August 2025
INTRODUCTION —
Persistent or excessive tearing (ie, epiphora) is defined as the intermittent or continuous overflow of tears from one or both eyes due to the overproduction or inadequate drainage of tears [1]. It may be accompanied by ocular discharge, depending on its cause. The causes of persistent tearing and ocular discharge in infants and children range from mild, self-limited conditions to vision-threatening ocular emergencies (table 1). Of these, congenital nasolacrimal duct obstruction is the most common. A comprehensive history and physical examination can usually facilitate triage and narrowing of the differential diagnosis to determine the appropriate intervention, including referral to an ophthalmologist for additional evaluation and management when needed.
This topic will provide an overview of the anatomy of the lacrimal system, differential diagnosis, and an approach to the evaluation and diagnosis of the infant and child with persistent tearing and ocular discharge.
The clinical evaluation, diagnosis, and treatment of specific conditions are discussed in more detail separately.
●Congenital nasolacrimal duct obstruction or cyst – (See "Congenital nasolacrimal duct obstruction (dacryostenosis) and dacryocystocele".)
●Corneal abrasions and foreign bodies – (See "Corneal abrasions and corneal foreign bodies: Clinical manifestations and diagnosis" and "Corneal abrasions and corneal foreign bodies: Management".)
●Conjunctivitis – (See "Infectious conjunctivitis" and "Allergic conjunctivitis: Clinical manifestations and diagnosis" and "Allergic conjunctivitis: Management".)
●Glaucoma – (See "Overview of glaucoma in infants and children" and "Primary infantile glaucoma".)
●Uveitis – (See "Uveitis: Etiology, clinical manifestations, and diagnosis" and "Uveitis: Treatment".)
●Traumatic eye injuries – (See "Overview of eye injuries in the emergency department".)
ANATOMY AND PHYSIOLOGY OF THE LACRIMAL SYSTEM —
The lacrimal system (figure 1) is composed of lacrimal glands, accessory lacrimal glands, and the lacrimal drainage system. It is responsible for producing tears and the tear film. Tears drain via the lacrimal drainage system. Obstruction, injury, or inflammation of the lacrimal system can result in abnormal tear production or drainage and persistent tearing (ie, epiphora).
●Tear film function – The functions of tears and the tear film are to:
•Prevent the cornea and mucosal surfaces from drying and provide lubrication to ease eyelid closure
•Keep the ocular surface flushed clear of debris and bacteria and prevent infection through secretory antibodies
•Maintain corneal clarity to provide a smooth, refractive surface for transmission of a focused image to the retina
●Tear composition and production – The tear film is composed of the inner mucin layer (smooths and lubricates the eye surface), the middle aqueous layer (provides the bulk of the tear film), and the outer lipid layer (coats other layers to slow evaporation) [1].
Tears are produced by the lacrimal and accessory lacrimal glands (figure 1):
•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
•The accessory lacrimal glands are scattered along the conjunctiva of the eyelid and produce the basal (ie, resting) tears that keep the eye moist
●Tear drainage – Tears drain through the lacrimal drainage system (figure 1), which begins at the punctum. The punctum is a small opening on the medial surface of each eyelid margin that leads to the canaliculus, which drains into the lacrimal sac. Tears that collect in the lacrimal sac drain through the nasolacrimal duct into the nose via the inferior meatus and into the posterior pharynx, where they are swallowed.
Tear drainage is both passive (due to gravity) and active (due to blinking, which produces negative pressure in the canaliculus and lacrimal sac, thus drawing tears into the lacrimal drainage system) [1].
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 (or epiphora) elevates the level of the tear meniscus, causing the tears to flow over the eyelids onto the face.
EVALUATION
Goals — Evaluation begins with a comprehensive history and physical examination. The goals of the evaluation are to:
●Identify serious or potentially vision-threatening conditions that warrant urgent ophthalmological referral for further evaluation and management
●Narrow the differential diagnosis to identify a specific etiology for initiation of the appropriate treatment
The causes of persistent tearing and ocular discharge (table 1) range from self-limited to vision-threatening conditions that require timely ophthalmology referral for additional evaluation and management [1-4]. (See 'Conditions primarily seen in infants or young children' below and 'Conditions seen in many age groups' below.)
For more common causes of abnormal tearing (eg, congenital nasolacrimal duct obstruction, conjunctivitis, corneal abrasion), the history is often sufficient to suggest the diagnosis, which can then be confirmed on physical examination.
For more serious conditions (eg, glaucoma, uveitis, ocular trauma), or in cases when the diagnosis is not readily apparent, evaluation by an ophthalmologist and/or additional testing may be warranted. (See 'Narrowing the differential' below and 'Lacrimal testing for selected patients' below.)
History — Pertinent features of the patient's history can help to differentiate among the causes of persistent tearing and ocular discharge (table 1):
●Patient's age – Are symptoms present or did they begin in infancy or older childhood?
