"Lazy eye" is a generic term for strabismus. Strabismus is a visual defect in which the eyes are misaligned and point in different directions. One eye may look straight ahead, while the other eye turns inward, outward, upward or downward.

The eye turn may be constant, or it may vary. Which eye is straight (and which is misaligned) may switch or alternate.

Strabismus is a common condition among children. About 4% of all children in the United States have strabismus.  It can also occur later in life.

Strabismus occurs equally in males and females. It may run in families: however, many people with strabismus have no relative with the problem.

When one eye is misaligned, two different images are sent to the brain.  To prevent seeing double, the brain learns to ignore the image of the misaligned eye and focus on the straight or better seeing eye.  The child then loses depth perception.

The exact cause of strabismus in not fully understood. Six eye muscles, controlling eye movement, are attached to the outside of each eye. To have proper alignment of each eye, all of the muscles in each eye must be balanced and working together.

Most common types of Strabismus:

Congenital Esotropia involves the eyes crossing toward the nose and is the most common type of strabismus in infants.

Accommodative Esotropia usually occurs in children around age 2 or older.  This type of strabismus involves an inward turn when the child focuses the eyes to see clearly.

Exotropia involves a turn outward, usually when focusing on distant objects. 

Strabismus can, in some cases, be treated with eyeglasses. Other treatments may involve surgery to correct the unbalanced eye muscles. Covering or patching the strong eye to improve amblyopia is often necessary.  This treatment works to improve vision in the bad eye.

If surgery is indicated, a general anesthetic is required.A small incision is made in the tissue covering the eye for the surgeon to reach the eye muscle.  The eye muscle is detached from the wall of the eye and repositioned, depending on which direction the eye is turning.  It may be necessary to perform surgery on one or both eyes.  Recovery time is rapid.  Children are usually able to resume their normal activities within a few days.

After surgery, glasses may still be required.  In some cases, more than one surgery may be needed to straighten the eyes.  As with any surgery, eye muscle surgery has certain risks.  These include infection, bleeding, excessive scarring and other complications that can lead to loss of vision.  Strabismus surgery is usually a safe and effective treatment for eye misalignment. It is not, however, a substitute for glasses or amblyopic therapy.

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Amblyopia is poor vision in an eye that did not develop normal sight during early childhood.  It is sometimes called a “lazy eye.”  Usually one eye is affected by amblyopia but it is possible for both eyes to be affected.  It is a common condition, affecting 2 or 3 out of every 100 people. The best time to correct for this is during infancy or early childhood.

Newborn infants are able to see, but as they use their eyes during the first months of life, vision improves. During early childhood years, the visual system changes quickly and vision continues to develop. If a child cannot use his or her eyes normally, vision does not develop properly and may even decrease. After the first nine years of life, the visual system is usually fully developed and the vision can usually not be improved.

Many occupations are not open to people who have good vision in only one eye.

People with amblyopia in one eye are more than twice as likely to lose vision in the healthy eye from trauma. If the vision in one eye should be lost later in life from an accident or illness, it is essential that the other eye have normal vision. For these reasons, amblyopia must be detected and treated as early as possible.

It is recommended that all children have their first eye exam between 3 and 4 years of age.  Most physicians test vision as part of a child’s medical examination. They may refer a child to an eye doctor if there is any sign of eye problems.  However, this visual screening should not replace a full eye examination by an eye doctor.

Amblyopia is caused by any condition that affects normal use of the eyes and visual development.  In many cases, the conditions associated with amblyopia may be inherited. The three most common causes are strabismus (misaligned eyes), unequal focus (refractive error), and cataracts (a clouding of the eye’s naturally clear lens). 

Amblyopia occurs most commonly with misaligned or crossed eyes. The crossed eye “turns off” to avoid double vision and the child uses only the better eye. The misaligned eye then fails to develop normal vision.

Refractive errors can also cause amblyopia. This occurs when one eye or both eyes are out of focus because of nearsightedness, farsightedness or astigmatism.  When one eye has more refractive error than the other the unfocused (blurred) eye “turns off” and becomes amblyopic. The eyes can look normal but one eye has poor vision. This is the most difficult type of amblyopia to detect since the child appears to have normal vision when both eyes are open.   Amblyopia can occur in both eyes, otherwise known as bilateral refractive amblyopia, when both eyes have high amounts of nearsightedness, farsightedness or astigmatism.

