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Watery eye
By
Magdy fawzy $ Taha sarhanProf of ophthalmology
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أال اروق ع اخطب د أعز أ سم
فن اتغي ازة غيه ا ذأ
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ZAGAZIG UNIVERSITY HOSPITAL
Ophthalmology department
Prof. Dr. Taha Sarhan
Prof. Dr. Magdy fawazy
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WATERY EYE
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Watering of the eye
Definition :It is an over flow of tears onto the
cheek.
Watering of the eye is an extremely
common ocular symptom.
What are the other common ocular
symptoms ?
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What are the causes of watery eye? A host of disease entities can lead to
this symptom.
It may be due to
OR
lacrimation
epiphora
What are the causes of watery eye? A host of disease entities can lead to
this symptom.
It may be due to
OR
lacrimation
epiphora
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How you can manage a case of watery eye?
A thorough understanding andidentifications of these causes isthe only way to successfully
manage this annoying symptom.
What is the first step in the
understanding of watery eye ?
How to differentiate epiphora
from lacrimation?
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* Epiphora . Watering that occurs secondary to
abnormal excretory system in thepresence of normal tear secretion.
* Lacrimation. Watering that occurs secondary toexcessive tear production in the
presence of a normal excretory system.
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Failure to differentiate thesetwo conditions can result inunwarranted and improper
medication of a large numberof patients.
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أطع انواشي ض َ انصذق
• If you listen to the telltale you will lose thefriend
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Watering of the eyeEpiphoraLacrimation
(patient syringing)Epiphoralacrimation
Syringing blocked
Syringingpatent
BlepharitisDry eyePunctalatresiaEpiplapharon
Punctalatresia
EctropionThichinedlid margin
ReducedLTM.
Canalicularatresia
Trichiasis
Punctalstenosis
Lid lagBlockedpuncta by
tarsal gland
IncreasedBUT
N.L.D. blocking
Distiachiasis
Canilicular
block
7TH nerve
palsy
Forthy
disharge
Schirmer
testCongenitalglaucoma
CC. block
NLD block
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Reflex irritation of conj. or cornea (lacrimation):
Rubbing lashes or trichiasis.
PTDs or PTCs.
Conjunctivitis.
Corneal FB or ulcer.
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• Inadequte tear drainage (Epiphora):
–Loss of sharpness of lid margin: blepharitis,.
–Ectropiopn : due to failure of lid
apposition onto the globe.
–Failure of the pump mechanism.
–Obstruction : of lacrimal passages.
–Nasal causes: nasal polyp, tumour,
hypertrophied IT bone. or marked deviated septum.
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How to reach diagnosis ?• Please at first you must exclude cases of
lacrimation
1-HISTORY
Present history
*Unilateral cases which is more worse out doors
especially in cold windy days are very suggestiveof epiphora
*bilateral cases associated with itching , irritationand photophobia are very suggestive of lacrimation
Past history *Bell,s balsy
*drug intake
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How to reach diagnosis ?
2-Examination:
*Inspection (slit lamp).
-Eye lid:
(ectropion,trichiasis,eversion of thelower punctum and lower lid
laxity)-Medial canthus :
:for lacrimal sac swelling (acute
dacryocystitis,mucocele or rarely tumour )
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How to reach diagnosis ?
2-PALPATION:
*Palpation of lacrimal sac andregurge test.
Reflux of a mucopurellentmaterial is diagnostic and nofurther investigations are
required.
*DDT.
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How to reach diagnosis ?
3-Propping & irrigation.
4-Jones dye test: 1ry. & 2ry.
5-Radiological ex.
6-Nasal examination.
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Case 1
• 40 yo. woman presented with
lacrimation, ocular irritation andredness 1 month ago.
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• Examination
• Slit lamp: see picture..• DDT: normal
• Lacrimal sac: not felt, no regurge.
•
Nasal ex: normal
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The cause of watering is due to?
OR
EPOPHORA
LACRIMATION
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The most likely diagnosis?
1.Entropion.
2.Trichiasis
3.Rubbing lashes.4.Non of the above
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• Treatment not include
1-epilation:2-electrolysis:
3-diathermy:
4-snellen’s operation:5-all of the above:
6-Vanmellingen’s opertion of the upper
lid
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• Trichiasis:
Definition:More than 4 mal-directed lashes are
rubbing against the bulbar conjunctivaand cornea
Clinical picture:
Symptoms:
1) Foreign body sensation.
2) Pain.
3) Photophobia.
4) Lacrimation.
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Signs:
1) Misdirected lashes
2) Conjunctival hyperemia3) Discharge
Treatment:
1) Van Mellingen’s operation for the
upper lid.
