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Can anything be done for my tearing?
Tearing is a condition that can be very annoying and frustrating. Usually tearing does not represent a serious problem. Tearing can interfere with vision in many situations. Visual difficulties and embarrassment from constant wiping of tears are what prompt most people to consult with me for relief. Most of the time tearing can be improved, if not cured. I will usually ask how symptomatic patients are from the tearing. This will dictate what course of treatment is considered.
The tear film is a very complex surface consisting of a mucin (mucus) layer, an oil layer and an aqueous (water) layer. All three of these layers must be healthy for the eye to function properly. Evaluation of the tear film must always be considered in looking for a cause of tearing.
What are the causes of tearing?
I like to think of the causes of tearing as threefold. One is that too many tears are produced (hypersecretion). Second that the tears are distributed in an abnormal way and third, that the tears can’t drain fast enough (excretory outflow obstruction). Tears are made in a gland located in the upper outer area under the eyelid (Fig.). The blinking action of the eyelids then distributes the tears over the surface of the eye and pushes them to the inner corner where the tear duct drain is located. There are two openings in the eyelids that drain tears, one in the upper and one in the lower eyelid. The lower eyelid probably drains most of the tears. The tears eventually drain down into the nose. That’s why you can sometimes taste your eye drops after instillation.
What causes too many tears to be produced?
This is usually caused by external factors. Situations such as the cold or wind can cause more tears to be produced. Allergies are a very common cause of excessive tear production. Certain eyelid inflammation such as blepharitis results in tearing. Any acute eye infection or inflammation results in the eye trying to lubricate itself and tears are produced in excess.
Interestingly, dry eyes can result in excessive tear production. That’s right! Dry eyes are actually a cause of tearing. How could this be, you ask? When your eyes are dry the brain senses this dryness through a reflex mechanism. As far as the brain is concerned, more tears need to be produced. Because the brain is the ultimate organ controlling tear production, a signal is sent to the tear glands to make more tears. If the tear duct drains can not handle the excess tearing will be the symptom. So believe it or not, sometimes the treatment for tearing is to use moisture drops or wetting drops.
What causes tears not to drain properly?
The most common cause of decreased drainage of tears through the tear duct drain is an obstruction (Figure 10). This can be the result of aging changes, trauma, scarring, inflammation,
and the use of certain medication. Both topical and systemic medications can cause scarring of the tear duct.
Certain chemotherapeutic drugs for cancer treatment can cause structural changes to the tear duct resulting in narrowing and loss of outflow.
In addition, laxity of eyelid tissue seen with aging can result in decrease of the pumping action of the lower eyelid. Every time the eyelid blinks, the lower eyelid moves back and forth pushing the tears into the tear duct drain. If the lower eyelid does not properly perform this task, the tears will roll over the top of the lower eyelid. Correcting these structural problems will usually improve the tearing.
How is the cause of tearing determined?
Evaluation of tearing requires a comprehensive eye exam. Vision, external exam, tear film, eyelid exam, blink mechanism and the inside of the eye are all carefully checked. Mechanical irritation of the eye can be caused by an ectropion (turning out of the lid), entropion (turning in of the lid) or trichiasis (abnormal eyelashes). Next, I evaluate whether there is a structural defect in the drainage system. There may be a blockage in the tear duct system right at the opening-referred to as punctal stenosis. The tear duct drain is evaluated by probing and irrigating the drain. This is a simple office procedure, but tells me if an obstruction is present and where it is. And remember from a previous question that an exam for testing for dry eyes must be performed. After this evaluation, a treatment plan is formulated. Pertinent history should also include sinus disease, nasal surgery, trauma, allergies, and topical medications (eye drops). Also it is necessary to know if the patient has been on chemotherapy as mentioned above. In some patients, more advanced testing may be necessary. This usually includes some form of radiology such as an MRI scan or a CT scan. In specific instances, these tests may be combined with injection of a radio opaque dye in to the tear drain to rule out a suspected tumor.
What treatments are available for the correction of tearing?
In some situations, tearing can not be completely cured. Most patients who are significantly bothered by tearing will be happy with any improvement.
If the eyes are found to be dry, I will first begin dry eye therapy. Most external inflammations such as allergies can be treated with combination drops and antihistamine medications, including nasal sprays. Sometimes a referral to an allergist may be necessary. Other eyelid inflammations-most commonly blepharitis- are usually treated with drops and ointments.
If eyelid malpositions are found, these are usually corrected with various surgical procedures. These procedures can range from simple lid tightened techniques with one stitch to more complex surgeries. Most of these can be done in our ambulatory surgical center right in our office.
If the tear duct drain is found to be obstructed, treatment usually involves a surgical repair. Again, depending on where the obstruction is, the surgery can be rather simple or more complex. The latter procedures often involve admission to the hospital for outpatient surgery. Some techniques involve inserting flexible tubes within the tear duct drain. Others involve creating a new drain into the nose. Still others involve bypassing the normal drain altogether and having the tears drain into the nose through a glass tube. This tube is completely concealed. It has been used for almost thirty years with excellent results and safety.
I have also cured many tearing patients by simply irrigating the tear duct. I believe that some patients may form a small stone in the duct that I am able to flush out. Periodic flushing helps prevent tearing from recurring.
Can tearing occur in children?
The simple answer is yes, but sometimes requires a different approach. Let me explain. It is not uncommon for many newborns to tear. This is because the tear duct drain (see Appendix) fully opens up somewhere between 36-40 weeks of gestation (the development of the newborn). Since most infants are born during this time, it is not unusual to have tearing and/or frank infection at birth. My approach to these infants is to do a careful eye exam to make sure there is no other eye disease present. These children are watched carefully.
Fortunately, most of the tearing resolves in the first few months. If not resolved by about one year, I will usually recommend a surgical procedure to open up the tear duct drain. Sometimes repeated infections may necessitate operating sooner. Other than a congenital origin, tearing in children is usually caused by some external process-like allergy- similar to the discussion above.
So you see that tearing involves a very detailed and comprehensive evaluation. Most of the time tearing can be significantly improved, if not cured. Some of my happiest patients are those that I have helped with tearing.