Crocodile tears

A man in his 30s came in because he saw flashes of light for 20 minutes two days ago.

He was having very blurry vision and could not focus as well at the time, but it all resolved on its own and he remained symptom-free. After a thorough dilated exam I determined that his retinas were completely normal and his symptoms were most likely from ocular migraine. 

Then he brought up something else completely unrelated. For three years now whenever he ate something his right eye would tear up and it’s always only the right eye. That eye was not red, itchy or painful, it simply teared up a bit. 

He did not have dry eye. And both of his eyes were white and quiet with no sign of tearing at the time. His description sounded almost like crocodile tear syndrome. This is a very rare condition where the nerve that supplies the salivary gland somehow also goes to innovate the lacrimal gland which secretes tears. When he’s having a meal his salivary gland gets a signal to start secreting saliva, and that cross talks to his lacrimal gland which makes his right eye tear up. This often happens after nerve injury when the nerve tries to repair itself and makes an inadvertent mistake. This is called aberrant nerve regeneration. But he denies any facial or head injury. He reports to be completely healthy and taking no medication. 

The treatment for crocodile tear syndrome is to inject Botox into the lacrimal gland so that a part of the gland doesn’t work and therefore not too many tears are produced. In his case this doesn’t really bother him so we will just monitor.