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Year : 2013  |  Volume : 20  |  Issue : 3  |  Page : 198-200  

Etiology of tearing in patients seen in an oculoplastic clinic in Saudi Arabia

Department of Ophthalmology, King Abdulaziz University, Jeddah 21589, Saudi Arabia

Date of Web Publication9-Jul-2013

Correspondence Address:
Amal Bukhari
Department of Ophthalmology, King Abdulaziz University, P.O. Box 80215, Jeddah 21589
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0974-9233.114790

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Aim: To determine the prevalence of various causes of tearing among patients referred to an oculoplastic clinic.
Materials and Methods: A prospective study on all patients seen in an oculoplastic clinic with a chief complaint of tearing. The cause of tearing was determined on the basis of the anatomical location of the primary etiology.
Results: This study included 357 patients with a mean age 53.9 years. Punctal stenosis was the most common etiology, affecting 37.8% of the patients. Among patients with punctual stenosis, 63.4% were women over 50-year-old (P = 0.001); 55.6% had tearing for less than 6 months (P = 0.038), and all of them had associated chronic blepharitis. The remaining study participants had dry eye with reflex tearing (27.7%), nasolacrimal duct obstruction (10.1%), canalicular obstruction (4.2%), entropion or ectropion (3.4%), pterygium (1.7%), megalo-caruncle (1.7%), and functional tearing (1.7%).
Conclusion: The outcomes of this study indicate the most common cause of tearing is punctal pathology. Therefore, slit lamp evaluation with careful attention to the punctum is warranted in all patients with tearing.

Keywords: Blepharitis, Dry Eye, Nasolacrimal Duct Obstruction, Punctal Stenosis, Tearing

How to cite this article:
Bukhari A. Etiology of tearing in patients seen in an oculoplastic clinic in Saudi Arabia. Middle East Afr J Ophthalmol 2013;20:198-200

How to cite this URL:
Bukhari A. Etiology of tearing in patients seen in an oculoplastic clinic in Saudi Arabia. Middle East Afr J Ophthalmol [serial online] 2013 [cited 2022 Oct 6];20:198-200. Available from: http://www.meajo.org/text.asp?2013/20/3/198/114790

   Introduction Top

Tearing is caused by increased tear production, which results from hyper-stimulation of the main lacrimal gland due to the ocular surface irritation, or by defective tear drainage due to an anatomical or functional defect. In addition to social embarrassment, tearing can affect the quality of a patient's life as it may interfere with daily activities, especially reading and driving. Although various pathologies can present as tearing, nasolacrimal duct obstruction (NLDO) is typically regarded as the most common cause. However, in our experience, very few patients who presented with tearing had NLDO upon completion of the clinical evaluation. Therefore, this study was designed to determine the prevalence of the various causes of tearing.

   Materials and Methods Top

All patients seen in the oculoplastic clinic with a chief complaint of tearing were recruited for this study. Patients were excluded if that had a concurrent ocular infection, a history of ocular or lacrimal surgery, facial palsy, ocular or peri-ocular trauma, facial radiotherapy, or those using any eye medication other than artificial tears. Slit lamp biomicroscopic evaluation was performed for all patients with the intention of identifying pathologies that can cause tearing, including entropion, ectropion, punctal stenosis, punctal occlusion, chronic blepharitis, and pterygium. Megalo-caruncle was diagnosed when the caruncle was abnormally large and covered the punctum, causing mechanical obstruction and preventing tear drainage. Diagnosis of dry eye with reflex tearing was based on the presence of at least two of the following signs: positive corneal fluorescein staining, tear film break up time of less than 10 s, and a result of less than 10 mm for Schirmer's test with anesthesia. All patients underwent lacrimal probing and irrigation. Diagnosis of canalicular obstruction was based on the presence of a soft block on probing, and NLDO was diagnosed when there was a failure to recover irrigation fluid in the nose. Functional tearing was diagnosed when the patient had a high marginal tear strip and all other causes of tearing had been excluded.

Statistical analysis was performed with SPSS software version 19 (SPSS, Inc., Chicago, IL, USA). Pearson Chi-square tests were performed to identify associations among variables. A P value of <0.05 was considered significant.

   Results Top

This study included 357 patients who presented to the oculoplastic clinic with tearing from September 2011 to May 2012.

