Evaluation of the tearing patient

Patients with insuffi cient lacrimal drainage may present to the ophthalmologist with a complaint of tearing. This tearing may be unilateral or bilateral, intermittent or constant, isolated or associated with other ocular symptoms. Tearing may cause blurred vision, problems with contact lens wear, or annoyance with tears fl owing down the cheek. Patients may also complain of a buildup of mucopurulent material in the medial canthus, leading to mattering of the eyes. To correctly identify and treat the cause of tearing, it is helpful to fi rst differentiate between hyperlacrimation (tear overproduction) and epiphora (decreased tear outfl ow). Hyperlacrimation may be attributable to a variety of causes and must be ruled out before addressing any potential outfl ow problems. Causes of hyperlacrimation, listed in Table 6.1, include the general categories of supranuclear and infranuclear etiologies, refl ex lacrimation, and direct lacrimal gland stimulation.1-3 Epiphora may be caused by problems at any point along the lacrimal outfl ow apparatus: punctum, canaliculus, lacrimal sac, lacrimal pump, nasolacrimal duct, and the valve of Hasner at the nasal opening of the nasolacrimal duct. Specifi c problems involving these areas are listed in Table 6.2.