Are These Ocular Symptoms Common or Concerning?

Brianne N. Hobbs, OD

Disclosures

July 06, 2018

In This Article

"My eyes are watering."

Tearing is a common complaint, especially in elderly patients. The degree of tearing is important; tearing that runs down the cheeks is more likely to have a pathologic origin.

Tearing usually indicates a problem with the ocular surface—that is, the cornea or the conjunctiva. Dry eye syndrome is paradoxically associated with tearing, because inflammation stimulates excess reflex tearing. Allergic conjunctivitis is another frequent cause of tearing because both the tear film and the conjunctiva are very active in the immune response.

Tearing accompanied by pain often indicates a compromise in the corneal epithelium, such as an abrasion or ulcer, and can be assessed with fluorescein dye. Bilateral tearing may occur even with unilateral injury, owing to reflex tearing.

Irregularities in the lids or lashes, such as ectropion or trichiasis, cause tearing and redness because the ocular surface is chronically irritated. Tearing also may be secondary to a blocked lacrimal drainage system. Surgical correction of lid malposition or blockage of the lacrimal system is invasive, so the risks of surgery must be carefully weighed against the severity of the patient's symptoms.

Most common diagnosis: It's a tie between allergic conjunctivitis and dry eye syndrome

Most concerning diagnosis: Corneal ulcer

Key factors

  • Inflammatory processes often contribution to tearing

  • Assess lid position and lash appearance

Clinical pearl

  • Unilateral tearing (watering) is more likely to indicate an etiology such as an ulcer or a nasolacrimal duct obstruction that requires a referral.

Figure 5. Characteristic corneal findings of dry eye. The left photo is without fluorescein dye, and the right photo is after staining with fluorescein. The patient presented with tearing and foreign body sensation.
Image courtesy of Pierce Kenworthy, OD

Identifying which ocular symptoms are most likely to be linked to concerning etiologies is critical to effective management. Different conditions may cause the same ocular symptom because the eye only has a limited number of responses. In general, anterior segment disease causes sharp pain, photophobia, tearing, and fluctuating blur. Conditions that affect the posterior segment are more likely to cause sustained blur and floaters and/or flashes, whereas orbital disease is often linked to sudden-onset diplopia. Thinking in a probabilistic and prognostic fashion is the best way to triage common ocular symptoms.

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