The patient's age at the time of presentation or symptom onset is particularly important in distinguishing among different etiologies, as certain conditions may be more common or start in early infancy (eg, congenital nasolacrimal duct obstruction, infantile glaucoma) versus later in childhood (eg, allergic conjunctivitis). (See 'Conditions primarily seen in infants or young children' below.)
●Characteristics of the discharge – Is the discharge watery or purulent? Is it scant or copious?
For example, watery or mucoserous discharge is typically seen with nasolacrimal duct obstruction or with viral or allergic conjunctivitis. Scant eyelash debris (ie, mattering) may also be present with nasolacrimal duct obstruction.
In contrast, purulent and more copious discharge is typically associated with bacterial conjunctivitis.
●Associated trauma – Is there recent or past trauma or other injury that preceded the onset of symptoms?
The presence or absence of trauma and type of injury is particularly important in triaging symptoms and distinguishing among different etiologies. For example, a history of blunt trauma can be associated with an acute orbital fracture or past trauma can result in obstruction of the lacrimal system, while a penetrating injury or toxic exposure may cause a corneal abrasion or chemical conjunctivitis, respectively. (See 'Narrowing the differential' below.)
●Associated symptoms – Are there other eye or constitutional symptoms (eg, photophobia, eye pain or itching, foreign body sensation in the eye, upper respiratory tract symptoms such as cough or rhinorrhea)?
For example, persistent watery discharge associated with conjunctival erythema and itching may be caused by allergic or viral conjunctivitis. A history of asthma or allergic rhinitis suggests allergic conjunctivitis, while symptoms of upper respiratory infection (eg, fever or cough) suggest viral conjunctivitis.
In a nonverbal child, symptoms such as eye pain, photophobia, or foreign body sensation can be assessed by evaluating the child's behavior on physical examination. (See 'Physical examination' below.)
●Exacerbating or ameliorating factors – Do any remedies or other factors (eg, antihistamines, environmental allergens) improve or worsen the symptoms?
For example, improvement with antihistamines and/or exacerbation with environmental allergens are more commonly associated with allergic conjunctivitis.
●Duration of symptoms – Did symptoms develop acutely or are they more intermittent or chronic?
Tearing may be more intermittent and/or chronic with glaucoma or nasolacrimal duct stenosis, or more acute with uveitis or conjunctivitis.
●Past medical history – Are there any prior medical conditions or medications?
Conditions and medications that are associated with specific causes (table 1) of persistent tearing include:
•Inflammatory or autoimmune disorders such as juvenile idiopathic arthritis, systemic lupus erythematosus, or Kawasaki disease are associated with uveitis. (See "Uveitis: Etiology, clinical manifestations, and diagnosis", section on 'Systemic immune-mediated causes'.)
•Past facial or orbital surgery (eg, following trauma), and craniofacial syndromes can cause obstruction of the lacrimal drainage system. (See 'Trauma to the eye and lacrimal system' below and 'Craniofacial or metabolic syndromes' below.)
•Asthma and/or allergic rhinitis are often associated with allergic conjunctivitis. (See "Allergic conjunctivitis: Clinical manifestations and diagnosis", section on 'Clinical manifestations'.)
•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). For example, preservatives in topical medications can cause corneal toxicity.
Physical examination — A comprehensive assessment of the eye (figure 2A-B) and lacrimal system (figure 1) provides additional information to determine the etiology of persistent tearing or ocular discharge. This includes assessment of visual acuity, ocular adnexa (eg, surrounding structures such as the eyelids and lacrimal ducts), and the anterior segment (eg, conjunctiva, cornea, aqueous humor). Findings in the ocular adnexa and anterior segment of the eye are particularly important in a child with persistent tearing. Examination of other organ systems may also be warranted based on symptoms elicited from the history (eg, lung examination in the setting of upper respiratory tract symptoms). (See 'History' above.)
●Visual acuity and behavior – It is important to assess visual acuity, when possible. Assessment of visual behavior can also provide important clues, particularly for younger children in whom visual acuity cannot be measured. Decreased visual acuity or abnormal visual behavior (eg, lack of eye contact and/or inability to track the examiner, respond to facial expressions, or recognize objects around them) in a child with tearing may indicate a vision-threatening disease (eg, glaucoma). Assessment of behavior is also helpful in evaluating for associated symptoms such as photophobia or eye pain that cannot be identified from the history (eg, in nonverbal children). For example, crying, grimacing, rapid eye blinking with exposure to bright lights, or self-manipulation of ocular or facial structures are suggestive of photophobia or pain.
Assessment of vision and pain in infants and children is described in detail separately. (See "Vision screening and assessment in infants and children" and "Pain in children: Approach to pain assessment and overview of management principles".)
