Dr Ben Wild The front of the eye, excluding the cornea, is composed of the sclera (white part of the eye with large and strong blood vessels), a layer called the episclera (a clear layer above the sclera with many small and delicate blood vessels), and the conjunctiva (another clear layer again with delicate blood vessels). Frontal view of a healthy eye. Subconjunctival hemorrhages occur when one of these small, delicate, blood vessels in the episclera or conjunctiva rupture and leak blood into the spaces between the aforementioned layers. These hemorrhages are very common occurrences but usually appear as emergencies because of their frightening appearance. If the affected person has a platelet deficiency or is on a blood thinner, the time between rupture and closure of the rupture is extended and more blood seeps into the subconjunctival space. Enough blood can enter this space to completely cover the sclera. Frontal view of an eye with a subconjunctival hemorrhage. Subconjunctival hemorrhages are most common after eye surgery, after conjunctivitis, post-trauma, post Valsalva maneuver (coughing, vomiting, difficult time on the toilet, heavy lifting, etc.), but is usually idiopathic (no known cause). They are usually asymptomatic but again, appear very cosmetically concerning. Rarely, one may feel a split second of sharp pain as the blood vessel ruptures. If there is enough swelling, the cornea can cause irritation and decreased vision. In infants, it may be a vitamin C deficiency, in young patients it is usually associated with contact lens wear and in the elderly, it is most commonly associated with high blood pressure. Signs Blood seeping into subconjunctival space over the underlying white sclera. Symptoms Usually no symptoms, sometimes a split second of sharp pain when the vessel pops, if very swollen, can cause blurry vision and ocular irritation. Causes Post ocular surgery, post conjunctivitis, post trauma, post Valsalva maneuver but usually idiopathic. Risk Factors Vitamic C deficiency in infants, contact lens wear in young adults, high blood pressure in elderly. Prevention Handle contact lens insertion and removal carefully, avoid high blood pressure. Treatments · Resolves without treatment like a bruise. · Artificial tears if irritating. Subconjunctival hemorrhages are very common and look much worse than their reality. They usually do not require any treatment or investigation. They are not vision threatening but may be caused by underlying health conditions if recurrent in nature. It is important seek diagnoses and treatment for the underlying conditions.

Dr Ben Wild The lacrimal system starts with the lacrimal gland and 2 other accessory glands that produce the watery (aqueous) portion of the tears responsible for oxygen transmission, removal of debris, antimicrobial activity, and optimal optical performance. The tears then pool along the lower eyelid margin and migrate towards the nose towards 2 small holes, one on the upper lid and one lower, called the puncta. These puncta connect to the canalicular canals which connect to the nasolacrimal sac and then into the nose. That is why when you cry, your nose starts to run. Frontal view of a healthy eye with tears pooling on the lower lid (grey) flowing towards the puncta (black dot). Epiphora, or excessive tearing, and tears running down your cheeks, are signs of either over production of tears or defective drainage. Over production usually stems from inflammation, medications, or, paradoxically, dry eyes. Defective drainage often stems from improper or incomplete eyelid blinks, displaced puncta (eyelid deformities or congenital deformation), obstruction along any point from the lower eyelid margin to the nose, or weakness of the facial muscles around the eyes responsible for pumping the tears into the nasal passages (facial palsies like Bell’s palsy). Frontal view demonstrating punctal stenosis (lack of black hole on lower eyelid) with tears building up on the lower lid and overflowing down the cheek. Signs Tears running down the cheeks or upwards onto the upper eyelid, skin erythema around the eyes. Symptoms Dry eyes, watery eyes in the wind or with the cold. Causes Either excess tear production or blockage of tear drainage. Risk Factors Prevention There are no known preventative measures. Treatments (depending on the cause) · Steroid drops or pills for inflammation. · Antibiotic drops or pills for infection. · Dry eye therapy. · Dilation and irrigation of puncta. · Surgery for conjunctivochalasis or nasolacrimal duct obstruction. · Eyelid reconstruction. Although irritating, epiphora is not vision threatening unless it is due to an inflammatory cause. It will likely take several treatments and through trial and error you may be able to get relief.

