watery eye

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Watery eye

By

Magdy fawzy $ Taha sarhanProf of ophthalmology



أال اروق ع اخطب د أعز أ سم

فن اتغي ازة غيه ا ذأ



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

OR

lacrimation

epiphora

What are the causes of watery eye? A host of disease entities can lead to

this symptom.

It may be due to

OR

lacrimation

epiphora



How you can manage a case of watery eye?

A thorough understanding andidentifications of these causes isthe 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 thepresence of normal tear secretion.

* Lacrimation. Watering that occurs secondary toexcessive tear production in the

presence of a normal excretory system.



Failure to differentiate thesetwo conditions can result inunwarranted and improper

medication of a large numberof patients.



أطع انواشي ض َ انصذق

• If you listen to the telltale you will lose thefriend



Watering of the eyeEpiphoraLacrimation

(patient syringing)Epiphoralacrimation

Syringing blocked

Syringingpatent

BlepharitisDry eyePunctalatresiaEpiplapharon

Punctalatresia

EctropionThichinedlid margin

ReducedLTM.

Canalicularatresia

Trichiasis

Punctalstenosis

Lid lagBlockedpuncta by

tarsal gland

IncreasedBUT

N.L.D. blocking

Distiachiasis

Canilicular

block

7TH nerve

palsy

Forthy

disharge

Schirmer

testCongenitalglaucoma

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 suggestiveof epiphora

*bilateral cases associated with itching , irritationand 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 thelower punctum and lower lid

laxity)-Medial canthus :

:for lacrimal sac swelling (acute

dacryocystitis,mucocele or rarely tumour )




2-PALPATION:

*Palpation of lacrimal sac andregurge test.

Reflux of a mucopurellentmaterial is diagnostic and nofurther investigations are

required.

*DDT.




3-Propping & irrigation.

4-Jones dye test: 1ry. & 2ry.

5-Radiological ex.

6-Nasal examination.

http://www.djo.harvard.edu/files/4836_731.jpg



Case 1

• 40 yo. woman presented with

lacrimation, ocular irritation andredness 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?

OR

EPOPHORA

LACRIMATION



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-snellen’s operation:5-all of the above:

6-Vanmellingen’s opertion of the upper

lid



• Trichiasis:

Definition:More than 4 mal-directed lashes are

rubbing against the bulbar conjunctivaand cornea

Clinical picture:

Symptoms:

1) Foreign body sensation.

2) Pain.

3) Photophobia.

4) Lacrimation.



Signs:

1) Misdirected lashes

2) Conjunctival hyperemia3) Discharge

Treatment:

1) Van Mellingen’s operation for the

upper lid.



نه انوم دن هى انذ انصرةا

• The gift of gab is a proof of jealousy



Case 2

• A 72 yo man presented with

lacrimation, corneal irritation andphotophobia.



• Examination

• Slit lamp: see picture..

• DDT: normal

• Lacrimal sac: not felt, no regurge.

• Nasal ex: normal




•

• OR

EPOPHORA

LACRIMATION

Th t lik l di i ?




1. Rubbing lashes.

2. Trichiasis.

3. Involutional entropion

4. Involutional ectropion



Entropion:

Definition:

rolling in of the lid margin,

trichiasis is always present.

Management:



Management:

1. Epilation.

2. Elyctrolysis

3. Snellens operation

4. Vanmellingin,s operation

5. webster operation

Case 3



Case 3• A 21y.o.male presented with Foreign-

body sensation and tearing in the left

eye While riding my bycicle 3 hoursago, 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 todo

What is the most likely diagnosis?



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 ?



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

Fl. test




OR

LACRIMATION

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



Case 4

• A 70 year-old women who complainedof watering and ocular irritation inthe left eye 3 ms ago.

E i i



Examination

Slit lamp: see picture:

DDT: prolonged:

Lacrimal sac: not felt, no regurge:

Nasal ex: normal:

Th f t i i d t ?




or

LACRIMATION

EPOPHORA

Th t lik l di i ?



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 ?



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



Case 5

• 40 years old man presented with

lacrimation and burning sensationin 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.

Th t lik l di i ?




1. Herpetic keratitis2. Third-Nerve Palsy

3. Dry eye syndrome

4. FB under the uppereyelid

5. Seventh-Nerve Palsy

•

What do you want toask the patient to do?

• Close your eyes !!





or

LACRIMATION

EPOPHORA

Whi h Th ?