●Ocular adnexa – Examination of the ocular adnexa includes inspection and/or palpation of surrounding eye structures (figure 2B), including the eyelids (eg, for blepharitis, foreign body, trauma), eyelashes (eg, for ingrown eyelashes), eyebrows, lacrimal system anatomy (eg, for obstruction, injury, or infection), and the orbital bones (eg, for fracture or other signs of trauma).
Examination of the lacrimal system is critical because tearing in children is most commonly due to abnormalities of the lacrimal drainage system. (See 'Anatomy and physiology of the lacrimal system' above and 'Congenital nasolacrimal duct obstruction' below.)
Examination of the lacrimal system (figure 1) includes:
•Gentle eversion of the eyelids to evaluate for the presence and patency of a punctum in the medial corner of each eyelid.
•Visualization of anomalous lacrimal ducts that exit to the skin (picture 1).
•Visualization of redness or swelling near, or discharge from, the punctum.
•Inspection and palpation of the lacrimal sac (beneath the medial canthal tendon) for swelling or redness of the lacrimal sac and discharge expressed from the punctum (eg, as seen in dacryocystocele).
●Anterior segment – The anterior segment of the eye consists of the conjunctiva, cornea, pupils, iris, anterior chamber, and lens (figure 2A and figure 2B). The anterior chamber contains the aqueous humor and is best examined with a slit lamp. A slit lamp may also be used to assess for corneal abnormalities (eg, abrasions, ulcers). If one is not available, the examiner can use a penlight with or without a magnifying lens (eg, a 20 diopter condensing lens). Referral to an ophthalmologist or optometrist is usually warranted for slit lamp examination and assessment of the aqueous humor. (See "Slit lamp examination".)
•Conjunctiva – The conjunctiva is examined for signs of inflammation (eg, erythema, chemosis [swelling], mucoserous or purulent discharge). (See 'Conjunctivitis' below.)
•Cornea – The cornea is inspected for a corneal abrasion or foreign body; scarring or ulceration (eg, indicative of prior trauma or infection); keratic precipitants or band keratopathy (indicative of uveitis); large or asymmetric corneal diameters (eg, indicative of glaucoma); or corneal defect or opacification (eg, indicative of corneal ulcer). The corneal diameter is the horizontal distance between the edges of the visible white part of the eye and can be visualized on gross inspection or estimated by using a ruler. (See 'Narrowing the differential' below.)
•Pupils and iris – Irregularly shaped pupils or differences in pupil size may be present in children with uveitis associated with juvenile idiopathic arthritis. (See "Uveitis: Etiology, clinical manifestations, and diagnosis", section on 'Systemic inflammatory diseases'.)
Aniridia is a rare congenital abnormality that can also cause glaucoma. (See "Overview of glaucoma in infants and children", section on 'Aniridia'.)
•Anterior chamber (aqueous humor) – Slit lamp examination of the anterior chamber is performed to assess for inflammation (eg, cells and flare sign in uveitis) or a cloudy appearance in the normally clear aqueous humor (eg, in glaucoma), which are caused by white blood cells and proteinaceous exudate. (See "Slit lamp examination", section on 'Cells and flare'.)
Children with suspected glaucoma (eg, tearing associated with photophobia, decreased visual acuity, corneal cloudiness, and/or increased corneal diameter) should be referred to an ophthalmologist. (See 'Narrowing the differential' below.)
Narrowing the differential — The likely etiology is usually determined based on the constellation of findings from the history and physical examination (table 1). Rarely, additional testing or imaging may be warranted to confirm a diagnosis (eg, orbital/facial fracture) or assess for a disorder of the lacrimal system. (See 'Lacrimal testing for selected patients' below.)
Patients with vision-threatening conditions should be referred for urgent ophthalmology evaluation. Ophthalmology referral may also be warranted in patients for slit lamp examination and for patients in whom the diagnosis is not readily apparent from the clinical evaluation. (See 'Indications for ophthalmology referral' below and "Slit lamp examination".)
History of trauma — In patients with a history of trauma preceding the onset of symptoms, tearing and ocular discharge in association with eye pain or burning, decreased visual acuity, photophobia, or conjunctival erythema or chemosis (ie, swelling) may be caused by:
●A laceration or fracture that obstructs or otherwise injures the lacrimal drainage system (eg, due to an eyelid laceration or orbital/facial bone fracture)
●Glaucoma or uveitis (eg, triggered by blunt or penetrating trauma)
●A corneal abrasion or foreign body (eg, due to flying debris)
●Chemical or mechanical conjunctivitis (eg, due to a burn, chemical splash, or foreign body)
●Nasolacrimal duct obstruction (eg, due to prior trauma or surgery)
These conditions can occur in isolation or in combination with other injuries and are often evident on history and physical examination (see 'History' above and 'Physical examination' above). In the setting of acute penetrating or blunt trauma, visual inspection of the eyes and surrounding structures often reveals a laceration or severe ocular trauma such as an open globe rupture or hyphema (ie, pooling of blood in the eye). If diffuse facial swelling, pain, bruising, and/or bony tenderness to palpation are present, imaging should be performed to evaluate for a fracture. (See 'Trauma to the eye and lacrimal system' below and "Orbital fractures", section on 'Evaluation'.)