Dr Ben Wild The eyelids are made up of various types of skin, muscle, glands, hair follicles and much more. Their purpose is to protect the eyes from dryness, bright lights and irritants. Frontal view of a healthy eye. Eyelid entropion occurs when, in most cases, the lower eyelids turn inwards towards the eye. This can occur due to the presence of an extra layer of skin normally found on babies (epiblepharon). It can also be due to scarring on the conjunctiva (the inner eyelid skin), or loss of muscle tone due to old age. This condition leads to the eyelashes scratching the eyes. Frontal view of entropion. The upper lid is turned inwards. Eyelid ectropion refers to a condition, where again, in most cases, the lower eyelids lose contact with the eye and pout outwards. This usually occurs due to loss of skin elasticity or muscle tone due to age, scarring of the skin below the eyelids, or Bell’s palsy. If the eyelid is turned outwards, the tears cannot exit the eye through the puncta to the nose resulting in tears running down one’s cheek. Frontal view of ectropion. The lower lid is turned outwards. Signs Usually bilateral turning of the eyelids inwards (entropion) or outwards (ectropion), red and inflamed eyelids, red eyes, tearing, and tears running down cheeks, recurrent eye infections. Symptoms Dry eyes, gritty eyes, foreign body sensation, corneal ulceration. Entropion: the presence of epiblepharon, loss of certain eyelid muscles and chemical burns or skin conditions that cause scarring to the inner eyelid skin. Ectropion: loss of eyelid muscles that hold the eyelids to the eyes often due to age, large weight loss, etc., chemical burns or skin conditions that cause scarring of the outer eyelid skin, Bell’s palsy or other facial nerve palsies, Botox injections, and growths on the outer eyelids. Prevention Avoid chemical or thermal burns and treat skin conditions that can cause scarring in conjunction with a dermatologist. Treatments Treatments usually start by managing the symptoms and when severe, surgery can be corrective. Managing the symptoms can include artificial tears, taping the eyelids into position, bandage contact lenses, Botox injections, or even a tarsorrhaphy (stitching the eyelids partially closed). Otherwise, corrective procedures include eyelid surgery. Even though surgery can be corrective, it usually does not “fix” all of the associated symptoms of dry eyes caused by eyelid entropion or ectropion. Managing these symptoms post operatively requires daily routine changes, but these habits are usually easily maintained. In an infant, if entropion is noticed due to the presence of epiblepharon, there is usually no treatment as it goes away as the child grows. If managed properly, there should be no permanent damage to the eyes or loss of vision.

Dr Ben Wild For fully functioning vision, light must be focused by the cornea and lens onto the retina. The retina senses this light and transmits signals via ganglion cells to the optic nerve. From the optic nerve the signals are then transmitted to the visual cortex in the brain for interpretation. View of a healthy retinal fundus (back of the eye) with a healthy optic nerve (yellow circle). Glaucoma is a set of progressive conditions whereby the ganglion cells that form the optic nerve start to die resulting in blind spots. This may be due to extended periods of elevated eye pressure, short periods of extremely elevated eye pressure, poor blood supply to the nerve or even auto-immune conditions. It affects 2-3% of people 40 years of age and older. View of a retinal fundus showing optic nerve damage related to glaucoma (yellow circle). Firstly, the eye is inflated with fluid called the aqueous humor. This fluid nourishes various structures of the inner eye and helps remove waste products. This fluid enters the eye via the ciliary body and exits the eye through a sieve-like structure called the trabecular meshwork. Simply put, elevated eye pressure is due to this sieve becoming blocked or clogged up and the fluid building up in the eye causing higher eye pressure. Without any damage to the eye, this is called ocular hypertension. Ocular hypertension can become glaucoma depending on various risk factors detailed below. Normal eye pressures range from 11mmHg to 21mmHg, anything over 21mmHg is deemed elevated. Primary open angle glaucoma (POAG) is most often bilateral, defined as eye pressures above 21mmHg, visible optic nerve damage and measurable blind spots, without any visible blocking of the trabecular meshwork. Clogging of this meshwork is assumed. Normal tension glaucoma (NTG) is also often bilateral, eye pressures under 21mmHg, visible optic nerve damage and measurable blind spots. This is often due to lack of oxygen supply to the optic nerve, abnormal eye structure, or possibly, auto-immune