Overflowing tears

Introduction Tear overflow is caused by the leakage of the lacrimal passage when the tear secretion is normal, causing the tear to overflow through the rim. Increased in the wind. Tears are the main symptoms of lacrimal disease. Lacrimal disease is a common eye disease that patients feel extremely painful. Tears should be distinguished from tearing caused by excessive secretion of reflex lacrimal glands.

Cause

The lacrimal duct is the drainage duct of tears. Including the upper and lower tears, upper and lower tear ducts, sometimes the upper and lower tear ducts merge to form a total tear duct into the lacrimal sac, and then the nasolacrimal duct opens in the lower nasal passage. The punctum and the lacrimal canal have a capillary siphon effect, and the tear is sucked from the conjunctival sac into the tube. When the blinking movement closes the eye, the orbicularis muscle contractes, and the inner ligament is pulled to make it nervous. The lacrimal sac is dilated by the anterior lacrimal fascia, and the negative pressure is increased, so that the tears in the lacrimal canal flow into the lacrimal sac. When the blinking action ends, the lacrimal sac is reset, and the tears are pressed into the nasolacrimal duct to reach the nasal cavity. If the cause of the orbicularis muscle weakness is caused by some reason, the scarlet sac scar shrinks, the lacrimal sac expands and causes no tension, and the narrowing or obstruction of the lacrimal duct in a certain part can cause tears.

1. Abnormal punctum position: due to puncture or valgus eversion.

2. Insufficient suction of the lacrimal sac: If the facial nerve palsy causes the orbicularis muscle to relax, the lacrimal sac is reduced or the expansion is weak.

3. Punctal obstruction: congenital, inflammatory, traumatic.

4. Tear tube, nasolacrimal duct obstruction: inflammation, birth injury.

5. Chronic dacryocystitis.

6. Lacrimal duct tumors.

an examination

Related inspection

Chlamydia trachomatis antibody ophthalmoscopy lacrimal examination

First, medical history

Ask the patient when the tears occur, whether it is congenital or acquired. There are no foreign body history, such as flying insects, dust, sand and so on. Have been directly exposed to electro-optic or ultraviolet light. There is no history of corneal injury or suture after eye surgery. There is no blepharitis, keratitis, iridocyclitis. The above reasons are all caused by excessive secretion of reflex tears, which causes tears to flow to the cleft palate. It is called "tears". If there is no such thing as tear overflow, it is called tears. Further inquiry should be made as to whether or not a purulent or fluid discharge is combined. If possible, consider chronic dacryocystitis. Pay attention to the history of trauma, if the lacrimal canal rupture or the lower scar valgus, can cause tears. Nasal septum deviation, middle turbinate hypertrophy, nasal polyps, nasal granulation tissue and other new organisms, as well as intranasal infections, can affect the normal excretory function of the lacrimal passage, causing nasal tears. Inquired in detail whether there is facial nerve palsy, which makes the orbicularis muscles weak, leading to tearing mechanism disorder and valgus valgus causing abnormal punctum position and tearing.

Second, physical examination

(1) Systemic examination

It should be noted that the nervous system has facial nerve palsy. Nasal examination is particularly important, with or without rhinitis, nasal polyps, nasal and paranasal sinus tumors that cause obstruction of the nasolacrimal duct.

(2) Eye examination

First, observe the size and position of the punctum. In order to exercise its function, the punctum must be aligned with the eyeball, otherwise the tears cannot be inhaled into the lacrimal passage and cause tears. Whether the lower puncture is everted or not is based on the fact that the punctum can be seen above. Common causes are genital valgus, facial nerve paralysis, and the elderly have no tension and no tension. The chin is turned inward, and the puncture is correspondingly involved. It is impossible to cause the tears to cause tears to the eye. But less common. Do not ignore the punctal stenosis or atresia caused by chronic conjunctivitis and blepharitis during the examination. Whether there are bulges, fluctuations, masses, fistulas, and secretions in the lacrimal sac.

(3) Special inspection

Fluorescein eye drops

The lower nasal tract is placed on a wet cotton film, and 2% fluorescein is dropped into the conjunctival sac, so that the patient's head is slightly tilted forward, and after a few minutes, the cotton piece is taken out for observation. If the lacrimal function is normal, the fluorescein solution of the conjunctival sac can reach the nasal cavity within a few minutes, and the cotton piece is colored. Infants can use this test instead of lacrimal passage.