Which Therapy?

1. Tarsorraphy.

2. Immediate Lid Surgery.

3. Acyclovir ointment .

4. Pressure patch.

5. Moisture chamber with lubricating

ointment.

M i h b i h l b i i



• Moisture chamber with lubricatingointment

C 6



Case 6

A 2 year old boy presented with tears

overflowing from left eye, matting of lashes since one month of age.

Examination




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?




DD of epiphora in infant Not include?

1. Buphthalmos.

2. Ophthalmia neonatorum.

3. Congenital nasolacrimal ductobstruction.

4. Cataract.

How should this patient be treated?





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




• More than 90% of congenital nasolacrimalduct obstruction resolves spontaneously

before one year of age.

• If the child has not had spontaneousresolution, probing ( success rate of > 90%).

• If tearing persists after probing, intubation

• ( the benefit of this procedure is not clearly established.)

Case 7



Case 7

• A 60 yo female presented with epiphora,

discharge together with swollen leftlower lid 7 months duration.

Examination



Examination

Slit lamp: see picture..

DDT: prolonged

The swelling: is below the medialpalpebral ligament

Regurge test: see..

Nasal ex: normal




or

EPOPHORA

LACRIMATION

What is the likely diagnosis?



• What is the likely diagnosis?

a. Acute dacryocystitis

b. Hordeolum (stye)

c. Chalazion

d. Chronic dacryocystitis

What are the possible complications?



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?



What is Not appropriate treatment?

1. Antibiotics: local & systemic.

2. Probing.

3. DCR.

4. Dacryocystectomy.

Case 8



Case 8• The patient is a 42-year-old man

presented with a 3 day history of epiphora, erythema and tendernessnear the left medial canthus.

EXAMINATION





Visual acuity: 6/6 OU

IOP: 11 12 Motility: normal Pupils :RRR DDT: prolonged

The swelling :is below medial palpibralligament.

The skin over: it is red& oedematous

Temperature: is 38.5






a. Hordeolum (stye)

b. Orbital cellulitis.

c. Chronic dacryocystitis

d. Acute dacryocystitis





LACRIMATION

EPOPHORA

or

What is the appropriate treatment?




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



Watering of the eye• Inadequte tear drainage (Epiphora):

ECTROPION

CHRONIC DACRYOCYSTITIS ACUTE DACRYOCYSTITIS

FACIAL NERVE PALSY NLD. OBSTRUCTION

كب انرق ف انس خئ فذ ، احق تجدل





كب قرنا يف سنا ئخ ذف ، قحا لدجت

• Don't argue with an ignorant for it will be hard for people todifferentiate between you

Thank U



Thank U

Case



Case• 70 yo female; coronary artery disease,

diabetes, recent history of chemotherapy for cancer Seen forirritable eyes, burning, itching,mattering of the lashes and foreign body sensation worse in am, "it’s

terrible"

Ocular history: cataract extraction



Ocular history: cataract extractionOU 2000, glaucoma .

Ocular medication: Xalatan 0.005%OU qhs. On examination Va: 20/40 ou

Slit lamp – see image.

What is the diagnosis?



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? –



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. Warm compresses

2. Lid hygiene

3. Topical antibiotics

4. Topical steroids ointment forrecalcitrant cases

5. Systemic tetracycline or doxycycline

Case



Case• This 26 year old woman was referred

to the eye clinic because of a leftchronic ocular irritation. On slit-lampexamination, the above picture is seen

• What is the cause of her left chronicocular irritation?



ocular irritation?

•

Pubic louse (Phthirus pubis)and multiple eggs attached tothe eyelashes

•It is most commonly found inthe groin and can be sexually transmitted. Other areas whereit can be found include axillae,

eyelashes and eyebrows. Itcontains claws that allow it tocling to the hairs of these areas.



• The louse lays its eggs within afew 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 orthree stages (instars) before

reaching adulthood

How would you treat this condition?



y

Several options are available:

Manual removal of the liceand nits with forceps

Aapplying petroleum to theedges of the lid margin cankill the lice but has no effecton the nits

How would you treat thiscondition?



Aanticholinesterase such asphysiostigmine 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



Ingrowing

eyelashes and

entropion, upper lid.

Trichiasis



تجدل احمق ،فذ خطئ انس في ارق نك



مكنب Don't argue with an ignorant for it

will be hard for people todifferentiate between you

Th k U



Thank U

watery eye

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