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Thread: The watery eye capsule

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    Default The watery eye capsule

    The watery eye capsule



    ✍️ common complaint, particularly in the elderly population.
    ✍️ ranges from the transient and trivial (associated with a local irritant) to the permanent and disabling.

    ur stepwise approach for watery eye
    Symptoms

    ✍️ symptoms

    • episodic/permanent
    • frequency of wiping eyes
    • exacerbating factors (in/outside, cold/warm)
    • site where tears spill over (laterally/medially)

    ✍️ History

    • previous surgery/trauma
    • concurrent eye disease(HSV)
    • previous ENT problems (sinusitis, surgery/nasal fracture, granulomatous disease)
    • pro-secretory drugs (pilocarpine)
    • Allergies or relevant drug contraindications

    watery capsule attachment.php?attachmentid=3472&d=1513502809


    examination

    ✍️ VA

    • Best corrected/pinhole

    ✍️ face

    • Scars (previous trauma/surgery)
    • asymmetry
    • prominent nasal bridge
    • mid-face hypoplasia
    • age-related sag

    ✍️Lacrimal sac

    • Swelling
    • any punctal regurgitation on palpation

    ✍️ Lid

    • MGD disease
    • lash malposition
    • lid position (ectropion,entropion,or low lateral canthus)
    • laxity (lid and canthal tendons)

    ✍️ punctum
    • position
    • scarring
    • concretions
    • patency

    ✍️ conjunctiva

    • Irritation (chronic conjunctivitis)
    • Inflammation

    ✍️ cornea

    • chronic corneal disease

    ✍️ tear film

    • meniscus high/low
    • TBUT
    • dry eye (Schirmer’s test)

    ✍️ Fluorescein dye disappearance test (FDT)

    • tear film height
    • symmetry
    • dilution

    ✍️ Dye recovery

    • Jones I (physiological—without syringing)
    • Jones II (non-physiological—after syringing)
    • retrieve dye with cotton bud under inferior turbinate or ideally visualize with nasendoscope

    ✍️ canulation
    • patency of puncta

    ✍️ syringing

    • Do gently with lateral distraction of lid to avoid false passage
    • do not advance through an obstruction
    • Careful assessment will indicate site of obstruction
    • assess flow and regurgitation through upper or lower punctum, and presence of fluoresceine or mucous in the fluid
    • perform nasendoscopy where possible
    • CT DCG if previous trauma/destructive disease/suspected tumour.
    • Lacrimal scintigraphy is more useful than DCG as it simulates physiologic tear drainage conditions.

    most common causes of  watery 

    Increased production
    ✍️Autonomic disturbance
    ✍️ pro-secretory drugs
    ✍️ Chronic lid disease (blepharitis)
    ✍️ Local irritant (FB, trichiasis)
    ✍️ Systemic disease (TED)
    ✍️ Chronic conjunctival disease (OMMP)
    ✍️ Chronic corneal disease (KCS)

    Lacrimal pump failure

    ✍️ Lid laxity
    ✍️ Orbicularis weakness (VIIn palsy)
    ✍️ Lid position Entropion or Ectropion

    Decreased drainage

    ✍️ punctal obstruction

    Congenital
    * punctal atresia
    * accessory punctum
    Idiopathic stenosis (elderly) 2° to punctal eversion
     HSV infection
     post-irradiation
     Trachoma
     Cicatricial conjunctivitis

    ✍️ Canalicular obstruction

     Idiopathic fibrosis
     HSV infection
     Actinomyces
     Chronic dacrocystitis
     Cicatricial conjunctivitis
     5-FU administration (systemic)

    ✍️ Lacrimal sac obstruction

     granuloma,
     sarcoid
     syphilis
     fungi
     papillomas
     epithelial papillary (squamous and transitional cell) carcinomas
     Lymphoma
     Invasive pharyngeal or sinus carcinoma

    ✍️ nasolacrimal duct obstruction

     Congenital(delayed canalization)
     Idiopathic stenosis
     Trauma (nasal or orbital fracture)
     nasal pathology (chronic inflammatory polyps)
     post-irradiation
     granulomatosis with polyangiitis (GPA)
    Tumours (nasopharyngeal carcinoma)

     never to forget the most important DD of watery eye 
    ✍️ in children ( glaucoma)
    ✍️ in adults ( Sebaceous gland carcinoma may resemble chronic conjunctivitis)











    Attached Images  
    Last edited by Reda Gomah El Garia; 12-17-2017 at 09:27 AM.

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