causes. Primary angle closure glaucoma (PACG) refers to a condition where the trabecular meshwork gets completely blocked by the iris (the colored part of the eye) and makes up 50% of glaucoma cases worldwide. It can be from a thick iris that bunches up into the trabecular meshwork or an iris that bulges forward and blocks the trabecular meshwork. A third type occurs when the lens of the eye grows so much that it pushes the iris forward and blocks the trabecular meshwork. This can be stimulated by dilating drops, emotional stress, dark rooms, certain medications (motion sickness, inhalers, cold remedies, sulfa drugs). Secondary types of glaucoma (glaucoma caused by other ailments) include pseudoexfoliation syndrome, pigment dispersion syndrome, neovascular glaucoma, inflammatory glaucoma, trauma, tumours, irregular corneal endothelial cells (iridocorneal endothelial syndrome) and many more. Glaucoma can also be congenital (born with), infantile (acquired under 3 years old) or juvenile (acquired between 3 and 16 years old). Signs Symptoms Causes Risk Factors Prevention Regularly scheduled eye exam can detect subtle changes to the optic nerve before blind spots develop. Glaucoma/pressure lowering drops in ocular hypertension can prevent future glaucoma. Laser iridotomies or iridoplasties can prevent PACG is people with trabecular meshworks that look almost blocked. There are no known preventatives for POAG or NTG other that healthy living and avoiding systemic medical issues. Treatments How soon glaucoma is detected is the biggest variable when it comes to prognosis. If caught early, primary glaucoma is very manageable with either drops or surgery. Early in POAG or NTG refers to within a few years of the onset of optic nerve damage whereas with PACG early refers to within hours to days. Ideally, individuals at high risk of PACG undergo preventative treatments before glaucoma starts. Secondary causes of glaucoma are much more difficult to manage and even on treatment will likely lead to progressing blind spots.

Dr Ben Wild The cornea is a clear tissue located in front of the iris. Its main functions are as a barrier to protect the inner eye and to focus light on the retina. It is composed of 5 layers. The 3 main layers include the epithelium (outermost barrier layer), the stroma (the middle layer providing the refractive power), and the endothelium (responsible for pumping fluid out of the stroma so that the cornea does not swell and cloud over). Sagittal view of a healthy eye (left) and frontal image of a healthy eye (right). Guttatta represent tiny deposits of collagen, like scar tissue, above the endothelial cells found bilaterally (both eyes). These spots are invisible to the naked eye. They signify poorly functioning or dying endothelial cells. Because we are born with more endothelial cells than needed, we can have many guttatta before developing any symptoms related to Fuch’s dystrophy. Fuch’s dystrophy occurs when there are enough failing endothelial cells that fluid starts accumulating in the corneal stroma and the cornea starts to swell and cloud over. If enough fluid enters the cornea it can rupture through the epithelium and cause pain and light sensitivity. Fuch’s dystrophy is a genetically inherited condition that typically affects women more than men and is very loosely correlated to glaucoma. White dots representing endothelial guttatta in the cornea (left), frontal view of guttatta (right). Signs Guttatta: microscopic collagen deposits on the back of the cornea. Fuch’s dystrophy: swollen and cloudy cornea. Symptoms Guttatta: none. Fuch’s dystrophy: decreased vision and halos/glare around lights that are worse in the morning and may improve throughout the day, pain and light sensitivity. Genetics or complications during cataract surgery. Prevention There are no known preventative measures. Treatments · Saline ointment (draws out excess fluid from cornea). · Blow dryer (lowest heat setting) to the eyes from arm’s length away for 2 minutes. · Dilating drops, antibiotics and a bandage contact lens if fluid is causing rupturing in the epithelial layer. · Endothelial transplant surgery. Guttatta are, not too uncommonly, found in patients who never develop Fuch’s dystrophy. Guttatta themselves do not cause pain or decreased vision or glare. If there is enough endothelial cell atrophy (enough guttatta) the patient will develop Fuch’s dystrophy. It is a condition that can permanently affect someone’s vision and may require surgery. It is typically managed with saline ointment and a blow dryer at first. Once those treatment stop working, a transplant surgery is needed. The surgery typically can improve a patients’ vision to 20/50 but its 5-year rejection rate is 15% in healthy eyes and 50% in glaucomatous eyes (eyes with glaucoma).

