During this live webinar, we will discuss eyelid causes of a watery eye. A systematic approach to categorising such causes will be presented and key details of what symptoms and signs to look for will be outlined. Questions received from registration and during the webinar will also be discussed. (Level: Intermediate and Advanced)
Lecturer: Dr. Raman Malhotra, Ophthalmologist, Corneoplastic Unit, Queen Victoria Hospital, East Grinstead, United Kingdom
RAMAN MALHOTRA: Hi there, everyone. So welcome, everyone, to this talk on eyelid masqueraders of epiphora. So I think the first thing I want to share with you is a picture of Sergei Rachmaninoff, famous 20th century composer. He has many eyelid factors that would explain why he had uncomfortable eyes and would have had watery eyes. He has lower eyelid sag, he has an entropion, he was retraction, and he probably also has some inturning of his upper eyelid, what I would term meibomian gland inversion. If you compare with him younger, you can see they were not there. The purpose of this talk is to help you identify eyelid components that are contributing to a patient’s watery eye. So one of the most important things to remember about assessing epiphora, watery eyes, is that quote by Lord Kelvin, if you can’t measure it, you can’t improve it. So just as we measure acuity with a vision chart, likewise you can just look at epiphora and say, you have a watery eye, it’s bad, it’s severe, unless you have some form of quantifying measure to gauge that by. And that’s important, because then if you want to see whether you’ve improved it, you need some way of comparing before and after. So I’ve shared with you a document, a publication that we wrote, a study we undertook. We developed a TEARS grading score which I have found really invaluable in documenting the severity of someone’s epiphora. In a way this is not new, we’ve traditionally used a score to record how many times an individual wipes their eye. And that’s an important measure, because no patient is going to want to put themselves through surgery if they’re wiping their eye twice a day. But if they’re wiping them ten times a day, their threshold to wanting some intervention is going to be quite low. So it’s not just about number of times you wipe your eyes, of course. The impact of watering on your life is important. So this grading scale actually uses the mnemonic TEARS. T is the number of times you’re wiping your eye. T1, less than twice a day. T2, wiping two to four times a day. And the relevancy is that someone who is a T2 is less likely to have surgery or a procedure. And it often phlebotomies the cause of their epiphora as well. So it’s relevant partly for diagnosis and also for management. The E, the effects, it may just be causing a nuisance, that would be E1, or that may be also causing soreness of skin, when they’re wiping, tears are running down their cheeks, that’s an E2. Requiring repeated attendances, E3. Causing stickiness or matting of their lashes, that’s an E4. If it’s causing pain, swelling, recurrent infections, that’s an E5 and 6. Then the activities that epiphora can influence, that’s the relevance, because someone may want a resolution because it’s actually affecting a key component of their life. It may not be troubling them otherwise. So if it’s affecting reading, driving, when walking outdoors or hobby outdoors, wearing glasses, ability to apply makeup, any key hobbies, this is usually scored on an accumulative basis, so the number of activities just gives you an idea of the impact it’s having on their life. The R score is reflex tearing. So I’ll cover this later on, but believe it or not, a significant proportion, maybe up to a third of patients who come to you with a watery eye will actually have reflex tearing as a component, if not the entire cause. So the important thing is to establish what would prompt reflex tearing. So activities of reduced blink rate. Is the watering worse when reading, watching TV, using computers, or in the evening? These are all activities or times when our blink rate reduces. So that gives you a clue as to whether this is a reflex tearing component. Is the watering worse with air conditioning or in dry environments? Again, there’s a reflex tearing factor to consider there. Is it worse outdoors or windy weather? Again, that would be due to reflex tearing. And are they aware of gritty, itchy, sore, or burning eyes? That could allude to the possibility of a dry eye which would cause reflex tearing. So it’s not necessarily an aqueous deficiency. Remember, there are two types of dry eyes, deficiency and evaporative. S is an objective score