The history and slit lamp examination can help to differentiate among other conditions as follows:
●Glaucoma after trauma may present acutely or as a late complication of trauma. Uveitis typically presents soon after trauma. On slit lamp examination, corneal clouding and increased intraocular pressure are suggestive of glaucoma, while inflammation of the aqueous humor (eg, cells and flare sign) are suggestive of uveitis. (See "Overview of glaucoma in infants and children", section on 'Trauma' and "Uveitis: Etiology, clinical manifestations, and diagnosis", section on 'Diagnostic evaluation and findings'.)
●A corneal abrasion or foreign body can be visualized by slit lamp examination or by direct visualization, as described below. (See 'No history of trauma' below.)
●A history of toxic exposure and conjunctival erythema or chemosis (ie, swelling) in the absence of the above findings suggests chemical conjunctivitis or a burn injury. Identification of a corneal foreign body suggests mechanical conjunctivitis. (See "Overview of eye injuries in the emergency department", section on 'Ocular chemical burns'.)
In the absence of other findings, persistent tearing and ocular discharge in the setting of prior orbital/facial trauma or surgery are suggestive of nasolacrimal obstruction or another disorder of the lacrimal system. (See 'No history of trauma' below and 'Trauma to the eye and lacrimal system' below.)
Patients with severe trauma (eg, laceration, fracture, globe rupture, traumatic hyphema), uveitis, or glaucoma warrant urgent referral to an ophthalmologist for further evaluation and treatment. In some cases, emergency management may also be warranted. (See "Approach to diagnosis and initial treatment of eye injuries in the emergency department", section on 'Manage vision-threatening injury'.)
No history of trauma — In patients without a history of recent or prior trauma, photophobia, abnormalities of the cornea or visual acuity/behavior, the most common cause of persistent tearing and ocular discharge is congenital nasolacrimal duct obstruction (picture 2). When patients without trauma present with photophobia or other clinical features, it is important to differentiate glaucoma, uveitis, and corneal ulceration from other more common conditions (eg, conjunctivitis) as they can threaten vision and warrant urgent ophthalmology referral.
●Patients with eye pain or decreased visual acuity – Although a minority of children with persistent tearing present with eye pain or decreased visual acuity, these are red flags that should prompt consideration of more serious causes, particularly glaucoma and uveitis. Generally, these children should be referred to an ophthalmologist.
•Glaucoma (specifically early-onset or primary infantile glaucoma) is primarily a concern in a young child (eg, <5 years of age) because later-onset (or juvenile glaucoma) in older children does not generally present with persistent tearing. Suggestive findings include a horizontal corneal diameter of >12 mm (or asymmetric corneal diameters) and corneal clouding on slit lamp or general physical examination.
Corneal clouding reflects corneal edema, which causes glare and leads to photophobia. Elevated IOP can also cause stretching of the cornea and sclera, which increases the size of the globe (buphthalmos, or "ox eye" (picture 3)). Patients may also have blepharospasm (ie, excessive blinking or eyelid twitching). Measurement of IOP can help to confirm the diagnosis and guide treatment. (See "Primary infantile glaucoma", section on 'Diagnosis'.)
•Uveitis can present acutely or insidiously. Suggestive features include ciliary injection (ie, conjunctival erythema surrounding the limbus) and/or a history of rheumatologic or other systemic condition (eg, arthritis, Kawasaki disease). Children with uveitis associated with juvenile idiopathic arthritis may present with irregularly shaped pupils or differences in pupil size due to posterior synechiae (iris adhesion to the lens), but eye redness and pain are less common. If performed, slit lamp examination may reveal inflammation of the aqueous humor (ie, cells and flare sign) and keratic precipitants or band keratopathy in the cornea. Corneal diameters are typically of normal size, and corneal clouding is absent. (See "Uveitis: Etiology, clinical manifestations, and diagnosis", section on 'Systemic inflammatory diseases' and "Uveitis: Etiology, clinical manifestations, and diagnosis", section on 'Diagnostic evaluation and findings'.)
Eye pain or decreased visual acuity can also occur with corneal injury, such as abrasions, foreign bodies, or ulcers. Corneal foreign bodies may be visualized on direct examination of the cornea or conjunctiva (over the eye or inner eyelid). The upper eyelid can be everted if there is a high suspicion for a foreign body and it is not visualized on the cornea. Foreign bodies under the upper eyelid may cause vertically oriented linear corneal abrasions. Slit lamp examination may also identify foreign bodies or abrasions (with or without fluorescein staining). A corneal defect or opacification on slit lamp examination suggests ulceration, which can be associated with eye pain, photophobia, conjunctival erythema, or chemosis (ie, swelling). (See 'Corneal ulcer' below and "Corneal abrasions and corneal foreign bodies: Clinical manifestations and diagnosis", section on 'Eye examination'.)