Dr Ben Wild The cornea is the clear tissue in front of the colored iris of the eye. The cornea is comprised of 5 layers but can be simplified into 3 main layers; the epithelium (outer most layer), the stroma (middle layer) and endothelium (inner most layer). Sagittal view of the front of the eye with the cornea being the leftmost blue tissue (left), frontal view of a healthy eye (right). Epithelial basement membrane dystrophy (EBMD) is a common condition, often misdiagnosed, usually seen unilaterally if caused by trauma or bilaterally if related to genetics. Another term for this condition is “map-dot-fingerprint dystrophy”. The corneal epithelium is continually shed and replenished. It is strongly attached to the underlying layers via a collagen network called the basement membrane. In EBMD, epithelial cells grow overtop of cellular debris on the basement membrane. This leads to raised areas of epithelium on the cornea. These areas can dry out more quickly and cause fluctuating vision throughout the day, making finding a reliable glasses prescription difficult, and at worst, can lead to recurrent corneal erosions (RCEs) in 10% of cases. Sagittal view of the front of the eye with EBMD (left), frontal view of an eye with exaggerated EBMD (right). When asleep, the eyes may dry out, the loose corneal epithelium associated with EBMD may attach to the inside of the eyelids, and upon awakening and opening the eyes, the epithelium may be torn. This situation, if recurrent, is RCE and can be extremely painful. Signs Areas of microscopic white areas of debris on the cornea. Symptoms Fluctuating vision, dry eyes, difficulty finding a working glasses prescription, foreign body sensation, grittiness and extreme pain after opening eyes after sleep if associated with RCEs. Causes Genetics. Risk Factors Trauma. Prevention Taking ocular ointments every night before sleep after a corneal abrasion, treating dry eyes correctly. Treatments EBMD · Artificial tears or gel drops to manage the symptoms. · Phototherapeutic keratectomy. RCE · See recurrent corneal erosions EBMD is an underdiagnosed cause of dry eyes and therefore a patient may suffer from dry eye symptoms longer than normal. Unfortunately, unlike other causes of dry eyes like blepharitis or meibomian gland dysfunction, there is no cure. It can, however, be managed well with artificial tears. If bad enough to cause RCEs, it can usually be managed with conventional therapy. If not, a simple surgery is 80-90% effective. EBMD does not cause permanent vision loss and is usually easily managed.

