Approach to the child with persistent tearing

INTRODUCTION — Nasolacrimal duct obstruction is the most common cause of persistent tearing, infection, and ocular discharge in infants and children. The other causes range from mild, self-limited conditions to sight-threatening ocular emergencies (table 1). Associated signs and symptoms usually help to narrow the differential diagnosis and facilitate appropriate triage of children with these complaints.

The anatomy of the lacrimal system and the differential diagnosis, evaluation, and treatment for persistent tearing in infants and children are reviewed here. Nasolacrimal duct obstruction and conjunctivitis are discussed separately. (See "Congenital nasolacrimal duct obstruction (dacryostenosis) and dacryocystocele" and "Conjunctivitis".)

ANATOMY AND PHYSIOLOGY OF THE LACRIMAL SYSTEM — The function of tears is to keep the ocular surface moist and flushed clear of debris and bacteria. The tear film is partly responsible for corneal clarity and the transmission of a focused image to the retina.

●Tear production and drainage – Tears are produced by the lacrimal and accessory lacrimal glands. The lacrimal glands are located in the upper/outer quadrant of the orbit and produce "reflex" tears when the eye is irritated or stimulated by emotions [1]. The accessory lacrimal glands are scattered along the conjunctiva of the eyelid and produce the basal (resting) tears that keep the eye moist.

Tears drain through the lacrimal drainage system, which begins at the punctum, a small opening on the medial surface of each eyelid (figure 1). The punctum is the opening of the canaliculus, which drains into the common canaliculus and then into the lacrimal sac. There are two canaliculi for each eye (one on the upper and one on the lower eyelid). Tears that collect in the lacrimal sac drain through the nasolacrimal duct and into the nose via the inferior meatus, located below the inferior turbinate. The valve of Hasner, a mucosal flap at the distal end of the nasolacrimal duct, prevents air from entering the lacrimal sac when the nose is blown; the valve of Hasner is called the "membrane of Hasner" if it hasn't opened. Tears are swallowed after they pass from the nose into the posterior pharynx.

Tear drainage is both passive and active. Gravity is responsible for passive drainage. Blinking facilitates active drainage by causing negative pressure in the canaliculus and lacrimal sac; the negative pressure draws tears into the lacrimal drainage system [2].

The tear meniscus or tear lake is a small layer of tears above the lower eyelid that rests against the cornea and conjunctiva. Excessive tearing (epiphora) causes the level of the tear meniscus to elevate, and the tears flow over the eyelids onto the face.

●Tear composition – The tear film is composed of three layers, each of different composition. The inner mucin layer smooths the surface of the eye and makes it wettable. The middle aqueous layer consists primarily of water and provides the bulk of the tear film. The outer lipid layer coats the other layers to slow evaporation [1].

●Functions of the tear film – Tears and the tear film have several functions, including:

•Preventing the cornea and mucosal surfaces from drying

•Keeping the ocular surface flushed clear of debris and bacteria

•Smoothing the refractive surface of the eye (the cornea)

•Lubricating the ocular surface to ease eyelid closure

•Protecting from infection through secretory antibodies

ETIOLOGY OF PERSISTENT TEARING — The causes of persistent tearing range from mild, self-limited conditions to sight-threatening ocular emergencies (table 1) [3-6]. Associated signs and symptoms usually help to narrow the differential diagnosis.

Nasolacrimal duct obstruction — Nasolacrimal duct obstruction (dacryostenosis) is the most common cause of abnormal tearing in infants and children, particularly during the first year of life. Infants with nasolacrimal duct obstruction present with a history of chronic or intermittent tearing, debris on the eyelashes (mattering), and, occasionally, redness of the conjunctiva (picture 1). On physical examination, the patient may have an increase in the size of the tear meniscus. Palpation of the lacrimal sac may cause reflux of tears and/or mucoid discharge into the eye through the puncta.

A bluish swelling of the skin overlying the lacrimal sac and superior displacement of the medial canthal tendon suggest the presence of a dacryocystocele (picture 2). Infants with dacryocystoceles should be evaluated promptly by an ophthalmologist as they may require early intervention.

