Teresa O. Rosales, MD
A 4-week-old girl has had a persistent watery discharge from both eyes since birth. Her mother has noticed white, crusty material on her daughter’s eyelids for the past few days. The infant’s birth and medical history are unremarkable. Examination of the eyes, including bilateral red reflexes and symmetric extraocular movements, is normal, except that the left eye appears “wetter” than the right.
1. What is the differential diagnosis of excessive tearing in infancy?
2. How do physical findings such as corneal enlargement and haziness influence the differential diagnosis?
3. How should excessive tearing in infants be managed?
4. When should a child with excessive tearing be referred to an ophthalmologist?
Excessive tearing or epiphora in 1 or both eyes in infants or young children is a common pediatric ophthalmologic concern. The pediatrician must be capable of differentiating benign causes of this common childhood condition from more serious illnesses (eg, glaucoma) that have the potential to threaten vision.
Obstruction of the Nasolacrimal Duct
Dacryostenosis, that is, congenital obstruction of the nasolacrimal duct (NLD), occurs in 1% to 6% of newborns and infants and is the most common cause of excessive tearing in infancy. Eighty percent of cases of dacryostenosis resolve spontaneously by 6 months of age.
Infants with dacryostenosis typically present with a history of a mucoid discharge and crusting along the eyelid margins. The affected eye appears “wetter” than the normal eye, and a small pool of tears may be noted along the lower eyelid. Frequent tearing is reported. Commonly, the patient has repeated episodes of infection with purulent discharge (Box 93.1).
The lacrimal system produces and drains tears away from the eyes and into the nose (Figure 93.1). Typically, reflex tearing is present shortly after birth; however, it may be delayed for several weeks to months until the lacrimal gland begins to function. Tears drain away from the eyes through the superior and inferior puncta into the superior and inferior canaliculi and finally into the NLD, which drains beneath the inferior turbinate into the nose.
Outflow obstruction, which typically results from dacryostenosis, is the most common cause of excessive tearing in infancy. The obstruction is usually bilateral and occurs during fetal development. Most commonly, a persistent, thin membrane (Hasner membrane) obstructs the opening of the sac in the nose. Typically, the membrane is located in the distal or nasal segment of the duct rather than the proximal portion. The term dacryocystitis is used in cases in which acute infection or inflammation is associated with the obstruction. If the canaliculi and NLD are obstructed, a dacryocystocele involving the nasolacrimal sac may be noted at birth. This sac appears as a bluish, firm mass located over the lacrimal sac. Atresia of some portion of the drainage system is an extremely rare occurrence. Infants with dacryocystocele, who have large intranasal cysts, may present with respiratory symptoms because infants are obligate nasal breathers. Symptoms range from difficulty during feeding (caused by obstruction of the mouth) to respiratory distress.
Box 93.2 outlines the differential diagnosis of excessive tearing in infancy. Although obstruction of the NLD is the most common cause of excessive tearing in newborns and infants, it is important to consider and rule out glaucoma when evaluating neonates and infants with excessive tearing. Infantile glaucoma may be unilateral or bilateral.
Acute onset of excessive tearing in older children is usually the result of ocular irritation. Any irritation of the conjunctiva, cornea, or eyelids may produce tearing. Conjunctivitis and corneal abrasion (secondary to a foreign body in the eye or human herpesvirus keratoconjunctivitis) are the 2 most common causes. Eye infections are discussed in Chapter 92.
Evaluation of excessive tearing begins with a thorough patient history. The nature of any discharge (eg, watery, mucoid, purulent) is noted. Parents or other caregivers should be questioned about the appearance of the infant’s eyes (Box 93.3). The excessive mucoid discharge in the medial canthal region and on the eyelashes is noticeable to the family, as is the increased tearing. Crusting along the eyelashes caused by drying of the mucoid material is usually noted when infants awake in the morning or after a nap. Mucopurulent discharge may be noted if an associated acute infection is present (eg, dacryocystitis).
Box 93.1. Diagnosis of Excessive Tearing
•Conjunctival edema or injection
•Crusting of the eyelids
•Reflux of tears with gentle pressure on the medial canthus
•Wetness of the eye
Figure 93.1. The lacrimal system, showing massage of the lacrimal sac (ie, Crigler massage).
Box 93.2. Differential Diagnosis of Excessive Tearing in Newborns and Infants
•Foreign body under the eyelid
•Obstruction of the nasolacrimal duct (ie, dacryostenosis)
•Anomalies of the lacrimal drainage system
•Mucocele of the lacrimal sac
•Atresia of the lacrimal punctum or canaliculus
•Craniofacial anomalies involving the midface