An eye disease such as a cataract (a clouding of the eye’s naturally clear lens) may lead to amblyopia.  Any factor that prevents a clear image from being focused inside the eye can result in amblyopia.

It is not easy to recognize amblyopia. A child may not be aware of having one strong eye and one weak eye. Unless the child has a misaligned eye or other obvious abnormality, there is often no way for parents to tell that something is wrong.

Amblyopia is detected by finding a difference in vision between the two eyes. Since it is difficult to measure vision in your children, your eye doctor estimates visual acuity by watching how well a baby follows objects with one eye when the other eye is covered.

Using a variety of tests, the eye doctor observes the reaction of the baby when one eye is covered. If one eye is amblyopic and the good eye is covered, the baby may attempt to look around the patch, try to pull it off or cry.

Poor vision in one eye does not always mean that a child has amblyopia. Vision can often be improved by prescribing glasses for a child.

Your eye doctor will carefully examine the interior of the eye to see if other eye diseases may be causing decreased vision, such as cataracts, inflammation, tumors or other disorders of the inner eye.

To correct amblyopia, a child must be made to use the weak eye. This is usually done by patching or covering the strong eye, often for weeks or months.

Even after vision has been restored in the weak eye, part-time patching may be required over a period of years to maintain the improvement.

Glasses may be prescribed to correct errors in focusing. If glasses alone do not improve vision, then patching is necessary. 

Occasionally, amblyopia is treated by blurring the vision in the good eye with special eye drops or lenses to force the child to use the amblyopic eye.

If present, amblyopia is usually treated before surgery and patching is often continued after surgery as well.  If your eye doctor finds a cataract or other abnormality, surgery may be required to correct the problem.  An intraocular lens may be implanted. After surgery, glasses or contact lenses can be used to restore focusing, while patching improves vision. 

Amblyopia cannot usually be cured by treating the cause alone. The weaker eye must be made stronger in order to see normally. Prescribing glasses or performing surgery can correct the cause of amblyopia, but your eye doctor must also treat the amblyopia.

If amblyopia is not treated, several problems may occur. The amblyopic eye may develop a serious and permanent visual defect. Depth perception (seeing in three dimensions) may be lost.  If the good eye becomes diseased or injured, a lifetime of poor vision may be the result.

Your eye doctor can give you instructions on how to treat amblyopia, and can help you and your child to carry out this treatment.

Children do not like to have their eyes patched.  But as a parent, you must convince your child to do what is best for him or her. Your interest and involvement will be necessary for successful treatment. 

Success in the treatment of amblyopia is dependent upon how severe the amblyopia is and how old the child is when treatment is begun. If the problem is detected and treated early, vision can improve for most children.  Amblyopia caused by strabismus or unequal refractive errors may be treated successfully during the first nine years of age. After this time, amblyopia usually does not recur.

If amblyopia is not detected until after early childhood, treatment may not be successful. Amblyopia caused by strabismus or unequal refractive errors may be treated successfully at a much older age than amblyopia caused by cloudiness in tissues in the eye. Amblyopia caused by cloudiness in tissues of the eye needs to be detected and treated extremely early---within the first two months of life---in order to be treated successfully.

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Dry Eye Syndrome

Dry Eyes or Dry Eye Syndrome is a very common eye condition that affects millions of Americans. It is estimated that dry eyes affect up to 11% of people aged 30 to 60 years of age and 15% of those 65 years of age or older according to the International Task Force assembled by the Johns Hopkins University-Wilmer Eye Institute. They also concluded that as many as 12 million Americans have moderate to severe dry eyes and that this number is likely to increase with the aging populations resulting in a significant decrease in the quality of life.

Simply, dry eyes are caused by either a deficiency in the quantity or the quality of the tears or tear film. Fortunately, today eye care patients can benefit from better diagnostic procedures for dry eyes as well as more advanced dry eye treatments from eye doctors.

Symptoms of Dry Eye Syndrome
The most common symptoms of dry eyes include dryness, itching, burning, irritation or grittiness, redness, blurry vision that gets clearer as you blink, light sensitivity and contrary to common sense….excessive tearing. These symptoms typically increase during vision related activities such as reading, computer use, night driving, and watching television. They may also increase in response to environmental conditions such as wind, low humidity, airplane travel, smoking or being in a smoky environment. Many of these symptoms of dry eyes may also be found in other eye conditions, making careful diagnosis especially important.