Nasolacrimal duct obstruction and dacryocystoceles are discussed in greater detail separately. (See "Congenital nasolacrimal duct obstruction (dacryostenosis) and dacryocystocele".)

Conjunctivitis — Conjunctivitis (inflammation of the conjunctiva) is caused by infection, allergy, chemical exposure, or mechanical aggravation. The signs, symptoms, and treatment vary depending upon the etiology.

●Bacterial infection – Bacterial conjunctivitis typically causes a purulent discharge and diffuse conjunctival injection. (See "Conjunctivitis", section on 'Bacterial conjunctivitis'.)

Ophthalmia neonatorum refers to bacterial conjunctivitis occurring in the neonatal period. It can be caused by gonococcal infection (typically presenting with copious discharge at two to five days of age) or chlamydial infection (typically presenting with a stringy mucopurulent discharge within the first 10 to 14 days of life). However, other bacteria can also cause conjunctivitis at this age (eg, skin and gastrointestinal flora). Evaluation and treatment are discussed in detail separately. (See "Gonococcal infection in the newborn", section on 'Ophthalmia neonatorum' and "Chlamydia trachomatis infections in the newborn", section on 'Conjunctivitis'.)

●Viral infection – Viral conjunctivitis typically presents with conjunctival injection, watery or mucoserous eye discharge, itching, and/or mild photophobia (picture 3). It is often preceded by a respiratory infection; an enlarged, tender preauricular lymph node may be present. (See "Conjunctivitis", section on 'Viral conjunctivitis'.)

●Allergic conjunctivitis – Allergic conjunctivitis typically presents as bilateral redness, watery discharge, chemosis, and itching (picture 4). Affected patients often have a history of atopy or seasonal allergy, and other allergic symptoms may be present (eg, rhinitis). (See "Allergic conjunctivitis: Clinical manifestations and diagnosis".)

●Mechanical and chemical conjunctivitis – These usually are elicited by the history. (See "Conjunctivitis", section on 'Noninfectious, noninflammatory conjunctivitis'.)

Glaucoma — Early-onset glaucoma is a sight-threatening condition and usually requires surgery for definitive treatment. It typically presents with chronic or intermittent tearing, photophobia, and/or corneal clouding.

The corneal clouding is caused by corneal edema resulting from increased intraocular pressure (IOP) and endothelial cell dysfunction. Corneal edema causes tremendous glare, which leads to photophobia.

In young children (ie, <3 years old), elevated IOP also can cause stretching of the cornea and sclera, which increases the size of the globe (buphthalmos, or "ox eye"). Increased corneal size and buphthalmos help to distinguish congenital or early-onset glaucoma from other causes of persistent tearing. The normal corneal diameter is 10 mm in infants and increases to 12 mm by two years of age. A horizontal corneal diameter of >12 mm or diameters that differ between eyes is abnormal and suggestive of glaucoma. Infants and children with these findings require prompt referral to an ophthalmologist.

Glaucoma in infants and children is discussed in greater detail separately. (See "Overview of glaucoma in infants and children" and "Primary infantile glaucoma".)

Uveitis — Uveitis is an inflammation of the pigmented portion of the eye (iris, ciliary body, and choroid). This condition is also called iritis or iridocyclitis. Uveitis can occur after blunt ocular trauma and in association with certain rheumatologic or systemic conditions (eg, juvenile idiopathic arthritis, Kawasaki disease, lupus, granulomatosis with polyangiitis, human leukocyte antigen [HLA] B27).

Children with uveitis typically complain of photophobia; deep, boring ocular pain; redness; tearing; and other signs. The exception occurs in children with uveitis associated with juvenile idiopathic arthritis who usually do not develop redness or pain. The onset may be acute or insidious.

On examination, the eyes are of normal size. Conjunctival injection, particularly of the area surrounding the limbus (ciliary injection), may be present. Slit lamp findings include anterior chamber cells and flare, posterior synechia, and keratic precipitants. Band keratopathy may occur in patients with chronic uveitis.

