Lacrimal System And
Disorders
Dr Asad Fraz
Physiology of tear drainage
• Tears secreted by the main and accessory lacrimal glands pass across
the ocular surface.
• A variable amount of the aqueous component of the tear film is lost by
evaporation, depending upon
a. Size of the palpebral aperture
b. The blink rate
c. Ambient temperature
d. Humidity
• The remainder of the tears drain
• Tears flow along the upper and lower marginal strips and enter the
upper and lower canaliculi by
i. capillary action
ii. And possibly by suction.
Causes of a watering eye
• Hypersecretion secondary to ocular
inflammation or surface disease. In these
cases watering is associated with symptoms of
the underlying cause and treatment is usually
medical.
• Epiphora is defined as the sign of overflow of
tears, and may be caused by the following:
Defective drainage due to compromise of the
lacrimal drainage system. This tends to be
exacerbated by a cold and windy atmosphere, and
is least evident in a warm dry room. It may be
caused by:
a. Malposition of the lacrimal puncta (e.g. secondary
to ectropion).
b. Obstruction along the lacrimal drainage system,
from the puncta to the nasolacrimal duct.
c. Lacrimal pump failure, which may occur
secondarily to lower lid laxity or weakness of the
orbicularis muscle (e.g. facial nerve palsy).
Primary punctal stenosis
• Primary stenosis occurs in the absence of punctal
eversion.
Causes in order of frequency are:
• Associated with chronic blepharitis.
• Idiopathic primary stenosis.
• Herpes simplex and herpes zoster lid infection.
• Following irradiation of malignant lid tumours.
• Cicatrizing conjunctivitis and trachoma.
• Systemic cytotoxic drugs such as 5-fluorouracil and
docetaxel.
Treatment
• Dilatation of the punctum can be tried but
rarely gives long-term benefit
• Punctoplasty is usually required. It involves
removal of the posterior wall of the ampulla
by a two- or three-snip technique
Dilatation of puncta
Punctoplasty
Secondary punctal stenosis
• Cause.
Secondary stenosis is caused by punctal
eversion
• Treatment
Ziegler cautery
Medial conjunctivoplasty
Lowerlid tightening
Canalicular obstruction
Causes:
include congenital, trauma, herpes simplex
infection, drugs and irradiation.
Chronic dacryocystitis can cause a thin
membrane to form at the common canaliculus.
Treatment
• Partial obstruction may be treated by
intubation using silicone stents through one or
both canaliculi, which are left in situ for 3–6
months
• Total individual canalicular obstruction
– Canaliculodacrocystorhinostomy c-DCR
– Conjunctivo-DCR
Nasolacrimal duct obstruction
Causes
• Idiopathic stenosis is by far the most common.
• Naso-orbital trauma and previous nasal and sinus
surgery.
• Granulomatous disease such as Wegener
granulomatosis and sarcoidosis.
• Infiltration by nasopharyngeal tumors.
Treatment is with DCR; other techniques include
intubation, stent insertion and balloon dilatation.
Silicone intubation
DACRYOCYSTITIS
• Dacryocystitis is inflammation of the
lacrimal sac which typically occurs secondarily
to obstruction within the nasolacrimal duct and
the resultant backup and stagnation of tears
within the lacrimal sac.
Etiology
The etiology of dacryocystitis is typically due to a
nasolacrimal duct obstruction (NLDO).
Dacryocystitis typically occurs secondary to obstruction
of the nasolacrimal duct. Obstruction of the
nasolacrimal duct leads to stagnation of tears in a
pathologically closed lacrimal drainage system, with the
stagnated tears providing a favorable environment for
infectious organisms.
The lacrimal sac will then become inflamed leading to
the characteristic erythema and edema at the
inferomedial portion of the orbit.
TYPES
Dacryocystitis can further be categorized into:
1. Acute Dacryocystits
2. Chronic Dacryocystits
……based on duration.
Or
a) Congenital Dacryocystitis
b) Acquired Dacryocystits
…….based on onset.
• Acute and chronic refer to the duration of
current symptoms, with acute usually being a
time frame less than three months.
• Acute dacryosystitis is common.
Signs and Symptoms
• Presentation differs for acute and chronic
dacryocystitis.
• In Acute dacryocystitis, the symptoms may occur
over several hours to several days and is
characterized by pain, erythema, and edema over
the medial canthus and the area overlying the
lacrimal sac at the inferomedial portion of the orbit.
The redness can extend to involve the bridge of the
nose. Purulent material can sometimes be expressed
from the puncta and tearing may be present.
In acute dacryocystitis, the area over lacrimal sac is red, swollen,
and painful.
• In cases of chronic dacryocystitis, excessive
tearing and discharge are the most common
symptom. Changes in visual acuity may be
present due to tear film production.
• Chronic dacryocystitis, often due to
longstanding nasolacrimal duct obstruction,
can manifest as bulging of the skin over the
lacrimal sac. When pressure is applied, the
bulge may not be painful, but a puslike or
cheeselike material often comes out of the
punctum.
Chronic Dacryocystits
• Erythema involving the entire orbit and pain
with extraocular movement are not typically
associated with dacryocystitis and should
prompt the health care provider to search for
alternative diagnoses. Extension of the mass
superior to the medial canthus should also
prompt imaging and further workup.
Differential Diagnosis
• · Acute ethmoid sinusitis
• · Infected sebaceous cysts
• · Cellulitis
• · Eyelid ectropion
• · Punctal ectropion
• · Lacrimal sac or sinonasal tumor
Diagnostic Procedures
• The diagnosis of dacryocystitis is generally made clinically
based off of the patient’s history and physical exam.
• Dacryocystography or plain film dacrosystogram (DCG)
can be performed when anatomic abnormalities are
suspected.
• DDT (Dye Disappearance test):fluorescein dye instilled into
the conjunctival fornices of each eye, and the tear firms
are then examined under a slit lamp. The persistence of
dye coupled with asymmetric clearance of the dye from
the tear meniscus after five minutes, indicates an
obstruction.
Management
Acute dacrocystitis:
Initial treatment is Oral gram positive antibiotics
If complicated with preseptal cellulititis then I.V
antibiotics can be given
• The patients who fail conservative treatment
often undergo lacrimal probing, which is
successful in 70% of cases. In still
unsuccessful, surgical interventions are
needed, such as stenting, balloon
dacryoplasty, and DCR. DCR can be done
percutaneously as an external DCR or
endoscopically as en endoscopic
dacryocystorhinostomy.
Prognosis and Complications
• Fortunately, the prognosis of dacryocystitis is
generally positive, but devastating
complications are possible, so prompt referral
to an ophthalmologist is encouraged. Possible
complications include the formation of
lacrimal fistulas, lacrimal sac abscesses,
meningitis, cavernous sinus thrombosis, vision
loss and possibly death.
DCR