Watering eye

Watering eyeDr. SOMESH.K.N

watering eye is characterised by overflow of tears from conjunctival sac.Watering eye is mainly due to hyperlacrimation and epiphora.

Causes of hyperlacrimation

Primary hyperlacrimationReflux hyperlacrimationCentral lacrimation

Epiphora(DOWN POUR)Obstruction to the outflow of normally secreted tears.Epiphora may be due to physiological (lacrimal pump failure) or anatomical(mechanical obstruction) cause.

Mechanical obstructionPunctal causesCanaliculiLacrimal sacNLD

Clinical evaluation Ocular examination with diffuse illumination using magnifiaction.Regurgitation test.Fluorescein dye disappearance test.Lacrimal syringing.Jones dye test.Dacryocystography.Radionucleotide dacryocystography(lacrimal scintillography).

DacryocystitisDacryocystitisis aninfectionof thelacrimal sac secondary to obstruction of thenasolacrimal ductat the junction oflacrimal sac.Dacryon= tear, cyst= sacSimply dacryocystitis is an inflammation of lacrimal sac.Dacryocystitis may be congenital or acquired.

Congenital dacryocystitisInflammation of lacrimal sac occuring in new born infants( dacryocystitis neonatorum) Etiology congenital blockage in NLDClinical picture 1.epiphora 2.positive regurgitation test 3.swelling

Differential diagnosisIt should be differentiated from ophthalmia neonatorum and congenital glaucomaComplicationsRecurrent conjunctivitisLacrimal abscessFistulae formation

Treatment Massage over lacrimal sac area and topical antibiotics in first month(3-4 weeks of age).Lacrimal syringing (if not cured up to 2months of age)Probing of NLD with Bowmans probe(if not cured up to 3-4months)Balloon catheter dilatation(if probing fails)Intubation with silicone tube(If probings and catheter dilation fails)DCR operation(final approach at the age of 4)

Acquired dacryocystitisIt may be acute or chronicChronic dacryocystitis:Etiology Etiology is of multifactorial.Vicious cycle of stasis and mild infection of long durationPredisposing factors.Factors responsible for stasis of tears in lacrimal sac(anatomical factors,foreign body,inflammation of lacrimal sac, obstruction of NLD)

Clinical picture1.chronic catarrhal dacryocystitisOnly symptom is watering eyeDCG reveals block in NLD, normal sized lacrimal sac with healthy mucosa.2.Lacrimal mucocoeleDistension of lacrimal sac.Characterised by constant epiphora associated with swelling below inner canthus.Milky or gelatinous fluid from lower punctum on pressing swelling.DCG reveals distended sac with blockage in NLD

Some times due to chronic infection, opening of both canaliculi into sac are blocked leading to negative regurgitation test. This is called encysted mucocele. 3.Chronic suppurative dacryocystitisDue to pyogenic infection, the mucoid discharge becomes purulent, converting it into pyocoeleCharacterised by epiphora, associated recurrent conjunctivitis and swelling at the inner canthus with mild erythema of overlying skin.On regurgitation test, frank purulent discharge flows from lower punctum. If openings of canaliculi are blocked then encysted pyocole.

4.Chronic fibrotic sac.Low grade repeated infections for a prolonged period ultimately result in a small fibrotic sac due to thickening of mucosa, which is often associated with persistant epiphora and discharge.DCG at this stage reveals very small sac with irregular folds in mucosa.

Treatment Conservative treatment with repeated lacrimal syringing.Balloon catheter dilatation(balloon dacryocystoplasty)DCRDCTConjunctivo dacryocystorhinostomy

Acute dacryocystitis

Acute dacryocystitis It is an acute suppurative inflammation of lacrimal sac, characterised by presence of a painful swelling in region of sac.Clinical picture stage of cellulitis stage of lacrimal abscess stage of fistula formation

Treatment

During cellulitis stageDuring stage of lacrimal abscessTreatment of external lacrimal fistulaSurgical technique of DCR:1.Conventional external approach DCR2.Endonasal DCR3.Endocanalicular laser DCR