the patient can report back after any intervention you undertake, whether that’s giving them drops or carrying out eyelid surgery or even lacrimal surgery. So it’s a useful basis. And I think the principles of this are important to incorporate in your history-taking, in your assessment. But if you printed out the PDF of this chart and gave it to each patient with a watery eye, they fill in when they’re waiting in the waiting area, it also helps save some time. So when you think of the causes of epiphora, I like to think of it as a Mercedes car sign with three main components, which are not necessarily mutually exclusive. The first is an outflow dysfunction. So what that means is any form of obstruction, even partial obstruction or stenosis. And that can be at the level of the puncta, the canaliculus, I.E. internal opening, and nasolacrimal duct. That’s something you’ll have to examine to determine. And I’m not going to cover the whole lacrimal process, but that’s the obvious start. The second component is eyelid malposition or some form of pump failure. So the concept of the lacrimal pump is the concept that when we blink, our eyes close, but the puncta is pulled in medially into the tear link which sits in the caruncle. When that pulls in, the corner muscle contracts and that actually dilates the lacrimal sac. So you get a pipette effect, where suddenly you get a vacuum, and tears are then dragged into the canaliculus and pumped into the sac. That pump function requires a normal functioning eyelid, so your blink needs to be complete and powerful. As you get older, spontaneous blink weakens, and so your punk function weakens. Any facial injury will worsen the pump function. Age-related change will further weaken or influence how your eyelids close and how that puncta is pulled into that medial tear lake. Then your malposition affects how the tears are directed medially do the tear lake. It’s important to look at that concept and assess your eyelids with that in mind. The third component is reflex tearing. So remember, this is an evaporative dry eye component that will cause secondary reflex tearing. That can be any incomplete eye closure that causes an exposure-related drive to prompt tear production. Maybe inflammation on the ocular surface. And it may be conjunctival. Multifactorial epiphora encompasses all three of these components. Actually in general no patient has a purely single component. Most of us will have more than one element of these three issues that cause our epiphora. In age, you often accumulate all three. And it’s often a sort of diagnostic challenge to work out what’s the most significant component in a patient’s epiphora. So two studies, one from Toronto — no, not Toronto — Ottawa. And the one that we did, looking at patients attending a lacrimal clinic and looking at their causes, what was identified is that up to a third of patients actually have reflex tearing. So these are patients who were referred to a lacrimal clinic with a view to having eyelid surgery — or not eyelid surgery but surgery of some sort but were found to have reflex tearing as their significant component. And what that highlights is that it’s actually sometimes difficult to diagnose. It can be missed. And the problem is that if you then do lacrimal surgery to increase drainage, you will worsen reflex tearing. And so you can have a successful DCR operation, it may be patent to syringing, there will still be watering because you worsened their reflex tearing and they will deem that procedure as being a failure when it may have been a surgical success but it was basically the wrong operation. And there’s a saying, you will get a much better result doing the right procedure badly than the wrong procedure beautifully. So it just adds to the importance of trying to diagnose the components prior to sort of selecting a procedure. And in these sort of patients with multifactorial epiphora, generally the first step would be to treat reflex tearing, and treating meibomian gland dysfunction, then depending on what’s present in the wellbeing of the patient, the suitability to general anesthesia, local anesthesia, you probably correct eyelid malposition, again improving blink and retraction or ectropion, et cetera, and lastly, outflow dysfunction. As people get older, they may need eyelid surgery or treatment and will cope with a level of T2, wiping to to four times a day, if it means they don’t have any more surgery, which incidentally may worsen their epiphora if it increases reflex tearing. So another important paradigm is to recognize that with age, it’s very difficult to cure an individual of all of their