattering may be present only when they first awaken. The cause of the obstruction is a congenital membrane occurring at the valve of Hasner. In greater than 90% of children, this membrane will rupture spontaneously within the first year of life.

Young adults—canalicular disease or trauma

When a young adult is seen with epiphora, the cause is usually related to canalicular obstruction or trauma. Canalicular obstruction can occur after viral conjunctivitis. Often this obstruction is in all four canaliculi, causing complete scarring of each canaliculus. In other patients, traumatic lacerations of the eyelid may be associated with canalicular lacerations. In these patients, the obstruction is usually focal and in one canaliculus. Facial fractures may cause damage to the nasolacrimal duct. As you might expect, trauma is more common in young men than in young women.

Middle-aged adults—dacryolith

A middle-aged adult, usually a woman, will describe to you recurrent symptoms of true epiphora. In some cases, the epiphora will be associated with slight pain and tenderness in the medial canthus suggesting mild dacryocystitis. In most patients, the epiphora will resolve spontaneously. Interestingly, some patients may sneeze a small cast of stones out the nose. Passing of the dacryolith usually results in resolution of the symptoms. In many patients, these symptoms will be recurrent and may require surgical treatment (Figure 10-3).

Figure 10-3 An unusually large dacryolith removed from the nasolacrimal sac and duct of a middle-aged woman (Figure 10-1), showing a cast of the entire lacrimal excretory system.

Older adults—nasolacrimal duct obstruction

An older adult, again usually a woman, will be seen with epiphora resulting from primary acquired nasolacrimal duct obstruction. The cause of this scarring in the distal portion of the nasolacrimal duct is not known. Symptoms include epiphora, chronic mucopurulent discharge (chronic dacryocystitis), and acute cellulitis of the lacrimal sac (acute dacryocystitis) (Figure 10-4).

Figure 10-4 Dacryocystitis implies a nasolacrimal duct obstruction. (A) Acute dacryocystitis. (B) Chronic dacryocystitis.

Although these diagnoses by age are generalizations, you will find that they are correct for most patients. The physical examination will prove or disprove your tentative diagnosis.

Ectropion and entropion

A number of eyelid problems may cause tearing. Ectropion resulting from any cause may prevent tears from reaching the lower punctum and canaliculus. Minor amounts of ectropion may go unnoticed, but may cause punctal eversion. More severe cicatricial or paralytic ectropion may prevent the lacrimal pump from functioning properly. Entropion is a cause of reflex tearing. If an older patient describes intermittent inward turning of the eyelid that is not seen on the examination, ask him or her to squeeze the eyes tightly. Forceful spasm of the orbicularis muscle may elicit entropion. Patients with cicatricial entropion will have eyelashes or keratinized skin against the ocular surface. Posterior lamellar scarring may be associated with damage to the conjunctiva, causing a poor tear film.

Lacrimal pump problems

Lacrimal pump problems are associated with lid deformity, incomplete blink, and involutional laxity of the eyelids. Scar tissue may cause the lids to be stiff and unable to blink completely and spontaneously. Facial nerve palsy is associated with an incomplete and weak blink that prevents normal lacrimal pump function. In the absence of a strong Bell’s phenomenon, corneal exposure may also be present, creating an element of reflex tearing as well.

Probably the most common lacrimal pump problem is related to the laxity of the eyelids associated with aging. These involutional changes do not allow tight apposition of the eyelid against the eye. Lid laxity can be diagnosed by the lid distraction test and the snap test. The normal lower eyelid cannot be pulled more than 6 mm off the eyeball. If more than 6 mm of distraction is present, the lid is said to be lax. The snap test is performed by pulling the lids downward off the eyeball. A lid with normal tone and no laxity should snap into position spontaneously. Greater amounts of laxity are associated with increasing numbers of blinks required to return the lid to normal position. I usually record the results of the snap test like this: lid returns to position with two blinks (see Chapter 3).

