Test 2: Lacrimal Drainage System

secondary punctal stenosis treatment

Ziegler cautery burns applied to palpebral conj near the punctum medial conjunctivoplasty involves excision of a diamond-shaped piece of taorsoconjunctiva to the canaliculus and punctum

canalicular obstruction

acquired obstruction causes are similar to those of primary obstruction

nasolacrimal duct obstruction causes

acquired obstruction idiopathic - most common naso-orbital trauma wegener granulomatous nasopharyngeal tumors

dacryolithiasis

acquired obstruction may occur in any part of the lacrimal system more common in males pathogenesis is unclear often discovered at the time of DCR symptomatic patents have intermittent epiphora, recurrent acute dacryocystitis and lacrimal sac distension

primary punctal stenosis causes

acquired obstruction occurs in absence of punctal eversion idiopathic - most common herpes simplex lid infection following irradiation of malignant lid tumors cicatrizing conjunctivitis and trachoma systemic cytotoxic drugs

secondary punctal stenosis

acquired secondary to punctal eversion

a hard stop

cannula enters the lacrimal sac and comes in contact with the lacrimal bone means the canalicular system is patent irrigate and if saline passes into the nose the lacrimal drainage system is patent - still could be stenosed failure of saline to reach the nose is indicative of total obstruction of the nasolacrimal duct while irrigating the sac will distend and a reflux through the punctum

lacrimation

caused by a reflex lacrimation hypersecretion secondary to ocular inflammation or disease

infections of lacrimal passages

chronic canaliculitis dacryocystitis dacryoadenitis

congenital dacryocele

congenital obstruction amniontocele is a collection of amniotic fluid or mucus in the lacrimal sac caused by an imperforate hasner valve presentation is perinatal with bluish cystic swelling at or below medial canthal area, with epiphora

nasolacrimal duct obstruction

congenital obstruction better termed delayed canalization of the nasolacrimal duct lower end of nasolacrimal duct is the last portion of nasolacrimal system to canalize complete canalization usually occurring soon after birth 20% of children manifest evidence of nasolacrimal obstruction in the first year of life

nasolacrimal duct treatment

depends on completeness of obstruction complete obstruction is treated by DCR incomplete obstruction may respond to intubation of lacrimal system with silicone tubes or stents otherwise a DCR is recommended

primary jones dye test

differentiates partial obstruction of lacrimal passages from primary hyper secretion of tears 2% fluorescein is instilled into conj sac wait about 5 minutes insert anesthetic moistened cotton-tipped bud under the inferior turbinate - modified jones test ask patient to blow their nose into a tissue

dacryolithiasis signs

distended and firm lacrimal sac without tenderness mucus reflux?

epiphora

due to a compromise of lacrimal drainage exacerbated by cold and wind

nasolacrimal duct obstruction signs

epiphora and efflux of purulent material from puncta

evaluation of watering - external examination of eyelids

examined for evidence of malposition ectropion is most common normally the punctum is opposed to the globe centurion syndrome is a childhood condition in which epiphora is secondary to an anterior malposition of medial part of lid with puncta displaced outward epiphora could be caused by large caruncle displacing the inferior punctum away from globe or obstruction of inferior punctum by fold of redundant conj

primary jones dye test positive finding

fluorescein is recovered indicates patent lacrimal system epiphora due to hyper secretion

secondary dye test positive finding

fluorescein stained saline is recovered indicates fluorescein entered the lacrimal sac confirming functional potency of the upper lacrimal passages partial obstruction of the nasolacrimal duct is inferred

secondary dye test

identifies the probable site of partial obstruction did the fluorescein enter the sac with the primary test topical anesthetic is instilled the drainage system is then irrigated with saline with a cotton tipped bud under the inferior turbinate

