Watery eye

By Magdy fawzy $ Taha sarhan Prof of ophthalmology

ZAGAZIG UNIVERSITY HOSPITAL Ophthalmology department

Prof. Dr. Taha Sarhan Prof. Dr. Magdy fawazy

WATERY EYE

Watering of the eye

Definition : It is an over flow of tears onto the cheek.
Watering of the eye is an extremely common ocular symptom.

What are the other common ocular symptoms ?

What are the causes of watery eye? A host of disease entities can lead to this symptom.
It may be due to

lacrimation
OR

epiphora

How you can manage a case of watery eye? A thorough understanding and identifications of these causes is the only way to successfully manage this annoying symptom.
What is the first step in the understanding of watery eye ? How to differentiate epiphora from lacrimation?

* Epiphora . Watering that occurs secondary to abnormal excretory system in the presence of normal tear secretion. * Lacrimation. Watering that occurs secondary to excessive tear production in the presence of a normal excretory system.

Failure to differentiate these two conditions can result in unwarranted and improper medication of a large number of patients.


If you listen to the telltale you will lose the friend

Watering of the eye

lacrimation Epiplapharon
Epiphora Punctal atresia Canalicular atresia N.L.D. blocking Lacrimation (patient syringing) Dry eye Blepharitis Epiphora Syringing patent Ectropion Syringing blocked Punctal atresia Punctal stenosis

Trichiasis

Reduced LTM. Increased BUT

Thichined lid margin Blocked puncta by tarsal gland

Distiachiasis

Lid lag

Congenital glaucoma

Schirmer test

Forthy disharge

7TH nerve palsy

Canilicular block
CC. block NLD block

 Reflex irritation of conj. or cornea (lacrimation):

Rubbing lashes or trichiasis. PTDs or PTCs. Conjunctivitis.

Corneal FB or ulcer.

 Inadequte tear drainage (Epiphora):

Loss of sharpness of lid margin: blepharitis,.

Ectropiopn : due to failure of lid apposition onto the globe.

Failure of the pump mechanism. Obstruction : of lacrimal passages. Nasal causes: nasal polyp, tumour,
hypertrophied IT bone. or marked deviated septum.

How to reach diagnosis ?

Please at first you must exclude cases of lacrimation 1-HISTORY Present history
*Unilateral cases which is more worse out doors especially in cold windy days are very suggestive of epiphora *bilateral cases associated with itching , irritation and photophobia are very suggestive of lacrimation

Past history
*Bell,s balsy *drug intake

How to reach diagnosis ?

2-Examination:

*Inspection (slit lamp). -Eye lid: (ectropion,trichiasis,eversion of the lower punctum and lower lid laxity) -Medial canthus : :for lacrimal sac swelling (acute dacryocystitis,mucocele or rarely tumour )

How to reach diagnosis ?

2-PALPATION:

*Palpation of lacrimal sac and regurge test. Reflux of a mucopurellent material is diagnostic and no further investigations are required. *DDT.

How to reach diagnosis ?

3-Propping & irrigation.

4-Jones dye test: 1ry. & 2ry. 5-Radiological ex. 6-Nasal examination.

Case 1
40 yo. woman presented with lacrimation, ocular irritation and redness 1 month ago.

 Examination Slit lamp: see picture.. DDT: normal Lacrimal sac: not felt, no regurge. Nasal ex: normal

The cause of watering is due to?

LACRIMATION

OR
EPOPHORA

The most likely diagnosis?

1.Entropion. 2.Trichiasis 3.Rubbing lashes. 4.Non of the above

 Treatment not include 1-epilation: 2-electrolysis: 3-diathermy: 4-snellens operation: 5-all of the above: 6-Vanmellingens opertion of the upper lid

 Trichiasis: Definition: More than 4 mal-directed lashes are rubbing against the bulbar conjunctiva and cornea Clinical picture: Symptoms: 1) Foreign body sensation. 2) Pain. 3) Photophobia. 4) Lacrimation.