Punctal problems

Eversion of the lower punctum may be subtle and associated with tearing, especially in a young patient (Figure 10-5). Stenosis of the punctum often follows eyelid eversion because of the drying of the mucosa. Spontaneous stenosis or closure of the punctum is associated with echothiophate iodide (Phospholine iodide) drops, but may be associated with most antiglaucoma medications. Congenital punctal atresia is uncommon but may be present in children, often seen as a family trait. In rare patients, the canalicular system may be normal, but the puncta may be covered with a thin membrane. A discharge from a dilated punctum—the “pouting punctum”—should alert you to a diagnosis of canaliculitis, an uncommon, but frequently overlooked cause of a mattering eye.

Figure 10-5 The normal punctum should be apposed to the globe. Punctal eversion (arrow) may be subtle and a cause of epiphora, especially in a young patient.

Rule out dacryocystitis first

Although the lacrimal system examination may seem daunting at first, it is really quite easy and quick when you get familiar with it. One short cut is to look for signs of dacryocystitis if you suspect a nasolacrimal duct obstruction. The diagnosis of nasolacrimal duct obstruction is made if:

Any one of these three findings diagnoses nasolacrimal duct obstruction. No further testing is necessary. The signs of acute dacryocystitis include swelling, erythema, and tenderness in the medial canthus. Any purulent or mucoid discharge that can be manually expressed from the sac is diagnostic for NLD obstruction. A mucocele is diagnosed when a palpable cystic mass is present in the medial canthus. A mucocele results when obstruction at both the nasolacrimal duct below and the common internal punctum above causes the lacrimal sac to fill with mucus.

Slit lamp examination

After you have checked the obvious signs of nasolacrimal duct obstruction, move the slit lamp into position and evaluate the tear lake. If lacrimal obstruction is present, the tear lake will be enlarged. Obstruction of the nasolacrimal duct will often cause a large tear lake with mucoid debris seen in it. This results from reflux of mucopurulent material in the sac into the tear lake. A block at the puncta or canaliculi results in a large tear lake without any debris present. Remember to evaluate the lacrimal lake before placing any drops in the eye. Next take a look at the cornea to rule out any obvious corneal pathologic changes. Watch the patient blink spontaneously and see how much of the cornea is covered with a blink. Look at the lid margins for signs of blepharitis or marginal entropion. Evaluate the position of the punctum. The normal punctum is not easily visible without slight manual eversion of the eyelid.

Lacrimal system vital signs

Next check the lacrimal system vital signs (Box 10-4):

The dye disappearance test (Figure 10-6) is one of the most important lacrimal tests that you will do. After instilling a drop of topical anesthetic, place a well-formed drop of 2% fluorescein into each conjunctival fornix. After 5 minutes, check to see how much dye is retained in the eye. The yellow dye will spontaneously clear from a normal eye. The dye disappearance test is very good for confirming lacrimal obstruction. A normal result is recorded as spontaneous symmetric dye disappearance. An abnormal result is recorded as dye retained in the right or left eye. This test is most valuable when symptoms of epiphora are asymmetric. This is a very good test to use in both children and adults. In most patients, the results of the tests are obvious. However, in some older adults, the conjunctiva will stain with fluorescein in both eyes. Nevertheless, you may be able to evaluate the size of the tear film as an indicator of spontaneous tear drainage.

Figure 10-6 Dye disappearance test showing delay of fluorescein drainage and overflow of dye unilaterally.

Next, demonstrate the patency of the upper and lower canaliculi using a lacrimal probe. This diagnostic test should not be confused with therapeutic nasolacrimal duct probing. To emphasize this distinction, we call this diagnostic procedure canalicular palpation (Figure 10-7, A). A 0 Bowman probe is carefully placed in the canaliculus (Figure 10-8). The lid should be pulled temporally and the probe directed toward the sac. If you meet resistance or the lid moves with the probe, you are probably pushing against the wall of the canaliculus and may cause a false passageway. The probe should pass easily to the lacrimal sac, where a hard stop should be present. This hard stop represents normal passage of the probe into the sac against the lacrimal bone. A soft stop is said to be present if a soft tissue obstruction at the lacrimal sac is encountered (Figure 10-9).

