Nasolacrimal System (pt 1)

Lacrimal gland

Produces majority of tears

Inflammation → Tear reduction, may be a cause of dry eye

Puncta

Drain tears

Lacrimal sac

Tear reservoir

Most common complaint from pts who are diagnosed with a nasolacrimal system disorder

Tearing/Epiphora

Epiphora

Excessive tearing caused by poor tear drainage or overproduction of tears

Reflex tearing

Epiphora cause

Commonly seen with dry eye

Outflow obstruction

Epiphora cause

Commonly seen with blockage of nasolacrimal system

Puncta/eyelid malposition

Epiphora cause

Commonly seen with ectropion, puncta pointing outward

Orbicularis oculi weakness

Epiphora cause

Decreases force needed to push tears to puncta

Who is at greatest risk for developing epiphora?

Age will help determine cause

Old: More likely to have lid malposition

Young: Nasolacrimal obstruction and potential dry eye

Females more likely

Epiphora clinical findings

• Excessive tears

• Adnexa irritation (looks like anterior bleph)

How to evaluate the nasolacrimal system for an infection

Press on lacrimal sac and canaliculi

Mucopurulent discharge will come out of puncta

Pt will also complain of pain

Tests for nasolacrimal blockage

• Tear meniscus evaluation

• Fluorescein disappearance test

• Jones Dye

• Dilation and irrigation

Fluorescein disappearance test

Determine amount of the it takes for al Fluorescein to disappear out of eye

Normal value is 5 minutes → If over it suggests inadequate drainage

Jones Dye testing

Determines if there is a blockage and its approximate location

Jones 1 and Jones 2

Jones 1

Determines if epiphora is from hypersecretion or blockage

Pt blows nose after 5 minutes and asked if Fluorescein is present

Positive test = Dye present

Jones 2

Approximates location of blockage

D+I after Jones 1 and blow nose again

Dye recovered = Blockage in lower part of nasolacrimal system

Dye not recovered = Blockage in upper part of nasolacrimal system

Dilation and irrigation

Removes blockage, cannot be performed if pt has active infection

Canula inserted in puncta and saline is flushed through

Ends when pt tastes saline or has saline dripping down nose

What does it mean if the canula cannot be inserted into the puncta

Potentially punctual stenosis or obstruction

What does it mean if the canula hits a hard stop?

Canula is in the lacrimal sac and it hitting the lacrimal bone

What does it mean if the canula hits a soft spot?

Obstruction of the canaliculi

Stopped at junction of common canaliculus and lacrimal sac

Where can an obstruction occur?

• Puncta

• Canalicular

• Lacrimal sac

• Nasolacrimal duct

Primary punctal stenosis

Closure of puncta when lid is in normal position

Tx: Dilation provides temporary relief and surgery opens up puncta

Secondary punctal stenosis

Closure of puncta when lid is in abnormal position

Tx: Surgery to fix lid position

Punctal stenosis complications

Epiphora and adnexa irritation

Canalicular obstruction

Caused by inflammation or infection (belph or canaliculitis), trauma (lacerations, chemical/thermal burns), iatrogenic (punctal plugs or cauterization), related to drugs or systemic disease

Canalicular obstruction clinical findings

Epiphora and adnexa irritation

Canalicular obstruction Tx

Goal is to keep canaliculus open

Treat causative infection or inflammation

Surgical tube insertion

Chronic canaliculus

Long lasting infection of the canaliculus

Caused by fungus (Candida albicans or aspergillus), viral (herpes simplex or zoster), bacteria (actinomyces israelii)

Chronic canaliculus clinical findings

• Pouting puncta

• Red and edematous lid margin with pain

• Mucopurulent discharge

• Canalicular stones (palpation feels hard)

Chronic canaliculus Tx

• Topical antibiotics, antiviral, antifungal drops (need to culture to figure it out)

• Surgery to remove stones

Lacrimal sac obstruction

Caused by inflammation, infection (Dacryocystitis, most common), or stones (Dacryolithiasis)

Dacryocystitis

Inflammation or infection of the lacrimal sac

Blockage causes tear stagnation that is favorable for infectious organism growth

Acute dacryocystitis

Less than 3 months, presentations are caused by staph or strep (see bleph)

Looks for preseptal and orbital cellulitis

Acute dacryocytisis hallmark findings

• Red and swollen lid

• Pain along lacrimal sac

• Distended lacrimal sac

Chronic dacryocytitis

Greater than 3 months, long standing obstruction causes repeated attacks of acute infections

Chronic dacryocystitis hallmark findings

• Distended lacrimal sac

• Swelling

• NO pain

Dacryocytitis complications

Orbital cellulitis

Dacryocystitis Tx

• Oral antibiotics

• D+I (only if subclinical)

• Surgery

Dacryolithiasis

Lacrimal stones form in lacrimal sac and nasolacrimal duct

Potentially due to tear stagnation from nasolacrimal obstruction that leads to chronic inflammation, changes in cells cause formation of stones

Dacryolithiasis clinical findings

• Medial canthal swelling or distention

• Palpable firm mass

• Mucopurulent discharge (if dacryocystitis is present)

Dacryolithiasis complications

Orbital cellulitis if infection is present

Dacryolithiasis Tx

• Oral antibiotics (infection present)

• D+I or probing to open nasolacrimal duct

• Surgical removal of stones

Dacryocystitis vs. Dacryolithiasis

Dacryolithiasis has stones

Nasolacrimal duct obstruction

Nasolacrimal duct doesn’t properly develop (congenital), narrows over time due to age, or scars from trauma/infection/inflammation

Nasolacrimal duct obstruction clinical findings

• Mucopurulent/purulent discharge

• Painful medial swelling

Congenital nasolacrimal duct obstruction

Occurs in infants several weeks after birth or those with down syndrome or cleft palates

Congenital nasolacrimal duct obstruction hallmark signs

Purulent discharge and matting of lashes

Adnexa irritation

Congenital nasolacrimal duct obstruction complications

Dacryocystitis

Congenital nasolacrimal duct obstruction Tx

Digital massage to open up nasolacrimal system

If massage doesn’t work after 1st birthday → Probe

Congenital dacryocele

Amniotic fluid collected in sac that causes a blueish cystic swelling at medial canthus, present at birth

Color will not bleach with pressure

Congenital dacryocele complications

Dacryocystitis

Congenital dacryocele Tx

Digital massage and probing few weeks after dignosis