Uveitis is discussed in greater detail separately. (See "Uveitis: Etiology, clinical manifestations, and diagnosis".)

Corneal abrasion or foreign body — Children who have an occult corneal abrasion or foreign body usually present with photophobia, tearing, redness, and a history that is suggestive of a mechanism of injury.

Foreign bodies may be present on the surface of the cornea or on the bulbar or palpebral conjunctiva. Those that are under the upper eyelid may cause vertically oriented linear corneal abrasions.

Fluorescein examination may reveal the corneal abrasions; the foreign body is viewed either directly or with the slit lamp. Eversion of the upper lid should be performed if the foreign body is not evident on the cornea.

Corneal foreign bodies that cannot be easily removed with irrigation or a cotton-tipped applicator should be removed by an ophthalmologist.

Corneal abrasions and foreign bodies are discussed in greater detail separately. (See "Corneal abrasions and corneal foreign bodies: Clinical manifestations and diagnosis" and "Corneal abrasions and corneal foreign bodies: Management".)

Eyelid abnormalities — Anatomic abnormalities of the eyelids may cause tearing, redness, and foreign body sensation.

●Trichiasis (misdirected eyelashes) – Trichiasis can irritate the cornea due to cornea lash touch, causing reflex tearing and redness. It may be caused by either of the following:

•Entropion, which is the in-turning of the eyelid and, if significant, is treated with surgical repair.

•Epiblepharon, which is a fold of skin along the lower lid margin, just below the eyelashes (picture 5). Children usually outgrow epiblepharon by two to three years of age.

●Blepharitis – Blepharitis refers to inflammation or infection of the eyelids. It can cause mattering, itching, burning, tearing, and redness. Blepharitis is discussed in detail separately. (See "Blepharitis".)

Trauma — Trauma to the canaliculus or the nasolacrimal duct (eg, as may occur with a lid laceration or facial bone fracture) may lead to complete or partial obstruction of the lacrimal system. This can occur when the nasolacrimal duct or lacrimal sac is injured, repositioned, or heals with stenosis. These injuries require surgical treatment and/or stent placement to reestablish and preserve a patent lacrimal drainage system.

EVALUATION OF THE CHILD WITH PERSISTENT TEARING — The evaluation of a child with persistent tearing begins with a history and physical examination. For the most common causes of abnormal tearing (eg, nasolacrimal duct obstruction, conjunctivitis, corneal abrasion), the history is often sufficient to suggest the diagnosis, which can then be confirmed on examination. Special tests to assess tear function and drainage can be performed if an abnormality of the lacrimal drainage system is suspected.

History — Pertinent features of the patient's history will help to distinguish the likely diagnosis among the possible causes of tearing in infants and children (table 1). The age of the child can help narrow the differential diagnosis. As an example, nasolacrimal duct obstruction is the most common cause of tearing in children younger than one year of age, whereas conjunctivitis is more common in school-age children.

The examiner should ask about the timing and duration of the symptoms, associated signs and symptoms, what remedies have been tried, and whether the remedies were successful. For example, in a child presenting with tearing associated with redness and itching, parental report of symptom improvement with topical antihistamine drops supports the diagnosis of allergic conjunctivitis.

The presence or absence of associated signs or symptoms and exacerbating factors may suggest specific causes:

●Photophobia – Common in uveitis, glaucoma, and abnormalities involving the corneal epithelium.

●Ocular itching – Prominent feature of allergic conjunctivitis.

●Characteristics of the eye discharge – In nasolacrimal duct obstruction, it appears like normal tears and there is often mattering on the eyelashes; in viral and allergic conjunctivitis, it is typically watery or mucoserous; in bacterial conjunctivitis, it is typically purulent and may be copious.

●Deep, boring pain – May occur with uveitis or acute glaucoma.

●Foreign body sensation – Occurs with corneal abrasion, occult foreign body, and trichiasis.