a soft stop

if the cannula stops at or proximal to the junction of the common canaliculus and the lacrimal sac (lateral wall of sac) the sac is thus not entered a spongy feeling is experienced as the cannula presses against the soft tissue of the common canaliculus and the lateral wall of the sac irrigation will not cause the lacrimal sac to distend obstruction of the inferior canaliculus will cause reflux through the lower canaliculus reflux through the superior canaliculus indicates an obstruction at the common canaliculus

congenital dacryocele signs

include a mucus filled lacrimal sac

nasolacrimal duct obstruction differential diagnosis

include punctal atresia and fistulae between the sac and skin must exclude congenital glaucoma in an infant with a water eye

nasolacrimal duct obstruction treatment

includes massage of lacrimal sac downwards while compressing the common canaliculus probing of the lacrimal system should be delayed until the age of 12 months spontaneous canalization occurs in about 95% of cases probing prior to age 2 under anesthesia is generally successful consider temporary intubation or DCR if symptoms persist

conventional DCR

indicated for obstruction beyond the medial opening of common canaliculus operation involves anastomosing the lacrimal sac to the nasal mucosa of the middle meatus success rate over 90%

dacryocystitis

infection of lacrimal sac is usually secondary to obstruction of the nasolacrimal duct may be acute or chronic most commonly caused by staphylococci

dacryoadenitis

inflamed lacrimal gland

primary punctal treatment

initially by dilation of the punctum using a dilator one-snip ampullotomy two-snip ampullotomy laser punctoplasty insertion of canalized plugs

evaluation of watering - external examination fluorescein retention test

instill fluorescein drops into both conjunctival fornices normally little or no dye remains after 3 minutes prolonged retention is indicative of inadequate lacrimal drainage

dacryolithiasis treatment

involves massage, lacrimal irrigation and probing DCR may be required for complete obstruction

chronic canaliculitis

is an uncommon condition caused by actinomyces, which are anaerobic gram positive bacteria unilateral epiphora with a chronic mucopurulent conjunctivitis edema of the canaliculus and pouting of the punctum concretions are expressed on canalicular compression treatment consists of topical antibiotics for 10 days

nasolacrimal duct

it is 12mm long and is the inferior continuation of the lacrimal sac it descends and opens into the inferior nasal meatus the opening of the duct is partially covered by a mucosal fold (valve of Hasner)

endoscopic DCR advantages

lack of skin incision shorter operating time less risk to the lacrimal pump mechanism minimal blood loss no risk of cerebrospinal fluid rhinorrhoea success rate is about 85%

causes of watering

lacrimation and epiphora

lacrimal sac

lies in the lacrimal fossa and is 10mm long the lacrimal bone and frontal process of maxilla separate the lacrimal sac from the middle meatus of nasal cavity dacryocystorhinoscotomy (DCR) is a surgical procedure to create an anastomosis between the sac and the nasal mucosa to bypass an obstruction in the nasolacrimal duct

puncta

located at posterior edge of lid margin junction of pars ciliaris and pars lacrimalis face slightly posterior on medial aspect of lids evaluate for stenosis or malposition

evaluation of watering - external examination of puncta

look for malposition, inflammation, stenosis or obstruction canaliculitis is characterized by pouting of punctum and expression of pus on manual canalicular compression abnormal findings of puncta in children: punctual agenesis, accessory puncta, congenital lacrimal fistula

epiphora may be caused by

malposition of lacrimal puncta obstruction anywhere along the lacrimal drainage system lacrimal pump failure, which may occur secondarily to lower lid laxity or weakness of orbicularis muscle (facial nerve palsy)

evaluation of watering - external examination

marginal tear strip of both eyes should be examined on slit lamp eyelids should be examined for malposition dynamics of eyelid closure puncta lacrimal sac should be palpated fluorescein retention test

endoscopic DCR

may be considered for obstructions beyond the medial opening of the common canaliculus following a failed conventional DCR a slender light pipe is passed through lacrimal puncta and canaliculi into the lacrimal sac and viewed from within the nasal cavity with an endoscope