●Other patients – The more common causes of persistent tearing and ocular discharge do not generally present with pain or decreased visual acuity. In some cases, the cause of tearing is evident on visual inspection. These causes include trichiasis (ie, misdirected or ingrown eyelashes), which can be caused by entropion (ie, in-turning of the eyelid) or epiblepharon (ie, an extra fold of skin along the lower lid margin below the eyelashes (picture 4)). Eyelid erythema (typically along the eyelid edges), itching, burning, and eyelash crusting or debris (ie, mattering) are suggestive of blepharitis. (See 'Eyelid disorders' below and "Blepharitis", section on 'Clinical findings'.) Eyelid erythema is also associated with other conditions (eg, preseptal cellulitis), as discussed separately. (See "Preseptal cellulitis", section on 'Clinical manifestations'.)
Corneal abrasions and foreign bodies, although typically associated with eye pain, can also present with milder symptoms, such as conjunctival erythema and foreign body sensation or irritation. (See 'History of trauma' above.)
Otherwise, persistent tearing or ocular discharge associated with conjunctival erythema may be due to conjunctivitis. Purulent, more copious discharge suggests bacterial conjunctivitis. In neonates, bacterial conjunctivitis may be caused by chlamydia or gonorrhea (ie, ophthalmia neonatorum). Testing of the eye discharge can identify the pathogen and guide treatment. (See 'Conjunctivitis' below and "Chlamydia trachomatis infections in newborns and young infants", section on 'Diagnosis'.)
In contrast to bacterial conjunctivitis, conjunctival erythema associated with itching and watery or mucoserous discharge is suggestive of allergic or viral conjunctivitis. A history of asthma or allergic rhinitis and exacerbation of symptoms after exposure to environmental allergens (eg, dust, pollen) suggest allergic conjunctivitis (picture 5). The absence of these findings and the presence of symptoms or examination findings consistent with an upper respiratory infection (eg, fever, cough, lymphadenopathy, pharyngitis) suggest viral conjunctivitis (picture 6). Chemosis or mild photophobia may also be present in allergic or viral conjunctivitis, respectively.
Congenital nasolacrimal duct obstruction (picture 7) typically presents in infants or in children with craniofacial syndromes as watery or mucoserous discharge, but may also be associated with conjunctival erythema or eyelash debris. Palpation of the lacrimal sac may cause a reflux of tears and/or mucoid discharge into the eye. Testing of the lacrimal system can confirm obstruction in patients for whom the diagnosis is not apparent on clinical evaluation. A bluish swelling of the skin overlying the lacrimal sac is suggestive of nasolacrimal duct obstruction due to a dacryocystocele (picture 8). (See 'Lacrimal testing for selected patients' below and "Congenital nasolacrimal duct obstruction (dacryostenosis) and dacryocystocele".)
Lacrimal testing for selected patients — Special testing of the lacrimal system can be performed to identify a disorder of tear drainage, production, composition, or function. Such testing is rarely necessary but may be useful for patients in whom a diagnosis is not readily apparent on clinical evaluation or for whom tearing persists despite treatment of an identified condition. (See 'Anatomy and physiology of the lacrimal system' above.)
●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 [5,6]. The diagnosis of nasolacrimal duct obstruction is often made clinically; thus this test is not always necessary. However, 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'.)
●Tests to assess tear production – Other tests are used to assess tear production [5]:
•Basal secretion test – Evaluates basal tear production by the accessory glands (figure 1). A topical anesthetic is applied to the eye, and a Whatman 41 filter paper (or Schirmer) strip is placed against the inferior cul-de-sac of each eye (between the eyelid and the conjunctiva (picture 9)) to measure tear absorption. After five minutes, normal basal tear secretion is indicated by a line of wetness measuring between 8 to 15 mm on the strip. A measurement of >15 mm indicates an overproduction of tears; a measurement of <8 mm indicates dry eyes (ie, deficient tear production).
•Schirmer 1 test – Measures reflex tearing from the orbital and palpebral lobes of the lacrimal gland. It is performed similarly to the basal secretion test, but the topical anesthetic is omitted. Normal reflex tearing is indicated by a measurement between 10 to 25 mm on the test strip after five minutes.
•Tear breakup time test – Usually performed in a cooperative child by placing fluorescein-stained saline in the inferior cul-de-sac of each eye and assessing the tear breakup time on slit lamp examination. The tear breakup time is the length of time that the tear film forms an unbroken sheet of fluid over the cornea (appears as a uniform green color of fluorescein dye). A normal tear film has a tear breakup time of at least 10 seconds. In patients with an imbalance of tear film components, the tear breakup time is reduced and often results in rapid blinking. (See 'Anatomy and physiology of the lacrimal system' above.)
