Infectious and Non Infectious Disorders of the Lacrimal Gland and Nasolacrimal Duct

main lacrimal glands

1. at temporal fossa of frontal bone

2. 2 divisions separated by the levator aponeurosis

   1. orbital

   2. palpebral

what part of tear film do the main and aaccespry la rimal glands make

aq layer

tubuloacinar exocrine gland secretion

merocrine —> product undergoes exocytosis out of cell

(meibomian are holocrine secretion)

MALT does what

plasma cells wi galnd secrete immunoglobulins

• IgA (highest amount) and IgG antibodies

blood supply to lacrimal gland

suplied by laacrimal artery

drained by superior ophthalmic vein

sensory nerve supply to lacrimal gland

CN 5

autonomics of lacrimal gland innervation

1. parasympathetics of CN 7 —> Facial —> Stimulates lacrimation

2. sympathetic —> inhibits lacrimation

what are the parts of the nasolacrimal drainage system

1. lacrimal lake

2. puncta (upper and lower)

3. canaliculus (upper and lower)

4. lacrimal sac

5. nasolacrimal duct

6. Valve of Hasner

7. Inferior Nasal Meatus

what does the Valve of Hasner do

prevent backflow

nerve supply to nasolacrimal drainage system

1. motor CN 7 —> orbicularis oculi contributes to nasal lacrimal pump mech

how are the canaliculi and sac when the eyes are open

they are expanded

creates - pressure that draws tears in

in closed eye state (by orbicularis) what happens w nasolacrimal system

1. pars lacrimalis

   1. creates + pressure that forces tears into nasolacrimal duct

2. pretarsal orbicularis

   1. compresses canaliculi and closes off puncta

   2. NO REGUGITATION OF TEARS

where are the pathoogies

dacryoadenitis (acute) signs

1. superior temporal eyelid redness

2. tender and warm to touch

3. S shaped

4. unilateral > bilateral

5. onset it sudden

6. preauricular lymphadenopathy

symptoms of dacryoadenitis (acute)

1. upper eyelid is swollen on one side

2. swollen

3. pufy

4. painful to touch

5. past few days

6. fever and flu symptoms

cause of acute dacryoadenities

1. inflammation of the main lacrimal gland secondary to systemic infection

2. most likely- viral: Epstein - Barr Virus, herpes zoster, mumps, influenza, adenovirus

3. bacterial- rare: Staph aureues , Streptococcus pneumonia, Neisseria gonorrhoeae, Mycobacterium tuberculosis (could be more chronic)

epi of acute dacryoadenities

1. rare

2. viral> bacteria

3. more ocmmon in kids and YA

exam of acute dacryoadenitis

1. ensure no orbital involvement

2. check for proptosis, mobility restrictions, (+) RAPD

   1. examine palpebral portion of lacrimal gland for enlargement

findings to look out for

lab test for dacryoadenitis

1. culture discharge

2. complete blodo count

imaging for dacryoadenitis

1. refer for CT if (+) proptosis, EOM restriction, (+) RAPD

2. SUSPECT ORBITAL CELLULITIS

treating viral Acute Dacryoadenitis

1. Epstein-Barr, Mumps, Influenza, Adenovirus

   1. observation

   2. palliative therapy - warm compresses BID

   3. self limiting in 4-6 weeks

2. Herpes Zoster Virus (rash)

   1. treat as so

whats the difference btw viral and bacterial Acute Dacryoadenitis

viral - no pirulent discharge (discharge is watery)

bacterial has pirulent discharge

treating bacterial Acute Dacryoadenitis thats Staphylococcus and Streptococcus:

1. Augmentin 500mg/125mg TID PO

2. or

3. Augmentin 875 mg/125 mg BID PO

4. f/u every day

   1. if no response after 24 horus —> need IV antibiotics (refer)

treating Acute Dacryoadenitis caused by Neisseria gonorrhoeae

IV antibiotic needed (Refer)

augmentin drug facts

Dacryoadenitis (Chronic) signs

1. • Superotemporal eyelid swelling and tenderness

   1. • S-shaped edema

2. • Possible globe displacement and/or ocular motility restriction

3. • Bilateral > Unilateral

4. • Enlarged lacrimal glands

5. • Onset is gradual

symptoms of Dacryoadenitis (Chronic)

“I have chronic upper eyelid swelling of both side, it’s been like this for months. It’s not painful, but I have occasional discomfort and redness.”

