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Epiphora is a clinical sign that can be caused from benign conditions and from conditions that can result in loss of vision if not detected in a timely manner. This section will cover the two most common causes of epiphora in infants (corneal abrasions and nasal lacrimal duct obstructions) as well as congenital glaucoma (which is a rare disorder but one that ultimately--if left undiagnosed and untreated--can have profound impact on the lives of children).
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Corneal Abrasion
Corneal abrasions can most often be diagnosed by the history. It is important to visualize the abrasion to rule out other causes of corneal insult (e.g., herpes simplex, corneal ulceration). In cases of blunt trauma, it is important to look closely for any resultant hyphema.
If a hyphema is present, communication with the pediatrician is important. Parents must be informed that the child needs to limit activity to help the hyphema dissipate and to decrease chances for a re-bleed. Further treatment in children less than 1 year old is unsubstantiated.
A corneal abrasion with a resultant hyphema should be treated with topical antibiotics, and the child should be monitored daily until the abrasion has healed and closely until the hyphema has dissipated.
Polytrim 1 drop 4-6 times per day for 7 days is recommended for children under 1 year.
A corneal abrasion without a hyphema should be pressure patched to help ensure that the child will keep his/her fingers out of the eye. Before placing the patch, Bacitracin ointment should be instilled to provide antibiotic coverage. Educate the parents to watch for signs of a secondary bacterial infection. Most infants will take the patch off within a few hours, so the optometrist should also prescribe Polytrim, as above, for the parent to use when the patch comes off. Children with a corneal abrasion should be monitored daily until the abrasion completely heals.
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Nasolacrimal Duct Obstruction
In infants, nasolacrimal duct obstruction may be due to stenosis, chronic infections, acute infections, developmental anomalies, or trauma. Obstructions due to stenosis are present in up to 30% of newborns.
Signs of congenital nasolacrimal duct obstruction include:
- Epiphora (unilateral or bilateral) can be continuous
- Breakdown of periorbital skin, especially at the lateral canthus
- Mattering of lids with discharge throughout the day
Due to the differential diagnoses of epiphora (including congenital glaucoma, bacterial conjunctivitis, and acute or chronic dacryocystitis), diagnosis of nasal lacrimal duct obstruction should only occur after a comprehensive examination with dilation has been performed. With all cases of confirmed nasal lacrimal duct obstruction, parents should be educated about the importance of their child seeing their pediatrician to rule out a concurrent or an acute otitis media.
Once the diagnosis is made there are a few treatment options dependent upon the time course and severity of the condition. Note that a large percentage of cases resolve spontaneously by the child's first birthday.
Treatment options:
- After initial diagnosis with only epiphora (no discharge or mattering): Recommend massaging of the lacrimal system multiple times each day (before a diaper change is a great time). Educate parents to wash their hands before massaging the system and to perform a few upward strokes first (in attempts to dislodge any debris). After that they should use a downward stroking method about 5-6 times for each involved eye.
- Initial diagnosis with epiphora and mattering, discharge: Recommend lacrimal massages as above and add a topical ophthalmic antibiotic. Currently Polytrim is the only topical ophthalmic antibiotic approved for use in children as young as two months of age. The typical treatment plan is igt QID in the affected eye(s) for 7-10 days with a follow-up visit at the end of treatment.
- Chronic mattering and/or discharge for a few months. If the massaging and antibiotic do not fully resolve the symptoms after a few months (3-5) you should make a referral to a pediatric ophthalmologist for possible surgical intervention.
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Congenital Glaucoma
Primary congenital glaucoma is associated with developmental anomalies of the eye which are present at birth. The disease usually presents within the first year of life. Occurs in approximately 1:10,000 live births. Secondary congenital glaucoma results from trauma, cataract surgery, neoplasms, severe retinopathy of prematurity, or inflammation.
Patient usually presents with:
- Tearing
- Shying away from bright lights
- Constant blinking
Clinical signs include:
- Epiphora
- Enlarged corneal diameter
- Corneal clouding
- Haab's stria
- Increased IOPs
- Increased cupping of optic nerve head(s)
- Increased axial length leading to increased myopia
When to be suspicious:
Treatment
Ophthalmic medications have limited value for the initial management of primary congenital glaucoma, so once a patient is identified as having (or possibly having) congenital glaucoma, refer the patient to a pediatric ophthalmologist for surgical consultation. After surgical intervention, the patient may be placed on topical anti-glaucoma medications.
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