About Tears & the Tear Film
Understanding the structure of tears is important in order to understand how the tears and tear film provide the eye with a number of specialized functions. Tears are composed of three layers. The innermost layer is called the mucus layer. The mucous layer acts to coat the cornea with a smooth layer of lubricating material called mucin. The mucous layer serves to provide a surface that allows the tear film to stick to the eye. The middle layer of the tear film is called the aqueous layer, and as the name implies is composed primarily of water. In fact, it is composed of about 98% water and serves to provide moisture, oxygen and nutrients to the cornea. The outermost layer of the tear film is called the lipid layer. The lipid layer is actually an oily film that acts to prevent evaporation of the tear film from the eye. A deficiency in any one or more of the tear film layers can lead to dry eyes. Eye doctors can use specialized diagnostic tests to determine which layers of the tear film are contributing to the dry eye symptoms.

Tears are produced by a number of different gland structures around the eye. The innermost layer, the mucous layer, and the outermost layer, the oily layer are produced by tiny tubular shaped glands that are in the eyelids. The middle layer, the aqueous layer, is produced by the lacrimal gland which is a structure located just under the upper eyelid. Each time you blink, the eyelids act like a squeegee to smooth and spread the tear film so that it is uniform across the surface of the cornea. This smoothing of a normal tear film creates a high quality optical surface. In some cases of dry eye, the tear film is deficient enough that the eyelids cannot provide a smooth optical surface and patients then experience blurry vision that clears with repeated blinking.

Normally, excess tears flow out of the eye along the lower eyelid toward the nose and into two tiny ducts called lacrimal puncta. The lacrimal puncta open into small tube like canals that drain into the nasal passage. As a result of this connection between the drainage of tears from the eye and the nasal passage, often times when we cry we may actually experience a runny nose. Usually tears are produced on a continual basis in order to lubricate the eye. And maintain the crisp optical surface of the cornea. Reflex tears are also produced in response to pain, trauma or even an emotional event. Reflex tears tend to be overly watery and do not alleviate a dry eye or even the symptoms of a dry eye.

What are the causes of Dry Eye Syndrome?

Environment: Sunny, dry, or windy weather, heaters, air conditioners, and arid high altitudes increase the evaporation of tears from the surface of your eyes. In fact there are a number of cities that have been recognized by the National Women's Health Resource Center as being "Dry Eye Hotspots". You may experience dry eye symptoms while viewing television, computer screens, while reading or doing anything that reduces your rate of blinking.

Aging: During the normal aging process, our bodies and our eyes produce gradually less and less oil. This reduction in oil in the tear film results in quicker evaporation leading to the formation of dry spots on our eyes.

Contact Lenses: Contact Lenses are subject to dehydration or loss of their water content. As they dehydrate, they can absorb the tear film causing dry eye symptoms. In some cases, the continued drying of the contact lens surface causes it to become deposited with protein making the lenses even more uncomfortable than the dryness alone.

Medical Conditions: Women experiencing hormonal changes, those patients suffering from thyroid disease, rheumatoid arthritis, psoriasis, eczema, acne rosacea and a number of other systemic conditions may experience dry eye syndrome.

Medications: Diuretics taken for high blood pressure, allergy medication, antihistamines, acne medications and many others may all produce dry eye symptoms.

Others: Incomplete closure of the eyelids, eyelid disease and a deficiency of the tear-producing glands are other causes. Recent research suggests that smoking, too, can increase your risk of dry eye syndrome.

Panoptx sunglasses can help with dry eyes because they keep out wind, pollen and dust with their Orbital Seal; 99 percent of wearers in a study reported a decrease in overall dry eye symptoms. Artificial tears help dry eyes feel better. Don't confuse artificial tears with formulas that just "get the red out." Salmon is a good source of omega-3 fatty acids, which may reduce your risk for dry eyes. Sardine, herring and cod liver oils are even better, or try a supplement.