Dacryoadenitis (Chronic) cause

1. nflammation of the main lacrimal gland secondary to inflammatory/autoimmune, or idiopathic origin.

2. Inflammatory/Auto-immune:

   1. • Thyroid eye disease

   2. • Sarcoidosis •

   3. Sjogren syndrome

   4. • Crohn’s Disease

   5. • IgG4-related disease

   6. • Granulomatosis with polyangiitis •

   7. Rheumatoid Arthritis

      1. DACRYOADENITIS IS CAUSED BY THESE DISEASES

3. Idiopathic: Idiopathic orbital inflammation/ orbital pseudotumor → diagnosis of exclusion

epi of Dacryoadenitis (Chronic)

• More common than acute infectious dacryoadenitis but overall, uncommon

• Females>Male (due to autoimmune component)

chronic dacruoadenitis eval

1. Exam:

   1. • Ensure no orbital involvement, check for proptosis, motility restrictions

   2. • Examine palpebral portion of lacrimal gland for enlargement

2. • Lab Tests: See Management •

3. Imaging:

   1. • Orbital CT or MRI

   2. • Chest X-ray or CT (if suspecting Sarcoidosis)

4. • Lacrimal gland biopsy if diagnosis uncertain

   1. • Refer to Oculoplastics

defining features osf lacrimal gland malifnancy

1. • Gradual onset

2. no symptoms

3. palpable hard mass

4. possible proptosis & double vision with orbital involvement

   1. 1. Adenoid Cystic Carcinoma

   2. 2. Metastasis from other cancers (Breast cancer most common)

   3. 3. Lymphoma

5. • Imaging essential for diagnosis

orbital cellulitis defining features

1. proptosis

2. double vision

3. pain

eyelid dermoid cyst defing features

1. congenital

2. firm

3. non tender

4. slow growing

5. unilateral

treating/managing chronic dacryoadenitis - 1 st step

1. determine cause

2. serum lab work

   1. Angiotensin Converting Enzyme (ACE), Serum Lysozyme→ Sarcoidosis

   2. Thyroid Panel→ Thyroid eye disease

   3. SS-A, SS-B Antibodies → Sjogren Syndrome

   4. HLA-B27→Crohn’s Disease

   5. Rheumatoid Factor→ Rheumatoid A

   6. rthritis Serum IgG4→IgG4 related disease (IgG4-RD)

   7. cANCA→ Granulomatosis Polyangiitis

punctal stenosis

narrowing or occlusion of puncta

<0.3 mm

cause of punctal stenosis

1. Congenital

   1. • Agenesis, Microphthalmia, congenital stenosis

2. Acquired Stenosis

   1. • Idiopathic

   2. • Inflammatory → Chronic blepharitis, dry eye

   3. • Mechanical → Lid malposition, trauma, tumors

   4. • Infectious → HSV, Trachoma (Chlamydia)

   5. • Iatrogenic → Surgical, Chronic topical medication use

epi of punctal stenosis

1. females

2. idiopathic: aging

pathophys of acquired puncatal stenosis

In acquired stenosis: Irritants draining through puncta causes chronic inflammation leading to gradual fibrotic changes (scar formation over puncta)

clinical presentation of punctal stenosis

Symptoms: Excessive Tearing, Ocular irritation

Signs: Increased tear prism, unable to probe puncta

treatment of puncal stenosis

Punctal dilation

Punctoplasty

canaliculitis signs

1. red and swelling of puncta and adjacent tisue

2. pouting punctum

3. • Mucopurulent discharge from punctum

4. • Concretions from punctum

5. • Secondary conjunctivitis

symptoms of canaliculitis

“I have some tenderness around the corner of my eye. There’s also lots of tearing and redness of that area. It’s been this way for awhile, and I noticed worsening gradually.”

canaliculitis cause

1. Inflammation of the canaliculus resulting in recurrent conjunctivitis.

2. Infection:

   1. • Bacterial: Actinomyces israelii* (Gram + anaerobe rod) —> ISREAL HAS LONG CANALS

   2. • Fungal: Candida albicans, Aspergillus

   3. • Viral: Herpes simplex or zoster

3. Retained Foreign body or punctal plug

epi of canaliculitis

1. uncommon accounts for <4% of lacrimal disease

2. females

3. middle aged

evaluation for canaliculitis

1. Careful slit lamp exam

2. • Compression of medial punctum to observe discharge and concretions (sulfur granules → actinomyces culprit)