watering, because they will have maybe an element of wetting in very dry or windy, cold conditions due to reflex tearing. And so it is often a lifestyle discussion, dealing with that water intake, caffeine, alcohol, any other factors that may increase reflex tearing. Okay. So that is a long section just talking about the aspects that cause epiphora. I didn’t give you a list because you can pick up any textbook and look for a list. This is a sort of principle approach, to look at the concept. So here are some tips. So looking at the laterality, medial spillover, lateral spillover, central spillover, it’s very useful in helping direct you to what would be the eyelid component. So a medial spillover, tears running down the inner course, that doesn’t really help you insofar as any form of obstruction, any reflex tearing, or even medial malposition of the eyelid, will give you medial spillover. So it’s useful to note, but it’s not going to be purely diagnostic. Lateral spillover, however, can be more specific. It will often suggest I have a lower eyelid laxity, lower eyelid retraction, or even upper eyelid wick syndrome, which I’ll talk about. So it’s really important, lateral spillover will be more an eyelid component, and think of laxity, retraction, or even upper eyelid hooding, which causes a wick. If it wets the upper eyelid as well as lateral spillover, then you are more likely dealing with upper eyelid wick syndrome and upper eyelid skin hooding. When the patient complains their tears only spill over when bending forward and otherwise not spilling over when they’re looking straight ahead, then you’re more likely to be dealing with a lower eyelid problem, either an intimate ectropion, just remember, a classic example, Doctor, when I’m doing my gardening it spills over, but when I’m watching television or any other activities, I don’t have any watering. That bending forward, think lower eyelid. And there’s a term called plerolacrima where the tears cause blurring but they’re not actually spilling over. In these patients the main things to think about are conjunctivochalasis, raised lower eyelid, or kissing puncta, which I’ll talking about. So if a patient complains they’ve got constant epiphora, both indoors and outdoors, that is to say, a T4 indoors and a T4 outdoors, then most likely in general you’re going to be dealing with some form of obstruction, either from the punctum or nasal duct. In general, sometimes you may be fooled, but in general reflex tearing will not give you constant epiphora both indoors and outdoors. Reflex tearing or dry eye component will give you more epiphora during activities of reduced blinking or in windy environments outdoors, eyelid malposition would tend to be worse outdoors compared to indoors. Okay. So, principles of those masqueraders. So I would consider them in these five categories. So the first would be ocular surface exposure, blink lagophthalmos. Misdirection, capillarity, tear film instability is the next. Mechanical irritation and secondary reflex tearing. And I’m going to cover some very subtle things that I suspect you may not have considered to date. And then we’ll talk about that lower eyelid punctum which is patent but dysfunctional. And lastly we’ll cover the discharging eye. So ocular surface and blink lagophthalmos is probably the most common group that you’re going to encounter. What I mean by blink lagophthalmos, it’s not lagophthalmos where you blink. It’s what one does when you’re not asked to blink, you’re just blinking without being told. And that reduces as the day progresses, and becomes less frequent when you’re concentrating, and is a major cause of reflex tearing. So this is a patient, she’s had eyelid surgery, and she’s got a watery eye. She may appear not to have any eyelid problems. But you can see she’s got lower eyelid retraction laterally in the right eye. And when she gently closes her eye, she has probably about a millimeter of lagophthalmos. You may say that’s not lagophthalmos. Actually if she’s gently closing and she’s got a small gap, actually during spontaneous blink she probably has a gap of 5 or 6 millimeters. One clue is when there is redness within the aperture but not behind the lids, this redness within the aperture is a good clue for reflex tearing. So she has a watery right eye with lower retraction, blink lagophthalmos and a sliver of generate closure lagophthalmos. How do you pick that up? One of the things is not to tell them to blink but to watch them. A patient like this, you watch his blink on the slitlamp, and you can say, I’m just going to examine you, don’t say I’m watching you blink. And you