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Tears have fascinated humanity since antiquity. They have been addressed in poetry, literature and religious writings, paintings, music and cinema.
There are three basic types of tears:
Basal production that lubricates the eye conjunctiva and is part of our immune barriers
Reflex tears for flushing out external irritants
Emotional tears
The lacrimal gland lies at upper external corner of the orbit, responsible for 90% of tear secretion. The remaining 10% is produced by accessory glands placed in the eyelids. Tears leave the conjunctival surface through two holes, the lacrimal punctum.
These holes drain to a lacrimal sac and then to a duct by which the fluid is conveyed into the cavity of the nose. There are a few valves along this pathway to avoid fluid reflux back to the eye.
An excess of tears, during reflex or emotional tears, causes the nose to run, and when exceeding the lachrymal draining capacity, tears will fall from the eyelid onto the cheek. The medical term for this tearing overflow is epiphora.
Having watery eyes affects daily activities, such as reading, driving, outdoor walking, watching television or computer work. It may be caused by an excess of basal tear production or their insufficient drainage.
Let me talk about the latter one, because those are the cases I get referred to.
An obstruction in the nasolacrimal system will result in a stagnation of tears and epiphora. Stagnation provides a favorable environment for infectious organisms to propagate and debris to form, leading to a local infection, named dacryocystitis.
There can be obstructions at any level of the nasolacrimal system, for several reasons: local debris, local trauma, lachrymal stones and systemic diseases such as auto-immune diseases.
In adults, dacryocystitis it occurs usually above 40 years old, and females represent around 70% of all cases, because their lacrimal conduit tend to be narrower.
During acute infection episodes, it may be necessary to use antibiotic therapy. In chronic dacryocystitis it is almost always managed surgically.
Whatever the case, it is highly recommended to visit an Ophthalmologist before referring to a surgeon.
Surgery is usually performed under general anesthesia, and the approach can be done entirely inside the nose using an endoscope, or combined with a small skin incision. A silicone tube is placed in the lachrymal conduit and left there during a few weeks to prevent re-occlusion.
When for some reason, it is not possible to restore the duct, due to trauma, oncological cases or very fibrotic ducts, a new channel can be opened in the inner corner of the eye with a Jones tube.
Patients leave hospital the same or the next day and should avoid strenuous activities, to prevent unnecessary nose bleeding.
For patients unfit for general anesthesia, there are other possible surgical approaches and managements.
A wide spectrum of tumors and pseudotumors (inflammatory disorders) involve the orbit. Their approach may require a handful of different medical fields, with Ophthalmology as pivotal speciality. My role as Maxillofacial Surgeon is to perform biopsies, tumor removal, orbital decompression, orbital and eyelid reconstruction.
Orbital tumors and inflammatory diseases do not have specific symptoms. They may present with proptosis (eye bulgidng), eye redness, eye pain, visual impairment, diplopia (double vision), eyelid ptosis, epiphora (constant basal tearing), headaches and/or nasal obstruction.
Imaging with CT scan and MRI are key for evaluation. While fine needle biopsy may be faster and cheaper to obtain, and useful for benign/malignant differatiation of orbital masses, a final diagnosis usually requires an open biopsy, in particular for bone, neural tumors and lymphomas.
The most common orbital tumoral masses include:
There are two main categories of inflammatory orbital diseases:
It is an autoimmune mediated thyroid hyperfunction. Approximatively 25% to 30% will develop an inflammatory orbit and eye disease, named Graves´ orbitopathy, Graves´ ophtalmopathy or thyroid eye disease. It is classified in three severity categories: mild, moderate and sight-threatening. It impacts negatively the quality of life, even in mild and moderate disease.
In Graves´orbitopathy there is an abnormal growth of adipose (fat) and muscle inside the orbit, which is a bony non-distensible cavity. Graves`s disease is classified in three severity categories: mild, moderate and sight-threatening. It impacts negatively the quality of life, even in mild and moderate disease. The growing tissues push the eye outward through the orbital natural opening, leading to proptosis (eye bulging), eyelid retraction and incapacity of eyelid closure leading to corneal dryness and consequently a corneal ulcer (sore). Besides changing the light refraction and visual power, it represents an open door for a severe eye infection.
The impaired muscle activity and unbalanced eye axis may lead to double vision. Optic nerve compressing by the growing surrounding tissues is a sight-threatening event and needs expeditious medical and surgical care.
Patient will probably present other hyperthyroidism signs such as tachycardia, excessive sweating, diarrhea, enlarged neck.
General recommendations:
The first and important active behaviour patient can do on their own: quit smoking and adopt a healthy lifestyle to reduce cholesterol.
Thyroid hormonal control is of paramount importance, as well eye ointment with artificial tears and gels when dry eye is present, therefore prompt counselling with Endocrinologist and an Ophthalmologist.
According to your disease activity and severity, the multidisciplinary medical team may decide for corticoid treatment and/or immunomodulatory drugs or in very selected cases radiotherapy.
In case of sight threatening Graves’ ophthalmopathy, without sufficient response to medication, it must be quickly referred to a surgeon, for a prompt orbital decompression to reduce the pressure on the optic nerve. It is usually done endoscopically through the nose, but in severe cases can also include external approach to the lateral orbital wall.
In case of inactive or stable disease, rehabilitative surgery may include eyelid surgery and orbital decompression as needed or required.
If you think you might have Graves´ disease or orbital tumor, please write to us so we can provide your multidisciplinary evaluation.
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At Faces, we offer a wide range of specialized services in facial health. Our highly qualified team is ready to meet your individual needs. In our clinic, you will find a global and comprehensive approach to facial and neck surgery, achieving results beyond restoration.
We provide treatments for conditions such as temporomandibular joint dysfunction, orthognathic surgery, salivary gland problems, neck conditions, snoring and sleep apnea, tear duct and eyelid issues, facial fat grafting, and trauma-related injuries.
Our dedicated team is here to answer all your questions and provide the most suitable treatment for you. Schedule a consultation with us today and discover how we can help you.
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