INDICATIONS FOR OPHTHALMOLOGY REFERRAL —
Referral to an ophthalmologist is warranted for all patients in any of the following circumstances:
●Signs and symptoms of glaucoma (eg, photophobia/abnormal visual behavior, large or asymmetric corneal diameters, and corneal clouding in a young child) (see 'No history of trauma' above and 'Conditions primarily seen in infants or young children' below)
●Uveitis (eg, inflammation of the aqueous humor in the setting of an autoimmune or inflammatory condition) (see 'No history of trauma' above and 'Conditions primarily seen in infants or young children' below)
●Significant ocular trauma (see 'History of trauma' above and 'Trauma to the eye and lacrimal system' below)
●Clinical findings suggesting dacryocystocele (picture 8) or persistent symptoms of nasolacrimal duct obstruction (see 'Congenital nasolacrimal duct obstruction' below)
●Abnormal visual testing or other signs suggestive of anisometropia, amblyopia, or other vision-threatening conditions (see "Vision screening and assessment in infants and children" and "Amblyopia in children: Classification, screening, and evaluation")
●Corneal foreign body that cannot be easily removed with irrigation or a cotton-tipped applicator (see "Corneal abrasions and corneal foreign bodies: Management", section on 'Management')
●Corneal opacity (eg, because of potential diagnosis of a corneal ulcer)
●Trichiasis (see 'Eyelid disorders' below)
●Other complications or symptoms that do not respond to standard treatment measures
CONDITIONS PRIMARILY SEEN IN INFANTS OR YOUNG CHILDREN
Congenital nasolacrimal duct obstruction — Congenital nasolacrimal duct obstruction (dacryostenosis) is the most common cause of persistent tearing and ocular discharge in infants and young children. It is typically self-limiting but may require intervention by an ophthalmologist, particularly if symptoms persist beyond age six to nine months because spontaneous resolution is uncommon after this age. Diagnosis is often made clinically; special testing can be performed to confirm the diagnosis when the diagnosis is unclear. (See 'Narrowing the differential' above and 'Lacrimal testing for selected patients' above.)
Typical findings of congenital nasolacrimal duct obstruction include:
●Chronic or intermittent tearing, eyelash debris (also known as mattering), and occasionally, conjunctival erythema (picture 7)
●Increased size of the tear meniscus
●Palpation of the lacrimal sac may cause a reflux of tears and/or mucoid discharge into the eye through the puncta
The evaluation and management of congenital nasolacrimal duct obstruction are discussed in greater detail separately. (See "Congenital nasolacrimal duct obstruction (dacryostenosis) and dacryocystocele", section on 'Nasolacrimal duct obstruction'.)
Congenital dacryocystocele — Dacryocystocele occurs less commonly and is typically noted shortly after birth. It is associated with potentially serious complications (eg, cellulitis, sepsis); thus, timely referral to an ophthalmologist is warranted. Typical findings include (picture 8):
●A bluish swelling of the skin overlying the lacrimal sac
●Superior displacement of the medial canthal tendon
The evaluation and management of dacryocystocele are discussed in greater detail separately. (See "Congenital nasolacrimal duct obstruction (dacryostenosis) and dacryocystocele", section on 'Dacryocystocele'.)
Early-onset (primary infantile) glaucoma — Early-onset (ie, primary infantile) glaucoma is a vision-threatening condition and usually requires surgery for definitive treatment. It typically presents in children prior to five years of age with chronic or intermittent tearing, photophobia, deep (boring) eye pain, blepharospasm, and/or corneal clouding (identified by slit lamp examination of the aqueous humor). In contrast, later-onset (ie, juvenile) glaucoma typically presents in older children as vision loss; tearing, photophobia, and eye pain are uncommon. Glaucoma may also present acutely or as a late complication after trauma.
Increased corneal diameter and globe size (picture 3) help to distinguish early-onset glaucoma from other causes of persistent tearing. Measurement of the intraocular pressure (IOP) can also help to confirm the diagnosis. Infants and children with findings concerning for glaucoma warrant prompt referral to an ophthalmologist for further evaluation and management. (See 'No history of trauma' above.)
The clinical features, evaluation, and management of glaucoma in infants and children are discussed in greater detail separately. (See "Overview of glaucoma in infants and children" and "Primary infantile glaucoma".)
Craniofacial or metabolic syndromes — Craniofacial syndromes may result in obstruction of the lacrimal drainage system and increased tearing. (See "Syndromes with craniofacial abnormalities".)
Rare metabolic diseases such as cystinosis and tyrosinemia can cause persistent tearing during infancy. These disorders may present with similar symptoms to and should be differentiated from primary infantile glaucoma. (See "Primary infantile glaucoma" and "Primary infantile glaucoma", section on 'Differential diagnosis'.)
CONDITIONS SEEN IN MANY AGE GROUPS
Conjunctivitis — Conjunctivitis (inflammation of the conjunctiva) is caused by infection, allergy, chemical exposure, or mechanical aggravation. The presentation and treatment vary depending on the etiology. (See 'No history of trauma' above.)