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نه انوم دن هى انذ انصرةا
• The gift of gab is a proof of jealousy
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Case 2
• A 72 yo man presented with
lacrimation, corneal irritation andphotophobia.
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• Examination
• Slit lamp: see picture..
• DDT: normal
• Lacrimal sac: not felt, no regurge.
• Nasal ex: normal
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The cause of watering is due to?
•
• OR
EPOPHORA
LACRIMATION
Th t lik l di i ?
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The most likely diagnosis?
1. Rubbing lashes.
2. Trichiasis.
3. Involutional entropion
4. Involutional ectropion
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Entropion:
Definition:
rolling in of the lid margin,
trichiasis is always present.
Management:
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Management:
1. Epilation.
2. Elyctrolysis
3. Snellens operation
4. Vanmellingin,s operation
5. webster operation
Case 3
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Case 3• A 21y.o.male presented with Foreign-
body sensation and tearing in the left
eye While riding my bycicle 3 hoursago, came suddenly
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• Examination
• Visual acuity: 6/6 OU
•
IOP: 15mmHg OU• Pupils: RRR
• Slit lamp: see picture..
•
DDT: normal• Lacrimal sac: not felt, no regurge.
• Nasal ex: normal
• DO YOU WANT TO DO ANY THING FURTHER ?
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Lid eversion is
what I need todo
What is the most likely diagnosis?
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What is the most likely diagnosis?
a- NLDO.
b- Foreign body c- Dry eye syndrome
d- Herpes simplex keratitis
If a foreign body is seen what test you want to do ?
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If a foreign body is seen what test you want to do ?
Fl. test
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The cause of watering is due to?
OR
LACRIMATION
EPOPHORA
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Which Therapy?
a- Irrigation of the eyes with saline
b- Topical steroids
c - Antibiotic ointment
d - Eversion of the upper eyelid, removal
of the foreign body
Case 4
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Case 4
• A 70 year-old women who complainedof watering and ocular irritation inthe left eye 3 ms ago.
E i i
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Examination
Slit lamp: see picture:
DDT: prolonged:
Lacrimal sac: not felt, no regurge:
Nasal ex: normal:
Th f t i i d t ?
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The cause of watering is due to?
or
LACRIMATION
EPOPHORA
Th t lik l di i ?
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The most likely diagnosis?1. Cicatricial ectropion.
2. Involutional entropion
3. Mild senile ectropion
4. Moderate senile ectropion
5. Sever senile ectropion
The most likely treatment ?
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The most likely treatment ?
1. Cautery puncture.
2. Snellens suture.
3. V-Y operation.
4. All of the above.
5. Non of the above.
Case 5
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Case 5
• 40 years old man presented with
lacrimation and burning sensationin the left eye Since yesterday
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Examination
Visual acuity: 6/9(OU).
IOP:11mmHg OU.
EOM motility: normal.
Slit lamp: normal.
Fl stain: normal.
DDT: prolonged.
Th t lik l di i ?
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The most likely diagnosis?
1. Herpetic keratitis2. Third-Nerve Palsy
3. Dry eye syndrome
4. FB under the uppereyelid
5. Seventh-Nerve Palsy
•
What do you want toask the patient to do?
• Close your eyes !!
The cause of watering is due to?
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The cause of watering is due to?
or
LACRIMATION
EPOPHORA
Whi h Th ?
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Which Therapy?
1. Tarsorraphy.
2. Immediate Lid Surgery.
3. Acyclovir ointment .
4. Pressure patch.
5. Moisture chamber with lubricating
ointment.
M i h b i h l b i i
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• Moisture chamber with lubricatingointment
C 6
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Case 6
A 2 year old boy presented with tears
overflowing from left eye, matting of lashes since one month of age.
Examination
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Examination
VA: cannot be checked.
IOP: 17 mmHg OU.
Slit lamp: normal.
DDT: This photo is five minutes after placing
fluorescein into each eye.
Lacrimal sac: not felt, no regurge.
Nasal ex: normal.
DD of epiphora in infant Not include?
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DD of epiphora in infant Not include?
1. Buphthalmos.
2. Ophthalmia neonatorum.
3. Congenital nasolacrimal ductobstruction.
4. Cataract.
How should this patient be treated?
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How should this patient be treated?a. No ttt and it will resolves spontaneously.
b. Probing.
c. Intubation .
d. DCR.
• More than 90% of congenital nasolacrimal
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• More than 90% of congenital nasolacrimalduct obstruction resolves spontaneously
before one year of age.
• If the child has not had spontaneousresolution, probing ( success rate of > 90%).
• If tearing persists after probing, intubation
• ( the benefit of this procedure is not clearly established.)
Case 7
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Case 7
• A 60 yo female presented with epiphora,
discharge together with swollen leftlower lid 7 months duration.