Dr Ben Wild The eyelids are made up of various types of skin, muscle, glands, hair follicles and much more. The outer skin is the normal, tough, keratinizing skin found all over the body. The inner eyelid skin, known as the palpebral conjunctiva, is more delicate non-keratinizing skin. Frontal image of a healthy eye. Xanthelasma is a condition characterized by yellow patches of skin on or around the eyelids. Although their appearance may be startling, these plaques are not harmful. They tend to progress slowly over time and are usually noticed on both sides of the head beneath the skin near the nose, on the eyelids, or around the eyelids. The cholesterol plaques, although not harmful themselves, could be a sign of high low-density lipoprotein (bad cholesterol) and/or low high-density lipoprotein (good cholesterol). Both of these conditions could lead to early heart disease. Frontal image of yellow xanthelasma spots. Signs Usually bilateral, yellowish subcutaneous cholesterol/lipid plaques typically seen nasally around the eyelids. Symptoms There are no symptoms. Causes High blood cholesterol levels found in 1/3 to 1/2 of patients with xanthelasma. Risk Factors Middle age to elderly, female. Prevention Ensure a healthy lifestyle through diet and exercise. Treatments Treatments aim at improving the appearance of the yellow plaques. · Lower cholesterol levels through diet and/or medication · Excision · Microdissection · Laser ablation · Dissolve with acetic acid solution (do not perform at home as some acetic acid solution can be corrosive) · Chemical peels Xanthelasma itself is not harmful to the eyes or vision, although, it may be the first sign of high blood cholesterol which can lead to heart disease. It is important to get tested early to know if you’re at risk. Otherwise, the yellow plaques are easily treated. Unfortunately, in 50% of people with high cholesterol, these plaques tend to reoccur.

Dr Ben Wild Dry eyes represent a breakdown of the complex interplay between tear volume (amount of tears), tear film stability (how long the tears last before evaporating), inflammation, and eyelid function. Frontal view of a healthy eye. Briefly, the lacrimal gland and 2 other accessory glands produce the watery (aqueous) portion of the tears responsible for oxygen transmission, removal of debris, antimicrobial activity, and optimal optical performance. The meibomian glands, located along the edges of the eyelids, produce the oil (lipid) portion of the tears responsible for protecting the aqueous portion from evaporation. Lastly, there is a mucous portion, found attached to the cornea and conjunctiva, that helps in spreading the tears for lubrication. For these tears to function properly, the eyelids must also be free of inflammation and provide frequent and full blinks. Dry eyes can be broken down into 2 main causes; aqueous deficient and evaporative. Aqueous deficiency can stem from old age, Sjogren’s syndrome, inflammation, scarring of the lacrimal gland, sensory loss (long history of contact lens wear, diabetes, laser surgery, etc.), nerve paralysis from botox or facial palsies, vitamin A deficiency, and certain medications. Evaporative dry eye occurs from meibomian gland dysfunction, incomplete lid closure or improper ocular anatomy, various dermatitis conditions (skin inflammation), low blink rate, certain medications, vitamin A deficiency, chronic inflammation, and more. Either of these causes can be made worse by environmental factors like allergens, smoke, humidity, hormones, and age. Front view of a severely dry eye. Signs Red eyes, stringy discharge, red eyelids, low tear volume, filaments. Symptoms Ocular grittiness and burning, itchy eyelids, fluctuating vision throughout the day or with each blink, watery eyes. Causes Prevention Address the health conditions and lifestyle / environmental factors listed above. Supplement your tears with artificial tears if you are taking a medication or have an eye condition listed above. Maintain proper lid hygiene, maintain a diet rich in omega 3s, avoid smoking, avoid dehydration, take 20 second breaks every 20 minutes to blink when reading or on the computer. Treatments Dry eye, in most cases, is very manageable. With that being said, depending on the cause, there may be no cure. Because there is a wide spectrum of symptoms and severities associated with dry eye, it is hard to elucidate a single prognosis. In most cases, dry eye will be only a minor inconvenience of comfort but in severe cases, can cause a lifetime of extreme discomfort, vision fluctuations, and ocular surface diseases.