3. • Lab test: Culture and Gram stain

4. • Imaging: Dacryocystography

dacryocysitis discriming features

1. Inflammation of the lacrimal sac • Painful swelling and redness below nasal canthus with no involvement of puncta or canalicular area

dacryolithiasis definig features

Formation of dacryoliths or lacrimal stones within lacrimal sac • Distended lacrimal sac, firm medial canthal mass, no involvement of puncta or canalicular area

dacryocystocele defining features

Ballooning of the lacrimal sac secondary to congenital nasolacrimal duct obstruction (NLDO) • Bluish cystic bump below nasal canthus occurring in infants

canaliculitis treatment

1. warm compresses BID to QID (usually doesnt help)

2. remove obstructing concretion or punctal pluf thru canaliculotomy

3. if suspecting bacterial infection (Actinomyces Israelli

   1. Canalicular irrigation with antibiotic solution (Penicillin G 100,000 U/mL) + Oral Penicillin V 500mg QID x 7 days. Follow up: 1-2 week

Dacryocystitis signs

1. Swelling and redness below the medial canthal tendon

2. • Lacrimal sac tenderness on palpation

3. • Expression of discharge

4. • Fistula or cyst formation

Dacryocystitis symptoms

1. corner of eye is very painful!!!

2. swollen and red

3. tearing and crusting

4. happend over last few days

Dacryocystitis Etiology cause

inflammation of the lacrimal sac

acute dacryocystitis cause

Bacterial infection • Streptococcus pneumoniae (Gram +) • Staphylococcus (Gram +) • Pseudomonas (Gram -) • Haemophilus influenzae (Gram -) → In children

dacryocystitis chronic cause

Secondary to Nasolacrimal Duct Obstruction (NLDO)

epi of dacryocystitis

Right after birth for congenital form

• >40 yo for acquired form

• Females>males

eval for dacryocystitis

1. • Careful slit lamp exam

2. • Digital massage of lacrimal sac

3. • Lab test: Culture and Gram stain punctal discharge

4. • Do NOT probe with acute infection —> would just spread it

canaliculitis discriminating features

1. milder pain

2. chronic presentaion

3. pouting punctum

treating acute dacryocystitis

1. warm compresses 2 or 4 times a day w gentle massage

2. NO FEVER AND MALAISE

   1. Oral Antibiotics

      1. • Augmentin 500mg/125mg TID x 10 days

      2. If Penicillin allergy: • Bactrim DS 800mg/160mg BID x 10 days

3. IF FEVER AND MALAISE

   1. refer

whats the f/u for acute dacryocystitis

daily until reprovement

they may need IV antibiotics

chronic dacryocystitis treatment

treat underlying nasolacirmral duct obstruction

what can crhonic dacryocystitis lead to

dacryolithiasis

dacryolithiasis cause

1. Formation of dacryoliths or lacrimal stones within lacrimal sac from chronic dacryocystitis and nasolacrimal duct obstruction.

2. • Clumping of lacrimal sac epithelial cells with protein and debris forming a calcified cast within lacrimal sac

3. • Often incidental finding during dacryocystorhinostomy (DCR)

clinical presentation of dacryolithiasis

1. Symptoms: Excessive and intermittent tearing or asymptomatic

2. Signs: Distended lacrimal sac, firm medial canthal mass

treatment of dacrylithiasis

removed during Dacryocystorhinostomy (DCR)

dacryocele (mucocele) sign

1. Cystic mass inferior to medial canthus

2. • Bluish discoloration of skin

3. • Mucopurulent discharge

4. • Matting of lashes

symptoms of Dacryocele (mucocele)

”My infant has this blue colored bump on the corner of his eye(s). He has some discharge and crusting when he wakes up.”