Dry Eye Testing
Testing for Dry Eyes can be performed through several methods. One of the simplest, Schirmer's test, is performed by placing a small piece of filter paper inside the lower part of the eyelids. The eyes are closed for a few minutes and taken out to measure the amount of tear production. The Schirmer's test can determine if there is difficulty in tear production or if the tears are not efficient in maintaining eye health. Fluorescein eye drops may also be used to determine tear production. . The eye drops contain a dye that can be traced with a special light as it is washed out of the eyes by the tears. This method can detect for any blocking or early evaporation of tears. Tears may also be examined to see if they contain enough moisture, proteins, and other materials.

Dry Eyes Treatment Options
Dry Eyes Treatments will vary depending on the level of dry eye syndrome. Most people can use artificial tears or similar eye drops or ointments that simulate the action of tears. These OTC medications can relieve many of the symptoms and discomforts caused by dry eyes. There are also oral capsules that can help the eyes maintain tear production and guard against tear loss. It is best to ask an eye care professional which one is better suited for your eyes.

RESTASIS® Ophthalmic Emulsion is an FDA approved prescription eye drop which supports the eyes to produce more natural tears.  It is great for dry eyes evoked by aging and other agents that cause deficient tear production.

Another solution without the use of eye drops is the use of punctal plugs. These plugs block the drainage of tears and conserve them in the eyes longer. There are temporary and permanent plugs. They are for the most part painlessly inserted and can be removed by an eye care doctor. Sealing of the drainage can also be done surgically. This method prevents tears from draining from the eyes and keeps the eyes moisturized.

Other recommendations:
Drink plenty of water to keep the body moisturized.
Minimize periods in certain weather conditions like windy and dry weather.
Protect the eyes from harsh weather conditions like wind and dust.
Make sure medication is not causing dry eyes.
Eat healthy food containing eye nutrients especially with vitamin A, C, and E and if need be take supplements containing flax seed and Omega-3 fatty acids.
When watching tv, using the computer or other eye straining activities, take frequent breaks and blink often.
People who wear contact lenses should take them out and keep eyes well hydrated.

If you wear contact lenses, be aware that many eye drops, especially artificial tears, cannot be used while your contacts are in your eyes. You'll need to remove them before using drops and wait 15 minutes or even longer (check the label) before reinserting the lenses. If your eye dryness is mild, then contact lens rewetting drops may be sufficient to make your eyes feel better, but the effect is usually only temporary.

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"Lazy eye" is also a generic term for ptosis.  Ptosis is a drooping of the upper eyelid. The lid may droop only slightly, or it may cover the pupil entirely. In some cases, ptosis can restrict and even block normal vision. It can be present in children, as well as adults, and is usually treated with surgery. It can affect one or both eyelids. It also can be present at birth or begin later in life. Ptosis which is present at birth is called congenital ptosis. If a child is born with moderate to severe ptosis, treatment is necessary to allow for normal vision to develop. If left untreated, amblyopia can lead to permanent loss of vision.

Congenital ptosis in children is often caused by poor development of the muscle which lifts the eyelid, called the levator.  Although it is usually an isolated problem, a child born with ptosis may also have eye movement abnormalities, muscular diseases, lid tumors, neurological disorders, or refractive errors. Congenital ptosis usually does not improve with time. 

The most obvious symptom is the drooping lid. Children with ptosis often tip their heads back into a chin-up position to see underneath their eyelids. Or they may raise their eyebrows in attempt to lift up their lids. Over many years, abnormal head positions may cause deformities in the head and neck.

The most serious problem associated with ptosis is amblyopia.  Amblyopia is poor vision in an eye that did not develop normal sight during early childhood.  This can occur if the lid is drooping severely enough to block the child’s vision. More frequently, it can occur because ptosis tends to change the optics of the eye, causing astigmatism.  Finally ptosis can hide misaligned or crossed eyes which can also cause amblyopia.   If amblyopia is not treated early in childhood, it persists throughout life.

In most cases, the treatment for childhood ptosis is surgery, although there are a few rare disorders which can be corrected with medications. In determining whether or not surgery is necessary and what procedure is the most appropriate, an eye doctor must consider some important factors: a child’s age, whether one or both lids are involved, measurement of the eyelid height, the eyelids’ lifting and closing strength, observation of the eye’s movements.