2. Lacrimal irrigation

Use a 2-5 ml syringe to rinse the needle with the lacrimal passage, and sterilize the normal saline. For local anesthesia, a 1% tetracaine swab is placed at the small point of the tear. The head of the examinee was slightly lower, the flushing needle was inserted vertically into the lower punctum 1-2 mm, and the needle was immediately placed horizontally. The walking direction of the lacrimal canal was 5-6 mm deep, and the saline was injected. If the water flows into the abalone or the pharynx, the patient consciously has water flowing down, which proves that the lacrimal passage is unobstructed. Although the rinsing liquid can flow to the pharynx and the nose, the amount is small, and a large amount of rinsing liquid flows back from the punctum, indicating that the lacrimal duct is narrow. When flushing, some liquid or purulent secretions are returned from the punctum, suggesting chronic dacryocystitis. If the nasolacrimal duct obstruction, chronic dacryocystitis, and total tear duct obstruction, the water can not flow into the pharynx, and the resistance is large when the injection is made, and the water flow returns from the upper punctum. These three conditions can be identified by lacrimal exploration. If the resistance is large when rinsing, the water can not flow into the pharynx or nasal cavity, and the lower punctum is returned, and there is no liquid reflux in the upper punctum, then the obstruction of the lower lacrimal canal is very likely. If the flushing is not smooth, the nose membrane is converged with 1% ephedrine, and then rinsed smoothly for obstruction of the nasal lacrimal duct.

3. lacrimal exploration

It is difficult to clear the obstruction site after flushing the lacrimal passage, and it is feasible to explore the lacrimal duct. It has the dual meaning of diagnosis and treatment. The method of inserting the canaliculus is the same as the flushing test. However, the lacrimal sac must be inserted. When the probe has touched the hard wall of the lacrimal sac, the needle is used as the fulcrum. The needle is rotated close to the eyelid to the brow 900, so that the probe is vertical and the probe is inserted. The nasolacrimal duct is 2cm deep. Depending on where the probe is blocked, it is possible to determine which part is blocked.

Third, laboratory inspection

Sputum secretion and culture of lacrimal passages are meaningful for drug selection. Pathological examination is reliable for the diagnosis of lacrimal sac tumor and tuberculosis.

Fourth, equipment inspection

(a) lacrimal radionuclide imaging

The camera flicker scans to understand the shape and function of the lacrimal passage.

(two) dacryocysin

The content of the lacrimal sac was first squeezed out, and the lipiodol or iodine water (diaphragmamine, etc.) was injected into the lacrimal sac with a lacrimal irrigator, and the lateral flank was taken 4 minutes later. Most of the iodized oil in the normal lacrimal passage is in the nasal cavity. Obstruction of the lacrimal duct, stenosis, adhesion of the lacrimal sac, or compression of nearby tumors can be shown to aid diagnosis.

(three) nasolacrimal endoscopy

Singh et al (1992) reported that nasolacrimal endoscopy directly observed the lacrimal passage, opening up a new way for lacrimal examination.

Differential diagnosis

First, the tears of the tears are smooth

It is often encountered in clinical practice. For such patients, the lacrimal passage is fluent, and the cause of further tears is often ignored.

(1) The position of the punctum is abnormal

Maintain normal tear function, compare the upper and lower tear points, mainly rely on the lower tear point. Therefore, the abnormal position of the lower puncture can bow the tears.

1. The punctum is turned out and the normal puncture is immersed in the tear lake and collided with the bulbar conjunctiva. Even if the patient is looked up, if the squat is not pulled, the punctum will not be seen. This close contact is a prerequisite for maintaining the normal function of attracting tears. The location of the punctum can be observed by visual inspection. Although the lacrimal passage is smooth, it is difficult to induce tears and cause tears. There are many reasons for the lacrimal valgus, such as congenital anomalies, scar valgus valgus, senile ecchymosis, facial paralysis. In particular, very mild facial nerve paralysis is often overlooked, and the patient can be found with a smile.

2, the lower puncture inversion often due to varus, all kinds of causes of sputum adhesion, so that the lower tears involute, although the lacrimal passage is smooth, but can also lead to overflow. This condition is often accompanied by varus irritations and tearing that causes excessive secretion of reactive tears.

(two) poor absorption of tears

This kind of tears is often overlooked. The patient's main party was crying, but the size and location of the tears were abnormal, and the lacrimal passage was smooth. Further, through the lacrimal sac iodide angiography, the scarlet sac scar shrinkage, the lacrimal sac expansion is weak, and the lacrimal sac wall thickening is inelastic. Exclusion of tears due to weakness of the orbicularis muscle should also be excluded. These four conditions can destroy the tearing mechanism and cause tears. The latter often causes tears to overflow before the facial paralysis has not undergone significant valgus and lower puncture eversion. Symptoms of tears can also occur in the early stages of a lacrimal sac tumor. At this point, the lacrimal passage is still smooth, only affecting the tearing function of the lacrimal sac. Diagnosis can be obtained by lacrimal sac iodide angiography.

Second, the road is blocked or narrow tears

Occlusion of the lacrimal duct occurs mostly at the junction of the punctum, the lacrimal canal, the lacrimal sac and the nasolacrimal duct, and the lower nasolacrimal duct.

