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. 1998 Jun;82(6):666–675. doi: 10.1136/bjo.82.6.666

Frequent association of delayed tear clearance in ocular irritation

P Prabhasawat 1, S Tseng 1
PMCID: PMC1722639  PMID: 9797670

Abstract

AIM—To explore the pathogenic role of delayed tear clearance.
METHODS—By comparing 10 patients with punctal obstruction and 20 asymptomatic normals, delayed tear clearance was diagnosed in 70 patients without apparent punctal obstruction using fluorescein clearance test.
RESULTS—The majority were older (71.4 (SD 1.2) years) and women (66%). Frequent complaints included redness, itching, mucus discharge, and crusting, which tended to be worse upon awakening. Common associated problems were medicamentosa (13%), drug induced pseudo pemphigoid, ocular hypertension (27%), and glaucoma (7%). Topical non-preserved 1% methylprednisolone resulted in subjective (83%) and objective (80%) improvement and resolution of delayed tear clearance (87%).
CONCLUSION—These results indicate strong association of delayed tear clearance with intrinsically and extrinsically generated ocular surface inflammation. The presence of delayed tear clearance may set up a vicious cycle to aggravate the existing inflammation. Future prospective studies are needed to delineate the pathogenic role of delayed tear clearance in various ocular surface disorders.

 Keywords: medicamentosa; ocular irritation; tear clearance; tear turnover

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Figure 1  .

Figure 1  

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Representative fluorescein clearance test (FCT) results of normal tear secretion and clearance (a, b), severe aqueous tear deficiency (c, d), mild aqueous tear deficiency (e, f), unilateral (left eye) delayed tear clearance (g, h), and bilateral delayed tear clearance (i, j). For each case, six sets of Schirmer paper strips were used in a period of 30 minutes, with one set per 5 minute interval. For each set, the first and second strip was obtained from right and left eye, respectively. The detail of how FCT was performed is given in the Methods section. The entire six sets of strips were taped onto the record card with the wetting length marked by pencil (left panel), and the fluorescein intensity can be better appreciated when photographed under blue light (right panel).          

Figure 2  .

Figure 2  

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External photographs of a representative case with delayed tear clearance showing no apparent obstruction at the punctum (a). The corresponding fluorescein clearance test (FCT) is shown in Figure 1(g) and (h). For comparison, another representative case with delayed tear clearance showing punctal obstruction (b), for which the corresponding FCT is shown in Figure 1(i) and (j). The remaining photographs illustrate the typical appearance of a swollen punctum yielding a slit-like appearance (c), the subcutaneous oedema of the adjacent skin (c, d), bulbar conjunctival injection preferentially in the inferior aspect (e), and tarsal conjunctiva with a mild papillary response (f).

Figure 3  .

Figure 3  

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External appearance of case example showing diffuse conjunctival injection of both eyes (a) which was also preferentially distributed in the inferior tarsal conjunctiva with a mixed papillary and follicular response (b) and the entire bulbar conjunctiva (c) before the use of methylprednisolone. After treatment for 2 weeks, the entire bulbar conjunctiva became white and quiet (d). Fluorescein clearance test revealed marked delayed clearance of fluorescein (e), which was markedly improved after treatment (f).

Figure 4  .

Figure 4  

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Hypothetical scheme of the pathophysiology of delayed tear clearance. Delayed tear clearance can be induced by ineffective or decreased blinking (functional block) or mucosal inflammation and oedema in the nasolacrimal drainage system (partial anatomical block). The former is contributed by such risk factors as old age, female sex, decreased corneal sensitivity, and lid laxity including floppy lids. The latter can intrinsically be generated by allergy, atopy, rosacea, and meibomian gland dysfunction, or extrinsically caused by medication toxicity. A vicious cycle can form between delayed tear clearance and mucosal inflammation and oedema leading to ocular irritation, medicamentosa, drug induced pseudopemphigoid, and steroid induced ocular hypertension.

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