The mean patient age was 53.9 years (range, 20-85 years) and 60.5% (216/357) of the patients were female. In the study cohort, 54.6% (195/357) had tearing for less than 6 months from presentation while 29.7% (106/357) had tearing between 6 months and 1 year and 15.7% (56/357) had tearing for more than 1 year. The most common cause of tearing was punctal disease such as stenosis or obstruction, affecting 49.9% (178/357) of the patients. There were 135 out of 357 patients with punctal stenosis. Among these patients, 64.4% (87/135) were female and 51.1% (69/135) had a tearing duration of <6 months (P = 0.147). The prevalence of punctal stenosis increased with advancing age (P = 0.015), and all patients with punctal stenosis had associated chronic blepharitis. Reflex tearing from dry eye disease was detected in 27.7% (99/357) of patients, 48.5% (48/99) of whom were female (P = 0.004). The prevalence of dry eye increased with advancing age (P = 0.000). Eighty-one of the 99 (81.8%) patients with dry eyes had tearing for less than 6 months (P = 0.000).

Of the 357 patients, 36 (10.1%) had NLDO, 18 of whom (50%) had a history of tearing for more than 1 year (P = 0.000). There was no statistically significant correlation between NLDO and gender or increasing age. [Table 1] shows the prevalence of the various causes of tearing in relation to age, gender, and duration.
Table 1: Causes of tearing in relation to age, gender, and duration of symptoms

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   Discussion Top

The current study indicates that 49.9% of patients referred to the oculoplastic clinic for the management of tearing had punctal diseases. Punctal stenosis was the most common cause (75.8%). Dry eye with reflex tearing constituted the second most common cause of tearing (27.7%), and NLDO occurred in only 10.1% of patients. The current study also found that there is a statistically significant correlation between the duration of tearing and etiological factor; the reason for this correlation was unknown. Patients with punctal disease and megalo-caruncle tend to seek medical advice within 6 months while patients with NLDO and functional tearing usually present after 1 year from symptom commencement.

Mainville and Jordan [1] also studied the etiology of tearing in patients referred to an oculoplastic clinic and reported that the main cause was NLDO, which affected 40.7% of their study population while punctal and canalicular pathologies constituted only 8% of the cohort. This can be explained by the fact that among the Saudi population there is a 54.3% prevalence of punctal stenosis [2] related mainly to chronic lid margin irritation and inflammation caused by chronic blepharitis, a disease that is very prevalent in the Saudi population. [3],[4]

It has been documented that blepharitis and dry eye disease can lead to stimulation of the neurosensory receptors in the cornea and conjunctiva; this can result in increased lacrimal gland secretion in an attempt to reduce the tear film osmolarity with resultant reflex tearing. [5] Although Saudi have the highest reported prevalence of dry eye disease (93.2%), [6] dry eye was the cause of tearing in only 27.7% of the study population while it was the cause in 40% of the study cohort in Mainville and Jordan investigation. This discrepancy may be attributed to the presence of patients with undiagnosed dry eye whose clinical manifestations had been masked by coexisting punctal stenosis.

   Conclusion Top

The etiology of tearing is influenced by racial differences; tearing may be primarily caused by NLDO in some parts of the world, whereas NLDO may be found in only 10% of patients with tearing in another geographical location. Among Saudi patients, the most common cause of tearing is punctal disease, and simple punctoplasty can remove the discomfort and improve the quality of life in almost 50% of the patients.

   References Top

1.Mainville N, Jordan DR. Etiology of tearing: A retrospective analysis of referrals to a tertiary care oculoplastics practice. Ophthal Plast Reconstr Surg 2011;27:155  Back to cited text no. 1
2.Bukhari A. Prevalence of punctal stenosis among ophthalmology patients. Middle East Afr J Ophthalmol 2009;16:85-7.  Back to cited text no. 2
[PUBMED]  Medknow Journal  
3.Bukhari A. Prevalence of meibomian gland disease among ophthalmology patients. JKAU Med Sci 2009;16:69-76.   Back to cited text no. 3
4.Bukhari A. Chronic blepharitis. JKAU Med Sci 2010;17:3-9.   Back to cited text no. 4
5.Shimazaki J, Sakata M, Tsubota K. Ocular surface changes
and discomfort in patients with meibomian gland dysfunction.
Arch Ophthalmol 1995;113:1266-70  Back to cited text no. 5
6.Bukhari A, Ajlan R, Alsaggaf H. Prevalence of dry eye in the
normal population in Jeddah, Saudi Arabia. Orbit 2009;28:392-7.  Back to cited text no. 6


  [Table 1]

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