“My child’s eyes keep watering”

History

As with all situations, the best strategy is to ask parents what the problem is and let them explain for a minute, without interrupting. “Listen to the patient/parent and they will tell you the diagnosis” is a great approach to history-taking in medicine. Photophobia is a particularly important symptom and suggests glaucoma (with corneal edema), corneal disease or uveitis.

A child with excessive tearing is a source of concern to parents. Frequent lid cleaning may be necessary due to build up of mucus and constant wetting of the lower lid can cause redness and maceration of the skin. Parents have often been prescribed repeated courses of topical antibiotics to no effect, and the constantly wet, sticky eye can impact negatively on the child’s appearance. Some authors have suggested that unilateral CNDO can cause amblyopia, but a recent, large retrospective study suggests this is not the case.

Try to establish the time of onset of the watering. Was it soon after birth, or later? Photophobia must specifically be asked about, as it is common in congenital glaucoma, or acquired glaucoma in early childhood (e.g. glaucoma after cataract surgery). The typical presentation is a child who avoids opening their eyes in normal daylight, often burying the eyes behind an arm or hand. Photophobia is also a symptom of corneal disease, such as corneal epithelial dystrophies (see Chapter 32 ), uveitis, or foreign body in the conjunctival sac or cornea. The possibility of trauma needs to be kept in mind, as children sometimes cannot (and occasionally will not) always give a detailed history and parents may not have observed the injury. Herpes simplex conjunctivitis can sometimes be associated with canalicular stenosis and scarring, causing a watery eye. A child with excessive lacrimation (e.g. from a corneal foreign body) may have a watery nostril on the same side as the watery eye. Ask about whether the child rubs the eyes, or has a history of eczema, allergic rhinitis or asthma, suggesting allergic eye disease. A history of eye rubbing or poking and concerns about whether the child can see suggests a retinal dystrophy, such as early-onset severe retinal dystrophy (Leber congenital amaurosis) (see Chapter 46 ).

External inspection

Tearing, red macerated skin, and stickiness may be evident. Look for misdirected lashes or lid malposition such as entropion, particularly if trachoma is possible. Check there is no facial nerve weakness, which would compromise the tear “pump.” In nasolacrimal duct obstruction, the tear lake is thickened, brimming the lower lid margin. Normally, the tear film is virtually invisible, and, with fluorescein staining of the tear film, measures less than 1 mm. With obstruction, it typically measures 2 mm or more. Look for perilimbal injection suggesting keratitis or uveitis and look for evidence of blepharoconjunctivitis (see Chapter 15 ). Generalized corneal haze with secondary corneal epithelial edema may be a sign of glaucoma. Corneal diameters can be estimated using a ruler held close to the lid. A tense swelling over the nasolacrimal sac in a neonate is probably a dacryocystocele.

Slit-lamp examination

A portable slit-lamp is ideal for young children, and it is helpful if another team member distracts the child with an engaging toy, such as a spinning LED multicolored light toy. Look for the presence or absence of puncta, punctal ectopia or fistula, or epiblepharon with inturned eyelashes. Inspect the inferior conjunctival fornix looking for diffuse redness and swelling of the conjunctiva, suggesting Chlamydia conjunctivitis. Everting the upper lid is unlikely to be possible in a young, awake child, but it is possible to retract the upper lid digitally and inspect the tarsal conjunctiva and fornix with the portable slit-lamp, looking from below. Corneal crystals, abrasions, scars, ulcers, and foreign bodies can be excluded, as can signs of uveitis, e.g. keratitic precipitates, hypopyon, posterior synechiae, or cataract (also check red reflex). Haab striae and corneal edema should be excluded.