Dr Ben Wild The cornea is the outermost layer of the eye in front of the iris. It is a clear tissue, void of any blood vessels, and is one of the main optical components responsible for focusing light on the retina. Corneal ectasia refers to the progressive thinning and subsequent bulging outwards of a specific part of the cornea. Keratoconus occurs when the central, or just off central, area of the cornea thins and balloons outwards, pellucid marginal degeneration occurs when the very bottom of the cornea thins and protrudes, keratoglobus refers to the entire cornea thinning and protruding, and post-keratorefractive ectasia refers to thinning and protruding of the cornea after laser eye surgery. A sagittal view of an eye depicting a healthy cornea (top left), keratoconus (top middle), pellucid marginal degeneration (top right), keratoglobus (bottom left) and a depiction of a hard contact lens doming over the cornea to produce good vision (bottom right). Corneal ectasias occur bilaterally, although affect one eye more than the other, present usually in teenage years to early 20s, and progression leads to large changes in nearsightedness and astigmatism over a short period of time. Signs Iron ring within cornea, scarring of the cornea, wrinkling of the cornea, protrusion of the cornea, swelling of the cornea, eye redness. Symptoms Blurry vision, poor vision even with an up-to-date glasses prescription, eye pain. Causes Progressive thinning and protruding of the cornea. Risk Factors Most prominent risk factor is eye rubbing. This is followed by laser eye surgery, connective tissue disorders (Down syndrome, Ehlers Danlos, Marfan, osteogenesis imperfecta), genetics, conditions that cause itchy eyes such as allergic conjunctivitis, chronic blepharitis, etc. Prevention Avoid eye rubbing at all costs. Treatments 1. Hard contact lenses for best vision (rigid gas permeable, scleral, or hybrid). 2. Corneal cross-linking surgery to slow progression. 3. Corneal Intacs insertion to flatten the cornea and allow better contact lens fitting. 4. Corneal transplant (either full thickness or a certain layer). Usually, corneal ectasias start with increasingly difficult to obtain eyeglass prescriptions that deliver adequate vision at best. Eventually, vision deteriorates to the point where hard contacts are needed. Unfortunately, there is no cure for most types of corneal ectasia. If detected early, corneal cross-linking surgery has been shown to dramatically slow or even stop progression of keratoconus. Otherwise, vision can continue to decrease until a corneal transplant is necessary.

Dr Ben Wild The cornea is the outermost layer of the eye in front of the colored iris. It is a clear tissue, void of any blood vessels, and is one of the main optical components responsible focusing light on the retina for proper vision. There are 5 layers within the cornea. The outermost layer is the epithelium responsible for creating a barrier against pathogens and foreign materials. This layer is attached to Bowman’s membrane which acts as a scaffold that connect the epithelium to the stroma. The stroma is the largest layer and is responsible for the cornea's rigidity and optical power. Descemet’s membrane is another scaffolding layer responsible for connecting the stroma to the endothelium. The endothelial layer is 1 cell thick and is responsible for pumping fluid out of the cornea so that the cornea doesn’t swell. Corneal dystrophies represent a collection of disorders that are categorized by the layer of the cornea they affect. From left to right: top line (healthy eye, EBMD, Meesman), 2nd line (Reiss-Bucklers, Thiel Behnke, Lattice), 3rd line (Granular, Macular, Schnyder’s), 4th line (Fuch’s, Posterior polymorphous, Congenital hereditary endothelial). Epithelial basement membrane dystrophy (EBMD) and Meesman dystrophy are the two main disorders that affect the corneal epithelium. EBMD is so common it has its own information page. Reiss-Bucklers (RB) and Thiel-Behnke (TB) dystrophies affect Bownman’s layer and affect the ability of the epithelium to stick to the remaining cornea. Lattice, granular, macular and Schnyder dystrophies represent the most common stromal dystrophies. Fuch’s dystrophy, posterior polymorphous dystrophy (PPD) and congenital hereditary endothelial dystrophy (CHED) all affect the endothelial layer. Fuch’s dystrophy is so common it has its own information page. Note: recurrent corneal erosions (RCEs) refer to the corneal epithelium sticking to the eyelids while sleeping and tearing open upon awakening. Refer to RCE information page. Causes Genetics. Risk factors Physical trauma (EBMD), irregular cholesterol or fat metabolism (Schnyder’s). Prevention There are no known preventative measures. Treatments · Treat the RCEs (see RCE information page). · Corneal transplant if vision is adversely affected by a stromal or endothelial dystrophy. · Phototherapeutic keratectomy for epithelial and Bowman’s layer dystrophies. · Treat the corneal swelling (see Fuch’s dystrophy information page). · Monitor for glaucoma (for PPD). In most cases, most corneal dystrophies are asymptomatic and do not affect vision. Treatment for RCEs almost always solves the symptoms. If vision is affected, a corneal transplant can help restore vision but the dystrophy can recur in lattice, macular and granular. Also, a corneal transplant does not fully correct vision and hard plastic contacts may be needed instead of glasses. CHED on the other hand, will leave affected newborns with a lifetime of poor vision.