●Bacterial infection – Bacterial conjunctivitis typically causes a purulent discharge and diffuse conjunctival erythema. It can occur in isolation or as a complication of other conditions (eg, congenital nasolacrimal duct obstruction or cyst, trichiasis [ingrown eyelashes]). (See "Infectious conjunctivitis", section on 'Bacterial conjunctivitis'.)
•Ophthalmia neonatorum – This 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 newborns and young infants", section on 'Conjunctivitis'.)
●Viral infection – Viral conjunctivitis typically presents with conjunctival erythema, watery or mucoserous eye discharge, itching, and/or mild photophobia (picture 6). It is often preceded by a respiratory infection; an enlarged, tender preauricular lymph node or pharyngitis may be present. (See "Infectious conjunctivitis", section on 'Viral conjunctivitis'.)
●Allergic conjunctivitis – Allergic conjunctivitis typically presents as bilateral conjunctival erythema or chemosis (ie, swelling), watery discharge, and itching (picture 5). Affected patients often have a history of asthma or seasonal allergies, and other allergic symptoms may be present (eg, rhinitis). (See "Allergic conjunctivitis: Clinical manifestations and diagnosis" and "Allergic conjunctivitis: Management".)
●Mechanical and chemical conjunctivitis – Mechanical and chemical conjunctivitis has different etiologies, including dry eye, chemical splashes, or a foreign body. These are typically identified by the history and present with conjunctival erythema, chemosis, burning, itching, and watery or mucoserous discharge. (See "Infectious conjunctivitis", section on 'Noninfectious, noninflammatory conjunctivitis'.)
Corneal abrasion or foreign body — Children with a corneal abrasion or foreign body usually present with tearing, photophobia, conjunctival erythema, and a history suggestive of a mechanism of injury. They can be identified by slit lamp examination. Abrasions may be better visualized with fluorescein dye. Foreign bodies may be visualized directly on the bulbar (covering the eye) or palpebral (lining the eyelids) conjunctiva or under the upper eyelid. Referral to ophthalmology is warranted if a foreign body cannot be easily removed. (See 'No history of trauma' above.)
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".)
Corneal ulcer — A corneal ulcer can occasionally occur as a complication of severe conjunctivitis, including infection with bacteria, fungi, acanthamoeba, herpes simplex virus, varicella, or other viruses. Presenting signs and symptoms include photophobia, eye pain, chemosis (ie, conjunctival swelling), and/or corneal defect or opacification on slit lamp examination. Patients with corneal ulceration should be referred to an ophthalmologist for urgent evaluation. (See 'Narrowing the differential' above.)
The etiology, evaluation, and management of corneal ulcers are discussed in more detail separately. (See "Infectious conjunctivitis", section on 'Other viral infections associated with conjunctivitis' and "Complications of contact lenses", section on 'Infectious keratitis'.)
Eyelid disorders — Eyelid disorders such as trichiasis and blepharitis can cause persistent tearing and ocular discharge.
●Trichiasis (ingrown eyelashes) – Trichiasis can irritate the cornea due to cornea lash touch, causing reflex tearing with or without conjunctival erythema, and foreign body sensation. It may be caused by either of the following:
•Entropion is the in-turning of the eyelid. Referral for surgical repair is warranted for significant lesions (ie, severe symptoms, vision impairment).
•Epiblepharon is an extra fold of skin along the lower lid margin, just below the eyelashes, that extends over the medial canthal tendon (picture 4). It is more common in younger children and usually resolves by two to three years of age.
●Blepharitis – Blepharitis refers to inflammation or infection of the eyelids and can cause trichiasis. Commonly associated symptoms include tearing, eyelash debris (ie, mattering), eyelid itching or burning, and conjunctival or eyelid erythema (typically along the eyelid edges). Blepharitis is discussed in more detail separately. (See "Blepharitis".)
Uveitis — Uveitis (also called iritis or iridocyclitis) is an inflammation of the pigmented portion of the eye (iris, ciliary body, and choroid). An ophthalmology referral is warranted if it is suspected. Uveitis presents with tearing, photophobia, deep (boring) eye pain, and conjunctival erythema, particularly of the area surrounding the limbus (ie, ciliary injection). It can be associated with ocular trauma and certain rheumatologic or systemic conditions (eg, juvenile idiopathic arthritis, Kawasaki disease, lupus, granulomatosis with polyangiitis, human leukocyte antigen B27).
Uveitis is distinguished from glaucoma and other etiologies by normal eye size and characteristic findings on slit lamp examination (ie, cells and flare sign or inflammation of the aqueous humor, keratic precipitants in the cornea). Band keratopathy may occur in patients with chronic uveitis. Irregularly shaped pupils or differences in pupil size due to posterior synechiae (iris adhesion to lens) may occur in patients with uveitis associated with juvenile idiopathic arthritis. (See 'No history of trauma' above.)