During surgery the levators, or eyelid lifting muscles, are tightened.  In severe ptosis, when the levator is extremely weak, the lid can be attached or suspended from under the eyebrow so that the forehead muscles can do the lifting.

Mild or moderate ptosis usually does not require surgery early in life. Children with ptosis, whether they have had surgery or not, should be examined annually by an eye doctor for amblyopia, refractive disorders and associated conditions. Even after surgery, focusing problems can develop as the eyes grows and changes shape.

The most common cause of ptosis in adults is the separation of the levator muscle tendon from the eyelid.  This process may occur as a result of aging, after cataract surgery or other eye surgery, as a result of injury, or from a restriction of the levator.

Adult ptosis may also occur as a complication of other disease involving the levator muscle or its nerve supply, such as diabetes. Blood tests, x-rays, or other tests can help to determine the cause of the ptosis and the best plan of treatment. Treatment is usually surgical. Sometimes a small tuck in the lifting muscle and eyelid can raise the lid sufficiently. More severe ptosis requires reattachment and strengthening of the levator muscle.

Ptosis in both children and adults can be treated with surgery to improve vision as well as cosmetic appearance.  It is very important that children with ptosis have regular ophthalmic examinations early in life to protect them from the serious consequences of untreated amblyopia.

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Refractive Errors

In order for your eyes to be able to see clearly, light rays must be bent or refracted by the cornea and the lens so they can focus on the retina, which is the layer of light-sensitive cells lining the back of the eye.The retina receives the picture formed by these light rays and sends the image to the brain through the optic nerve.

The retina receives the picture formed by these light rays and sends the image to the brain through the optic nerve.

A refractive error means that due to the shape of the eye, the eye doesn’t refract the light properly, so the image you see is blurred. Although refractive errors are called eye disorders, they are not diseases.

Myopia (Nearsightedness)
A nearsighted eye is longer than normal or has a cornea that is too steep, or more curved.  As a result, light rays focus light in front of the retina instead of on it.  Close objects look clear but distant objects appear blurred.   Myopia, or nearsightedness, is normally inherited and is often discovered in children when they are between the ages 8 and 12 years old. 

Hyperopia (Farsightedness)
A hyperopic eye is shorter than normal or has a cornea that is too flat.  As a result, light rays focus beyond the retina instead of on it. Most children are farsighted, yet they do not experience blurry vision.  With focusing (accommodation), children’s eye are able to bend the light rays and place them directly on the retina.  As long as the farsightedness is not too severe, hyperopic children will have clear vision for seeing objects at a distance and up close.  As we get older, we slowly lose our ability to focus, and adults with hyperopia may experience increased difficulties with reading. 

Like nearsightedness, farsightedness is usually inherited.  Babies and young children tend to be slightly hyperopic. As the eye grows and becomes longer, hyperopia lessens.

Astigmatism (Distorted Vision)
The cornea is the clear front window of the eye.  A normal cornea is round and smooth, like a basketball.  If you have astigmatism, the cornea curves more in one direction than in the other, like a football.  It can distort vision for both near and far objects.  It’s almost like looking into a fun-house mirror in which you appear too tall, too wide, or too thin. It is possible to have an astigmatism in combination with myopia or hyperopia.

When you are young, the lens in your eye is soft and flexible. The lens of the eye changes its shape easily, allowing you to focus on objects both close and far away.  After the age of 40, the lens becomes more rigid.  Because the lens can’t change shape as easily as it once did, it is more difficult to read at close range. This normal condition is called presbyopia. You can have presbyopia in combination with myopia, hyperopia, or astigmatism.

Eyeglasses and contact lenses are the most common methods of correcting refractive errors.  They work by focusing light rays on the retina, compensating for the shape of your eye. Refractive surgery is also an option to correct or improve your vision. This surgical procedure is used to adjust your eye’s focusing ability by reshaping the cornea, or front surface of your eye. All of your options can be discussed with your eye doctor.

Wearing eyeglasses is an easy way to correct refractive errors.  They can also help protect your eyes from harmful light rays, such as ultraviolet (UV) light rays.  A special lens coating that screens out UV light is available.  Glasses or goggles made of protective lens material (polycarbonate) should be used for  sports and all hazardous activities.  All children and adults who have one poorly seeing eye should wear protective polycarbonate lenses at all times to protect their “good” eye. 