see every few blinks, his blink is incomplete. Sometimes it’s a flicker, a twitch. And sometimes it comes down halfway. And the staining, the punctate staining that a patient like this will have, inferior punctate staining is a clue. If you see inferior punctum staining, think lagophthalmos. Lagophthalmos is a Greek word, it comes from — lagos is the wild rabbit, I think the Greeks said basically — I think it’s known that rabbits don’t sleep with their eyes completely closed. And the Greeks said the wild rabbit sleeps with an eye open. So in literal terms it’s the eye of the rabbit. And actually they probably had it right in terms of lagophthalmos and nocturnal lagophthalmos is a big factor in people’s dry eye symptoms, discomfort in the morning or soreness first half of the day, just not closing your eyes at night. And it’s very common. So it’s really important to look and pay particular attention for blink lagophthalmos. And then so if you identify this, then set your patient on the pathway of treating their evaporative dry eye. The next group would be misdirection, capillarity. Classic Rachmaninoff type eyelid, lower eyelid sag, this patient will have lateral spillover. As you can see on the right here, this patient has right epiphora and the fluorescein in the middle picture shows tears trickling laterally. The bottom picture shows he’s had a tightening. He hasn’t tightened it equal to the other side. And there is a small degree of spillover still, but it’s significantly better. But this sort of configuration, this appearance of lateral sag is a good reason for having lateral spillover. Wick syndrome is where the upper eyelid will contribute. Upper eyelid wick syndrome is where you have a hooding of skin causing a wick or a capillarity misdirection of tears. It typically causes soreness and wetting also of the upper eyelid. That’s a very important distinction. Remember when — so we published this, it’s now about 11 years ago, and remember, if you have a syndrome, there has to be a diagnostic criteria. So top two pictures are examples of the hooding that would be typical in a patient who complains of lateral spillover and wetting. The middle pictures are hooding. And then on the right, this patient has had a brow lift and a small blepharoplasty. In a patient with a watery eye and lateral spillover, you can’t say that’s wick syndrome unless you’ve done a fluorescein test and see there is also misdirection of fluorescein onto the upper eyelid. So typically, these patients should be patent to syringing, there shouldn’t be any other cause, but if there’s misdirection of fluorescein onto the upper eyelid as well as laterally then it’s upper eyelid wick syndrome as a cause. These patients typically need that hooding corrected to reduce that wicking of the upper eyelid skin hood. Okay. Conjunctivochalasis, typically you’ll see it medially sitting over the punctum as a hood. That it comes from loose tenons in the area. This is effectively acting as a lid obstructing tears. However, actually what’s more subtle and perhaps more common is the other cause of how conjunctiva can cause epiphora. It can interfere with the tear meniscus and cause spillover even centrally because it doesn’t sit very well. If you pull the lid away from the globe, you’ll see in these patients that loose conjunctiva sits quite high and obliterates of inferior fornix. That inferior fornix is a very important component. Why do we have fornices? One reason is to allow a reserve of tissue to allow us to look up, down, left, and right. If we didn’t have that, then, you know, it would restrict full movement of your eyes. But one of the other reasons why you have a fornix is a tear lake. So tears are produced by the lacrimal gland and are on the lid margin, that’s the tear meniscus. And that tear meniscus is fed by the tear reservoir which is in the fornix. And the upper fornix has a tear reservoir as well as the lower fornix. Now, when you obliterate that fornix and you have loose conjunctiva, patients with conjunctiva typically complain of dry eyes as well as water. You can get lid parallel conjunctiva folds which can cause wicking to misdirect tears laterally. So it’s an important thing to look for both in terms of an explanation for dry eyes and also misdirection of tears laterally that may not be simply due to lower eyelid laxity. Now, I’m going to raise a very interesting study that was carried out ten years ago in Miami, where they took the tear film and — or the tear meniscus and pipetted off that tear meniscus, and then measured how quickly it returned in seconds. And in a normal individual, the tear meniscus is