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The Problem
“My baby doesn’t cry.”
Common Cause
Absent reflex tears
Other Causes
Dry eyes (alacrima)
• Isolated
• Associated with other systemic diseases
Absent reflex tears
Baby doesn’t make tears when crying
Otherwise completely normal
Dry eyes
Decreased tears
Glassy appearance to eyes
Increased light sensitivity
Paradoxically, some patients with dry eyes have symptoms of excess tearing (see text)
Absent reflex tearing
Eyes otherwise appear normal
Cornea and conjunctiva crisp and clear
Normal tear lakes
Dry eye
Conjunctival redness
Possible visible corneal scars
Other systemic abnormalities
Sometimes excess tearing

If there are no other symptoms are present and the examination is otherwise normal (including a clear cornea), reassurance is usually all that is necessary.

If the patient has symptoms of ocular irritation and photophobia, referral is indicated.

What Shouldn’t Be Missed

Riley-Day syndrome (familial dysautonomia) causes markedly decreased tear production, which increases the risk of vision loss due to corneal scarring and infection. Early treatment with aggressive lubrication is indicated.

In children, underproduction of tears is much less common than excess tearing. There are 2 types of tears. Basal tears are continuously secreted. They are necessary to keep the eye lubricated and healthy. Reflex tears occur in response to either external or emotional stimulation, such as increased tearing in a brisk wind or crying when upset. They are not necessary for ocular health.

  • 1. Decreased reflex tears. This is much more common than true dry eyes. These children have normal basal tears (Figure 8–1) and their eyes are otherwise normal.
  • 2. Dry eyes. Dry eyes occur frequently in adults as part of the aging process. They are less common in infants and children. Patients with dry eyes have decreased or unstable basal tear layers. This usually results in chronic ocular irritation. This may be an isolated finding, or it may occur in association with other systemic problems (Table 8–1). Paradoxically, some patients with dry eyes may have symptoms of excess tearing (Figure 8–2). This occurs because the decreased basal tears predispose the patient to ocular irritation. If the patients have normal reflex tears, they will produce a bolus of tears in response to the irritation, often enough to overflow and produce epiphora. As this bolus wears off, the irritation recurs, and the patients go through a repetitive cycle of decreased tears, irritation, and excess tears.


Normal tear lake. This is most easily visualized with a penlight as a thin layer of fluid between the lower eyelid and the eyeball (arrow). Note that the cornea is clear and the corneal light reflex (long arrow) is crisp.

Table 8–1. Systemic Diseases Associated with Dry Eye...

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