Definition
A.Excessive tears disorder is an overproduction of tears. Complaints vary from watery eyes to overflowing tears that run down the cheeks, a condition known as epiphora.
Incidence
A.The incidence is unknown.
Pathogenesis
A.The most common cause is reflex overproduction of tears (as occurs in the elderly) due to a deficiency of the tear film.
B.Lacrimal pump failure and obstruction of the nasolacrimal outflow system are other causes of excessive tears.
C.Canalicular infections may be caused by Actinomyces israelii (Streptothrix) and Candida.
Predisposing Factors
A.Blepharitis (inflammation of the eyelid).
B.Allergic conjunctivitis (infectious or foreign body).
C.Exposure to cold, air conditioning, or dry environment.
D.Lid problems: Impaired pumping action of the lid motion due to seventh nerve palsy or conditions that stiffen the lids such as scars or scleroderma.
E.Lid laxity from aging or ectropion (sagging of the lower lid).
F.Sinusitis.
G.Atopy.
H.Age: Increased incidence in the elderly due to an overproduction of tears by the lacrimal gland.
I.Congenital obstruction.
Common Complaints
A.Watery eyes or tears running down cheeks are common complaints.
Other Signs and Symptoms
A.Unilateral tearing: Obstructive etiology.
B.Bilateral tearing: Environmental irritants.
Subjective Data
A.Inquire about onset, course, and duration of symptoms. Note frequency of excessive tearing.
B.Ascertain whether this is a new symptom or whether the patient has a past history of similar complaints. Ask how it was treated, and what the response was to treatment(s).
C.Determine severity. Do the tears run down the cheek?
D.Ascertain whether tearing is unilateral or bilateral.
E.Review common environmental predisposing factors.
F.Question the patient regarding vision changes.
G.Review medical history.
H.Review recent history for sinus infections or drainage, facial fractures, and surgery.
I.Confirm no pain associated with condition.
Physical Examination
A.Inspect:
1.Evaluate both eyes.
2.Observe the lid structure and motion.
3.Conduct a dermal exam to rule out butterfly rash.
4.Confirm pupil reactivity
5.Perform a funduscopic exam for vascular changes.
B.Palpate:
1.Apply gentle pressure over the lacrimal sac to check drainage.
2.Invert upper lid to check for foreign body.
3.Palpate face for sinus tenderness.
Diagnostic Tests
A.Culture any drainage expressed from the lacrimal sacs.
Differential Diagnoses
A.Excessive tears.
B.Dendritic ulcer: Early symptoms are tears running down cheeks associated with a foreign-body sensation.
C.Congenital glaucoma.
D.Dacryocystitis (purulent discharge).
E.Reflex tearing caused by dry eye.
F.Blepharitis.
Plan
A.General interventions:
1.Eliminate identifiable irritants.
2.Treatment is aimed mainly at the underlying condition (i.e., ocular infection).
3.Dacryocystitis is treated with hot compresses at least four times a day and systemic antibiotics.
B.Patient teaching:
1.Instruct the patient on the application of compresses if dacryocystitis is suspected.
2.After pathology is ruled out, reassure the patient excessive tearing is common and more frequent with aging.
C.Pharmaceutical therapy:
1.None is required for diagnosis of excessive tears without infections pathology.
2.Dacryocystitis:
a.Erythromycin 250 mg four times daily for 7 days.
b.Dicloxacillin 250 mg four times daily for 7 days.
Follow-Up
A.See patient in 48 to 72 hours to evaluate symptoms, especially if antibiotic therapy was needed for infection.
Consultation/Referral
A.Patients unresponsive to treatment should be promptly referred to an ophthalmologist.
B.Consider referral for lid malposition or nasolacrimal duct obstructions.
Individual Considerations
A.Adults:
1.Consider mental health support if condition alters self-image and limits socialization.
B.Geriatrics:
1.Encourage geriatric patients to protect eyes when traveling (airplanes, dry environments, and hot rooms during winter) and when facing exposure to windy areas, bright sunlight, and abrupt temperature changes. All these sources could easily cause older adults with dry eyes to excessively tear.
2.If shielding/protective measures do not resolve the symptom, further evaluate for infection or blocked tear duct. Common causes for geriatric increased tear production are dry eyes, allergic sinusitis, and upper respiratory infections.
3.How to determine dry eyes versus obstruction (excessive tears versus nasolacrimal drainage) is as follows: If tears do not run down the cheeks, then it most likely is dry eyes. If tears run down the cheeks, then it most likely is nasolacrimal drainage. Unexplained excessive tears (epiphora) in geriatric patients will need to be referred to a specialist for further evaluation to rule out tumors or abscess.