returned within three seconds. Now, you know that the tear production from the lacrimal gland is in micromoles. So that tear meniscus returning in three seconds cannot be because of direct tear production from the lacrimal gland. So what they then did was take a group of conjunctivochalasis patients and looked to those who were symptomatic of dry eyes and those that were not symptomatic. And the ones that were symptomatic, that’s itching, sore, foreign body, gritty, watering, burning, we saw that without symptoms, the wick symptoms, once you pipetted the tear film, their tear meniscus took ages to return, it was a very delayed return. And if I take you back to that loose conjunctiva obliterating the fornix, they have basically no fornix tear reservoir. So it took a lot longer for them to replenish their tear film. Imagine reflex tearing, if you evaporate your tear meniscus or your tear film, you are going to take longer to restore that, you’re going to get dry eyes as well as a watery eye. There’s conjunctivochalasis patients whose tear film returned faster. What they did then was they reconstructed the fornix, deepened the fornix, and after surgery they repeated that test and found that the tear meniscus returned just as fast as in normal individuals. And therefore they concluded that this has occurred because the tear reservoir, that fornix has been restored, so you’ve improved the reserve of tears that are on the surface. What they did at the time was they recessed down the loose conjunctiva and resurfaced the defect with amniotic membrane. But effectively what they were doing was deepening the fornix. So when you have loose conjunctiva, you could pin that down, deepen it. So you’ve seen the post-fornix reconstruction. The tear films returned very quickly. And their symptoms also resolved in the majority of patients. So even simply deepening the fornix in these patients, so we did a similar study, it’s been submitted for publication. Just recessing the retractors and reattaching them to the loose conjunctiva to deepen that inferior fornix can benefit people with conjunctivochalasis with dry eye and watery eye. We set a standard, there had to be at least 70% improvement in scores. Anatomically there had to be a deeper fornix in at least 90 patients. We took all the patients that did not improve just with conservative treatment and were willing to have some form of procedure, and we graded the conjunctivochalasis, remember, grade 1 is a single fold, grade 2 is where there’s two or more, and it’s up to the tear meniscus but not as high, and grade 3 is multiple folds that are higher than the normal tear meniscus. And we graded these patients with the TEAR score. What we found in 18 eyes, all of whom had shallow fornices with a mean grading of 1.7 of conjunctivochalasis, generally they had two folds, not as high as the tear film, and this was either diffuse, the entire length of the eyelid, or in the middle, and sometimes nasal, some temporal. They all improved their fornix depth. This is a picture of someone four months post-surgery. You can see before there’s loose conjunctiva and then after they’ve got a deeper fornix. And just — I won’t bore you with these results, but bottom line, if you look at the T scores, they improved from an average of 3.7, so remember, 4 is wiping more than ten days a day, 3 is wiping four times a day, to about 1.3. So that’s like wiping two to four times a day. Remember, these are multifactorial patients, so they will have other elements. Their E scores improved from 1.5 to 0.5. Activity scores improved from A2 to 0.2. Before, affecting at least two activities. After that procedure, very little effects on activities. And then dry eye scores and reflex tearing scores improved from a mean of 2.3 to 1. In terms of a two-point improvement, how many patients improved from A3 to A1, these were the scores. So 73% improved 2-point minimum score, then E scores, 36%, A scores 64%, same for R scores. So the point being, looking at that tear reservoir, conjunctivochalasis, not just excising it but deepening the fornix, you will get an improvement in dry eye and watery eye scores. An important lesson to learn from this is in that patient with a water eye and a dry eye, with conjunctivochalasis, there is no benefit in putting punctal plugs, because you will just cause excessive watering. They have no reserve to retain the tears that will be prevented from leaving. In these patients, you should correct their conjunctivochalasis and then you are in a better position to manage their aqueous tear deficiency dry eye. And then therefore you can consider punctal plugs. It’s an important