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The common complaint of a watering eye may be caused by a variety of problems, including lacrimal hyposecretion, lacrimal hypersecretion, or blockage of the lacrimal drainage system. This system is a complex membranous channel whose function depends on the interaction of anatomy and physiology. Effective tear drainage depends on a variety of factors, including the volume of tear secretion, eyelid position, and anatomy of the lacrimal drainage passages. Epiphora is defined as an abnormal overflow of tears down the cheek. The patient with symptomatic tearing may have a normal lacrimal drainage system overwhelmed by primary or secondary (reflex) hypersecretion or a drainage system that is anatomically compromised and unable to handle normal tear production. On the other hand, a patient with partial drainage obstruction may have a concomitant reduction in tear production and therefore be completely asymptomatic or may even suffer from symptomatic dry eye syndrome. Epiphora is determined by the balance between tear production and tear drainage, not by the absolute function or dysfunction of either one. The causes of lacrimal drainage problems can be divided into two categories: anatomic and functional. Anatomic obstruction refers to a mechanical or structural abnormality of the drainage system. The obstruction may be complete, such as punctal occlusion, canalicular blockage, or nasolacrimal duct fibrosis, or partial, caused by punctal stenosis, canalicular stenosis, or mechanical obstruction within the lacrimal sac (i.e., dacryolith or tumor). In patients with functional obstruction, epiphora results not from anatomic blockage but from a failure of lacrimal drainage physiology. This failure may be caused by anatomic deformity such as punctal eversion or other eyelid malpositions, but can also result from lacrimal pump inadequacy caused by weak orbicularis muscle action. It is helpful to determine whether the patient’s complaint is true epiphora or a “watery eye.” Detailed history-taking and careful examination will help direct the evaluation of a tearing eye. A host of clinical tests have been described, and the selection of appropriate tests will depend on the initial history and ophthalmic examination. 13-1-1 History-Taking. Any clinical evaluation should begin with a thorough history. A complaint of watery eye does not necessarily imply a lacrimal drainage problem.

Facial palsy can devastate patients. Facial appearance can be grossly distorted by the sagging of half the face, often accompanied by drooling of food and saliva from the paralyzed lip. Blurred vision and ocular pain from exposure and dryness may interfere with the patient’s ability to perform an occupation or interact socially. Many patients with facial palsy experience depression or severe discouragement. Effective management of ocular problems by the ophthalmologist can have a profound effect on the patient’s rehabilitation. The ophthalmologist managing facial palsy should be aware of wide-ranging choices in the medical and surgical armamentarium to treat facial palsy. This chapter describes the varying clinical dimensions of facial palsy so that treatment can be individualized for effective management. The facial nerve (cranial nerve VII) has four important functions: 1. The facial motor nucleus controls muscles of facial expression, including the orbicularis oculi. 2. The superior salivatory nucleus sends parasympathetic fibers for lacrimal gland secretion and salivary secretion. 3. The nucleus solitarius receives sensory fibers of taste for the anterior two thirds of the tongue. 4. The trigeminal sensory nucleus receives sensory fibers for a small portion of the external ear. Facial motor fibers constitute about 58% of the 7,000 fibers of the facial nerve, while preganglionic fibers for tearing and salivation represent about 24%. The facial nerve leaves the cerebellopontine angle caudal to the trigeminal nerve adjacent to the nervus intermedius and then enters the internal auditory canal of the temporal bone. Large lesions of cranial nerve VII or VIII may cause loss of corneal sensation from pressure on the trigeminal nerve. The 30-mm course through the temporal bone is the longest interosseous course of any cranial nerve, which makes the facial nerve vulnerable to swelling. Three branches leave the facial nerve within the temporal bone. The first, and most important, arises at the geniculate ganglion just as the nerve makes a sharp bend, or genu, to head posteriorly. These fibers for lacrimal and palatine gland secretion constitute the greater superficial petrosal nerve carrying lacrimal secretory fibers to the pterygopalatine ganglion.