balloon dacryocystoplasty

may be indicated for adults with a partial nasolacrimal duct obstruction

primary jones dye test negative finding

no dye is recovered indicates a partial obstruction or failure of the lacrimal pump mechanism now the secondary dye test is performed 22% false negatives

evaluation of watering - external examination dynamics of lid closure

normally lid margins approximate and the puncta are opposed when the eyes close with lower lid laxity one lid may override the other or the puncta may evert

canalicular obstruction treatment

partial obstruction anywhere in the nasolacrimal drainage system may be treated by intubation left in situ for 3-6 months total individual canalicular obstruction involves either a canaliculodacryocystorhinostomy CDCR or conjunctivodacryocystorhinostomy and the insertion of a special tube total obstruction of lateral end of the common canaliculus requires resection of the obstructed common canaliculus and CDCR total obstruction of the medial end of the common canaliculus is treated by dacryocystohinostomy DCR and excision of the abnormal membrane

chronic dacryocystitis

patient complains of unilateral epiphora and may have chronic conjunctivitis painless swelling at inner canthus caused by a mucocele may have reflux of mucopurulent material with pressure on the sac treatment is a DCR

probing and irrigation

performed only after ascertaining punctal patency instill topical anesthetic gently curved, blunt tipped lacrimal cannula

endolaser DCR

performed with a holmium YAG laser can be performed under local anesthesia more suitable for elderly patients success rate is only 70%

the lacrimal drainage system consists of the following structures

puncta canaliculi lacrimal sac nasolacrimal duct

evaluation of watering - external examination of lacrimal sac

punctal reflux of mucopurulent material on lacrimal compression is indicative of a mucocele with a patent canalicular system with an obstruction at or distal to the lower end of the lacrimal sac in acute dacryocystitis palpation is severely painful occasionally palpation of the sac will reveal a stone or tumor

acute dacryocystitis

subacute onset of pain, redness and swelling at the medial canthus and epiphora signs include tender, red, tense swelling at medial canthus - may be associated with preceptal cellulitis in severe cases treatment involves the application of local warmth and oral antibiotics irrigation and probing should not be performed incision and drainage may be considered if a lacrimal abscess develops DCR is usually necessary after the acute episode

the remainder of tears drain

tears flow along the upper and lower marginal strips tears enter the upper and lower canaliculus by capillary attraction about 70% of tears drain through lower canaliculus with each blink: pretarsal orbicularis compresses the ampullae, shortens the horizontal canaliculi and moves puncta medially, lacrimal part of orbicularis contracts and expands the sac creating a negative pressure which sucks the tears from canaliculi into the sac when eyes open the muscles relax: sac collapses and positive pressure is formed, pressure forces tears down nasolacrimal duct, gravity also plays a role

lacrimal scintillography

tests tear drainage under more physiological conditions vs dacryocystography test does not provide a detailed anatomical visualization it is more sensitive in assessing incomplete blocks gamma emitting radioactive substance is placed in the tears a gamma camera records images for 20 minutes

tears secreted by what

the main and accessory lacrimal glands pass laterally across ocular surface some aqueous component is lost by evaporation - related to size of palpebral fissure, temperature and humidity

jones dye test

this is only indicated in patients with suspected partial obstruction of drainage system these patients manifest epiphora but lacrimal system can be successfully syringe irrigated

secondary dye test negative finding

unstained saline is recovered indicates fluorescein did not enter the lacrimal sac indicates partial obstruction of the upper lacrimal passages or a defective lacrimal pump mechanism

lester jones tube

used when there is absence of canalicular function DCR is performed

contrast dacryocystography

using plastic catheters a contrast medium is injected postero-anterior radiographs are taken five minutes later an erect oblique film is taken use this test to determine the site of an obstruction

congenital dacryocele treatment

usually conservative probing can be performed

canaliculi

vertical from lid margin for about 2mm turn medially and run horizontally for 8mm to reach lacrimal sac superior and inferior canaliculi unite to form the common canaliculus common canaliculus opens into the lacrimal sac valve of rosenmuller overhangs this junction