algorithm, if you have conjunctivochalasis, don’t go for plugs first, treat the conjunctivochalasis and then treat the aqueous deficiency dry eye. Okay. So we’re going to go to question 1 at this stage. So question 1, which of the following causes is incorrect? Lateral eyelid tear spillover is typically due to lower eyelid laxity, lower eyelid retraction, upper eyelid wick syndrome, or lacrimal sac mucocele. So which one of these is incorrect? Okay. So the incorrect answer was a mucocele. Generally if you have lateral eyelid spillover, you are looking at either lower eyelid laxity, lower eyelid retraction, or even upper eyelid wick syndrome, okay? So generally an obstructed lacrimal system is not going to give you lateral spillover unless there is a cause. Okay. And moving on to question 2. Which of the following causes is incorrect? Plerolacrima, remember, a raised tear film that may cause blurring of vision but no spillover, is typically due to: Lower eyelid ectropion, conjunctivochalasis, a raised lower eyelid height, kissing puncta. Which of those was incorrect? So the incorrect answer that you should have chosen was ectropion, which would cause more spillover. But conjunctivochalasis, raised lower eyelid height, and kissing puncta would be causes of plerolacrima. Moving on, secondary reflex tearing. I want to talk to you about the issue of meibomian gland inversion but without lash contact where the posterior lamellar glands are inverted. It may appear otherwise normal. In these patients, when you get them to look up, you may think there’s a normal lid margin, but there isn’t. This patient here, the top two pictures, before. And then after, you can see a bit more of the lid margin, whereas before you couldn’t. Now, I’ll give you another example. The left picture, patient is looking up. You may think that the eyelid margin looks normal, but actually with a cotton tip everting the lid, you’ll see the meibomian gland. They will benefit from having their upper eyelid turning corrected. The left picture shows what may appear as a normal eyelid but actually everting the lid, they’ll be more comfortable. You’ll see the meibomian gland orifices. Meibomian gland inversion is something that is commonly missed, unrecognized, but it’s a very important component of ocular discomfort, even blepharospasm and can cause epiphora, reflex tearing. It causes a subtle superior corneal staining. Remember when you put fluorescein, you don’t examine straight away, you give it a minute or some time before you examine the patient. And look for the subtle staining on the superior limbus. We’ve published a paper looking at patients with facial palsy. Remember, with facial palsy, they get an acceleration of meibomian gland dysfunction. They actually develop meibomian gland inversion more commonly than most. What we found was, in these patients with epiphora and MGI, I call it MGI, treating that with repositioning, their epiphora scores improved from T3 to 4, to T2. Effects, 1.7 to 0.4. Activity scores, affecting 2.2 on average. After surgery, 0.3. And their reflex tiering, again, before, 1.8, to 1. And the big important learning important is, when you have a patient with epiphora, look for MGI, meibomian gland inversion. This is why I suggest that Rachmaninoff had an element of that, you can see the lashtosis. Before you think about doing lacrimal surgery on patients with facial palsy, after you’ve corrected their eyelid, think upper eyelid meibomian gland inversion. So question 3. Which of the following statements about upper eyelid meibomian gland inversion is correct? So that should have “inversion.” Upper eyelid meibomian gland causes ectropion, typically causes inferior corneal punctate staining, is an underrecognized cause of ocular discomfort and epiphora, or is diagnosed only by using a cotton tip test. So which of those statements is correct? That’s correct. So it’s an underrecognized cause of discomfort. It will be an entropion, not ectropion. It will typically cause superior punctate staining. The cotton tip test, you may find it’s present in someone who is not too symptomatic. So there’s not really a lot of benefit in correcting MGI in that sort of patient. Okay. So moving on now, the last few aspects of the eyelid causes, 3-snip punctoplasty, we should be beyond the era where you see these large punctoplasties. The problem with doing these large slit-like openings is that pump function that I mentioned earlier, you will interfere with the lacrimal pump function by reducing the ability for that pipette function. With a large punctum like this, you will not get a complete seal. So it’s important