●Upper respiratory tract symptoms – Often are present with viral conjunctivitis.

In reviewing the past medical history, the clinician should ask if the child has any conditions that are associated with specific causes of persistent tearing, including:

●Inflammatory or autoimmune disorders (eg, juvenile idiopathic arthritis, systemic lupus erythematosus, Kawasaki disease), which are associated with uveitis (see "Uveitis: Etiology, clinical manifestations, and diagnosis", section on 'Systemic immune-mediated causes')

●Craniofacial syndromes, which can be associated with bony obstruction of the lacrimal drainage system (see "Syndromes with craniofacial abnormalities")

●Past facial or orbital trauma or facial surgery, which can contribute to obstruction of the lacrimal drainage system

●Asthma and/or allergic rhinitis, which are often associated with allergic conjunctivitis (see "Allergic conjunctivitis: Clinical manifestations and diagnosis")

In addition, the child's medications should be reviewed since some systemic and topical medications can contribute to increased tearing through various mechanisms (eg, increased tear production, reduced drainage, conjunctival or corneal toxicity, nasolacrimal duct stenosis).

Physical examination — A comprehensive eye examination includes visual acuity testing; examination of the ocular adnexa (ie, the structures surrounding the eye), anterior segment, pupils, confrontation visual fields, ocular motility, and fundus; and measurement of intraocular pressure (IOP). Findings in the ocular adnexa and anterior segment are particularly important in the child with persistent tearing.

●Visual acuity – When possible, visual acuity testing should be performed. Abnormal visual behavior (eg, not making eye contact, not tracking the examiner, not responding to facial expressions, not recognizing objects around them) in a child with tearing may be an indication of a vision-threatening disease (eg, congenital glaucoma). Assessment of vision in children is described in detail separately. (See "Vision screening and assessment in infants and children".)

●Ocular adnexa – Evaluation of the child with persistent tearing should include examination of the ocular adnexa, including the eyelids (for blepharitis), eyelashes (for trichiasis), eyebrows, lacrimal glands, and lacrimal fossa, as well as palpation of the orbital bones. The examination of the lacrimal drainage apparatus is critical because most problems that cause tearing in children are related to lacrimal drainage apparatus abnormalities (figure 1).

•The eyelids can be gently everted to evaluate for the presence of a punctum in the medial corner of each eyelid

•The presence of anomalous lacrimal ducts that exit to the skin should be noted (picture 6)

•The presence of redness or swelling near the punctum and discharge from the punctum should be noted

•The lacrimal sac, beneath the medial canthal tendon, should be inspected and palpated; swelling and/or redness of the lacrimal sac and discharge expressed from the punctum should be noted

●Anterior segment – The anterior segment consists of the conjunctiva, cornea, anterior chamber, iris, and lens (figure 2 and figure 3). The anterior chamber is best examined with a slit lamp; however, if one is not available, the examiner can use a penlight with or without a magnifying lens (eg, a 20 diopter condensing lens). (See "Slit lamp examination".)

•The conjunctiva is examined for signs of inflammation (eg, redness, chemosis, discharge).

•The cornea is inspected for corneal abrasion, foreign body, scar, signs of uveitis (eg, keratic precipitants, band keratopathy), or signs of corneal ulcer. The diameter of the cornea should be measured if glaucoma is suspected; a horizontal corneal diameter greater than 12 mm or a diameter that is different for each eye is suggestive of glaucoma. (See 'Glaucoma' above.)

•The anterior chamber is examined for inflammation (eg, cells and flare) or a cloudy appearance in the normally clear aqueous humor caused by white blood cells and proteinaceous exudate in the anterior chamber.

•In children with tearing associated with photophobia, corneal cloudiness, and/or increased corneal diameter, the IOP should be measured, when possible. Tactile IOP may be assessed by digital examination by experienced examiners, but tonometry is preferred. Cooperation of the child is essential. Examination under anesthesia may be necessary if there is a strong suspicion of glaucoma. (See "Overview of glaucoma in infants and children".)