Dr Ben Wild The eyelids are made up of various types of skin, muscle, glands, hair follicles and much more. Their purpose is to protect the eyes from dryness, bright lights and irritants. Frontal view of a healthy eye with minimal pressure being used to pull the upper eyelid upwards. Floppy eyelid syndrome typically occurs unilaterally (in one eye) but can be bilateral (both eyes) and is usually seen in overweight males who sleep on their stomachs. This syndrome is characterized by the loss of upper eyelid muscles to the point where the eyelids can spontaneously flip upwards. Once flipped, usually occurring when the affected person is sleeping, the eyes remain exposed, can dry out, and can rub against a pillow thus damaging the inner eyelids and eye. This can lead to chronic eye infections. Frontal view of an eye displaying floppy eyelid syndrome. The upper lid flips upwards with minimal pulling pressure. Interestingly, this condition is highly associated with sleep apnea. The association is so strong that if someone is diagnosed with floppy eyelid syndrome, they should undergo sleep testing for sleep apnea. It is also associated, to a lesser extent, to cardiopulmonary disease. Signs Extremely malleable upper eyelids, excess eyelid skin, large bumps on the inside of the upper eyelids and extreme ease when everting (flipping) eyelids. Symptoms Chronic discharge, dry eyes and discharge worse in the mornings, grittiness and burning of the eyes. Causes Loss of eyelid muscle. Risk Factors Being overweight, elderly, sleep apnea, cardiopulmonary disease and sleeping on stomach. Prevention Sleep on sides or on back, treat sleep apnea, and weight control. Treatments · Lose weight. · Artificial tears. · Tape eyelids or wear an eye shield at night. · Surgery. Surgery typically can dramatically reduce the number of times the eyelids flip but can lead to the loss of the ability to fully close the eyes on a normal eyelid blink. This can result in dry eyes which can be treated with artificial tears. If managed properly, there should be no permanent damage to the eyes or loss of vision.

Dr Ben Wild The lacrimal system starts with the lacrimal gland and 2 other accessory glands that produce the watery (aqueous) portion of the tears responsible for oxygen transmission, removal of debris, antimicrobial activity, and optimal optical performance. The tears then pool along the lower eyelid margin and migrate towards the nose towards 2 small holes, one on the upper lid and one lower, called the puncta. These puncta connect to the canalicular canals which connect to the nasolacrimal sac and then into the nose. That is why when you cry, your nose starts to run. Frontal view of a healthy eye. Dacryocystitis occurs when the nasolacrimal duct, or sac in the nose, becomes infected or inflamed. This can lead to a nasolacrimal duct obstruction. This usually presents unilaterally (in one eye) as a tender, sometimes painful, red bump immediately below the nasal corner of the eye, by the nose. It can be present all of a sudden and last for under 3 months (acute) or remain for much longer (chronic). It can also be seen congenitally (at birth). Frontal view showing inflamed nasolacrimal duct and inner canthus with dacryocystitis. Signs Large bump or area of swelling immediately below the nasal corner of the eye, often red, swollen canthus (inner corner of the eye), mucous discharge emanating from the puncta. Symptoms Pain (if acute), tenderness, heat, epiphoria (excessive tearing). Causes Risk Factors Nearby infections of conjunctiva, cornea, sinuses or inflammation. Prevention There are no known preventative measures. Treatments Dacryocystitis can be quite irritating and is often difficult to treat non-surgically. Thankfully, it is not known to be a threat to vision.