to try and stay as physiological as possible. Second aspect of the patent punctum is that punctum which is kissing the upper punctum. You see both upper and lower puncti are kissing. We published a paper a number of years ago on kissing puncta, again, reiterating the same observations from the first few papers. The triad that you will see is that you typically will see medial ptosis and fat prolapse, a patient with horizontal laxity, and punctal acquisition. On the right, there’s a gap. On the left, a close proximity of upper and lower puncti. Slightly more bulge with the medial fat pad on the left than the right side. Here is a video showing a more obvious one. So you can compare the right, which doesn’t have kissing puncta, and the left, which does. And you see there’s more fat prolapse above that. And effectively when this patient blinks, they’re occluding their puncti just because it is in opposition with the other punctum. Let’s go on to question 4. So which three of the following are features usually present in kissing puncta? Medial ptosis with fat prolapse, horizontal lower eyelid laxity, punctal apposition? Or upper eyelid entropion? So which three are present in kissing puncta? The first three are usually present. Upper eyelid entropion, you wouldn’t expect to see that. Fat prolapse may contribute to an inturning, but entropion is not usually a feature. Okay. So the next thing to look at is what was coined megalocaruncle. Remember, there’s a saying, if you don’t think about it, you won’t diagnose it. In patient with unilateral or even bilateral epiphora, look at the size of the caruncle. What can happen is this caruncle can displace the plecha and actually influence the way tears enter the punctum. The plecha may act to semi occlude the puncta. Typically in patients with lower lid laxity. This was published 20 years ago, and she reported I think in about 26 patients who underwent a partial carunclectomy, they improved from mild to significant, there was no grading, but I think 77% of patients reported a significant improvement. Remember, again, these will have multifactorial epiphora. This patient has lower eyelid sag, so there will be other components. So it will be difficult to cure someone just by treating their megalocaruncle. So it’s something to consider. Let’s go on to question 5. Which of the following statements about megalocaruncle is correct? It causes epiphora by causing lower eyelid ectropion. Carunclectomy of a symptomatic megalocaruncle can improve. Which of those statements is correct? Yes, the second statement, the carunclectomy of a symptomatic patient. It may not be present in floppy eyelid syndrome, it’s not an associated feature. Okay. Synkinesis now. Synkinesis following patient palsy, the classic synkinesis is causing epiphora, crocodile tears. That’s an eyelid cause. The reason I’m mentioning that is one of the typical treatments we do is Botox to the lacrimal gland for this cause. Usually it’s for patients’ bothersome symptoms of epiphora when eating, okay? So we usually ask them, what about your eating symptoms, they’ll say, yes, much better. But we evaluated the outcomes of Botox for crocodile tears using the TEARS score. What we found is in two-thirds of these patients, their R scores, reflex tearing scores, also improved. So remember, that means epiphora with reduced blink rate, air conditioning, outdoors, windy weather, dry eye symptoms. So basically, when you do Botox with these patients, you’re going to also improve their reflex tearing outdoors and in air conditioned environments in addition, over and above the improvement that they are hoping for just when eating. So it’s useful to bear that in mind. But I want to end on the kissing puncta and synkinesis of the medial puncta. The medial canthus, all the facial nerve branches don’t just come from temporal medially but one or two branches come from medial. And that would explain why external DCR is associated with a weaker blink sometimes. You see this patient has had a cystectomy, she’s got a weaker right blink than left. It’s less than 10% of patients, but up to 20% [indiscernible] permanent. So bottom line, if you’re doing an external DCI, you need to tell patients that the blink may be weaker after. And the relevance that have is obviously the pump function, because that will eliminate the — or weaken that pump function. And what I want to talk to you about is the buccinator synkinesis. This was published by an ophthalmologist many years ago. You see this patient here, I’m asking her to blink. And she’s got synkinesis. At the same time the buccinator muscle in the inner cheek, she’s blinking