Examination
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Examination
Slit lamp: see picture..
DDT: prolonged
The swelling: is below the medialpalpebral ligament
Regurge test: see..
Nasal ex: normal
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The cause of watering is due to?
or
EPOPHORA
LACRIMATION
What is the likely diagnosis?
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• What is the likely diagnosis?
a. Acute dacryocystitis
b. Hordeolum (stye)
c. Chalazion
d. Chronic dacryocystitis
What are the possible complications?
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What are the possible complications?
1. Chronic conjunctivitis.
2. Hypopyon corneal ulcer.
3. Cicatrical ectropion.
4. lacrimal muococele.
5. Acute dacryocystitis.
6. All of the above
What is Not appropriate treatment?
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What is Not appropriate treatment?
1. Antibiotics: local & systemic.
2. Probing.
3. DCR.
4. Dacryocystectomy.
Case 8
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Case 8• The patient is a 42-year-old man
presented with a 3 day history of epiphora, erythema and tendernessnear the left medial canthus.
EXAMINATION
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Visual acuity: 6/6 OU
IOP: 11 12 Motility: normal Pupils :RRR DDT: prolonged
The swelling :is below medial palpibralligament.
The skin over: it is red& oedematous
Temperature: is 38.5
What is the likely diagnosis?
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What is the likely diagnosis?
a. Hordeolum (stye)
b. Orbital cellulitis.
c. Chronic dacryocystitis
d. Acute dacryocystitis
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The cause of watering is due to?
LACRIMATION
EPOPHORA
or
What is the appropriate treatment?
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What is the appropriate treatment?• Antibiotics ( topical & systemic).
• Analgesics
• Warm compresses.
• All of the above.
• Non of the above.
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Watering of the eye
• Reflex irritation of conj or cornea(lacrimation):
trichiasis entropion Forign body
Watering of the eye
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Watering of the eye• Inadequte tear drainage (Epiphora):
ECTROPION
CHRONIC DACRYOCYSTITIS ACUTE DACRYOCYSTITIS
FACIAL NERVE PALSY NLD. OBSTRUCTION
كب انرق ف انس خئ فذ ، احق تجدل
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كب قرنا يف سنا ئخ ذف ، قحا لدجت
• Don't argue with an ignorant for it will be hard for people todifferentiate between you
Thank U
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Thank U
Case
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Case• 70 yo female; coronary artery disease,
diabetes, recent history of chemotherapy for cancer Seen forirritable eyes, burning, itching,mattering of the lashes and foreign body sensation worse in am, "it’s
terrible"
Ocular history: cataract extraction
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Ocular history: cataract extractionOU 2000, glaucoma .
Ocular medication: Xalatan 0.005%OU qhs. On examination Va: 20/40 ou
Slit lamp – see image.
What is the diagnosis?
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What is the diagnosis?• What changes do you see on the lids?
• What is the recommended management?
• Blepharitis
What changes do you look for on the lids? –
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What changes do you look for on the lids? –
• crusting on the lashes, telangectasia of the lid margin blood vessels, foamy tear film, low tear film meniscus
What is the recommended management?
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1. Warm compresses
2. Lid hygiene
3. Topical antibiotics
4. Topical steroids ointment forrecalcitrant cases
5. Systemic tetracycline or doxycycline
Case
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Case• This 26 year old woman was referred
to the eye clinic because of a leftchronic ocular irritation. On slit-lampexamination, the above picture is seen
• What is the cause of her left chronicocular irritation?
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ocular irritation?
•
Pubic louse (Phthirus pubis)and multiple eggs attached tothe eyelashes
•It is most commonly found inthe groin and can be sexually transmitted. Other areas whereit can be found include axillae,
eyelashes and eyebrows. Itcontains claws that allow it tocling to the hairs of these areas.
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• The louse lays its eggs within afew days of becoming sexually mature. The tiny, white eggs or
nits are cemented to the base of the hair shafts. After hatching,the nymphs pass through two orthree stages (instars) before
reaching adulthood
How would you treat this condition?
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y
Several options are available:
Manual removal of the liceand nits with forceps
Aapplying petroleum to theedges of the lid margin cankill the lice but has no effecton the nits
How would you treat thiscondition?
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Aanticholinesterase such asphysiostigmine 0.25%ointment can be used to kill
the lice
Malathion 1% which is an
organophosphorus can kill both the lice and the nits
Ingrowing
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Ingrowing
eyelashes and
entropion, upper lid.
Trichiasis
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تجدل احمق ،فذ خطئ انس في ارق نك
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مكنب Don't argue with an ignorant for it
will be hard for people todifferentiate between you
Th k U
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Thank U
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