Figure 10-7 Lacrimal examination. (A) Canalicular “palpation” using a 0 or 00 Bowman probe (Storz E4200–E4205 for a complete set) to test patency of the canaliculus. (B) Lacrimal irrigation, using a lacrimal cannula (Storz E4406 or E4404) to test patency of the nasolacrimal duct. No reflux through the opposite canaliculus should be present.

Figure 10-8 Introducing an instrument into the canaliculus. (A) Stabilize the lid with a finger. The probe should be placed vertically in the punctum for 1–2 mm. The lid should be pulled temporally and the probe directed toward the canthal angle. If the eyelid moves with palpation of the canaliculus, you are either hitting an obstruction or pushing against the wall of the canaliculus, risking a false passageway. (B) Stop. Pull the lid temporally again and redirect the probe.

Figure 10-9 (A) A “hard stop” with canalicular palpation indicating a normal canaliculus. (B) A “soft stop,” indicating obstruction of the canaliculus.

Careful passage of a 0 or 00 Bowman probe should not cause pain. A mild to moderate amount of tenderness may be encountered as the probe passes through the common internal punctum. Under no circumstances, should you probe the nasolacrimal duct as a diagnostic procedure.

Lacrimal irrigation (Figure 10-7, B) will tell you if the NLD is normal, partially obstructed, or closed. Using a lacrimal irrigation cannula in the lower canaliculus (not the sac), you should be able to irrigate saline or water easily into the nose without any reflux around the cannula or out the upper canaliculus (normal NLD). If you can’t irrigate at all, make sure the cannula is properly placed and is not against the wall of the canaliculus. Any reflux is abnormal, suggesting resistance to flow down the duct. If the patient doesn’t taste the fluid in the throat, occlude the upper punctum with a cotton-tipped applicator (an assistant can help with this) and irrigate again. If you can irrigate into the nose with pressure on the syringe, the patient has a partially obstructed or narrow duct (functional obstruction). If you can’t irrigate with pressure on the syringe, the duct is closed (anatomic obstruction). After you are comfortable with the irrigation process, try this: when your patient has a functional obstruction, try to irrigate with progressively more pressure until you get a bit of reflux. This will give you an idea of how much fluid the NLD can drain—another form of tear drainage stress test.

You may notice that the historically recommended Jones’ test for epiphora (that you may have read about elsewhere) is not recommended. It is time consuming and inaccurate.

Nasal examination

The last portion of the lacrimal examination includes a nasal examination. Three options for illumination and exposure are available. A hand-held illuminated speculum is a handy office tool (Welch Allyn no. 26030 illuminator and speculum or no. 26035 speculum only). Alternatively, a nonilluminated speculum may be used for exposure and a headlight can be worn to provide illumination. If you do many lacrimal operations, you may want to purchase a fiberoptic nasal endoscope, which will permit you to do the best intranasal examination. Regardless of the technique, intranasal tumors or mucosal abnormalities should be ruled out (Box 10-5).

On rare occasions, the examination does not fit with the history. The patient gives a history typical of primary acquired NLD obstruction (PANDO), but you cannot demonstrate an obstruction. In these patients, dacryoscintigraphy can be helpful. In this nuclear medicine procedure, a labeled teardrop is placed in the conjunctival cul de sac. Its passage into the nose is imaged over time. This test is similar in concept to the dye disappearance test. It gives an estimate of the physiologic drainage of tears. If any delay is noted, a dacryocystorhinostomy (DCR) is recommended. The only other imaging test that I use is a computed tomography (CT) scan when a lacrimal sac tumor is suspected.

Ectropion, entropion, and lacrimal pump problems

In all cases, eyelid and eyelash problems should be treated before lacrimal surgery. Standard treatments for ectropion and entropion should be used. Conditions affecting the lacrimal pump should be treated. Lid deformities such as cicatricial entropion should be treated with skin grafts. Incomplete blinking can be treated with topical lubricants and gold weight placement in the upper lid. Laxity of the lower lid can be repaired using standard horizontal lid tightening procedures. Additional procedures are available for facial nerve palsy and are covered in a later chapter. In most patients, the lacrimal pump can be improved, but it is often difficult to eliminate all symptoms of tearing (Box 10-6).