and that’s pulling in. But on the right side, her cheek is not pulling in. So when people have buccinator synkinesis, they get cheek biting. What’s interesting is they also can get synkinesis, they get kissing puncta. So this reminds me or this highlights the valuable work recently, the description of new insights into the lacrimal pump function in terms of a sphincter-like muscle around the lower canaliculus. He described Horner’s muscle in more detail. You’re probably weakening the peristalsis of the tears going down the canaliculus. It also highlights maybe we should be cutting down on the number of punctal procedures we do. You see when she blinks, she has kissing puncta on that left side. You see the right side here. When she blinks, she has a normal blink, there’s no kiss, okay? I’m going to go back and show you her left eye, this is the eye that had a facial palsy. When she blinks here, you see how the eyelid sort of kisses and separates slower compared to the left, okay? And when you watch her, this is on the left, you see that she’s got signs of synkinesis, a smaller eye. When she blinks she’s got a pulling-in of that lower eyelid. So you can see that movement more. Now, she had a T4, she’s wiping her eyes more than ten times a day, more outdoors than indoors. It’s only occasionally watering when she ate. She was patent to syringing. She wasn’t really a candidate for Botox to her lacrimal gland. So instead, this is a chart to show you I did 1.25 units of Botox to the lower punctum. I didn’t treat her lateral gland. I treated some of her synkinesis. She reported a 50% improvement in her epiphora. She said sometimes it still waters but there is days now when it doesn’t water. And when her movement, she was troubled by the movement of the synkinesis, that improved by 90%. But her watering improved just by reducing the synkinesis. So lastly, discharge. The watery eye with discharge, obviously the cause is mucocele, lateral obstruction. But remember, think of giant fornix syndrome. With copious discharge in an elderly patient, particularly with ptosis, you’ll see the fornix, these patients will typically have recurrent or persistent discharge even after successful DCR, they often need long term antibiotics or pilocarpine iodine drops to treat infection in their fornix. And don’t forget the granuloma that may be under the upper eyelid that may be causing discharge and epiphora. This patient had a ptosis procedure and was bothered by a persistent watery eye. And this was due to the small pyogenic granuloma in the upper eyelid. In summary, I’ve talked about eyelid masqueraders of epiphora and tried to give you a more systematic approach to dealing with these. So I’m now going to stop sharing and we’re going to deal with any questions that you have. So in essential spasm, what can be the mechanism? A patient with essential blepharospasm, you should be looking for the reflex tearing component because they will have a dry eye reflex tearing. These patients sometimes even punctal occlusion helps. A good test is to see if their spasm improves. If it does, there is probably a meibomian gland inversion. Punctal occlusion with plugs paradoxically is often the first step with these patients. Next question, what’s the approach to a paralytic ectropion when the medial eyelid is involved? Well, my preferred approach to paralytic ectropion to medial is to restore the vector, some form of retro or trans caruncular. Basically restoring fixation. Now, next, can we simply excise excess conjunctivitis in conjunctivochalasis? What is the returns rate of conjunctivochalasis after surgical correction? These are elderly patients, we don’t often follow them up long term. So I don’t really have any honest answer about that. But I can tell you that certainly within two years, you don’t get a recurrence. Meibomian gland inversion, how do you treat it? If you look at the publications I’ve done, you need to do some form of repositioning. If there’s tassel curling, some sort of scrape or thermoplasty to straighten out the tassel plate. Does punctal snip surgery interfere with sphincter properties? I think it does, I would avoid it if possible. Use perforate punctal plugs if you can. Do I recommend punctal plugs, yes, in a tear deficiency, I would definitely recommend punctal plugs, yes. And that’s about it. Sorry, I sort of overran. We had one hour, I’ve reached an hour, and unfortunately I have to go as well, so I’m going to have to say goodbye. I hope you found it useful. If you have any further questions, just email it to the team and I’m happy to answer them. Okay. Thank you. I hope you have a good weekend.