Evaluation and Management of the Tearing System

Educational Objectives

The goal of this program is to improve diagnosis and management of disorders of the nasolacrimal system. After hearing and assimilating this program, the clinician will be better able to:

1. Determine the etiology of clinical epiphora.

Summary

Tear film: composed of 3 layers; middle aqueous layer produced by accessory glands of Wolfring and Krause and main lacrimal gland; bottom mucous layer made by goblet cells and serves to distribute tear film evenly across cornea; top lipid layer produced by Meibomian and Zeis glands and helps prevent evaporative loss of tear film

Nasolacrimal system: allow tears to drain; begins with 2 puncta in medial eyelid that extend to canaliculi; these join to form common canaliculus, which enters lacrimal sac; tears descend through lacrimal duct and exit at inferior meatus in nose below inferior turbinate; in presence of eyelids with good blink and proper position, lacrimal pump moves tears into lacrimal system

Causes of tearing: clinical epiphora — patients present with chief complaint of watery eyes; defined as tears that flow onto cheek; usually represents disorder of drainage (intermittent tearing likely results from partial blockage; constant tearing indicates complete blockage); other causes — problem with production or distribution of tears or tear film; foreign body can cause reflex tearing; issues may overlap

Age and history: younger patients more symptomatic than older patients, as they produce more tears; obtain history of infections, trauma, and surgery (can lead to scarring in lacrimal system)

Nasolacrimal duct obstruction (NLDO): congenital form caused by membrane over Hasner valve; resolves in >90% of children by 1 yr of age; in young adults, NLDO caused by trauma or herpetic canalicular disease; middle-aged patients may have dacryolith (stone) in canaliculus; older patients likely have primary NLDO with scarring in distal nasolacrimal duct (cause unknown)

Inflammatory sources: include blepharitis (condition of eyelid margin marked by telangiectatic vessels or scurf on lash bases), dry eye (diagnosed via Schirmer test and tear break-up time), conjunctivitis, and foreign body

Evaluation of eyelid position: patient may have eyelid laxity; eyelid distraction test — pulls eyelid out; distance >6 mm from globe considered lax; snap-back test — on release, eyelid should retract toward eye in proper position; ectropion or entropion — can be caused by scarring; eyelid malposition leads to poor lacrimal pump function; with entropion (inward-turning eyelid), lashes touch eye and cause tearing; often results from aging; trichiasis — condition of aberrant eyelash growth; causes corneal irritation; quality of blink — important to tear drainage; decreased blink often noted in patients with Parkinson disease or facial nerve palsy; signs include ectropion (outward-turning eyelid), poorly functioning orbicularis muscle, and eyelid retraction

Evaluation of lacrimal duct system: stenosed (closed-off) puncta — may cause epiphora; may be caused by use of echothiophate iodide eye drops or other glaucoma medications, congenital condition, or ectropion secondary to drying out of mucosal surface (in latter case, correcting ectropion opens punctum); pouting punctum — usually caused by canaliculitis; dacryocystitis — swelling and erythema of medial canthal area below medial canthus

Diagnosis: punctal stenosis indicated by enlarged asymmetric tear lake; tests — dye disappearance test evaluates for fluorescein stain remaining on eye after 5 to 10 min; lacrimal irrigation involves injecting salt solution into punctum and irrigating to determine whether lacrimal system open (if open, the patient tastes fluid and no reflux occurs); dacryoscintigraphy uses radionuclide tracer and imaging to reveal potential blockage (rarely performed)

Treatment options: ocular surface — treat dry eye first, using lubricating drops, ointment, cyclosporine, or punctal plugs (avoid punctal cautery); treat blepharitis using warm compresses, eyelid hygiene, and hypochlorous acid sprays; eyelid laxity — corrected with horizontal tightening procedures; entropion or ectropion repairs correct any instability of eyelid; if blink incomplete, eye requires lubrication and potentially, gold weight for lid retraction; scarring corrected with skin or mucous membrane graft; medial spindle procedure corrects everted punctum; punctal stenosis — treated by discontinuing offending eye drops and/or performing punctalplasty; tight canaliculi — treated with stenting; canaliculitis — requires curettage; persistent NLDO — dacryocystorhinostomy (DCR) used resolve to distal obstructions; opening made in ethmoid bone of nose and lacrimal sac; lacrimal stents passed through canaliculi and osteotomy, and tied in nose; canalicular scarring may preclude DCR and necessitate conjunctivo-DCR (passage of glass or borosilicate [Pyrex] tube from area of caruncle, bypassing canaliculi, passing through osteotomy, and exiting into nose)

Readings

Bukhari A: Etiology of tearing in patients seen in an oculoplastic clinic in Saudi Arabia. Middle East Afr J Ophthalmol 2013 Jul-Sep;20(3):198-200; Lee H et al: Clinical characteristics and effectiveness of the lateral tarsal strip and medial spindle procedure.Ann Plast Surg 2015 Oct;75(4):365-9; Ozcan EM et al: Prevalence of nasolacrimal canal obstruction and epiphora following maxillary orthognathic surgery.[published online ahead of print February 2, 2018]. Int J Oral Maxillofac Surg doi: 10.1016/j.ijom.2018.01.003; Petris C, Liu D: Probing for congenital nasolacrimal duct obstruction. Cochrane Database Syst Rev 2017 Jul 12;7:CD011109. doi: 10.1002/14651858.CD011109.pub2; Saleh GM et al: Tear film osmolarity in epiphora. Ophthal Plast Reconstr Surg 2012 Sep-Oct;28(5):338-40.

Disclosures

For this program, members of the faculty and planning committee reported nothing to disclose.

Acknowledgements

Dr. Distefano was recorded at Ophthalmology Update and Haimovici Lecture, presented by the Boston University School of Medicine, on March 23, 2018, in Boston, MA. To learn more about upcoming CME programs at Boston University School of Medicine, please visit www.bucme.org. The Audio Digest Foundation thanks the speakers and the Boston University School of Medicine for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

OP561203

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.