The clinical manifestations, diagnosis, and treatment of uveitis are discussed in greater detail separately. (See "Uveitis: Etiology, clinical manifestations, and diagnosis" and "Uveitis: Treatment".)
Trauma to the eye and lacrimal system — Trauma to the canaliculus or the nasolacrimal duct (eg, due to an eyelid laceration or an orbital/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 (eg, after surgery). Surgical treatment and/or stent placement may be required to re-establish and preserve a patent lacrimal drainage system.
The presentation varies depending on the cause of injury. For example, eyelid lacerations are often directly visualized on physical examination. Facial/orbital bone fractures may present with diffuse facial pain, swelling, ecchymoses, or bony tenderness to palpation. (See 'History of trauma' above.)
Traumatic eye injuries, including emergency management, are reviewed in more detail separately. (See "Eyelid lacerations" and "Orbital fractures" and "Approach to diagnosis and initial treatment of eye injuries in the emergency department".)
Other conditions — Autoimmune and collagen vascular disorders and other conditions can cause an imbalance in tear composition or a deficiency in tear formation. These include rheumatoid or juvenile idiopathic arthritis, systemic lupus erythematosus, scleroderma, Graves' disease, and graft-versus-host disease in bone marrow transplant patients. (See "Polyarticular juvenile idiopathic arthritis: Clinical manifestations, diagnosis, and complications" and "Childhood-onset systemic lupus erythematosus (cSLE): Clinical manifestations and diagnosis".)
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 5th to 6th 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 10th to 12th 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
●Lacrimal system and tear function – Tears and the tear film are produced by the lacrimal and accessory lacrimal glands and drain through the lacrimal drainage system (figure 1). They lubricate and keep the ocular surface clear of debris, prevent infection, and smooth the refractive surface of the eye (cornea). Obstruction, injury, or inflammation of the lacrimal system can result in abnormal tear production or drainage and persistent tearing and ocular discharge. (See 'Anatomy and physiology of the lacrimal system' above.)
●Etiology – The causes of persistent tearing and ocular discharge range from self-limited (eg, allergic or viral conjunctivitis, congenital nasolacrimal duct obstruction) to vision-threatening conditions (eg, ocular trauma, glaucoma, uveitis) that require timely ophthalmology referral for additional evaluation and management. Of these, congenital nasolacrimal duct obstruction is the most common. These conditions and their associated clinical findings are summarized in the table (table 1). (See 'Conditions primarily seen in infants or young children' above and 'Conditions seen in many age groups' above.)
●Approach to evaluation and diagnosis – Evaluation begins with a comprehensive history and physical examination. In most cases, the diagnosis can be determined based on the constellation of findings from the clinical evaluation (table 1). In particular, the presence or absence of trauma in association with other findings can help to narrow the differential diagnosis. Additional testing may be warranted in selected patients for further evaluation or to confirm the diagnosis. (See 'Evaluation' above.)
•History – Important aspects of the history include age at presentation or symptom onset; associated (instigating) trauma or other eye and constitutional symptoms (eg, photophobia, itching, pain, cough); exacerbating or ameliorating factors (eg, remedies or environmental triggers); characteristics and duration of eye discharge (eg, acute versus chronic, purulent or watery); and past medical history (chronic medical conditions, craniofacial abnormalities, medications). (See 'History' above.)
•Physical examination – Eye examination includes assessment of visual acuity and behavior, the ocular adnexa (eg, eyelids, eyelashes, lacrimal glands (figure 1)), and the anterior segment (eg, conjunctiva, cornea, pupils, iris, aqueous humor (figure 2A-B)). Findings in the ocular adnexa and anterior segment of the eye are particularly important in a child with persistent tearing. Examination of other organ systems may also be warranted based on symptoms elicited from the history (eg, lung examination in the setting of upper respiratory tract symptoms). (See 'Physical examination' above.)
•Additional testing – Additional laboratory testing or imaging may be warranted for further evaluation of an associated symptom or condition that is identified on the history and physical examination. Special testing of the lacrimal system (eg, dye disappearance test, basal secretion test) is rarely necessary but can be performed in selected patients to evaluate for a disorder of tear drainage, production, or function. (See 'Lacrimal testing for selected patients' above.)
●Referral – Referral to an ophthalmologist is warranted for patients with suspected glaucoma (suggested by tearing associated with photophobia, blepharospasm, and/or large or asymmetric corneal diameters (picture 3) in a young child), other sight-threatening conditions (eg, uveitis, significant ocular trauma, evidence of impaired vision), or a dacryocystocele (picture 8). Patients with significant orbital or facial trauma may warrant emergency management. Other indications for referral are summarized above. (See 'Indications for ophthalmology referral' above.)
ACKNOWLEDGMENTS —
The editorial staff at UpToDate acknowledges Michael Cassidy, COT, who contributed to an earlier version of this topic review.
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