(1) The punctum is narrow or obstructed

It can be congenital, or scar formation due to trauma and inflammation. Visual inspection revealed that the punctum was narrow or atresia at the nipple, that is, a small white protrusion was formed at the punctum, or there was no trace of puncture at all.

(two) tear duct obstruction

It is a common disease. In particular, the medial segment of the lacrimal canal, the total tear duct and its into the lacrimal sac. The causes are congenital malformations, scars after inflammation, and trauma. The lacrimal passage cannot be flushed, and the liquid flows back from the original punctum. If there is resistance or impediment at the lacrimal canal at the lacrimal duct, the diagnosis can be confirmed.

Tracheal canal inflammation is less common. Inflammation is hyperemia and swelling, leading to narrowing or obstruction of the lacrimal duct and causing tears. Tracheal canal inflammation often combined with inflammation of the lacrimal point, mostly from chronic conjunctivitis. Sometimes tears are often attributed to conjunctivitis and the lesions of the lacrimal canal are ignored. The swelling of the punctum is the only thing that can be observed. The swollen tear nipples are prominently congested and sometimes misdiagnosed as stye. At this time, the lacrimal passage is often not smooth, and once the inflammation subsides, the symptoms of tears naturally disappear.

(three) nasolacrimal duct obstruction

Mostly caused by rhinitis, the nasolacrimal duct is blocked. The main complaint was tears, and no secretions from the lacrimal sac were spilled from the punctum, flushing the lacrimal passage. Lacrimal exploration helps diagnose.

(four) chronic dacryocystitis

It is a common disease. More women than men. The accumulation of tears in the lacrimal sac due to obstruction of the nasolacrimal duct is a prerequisite for causing dacryocystitis. The main symptom of the patient is tears, often accompanied by chronic conjunctivitis on the side. The appearance is normal, sometimes there is a slight bulge in the lacrimal sac area, and mucus, mucopurulent or purulent discharge can be seen in the lacrimal sac area. When the lacrimal canal is also blocked, the secretion can accumulate in the lacrimal sac, causing the lacrimal sac to form a spherical sac cyst. At this time, the lacrimal sac area has a spherical bulge, the surface is smooth, and there is no adhesion to the skin, and the pressure capsule is sexy and elastic. If forced, the contents are discharged from the small punctum or discharged through the nasolacrimal duct to the nasal cavity. But soon it was full again, and it formed a cyst again. Need to distinguish from tumor or cold abscess. The lacrimal sac tumor can show the shadow of the tumor through lacrimal sac angiography, and there is no mucus or purulent reflux. The biopsy is the most reliable for the diagnosis of tumor and tuberculosis. The lacrimal gland cyst in the lacrimal sac area is shallow and adheres to the skin. The lacrimal passage is smooth and easy to identify.

(5) Neonatal dacryocystitis

Also known as congenital dacryocystitis. It can occur anywhere between the junction of the lacrimal sac and the nasolacrimal duct to the lower mouth of the nasolacrimal duct. During the formation of the nasolacrimal duct, the primordial epithelial column of the lacrimal duct was not fully opened, that is, the congenital nasolacrimal duct was not opened, so that tears and bacteria were left in the lacrimal sac, causing secondary infection. To. About 2%-4% of term infants have this type of membranous obstruction.

However, most of the residual membranes atrophy and regain patency 4-6 weeks after birth. Cassady (1952) reported that 73% of births were unreasonable, with an average of three and a half weeks after birth. Generally, starting from 10 days or more after birth, there is tears first, gradually becoming purulent secretions, often misdiagnosed as conjunctivitis. The pressure in the lacrimal sac area can be diagnosed if there is a purulent discharge.

(6) Lacrimal duct tumor

1. The lacrimal duct tumor mainly has inflammatory granuloma, followed by papilloma, which can cause obstruction of the lacrimal passage and tears.

2. The lacrimal sac tumor is rare. In the early days, the main complaint was tears. This was because the tumor cells in the lacrimal sac wall infiltrated and lost their elasticity. The lacrimal passage flush test is smooth, occasionally painful, and sometimes bleeding from the punctum. Often misdiagnosed as chronic dacryocystitis. X-ray lacrimal sac angiography showed abnormal expansion, displacement or curve of the lacrimal sac. If there is a mass in the lacrimal sac area, it should be differentiated from the cystic fluid cyst. If the tumor spreads to the skin, it forms an ulcer, and the lymph nodes are partially accessible, and there may even be metastasis. It needs to be differentiated from the surface skin tumor in the lacrimal sac area. The latter has a smooth lacrimal passage and a normal lacrimal sac.

Tearing is a general term for eye diseases in which tears often overflow the chord and the outflow is a clinical feature.

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