SPECIAL TESTING OF THE LACRIMAL SYSTEM — Special tests to assess tear function and drainage can be performed if an abnormality of the lacrimal drainage system is suspected.

Dye disappearance test — The dye disappearance test is used to determine if tears are draining at the proper rate; abnormal drainage is diagnostic of nasolacrimal duct obstruction [2]. This test is not always necessary, since the diagnosis of nasolacrimal duct obstruction often can be made clinically. It is particularly helpful when symptoms are intermittent and not present at the time of the examination. The dye disappearance test is described in detail separately. (See "Congenital nasolacrimal duct obstruction (dacryostenosis) and dacryocystocele", section on 'Evaluation and diagnosis'.)

Basal secretion test — The basal secretion test is used to evaluate basal tear production by the accessory lacrimal glands [2]. The test is performed in the following manner:

●Place a drop of topical anesthetic in the inferior cul-de-sac of each eye to anesthetize the eye and decrease the production of reflex tears.

●Wipe away the excess tears.

●Place a Whatman 41 filter paper strip, also called a Schirmer strip, into each inferior cul-de-sac between the eyelid and the conjunctiva near the temporal corner of the lower eyelid (picture 7). Fold the strips at the notch, and place the small side in the cul-de-sac.

●Leave the strips in the inferior cul-de-sac for five minutes. An advancing line of wetness on the strip becomes visible as basal tears are absorbed by the strips.

●After five minutes, carefully remove the strips. The distance from the notch in the filter paper to the edge of the tear line is measured in millimeters.

Normal basal tear secretion is 8 to 15 mm after five minutes. Overproduction of tears is indicated by a strip that becomes soaked by more than 15 mm during the test; dry eyes are indicated by a basal secretion rate of less than 8 mm.

Deficient tear formation can be caused by collagen vascular diseases (eg, juvenile idiopathic arthritis, systemic lupus erythematosus), graft-versus-host disease in bone marrow transplant patients, Graves disease, and other diseases.

Schirmer 1 test — The Schirmer 1 test measures reflex tearing from the orbital and palpebral lobes of the lacrimal gland [2]. This test is performed in the same manner as the basal secretion test, except that the topical anesthetic is omitted. Reflex tearing is considered normal if between 10 and 25 mm of the strip is moistened after five minutes; greater than 25 mm of wetting indicates excessive tearing.

Tear breakup time — The tear breakup time test provides information about the composition and function of the tears [2]. The tear breakup time is the length of time that the tear film forms an unbroken sheet of fluid over the cornea. The normal tear film forms an unbroken sheet of fluid over the cornea for at least 10 seconds before separating into its component layers. The tear breakup time is reduced in patients with an imbalance of components in the tear film; patients with such an imbalance often blink at an increased rate. The tear breakup time test requires a cooperative child and a slit lamp; it is performed as follows:

●Place a drop of fluorescein-stained saline in the inferior cul-de-sac of each of the patient's eyes

●Wipe away the excess tears

●Place the child's head into the slit lamp in the normal fashion

●Focus on the cornea using the cobalt blue light of the slit lamp

●Have the child blink two or three times, and then keep his or her eyes open for approximately 15 seconds

●Observe the tear film

The surface of the tear film should remain smooth, and the green color of the fluorescein dye should remain uniform for at least 10 seconds. Dry spots eventually develop on the cornea and appear as dark areas surrounded by the green of the fluorescein in the remainder of the tear film. The tear composition may be out of balance if dry spots are seen sooner than 10 seconds after the last blink.

Imbalance of tear composition is caused by autoimmune disorders such as systemic lupus erythematosus, rheumatoid arthritis, Graves disease, and scleroderma.