 Signs: 1) Misdirected lashes 2) Conjunctival hyperemia 3) Discharge

Treatment: 1) Van Mellingens operation for the upper lid.


The gift of gab is a proof of jealousy

Case 2
A 72 yo man presented with lacrimation, corneal irritation and photophobia.

Examination Slit lamp: see picture.. DDT: normal Lacrimal sac: not felt, no regurge. Nasal ex: normal

The cause of watering is due to?

LACRIMATION

OR
EPOPHORA

The most likely diagnosis?

1. Rubbing lashes. 2. Trichiasis.

3. Involutional entropion 4. Involutional ectropion

Entropion: Definition:
rolling in of the lid margin, trichiasis is always present.

Management:
1. Epilation. 2. Elyctrolysis 3. Snellens operation 4. Vanmellingin,s operation

5. webster operation

Case 3
A 21y.o.male presented with Foreignbody sensation and tearing in the left eye While riding my bycicle 3 hours ago, came suddenly

Examination Visual acuity: 6/6 OU IOP: 15mmHg OU Pupils: RRR Slit lamp: see picture.. DDT: normal Lacrimal sac: not felt, no regurge. Nasal ex: normal

DO YOU WANT TO DO ANY THING FURTHER ?

Lid eversion is what I need to do

What is the most likely diagnosis?

a- NLDO. b- Foreign body c- Dry eye syndrome d- Herpes simplex keratitis

If a foreign body is seen what test you want to do ?

Fl. test

The cause of watering is due to?

LACRIMATION

OR
EPOPHORA

Which Therapy?
a- Irrigation of the eyes with saline
b- Topical steroids c - Antibiotic ointment d - Eversion of the upper eyelid, removal of the foreign body

Case 4
A 70 year-old women who complained of watering and ocular irritation in the left eye 3 ms ago.

Examination
Slit lamp: see picture:

DDT: prolonged:
Lacrimal sac: not felt, no regurge: Nasal ex: normal:

The cause of watering is due to?

LACRIMATION

or
EPOPHORA

The most likely diagnosis?

1. Cicatricial ectropion.

2. Involutional entropion 3. Mild senile ectropion

4. Moderate senile ectropion 5. Sever senile ectropion

The most likely treatment ?

1. Cautery puncture. 2. Snellens suture. 3. V-Y operation. 4. All of the above.

5. Non of the above.

Case 5
40 years old man presented with lacrimation and burning sensation in the left eye Since yesterday

 Examination Visual acuity: 6/9(OU). IOP:11mmHg OU. EOM motility: normal. Slit lamp: normal. Fl stain: normal. DDT: prolonged.

The most likely diagnosis?

Herpetic keratitis Third-Nerve Palsy Dry eye syndrome FB under the upper eyelid 5. Seventh-Nerve Palsy What do you want to ask the patient to do? Close your eyes !! 1. 2. 3. 4.

The cause of watering is due to?

LACRIMATION

or
EPOPHORA

Which Therapy?
1. Tarsorraphy.

2. Immediate Lid Surgery.

3. Acyclovir ointment . 4. Pressure patch. 5. Moisture chamber with lubricating ointment.

 Moisture chamber with lubricating ointment

Case 6
A 2 year old boy presented with tears overflowing from left eye, matting of lashes since one month of age.

 Examination VA: cannot be checked. IOP: 17 mmHg OU. Slit lamp: normal. DDT: This photo is five minutes after placing fluorescein into each eye. Lacrimal sac: not felt, no regurge. Nasal ex: normal.

DD of epiphora in infant Not include? 1. Buphthalmos.

2. Ophthalmia neonatorum. 3. Congenital nasolacrimal duct obstruction. 4. Cataract.

How should this patient be treated?

a. No ttt and it will resolves spontaneously. b. Probing.

c. Intubation .
d. DCR.

 More than 90% of congenital nasolacrimal duct obstruction resolves spontaneously before one year of age. If the child has not had spontaneous resolution, probing ( success rate of > 90%). If tearing persists after probing, intubation ( the benefit of this procedure is not clearly established.)

