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The Problem
“My baby looks like she is crying all the time.”
Common Causes
Nasolacrimal duct obstruction
Other Causes
Other anatomic abnormalities of the lacrimal system
• Absent lacrimal puncta
• Lacrimal fistula
Misdirected eyelashes
Glaucoma
Corneal problems
Retinal dystrophies
KEY FINDINGS
History
Nasolacrimal obstruction (by far most common)
Overflow tearing
Periocular crusting, worse in morning
Child otherwise fine, does not appear bothered by problem
Other anatomic problems
Absent lacrimal puncta
Excess tearing only
No crusting
Lacrimal fistula
Excess tearing
Tears emanate from fistula tract between the eye and the nose
Misdirected eyelashes
Parents note in-turning of lower eyelid
Excess tearing, mucoid discharge
Cornea problems
Child is light sensitive
Frequent blinking
Eye rubbing
Glaucoma
One or both eyes larger than normal
Glassy or cloudy appearance to cornea
Tearing only, not crusting
Photophobia (light sensitivity)
Retinal dystrophies
Photophobia
Usually markedly decreased vision
Nystagmus
Examination
Nasolacrimal obstruction
Increased tear lakes, periocular crusts
Child usually otherwise normal
Conjunctiva white, no inflammation
Cornea clear
Other anatomic abnormalities
Punctal atresia
Same except no ocular discharge
Lacrimal fistula
Excess tears (arise from fistula)
Eyelid malposition
Same except mucoid discharge
Lower eyelashes turned inward against cornea (epiblepharon)
Corneal problems
Photophobia
Cloudy cornea
Glaucoma
One or both eyes enlarged (buphthalmos)
Cloudy or glassy appearance to cornea
Clear tears only
Photophobia
Retinal dystrophies
Photophobia
Decreased vision
Nystagmus
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In case of a lacrimal obstruction, lacrimal massage and topical antibiotics as needed are indicated. If no improvement occurs with age, refer to an ophthalmologist.

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If corneal problems or glaucoma are suspected, refer immediately to an ophthalmologist.

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What Shouldn’t Be Missed

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Glaucoma should not be missed. Early treatment of glaucoma is critical to optimizing vision. If a child with excess tearing has corneal clouding or eye size asymmetry, immediate referral to an ophthalmologist is indicated.

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Excess tearing in infants is one of the most common eye problems that pediatricians encounter. Approximately 6% of infants have some symptoms of excess tearing. Most of these spontaneously improve. Because this symptom is so common, however, it is possible to overlook much rarer but potentially serious disorders that present with the same clinical picture.

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  • 1. Nasolacrimal duct obstruction (NLDO). This is by far the most common cause of excess tearing in infants. It results from incomplete opening of the tear ducts, with symptoms of overflow tearing (epiphora), periocular crusting, or both (Figure 7–1). Most symptoms of NLDO resolve within the first 1 to 2 months of life.
  • 2. Other anatomic abnormalities of the lacrimal system.
    • a. Absent lacrimal puncta. Much less frequently, infants are born with absent or imperforate lacrimal puncta (the site on the eyelid where the tears enter the lacrimal system) (Figure 7–2A and B). These children present with overflow tearing only. Unlike most children with NLDO, these patients do not get periocular crusts or other symptoms of infection.
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