After appropriate treatment of the eyelid abnormalities, the lacrimal symptoms should be re-evaluated. Before we move on to treatment of NLD obstruction, we will discuss treatment of punctal problems. Instruments and sutures of special interest in lacrimal surgery are listed in Boxes 10-16 and 10-17.

Punctal stenosis

Stenosis of the punctum can be treated with dilation; however, the effect of punctal dilation is usually temporary. Substitution of an alternative antiglaucoma medication for an offending drug is appropriate if possible. Although punctoplasty procedures are described, I find that I seldom use them. Two-snip and three-snip punctoplasties are possible. The two-snip punctoplasty consists of a V-shaped excision of the posterior portion of the punctum and vertical part of the canaliculus. A three-snip punctoplasty is somewhat more useful. In this operation, a small triangle of the posterior wall of the vertical and horizontal portion of the canaliculus is excised.

The steps of the three-snip punctoplasty are:

Figure 10-10 The three-snip punctoplasty. A triangle is removed from the posterior wall of the canaliculus. Snip 1 is in the vertical portion of the canaliculus. Snip 2 is along the horizontal portion of the canaliculus edging slightly posteriorly. Snip 3 is the diagonal cut connecting snips 1 and 2.

In some patients, you will find that the stenosis of the punctum is associated with stenosis of the canaliculus as well. For these patients, intubation of the entire nasolacrimal system with silicone stents is appropriate. Make sure that stents will not be required before you perform a punctoplasty procedure. Once the integrity of the punctum is disturbed, stents can erode the remaining canaliculus (Box 10-7).

Punctal eversion

Eversion of the punctum is most commonly caused by laxity in the lower eyelid. The lid distraction or snap test will demonstrate if laxity is present. Before proceeding with any lid tightening procedure, be sure that there is no anterior lamellar shortening pulling the puncta outward. If cicatricial causes are present, a full-thickness skin graft is usually required. If laxity alone is present, evaluate the potential effectiveness of the lateral tarsal strip procedure during the slit lamp examination. While viewing the punctum, place your index finger at the lateral canthus and simulate tightening the eyelid. If the punctum returns to normal position, a horizontal lid tightening procedure will be effective. If the punctum remains somewhat everted, consider adding a medial spindle operation. If no horizontal lid laxity is present, use the medial spindle operation alone. This is a rare situation, however.

The medial spindle procedure is simple to perform and quite effective. It is a combination of a posterior lamellar shortening procedure and a mechanical inversion of the lid margin with an absorbable suture (see Chapter 3).

The medial spindle operation includes:

The steps of the medial spindle operation are:

Figure 10-11 The medial spindle operation. (A) Place a no. 1 Bowman probe in the canaliculus and evert the medial aspect of the lower eyelid. Excise a diamond of conjunctiva and lower lid retractors inferior to the punctum. (B) Close the diamond using a double-armed 5-0 chromic suture through the retractors, through the superior apex of conjunctiva, and through the lower edge of the conjunctiva, continuing full thickness through the eyelid and emerging superior to the inferior orbital rim. (C) Lateral view showing closure of the diamond using the “spiral” suture to create slight inversion of the punctum.

The chromic suture will fall out on its own in approximately 7–10 days. The overcorrection will reduce spontaneously, leaving the punctum in its normal position. Remember that the medial spindle operation must be performed before the eyelid is tightened with a lateral tarsal strip operation. Once the lateral tarsal strip sutures are tied, the medial eyelid cannot be everted to perform the medial spindle operation (Box 10-8).

Box 10-8 The Medial Spindle Operation

Patient preparation

• Instill topical anesthetic

• Inject local anesthetic into the conjunctiva and skin on the medial one third of the lid

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