Epiphora in infants and children

Approximately 6% of infants around the world have some symptoms of excess Tearing also known as EPIPHORA. Excess tearing in infants is one of the most common eye problems that optometrists and ophthalmologists encounter. In most cases, the condition spontaneously improve but sometimes it can also indicate numerous medical conditions. Epiphora is an eye condition in which there is an overproduction of tears resulting to excess tearing onto the cheek. This often happen when there is an insufficient tear film drainage from either one or both eyes which is needed to provide adequate lubrication for the eyes and keep them healthy. Epiphora could also obstruct a child’s vision and when prolonged could lead to other eyes complications. 

Epiphora mostly occurs in children under 12 months of age. At birth, there is a minimal baseline production by the lacrimal glands. Lacrimal glands are exocrine glands that secrete lacrimal fluid or tears onto the surface of the conjunctiva and cornea of the eyes. Normal tearing develops several days after birth. There are two physiological types of tearing: 

• Basal tear production: This type of tear production always keeps the eyes moist during normal conditions. 
• Reflex tearing: It occurs in response to irritation or emotion. 

SYMPTOMS OF EPIPHORA 

Epiphora often causes constant streams of tears onto the cheeks. Other symptoms may include: 

• Redness 
• Blurry vision 
• Swollen eyelid 
• Sharp eye pain 
• Dilated blood vessels 
• Light sensitivity (photophobia) 

CAUSES OF EPIPHORA 

Epiphora can be caused by an increased production of tears or by an obstruction of the nasolacrimal outflow system, which is the blockage of the lacrimal drainage system. The causes of Epiphora are classified according to the age of onset: 

1. Neonatal epiphora 

2. Acquired Epiphora 

NEONATAL EPIPHORA 

Neonatal Epiphora is usually as a result of a congenital abnormality of the lacrimal drainage system in the form of a membranous obstruction at the lower end of the nasolacrimal duct termed nasolacrimal duct obstruction. Tears normally drain from the eyes down the nose through the tear duct also called nasolacrimal duct. If one looks in the mirror, the opening of tear duct could be seen in the corner of the upper and lower eyelids. They look like two small dots, one in the upper lid and one in the lower lid and are called Puncta. Tears normally drains through the puncta. Tears duct obstruction prevents tears from draining through the lacrimal system normally and provokes a buildup of water in the eyes. 

The most common cause of nasolacrimal duct obstruction is a membrane at the end of the tear duct called valve of Hasner that is present in 50% of newborns but normally disappears soon after birth. Other causes of nasolacrimal duct obstruction in children include: 

• Infection of the nasolacrimal duct 

• Narrow tear system 

• Absent puncta 

• Incomplete development of the tear duct that does not connect to the nose 

Another type of neonatal Epiphora is congenital glaucoma. Tearing is one of the most common presenting signs of congenital glaucoma. This rare condition may be inherited, and caused by incorrect development of the eye’s drainage system before birth. Infants with congenital glaucoma often present with an increased intraocular pressure of the eyes, which in turn damages the optic nerve. The optic nerve is the nerve at the back of the eyes that sends signal to the brain. Other symptoms of congenital glaucoma include enlarged eyes, cloudiness of the cornea and sensitivity to light. 

It affects children between birth and 3 years of age. In contrast to nasolacrimal duct obstruction, the tearing associated with congenital glaucoma is not caused by any obstruction of the nasolacrimal system but by corneal edema. 

ACQUIRED EPIPHORA: 

Some children are born with underdeveloped tear ducts while in some other children; the excess production of tears can be acquired or caused by other eyes conditions. The following eye conditions can cause the overproduction of tears in children: 

1. Eyelid Changes: 

Blinking of eyelids helps to evenly sweep tears on your eyes. Any changes in the structure and function of the eyelids can cause a great deal of irritation, watery eyes and redness. 

2. Dry Eye Syndrome: 

Dry eye syndrome is an eye condition that occurs when the eyes do not produce enough tears to provide adequate lubrication for the eyes or when the tears evaporate too quickly. It often presents with symptoms of tearing, redness, stinging or burning sensation, photophobia, foreign body sensation, blurry vision. The following can cause dry eyes: 

• Lack of tear production 
• Exposure caused by poor eyelid closure, lids defects, facial nerve palsy and poor blink response 
• Congenital scarring caused by vitamin A deficiency, trachoma, Alkalin burn, Steven Johnson Syndrome, Ocular pemphigoid 

3. Conjunctivitis: 

Conjunctivitis also referred as pink eye is an inflammation of the conjunctiva, which is the inner part of the eye and the inner eyelids. This is a more common condition in young kids. Some types of conjunctivitis can cause Epiphora such as: 

• Allergic conjunctivitis: It is an eye inflammation caused by an allergic reaction to substance like pollen, mold pollen. This happens more in kids with other allergic conditions such as hay fever. Other triggers include grass, ragweed, animal dander and dust mites. 
• Irritant conjunctivitis: This type of conjunctivitis is caused by anything that irritates the eyes such as air pollution. 
• Viral conjunctivitis: This is a common, self-limiting condition that is typically caused by adenovirus and is highly contagious as airborne viruses can be spread through sneezing and coughing. 

4. Crocodile Tears: 

Crocodile tears is a term used to describe tearing secondary to mastication and gustatory stimulation. It occurs following facial paralysis where nerve fibers destined for salivary glands are damaged and by mistake regrow into a tear gland. 

5. Foreign Objects and injury: 

Epiphora may be provoked when a foreign body gets into the eye. The resulting irritation can trigger sudden blinking and watering to flush it out. A speck of dust, dirt or other material may cause an abrasion or scratch on the cornea leading to Epiphora. 

TREATMENT: 

Epiphora is a common condition with many causes; it may clear up without treatment. However, it is important that an ophthalmologist or optometrist examines the child and identify the possible cause. A thorough history should be taken and examinations required to provide appropriate treatment tailored to the underlying cause. Early detection of the cause could also help to save the child’s vision from serious eye conditions like congenital glaucoma. 

References 

• Noreen Iftikhar, MD (2018, July 26) What Causes Watering Eyes retrieved: https://www.healthline.com/health/epiphora#causes 
• James McIntosh (2017, February 23) Causes and treatments for watering eyes retrieved: https://www.medicalnewstoday.com/articles/169397 
• American Association for Pediatric Ophthalmology and Strabismus (2020. April 4) Nasolacrimal Duct Obstruction retrieved: https://aapos.org/glossary/nasolacrimal-duct-obstruction 
• Sam Barnes (2018, September 23) The Lacrimal Gland retrieved from: https://teachmeanatomy.info/head/organs/eye/lacrimal-gland/ 
• Kenneth W. Wright, MD FAAP (2008) Pediatric Ophthalmology for Primary Care, American Academy of Pediatrics ISBN-13:978-1-58110-264-2 (145-157) Eye institute and research center (2018) Pediatric-Glaucoma-A-Review-of-the-Basics 
• Retrieved from https://www.madhavnetralaya.org/Encyc/2019/11/21/Pediatric-Glaucoma-A-Review-of-the-Basics.html