REFERRAL — Referral to an ophthalmologist is warranted in any of the following circumstances:

●Concern for glaucoma or a process involving the cornea (suggested by abnormal tearing associated with photophobia, blepharospasm, and/or large or asymmetric corneal diameters) or other sight-threatening condition (see "Overview of glaucoma in infants and children" and "Primary infantile glaucoma")

●Clinical findings suggesting dacryocystocele (a bluish swelling of the skin overlying the lacrimal sac and superior displacement of the medial canthal tendon (picture 2)) since these lesions frequently require intervention (see "Congenital nasolacrimal duct obstruction (dacryostenosis) and dacryocystocele", section on 'Dacryocystocele')

●Impaired vision (ie, abnormal visual acuity testing or signs of anisometropia or amblyopia) (see "Vision screening and assessment in infants and children" and "Amblyopia in children: Classification, screening, and evaluation")

●Persistent symptoms of nasolacrimal duct obstruction (eg, in an infant, abnormal tearing that persists beyond the age of six to nine months since spontaneous resolution is uncommon after this age) (see "Congenital nasolacrimal duct obstruction (dacryostenosis) and dacryocystocele", section on 'Natural history')

●Corneal foreign body that cannot be easily removed with irrigation or a cotton-tipped applicator (see "Corneal abrasions and corneal foreign bodies: Clinical manifestations and diagnosis" and "Corneal abrasions and corneal foreign bodies: Management")

●Corneal opacity

●Symptoms that do not respond to standard treatment measures

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or email these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword[s] of interest.)

●Basics topic (see "Patient education: Blocked tear ducts in babies (The Basics)")

SUMMARY AND RECOMMENDATIONS

●Functions of the tear film – Tears are produced by the lacrimal and accessory lacrimal glands and drain through the lacrimal drainage system (figure 1). Tears and the tear film have several functions, including (see 'Anatomy and physiology of the lacrimal system' above):

•Preventing the cornea and mucosal surfaces from drying

•Keeping the ocular surface flushed clear of debris and bacteria

•Smoothing the refractive surface of the eye (the cornea)

•Lubricating the ocular surface to ease eyelid closure

•Protecting from infection through secretory antibodies

●Causes of persistent tearing in children – Causes of persistent tearing in infants and children are summarized in the table (table 1). They range from mild, self-limited conditions to sight-threatening ocular emergencies. Associated signs and symptoms usually help to narrow the differential diagnosis. (See 'Etiology of persistent tearing' above.)

●Evaluation – The evaluation of a child with persistent tearing begins with a history and physical examination. The history and examination are sufficient to make the diagnosis for most common causes of abnormal tearing (eg, nasolacrimal duct obstruction, conjunctivitis, corneal abrasion). Special tests to assess tear function and drainage can be performed if an abnormality of the lacrimal drainage system is suspected.

•History – Important aspects of the history in the child with persistent tearing include age, associated signs and symptoms (photophobia, itching, pain), characteristics of the eye discharge, foreign body sensation, associated illnesses (eg, upper respiratory infection, systemic illness), and past medical history (chronic medical conditions, trauma, craniofacial abnormalities, medications). (See 'History' above.)

•Eye examination – Comprehensive eye examination in the child with persistent tearing includes visual acuity testing; examination of the ocular adnexa (ie, the structures surrounding the eye, including the eyelids, eyelashes, eyebrows, lacrimal glands, lacrimal fossa, and orbital bones), the anterior segment, pupils, confrontation visual fields, ocular motility, and fundus; and measurement of intraocular pressure (IOP). (See 'Physical examination' above.)

•Tests to assess tear function and drainage – Special tests of tear function and drainage may be indicated if an abnormality of the lacrimal drainage system is suspected. These include the dye disappearance test, basal secretion test, Schirmer 1 test, and tear breakup time. (See 'Special testing of the lacrimal system' above.)

●Referral – Referral to an ophthalmologist is warranted if there is concern for glaucoma (suggested by abnormal tearing associated with photophobia, blepharospasm, and/or large or asymmetric corneal diameters) or other sight-threatening condition or if the evaluation reveals evidence of impaired vision. Other indications for referral are summarized above. (See 'Referral' above.)

ACKNOWLEDGMENTS — The editorial staff at UpToDate acknowledges Michael Cassidy, COT, who contributed to an earlier version of this topic review.