Case 7
A 60 yo female presented with epiphora, discharge together with swollen left lower lid 7 months duration.

 Examination Slit lamp: see picture.. DDT: prolonged The swelling: is below the medial palpebral ligament Regurge test: see.. Nasal ex: normal

The cause of watering is due to?

LACRIMATION

or
EPOPHORA

What is the likely diagnosis? a. Acute dacryocystitis b. Hordeolum (stye) c. Chalazion d. Chronic dacryocystitis

What are the possible complications?

1. Chronic conjunctivitis. 2. Hypopyon corneal ulcer.

3. Cicatrical ectropion.
4. lacrimal muococele. 5. Acute dacryocystitis. 6. All of the above

What is Not appropriate treatment?

1. Antibiotics: local & systemic. 2. Probing. 3. DCR.

4. Dacryocystectomy.

Case 8
The patient is a 42-year-old man presented with a 3 day history of epiphora, erythema and tenderness near the left medial canthus.

 EXAMINATION
Visual acuity: 6/6 OU IOP: 11 12 Motility: normal Pupils :RRR DDT: prolonged The swelling :is below medial palpibral ligament. The skin over: it is red& oedematous Temperature: is 38.5

 What is the likely diagnosis? a. Hordeolum (stye) b. Orbital cellulitis. c. Chronic dacryocystitis
d. Acute dacryocystitis

The cause of watering is due to?

LACRIMATION

or
EPOPHORA

What is the appropriate treatment?

Antibiotics ( topical & systemic).

Analgesics
Warm compresses. All of the above.

Non of the above.

Watering of the eye

Reflex irritation of conj or cornea (lacrimation):

trichiasis

entropion

Forign body

Watering of the eye

Inadequte tear drainage (Epiphora):

ECTROPION

FACIAL NERVE PALSY

NLD. OBSTRUCTION

CHRONIC DACRYOCYSTITIS

ACUTE DACRYOCYSTITIS


Don't argue with an ignorant for it will be hard for people to differentiate between you

Thank U

Case
70 yo female; coronary artery disease, diabetes, recent history of chemotherapy for cancer Seen for irritable eyes, burning, itching, mattering of the lashes and foreign body sensation worse in am, "its terrible"

Ocular history: cataract extraction OU 2000, glaucoma . Ocular medication: Xalatan 0.005% OU qhs. On examination Va: 20/40 ou Slit lamp see image.

What is the diagnosis?

What changes do you see on the lids? What is the recommended management?

Blepharitis

What changes do you look for on the lids?

crusting on the lashes, telangectasia of the lid margin blood vessels, foamy tear film, low tear film meniscus

What is the recommended management?

1. 2. 3. 4.

Warm compresses Lid hygiene Topical antibiotics Topical steroids ointment for recalcitrant cases 5. Systemic tetracycline or doxycycline

Case
This 26 year old woman was referred to the eye clinic because of a left chronic ocular irritation. On slit-lamp examination, the above picture is seen

 What is the cause of her left chronic ocular irritation?

Pubic louse (Phthirus pubis) and multiple eggs attached to the eyelashes
It is most commonly found in the groin and can be sexually transmitted. Other areas where it can be found include axillae, eyelashes and eyebrows. It contains claws that allow it to cling to the hairs of these areas.

 The louse lays its eggs within a few days of becoming sexually mature. The tiny, white eggs or nits are cemented to the base of the hair shafts. After hatching, the nymphs pass through two or three stages (instars) before reaching adulthood

 How would you treat this condition? Several options are available:

Manual removal of the lice and nits with forceps

Aapplying petroleum to the edges of the lid margin can kill the lice but has no effect on the nits

How would you treat this condition?

Aanticholinesterase such as physiostigmine 0.25% ointment can be used to kill the lice Malathion 1% which is an organophosphorus can kill both the lice and the nits

Ingrowing eyelashes and entropion, upper lid.

Trichiasis

Don't argue with an ignorant for it will be hard for people to differentiate between you

Thank U