Progressive Addition Lenses are the newest design of lenses to correct for presbyopia. These lenses help to focus your vision at distance, intermediate (or in between) and near.  Some of the newest types of progressive lenses are easier to adapt to and give less peripheral distortion. If you don’t need correction for seeing at a distance, you can receive a prescription for reading glasses or purchase them over the counter to correct for presbyopia.

Contact Lenses
There is now a wide variety of contact lenses available.  The type best suited for you depends on your refractive error and your lifestyle.  Some of the newest types of contact lenses are made with more water and  are more permeable to oxygen which provide maximum comfort and optimum health.  After a contact lens exam, we are able to determine the best type of contact lens for you.

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Ocular Emergencies

Our office provides emergency services for eye infections and eye injuries.  Our doctors and staff will work with you to schedule an appointment as soon as possible.  Our high resolution slit lamps, or microscopes, and equipment allow us to view the eye at the microscopic level.  After assessing the extent of the injury or infection a treatment plan will be formulated and explained to you.  The treatment may include topical and/or oral medications and supportive care.  Follow-up visits to monitor your recovery will be scheduled as needed.

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Corneal Abrasion

One particular type of eye injury is a corneal abrasion, where the clear, front surface of the eye is scratched, scraped or cut. Abrasions are commonly caused by fingernails, paper cuts, makeup brushes, scrapes from tree or bush limbs, and rubbing of the eye. This normally will cause mild pain, tearing, light sensitivity, blurred vision, or a feeling of having something in your eye. To detect a corneal abrasion, your eye doctor will use a special dye called fluorescein to illuminate the injury.

Treatment may include: patching the injured eye to prevent eyelid blinking from irritating the injury, applying lubricating eyedrops or ointment to the eye to form a soothing layer between the eyelid and the abrasion, using antibiotics to prevent infection, dilating or widening the pupil to relieve pain, or wearing a special contact lens to help healing. Minor abrasions usually heal within a day or two; larger abrasions usually take about a week. It is important to not rub the eye while it is healing. Some of the ocular medications that we use in-office can help to drastically lessen the pain level and light sensitivity. A bandage contact lens or pressure patch can be utilized to aid the healing process and to help prevent a recurrence of the abrasion (recurrent corneal erosion).

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Blocked Tear Duct

Blocked tear ducts are also known as nasolacrimal duct obstructions.  It occurs when a membrane (a skin-like tissue) in the nose fails to open before birth, blocking part of the tear drainage system. If tears do not drain properly, they can collect inside the tear drainage system and spill over the eyelid onto the cheek. They can also become infected, which may lead to the development of conjunctivitis, commonly known as “pink eye.”  You should contact your eye doctor if the discharge becomes thicker or changes color from white to yellow or green, or the white of the eye becomes red.

Tears are produced to keep your eyes moist.  As new tears are produced, old tears drain from the eye through two small holes called the upper and lower punctum, located at the corner of your upper and lower eyelids near the nose. The tears then move through a passage called the canaliculus and into the lacrimal sac. From the sac, the tears drop down the tear duct (called nasolacrimal duct), which drains into the back of your nose and throat.  That is why your nose runs when you cry.

In infants with overflow tearing, the membrane blocking the tear duct prevents tears from draining into the back of the nose and throat.  The treatment of this condition may include applying antibiotic eye drops or ointment to the eye once or twice daily to fight infection, cleaning the eyelids with warm water, and applying pressure (or massage) over the lacrimal sac.

To apply pressure, place your finger under the inner corner of the infant’s eye next to the nose, and roll your finger over the bony ridge while pressing down and in against the bony side of the nose.  This movement helps squeeze tears and mucus out of the sac.

The blocked tear duct often spontaneously opens six to eight months after birth. If overflow tearing persists, it may be necessary for Dr. Piccione to open the obstruction surgically by passing a probe through the tear duct.  This is a thin, metal probe that is gently inserted through the tear drainage system to open the obstruction.The procedure is performed in an outpatient setting under general anesthesia. It causes little or no pain, but tears may be stained briefly with blood or a nosebleed may occur. An antibiotic or ointment will be prescribed.

Re-obstruction of the tear duct may require another probe or additional surgery. Dr. Piccione will discuss potential complications with you before surgery.

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