cause of dacryocele

Ballooning of the lacrimal sac secondary to congenital nasolacrimal duct obstruction (NLDO)

pathophys of dacyocele

Trapping of mucus or amniotic fluid in nasolacrimal sac causing distention of the sac which can close off the common canaliculu

epi of dacryocele

1. Occur in utero or during early neonatal period

2. • Females>Males

3. • Occur in 30% infants with congenital NLDO

4. • Most often unilateral but 30% can be bilateral

5. • ~50% develop acute dacryocystitis (infection)

congenital NLDO —> can cuase

if left untreated then you can get acute dacryocystitis

evaluation of dacryocele

1. Exam:

   1. • Digital massage to express mucus

   2. • Evaluate for signs of infection (fever, malaise, purulent discharge) •

2. Imaging: Endoscopic nasal examination

dermoid cysts definign feature

1. Congenital benign tumor

2. • Occurs nasally if frontomaxillary suture is affected

3. • Well delineated, mobile, skin colored cyst located above nasal canthal tendon

nasofrontal encephalocele differentials

1. we aren’t talkin ab it

2. Congenital incomplete closure o neural tube causing herniation of brain tissue

3. • Typically located above nasal canthal tendon

4. • May have neurological complications

5. pretty obvious

orbital rhabdomyoscarcoma defining things

Rapidly progressive rare childhood soft tissue cancer, not present at birth

• Rapidly developing proptosis and globe displacement, and nose bleeds

treating dacryocele if theres an infection

acute dacryocystitis

• Hospital admission for observation and treatment with IV antibiotics.

dacryocele wo infection

1. unilateral

   1. conservative management

   2. digital massage

2. bilateral

   1. prompt sx to prevent airway obstruction

Nasolacrimal Duct Obstruction (NLDO) signs

1. • Chronic, typically unilateral

2. • Watery eyes, eyelash crusting

3. • Medial lower eyelid redness (secondary to excessive dabbing with tissue)

Nasolacrimal Duct Obstruction (NLDO) symptoms

”I have constant watering of one eye that I’m always wiping away. It’s been on going. There’s no pain, it’s just bothersome.

redness on old ppl could be from excessive dabbing

congenital NLDO cause

Present since birth most often due to imperforate membrane over the valve of Hasner at nasal end of duct.

primary acquired LNDO cause

Involutional stenosis of the nasolacrimal duct due age-related narrowing of the bony lacrimal canal.

Secondary Acquired NLDO (SANDO) cause

1. Stenosis of nasolacrimal apparatus secondary to:

   1. Infection→ Bacterial, viral, fungal

   2. Inflammation → Granulomatosis with polyangiitis, Sarcoidosis

   3. Neoplasm→ Primary tumor

   4. Trauma→ Naso-orbital-ethmoidal fractures

   5. Mechanical→ Foreign bodies such as dacryoliths

epi of congenital NLDO

1. premature birth or with Down Syndrome

2. bilateral in 1/3 of cases

eval of congenital LNDO

fluorescein dye disappearance test

1. yellow in eye = abnormal so blocked drain

2. yellow in snot = clearance of dye if godo

trichiasis defining features

1. normal lacrimal drainage

2. tearing is due to reflex tearing

congenital glaucoma defining features

1. increased IOP

2. cloudy cornea

3. buphlatlmos (large yes)

4. photophobia

bacterial conjunctivitis defining features

1. thick and purulent discharge

2. red eyes

congenital NLDO conservative management

1. Crigler Maneuver 2-3 x a day

   1. gentle massage over lacrimal duct area

   2. just og down nose basically

surgical managemetn fro congenital NLDO

1. IF Symptoms persisting > 6 months

   1. 1. Probing

   2. 2. Balloon Dacryoplasty

      1. • Passage of an inflatable balloon catheter to dilate blocked duct

primary acquired NLDO patho phys

Diameter of lacrimal duct tends to narrow further with age, osteoporotic, and hormonal changes along with built up of sloughed off epithelial cell debris within the ducts leading to obstruction.

epi of primary acquired NLDO

1. females

   1. females have smaller diameter of lacrimal ducts

eval for acquired NLDO

1. In Office:

   1. • Fluorescein dye disappearance test

   2. • Jone 1 & 2

   3. • Lacrimal probing

   4. • Dilation and Irrigation

2. Imaging:

   1. • Dacryocystography, Dacryoscintigraphy, CT, MRI

viral conjunctivitis defining features

1. acute

2. bilateral

3. follicular conjunctivitis

4. watery discharge

fluorescein dye disappearance test

1. Checks for presence/ absence of adequate lacrimal outflow

   1. – Especially useful for unilateral tearing

2. • Step 1: Instill NaFl onto conjunctival fornices

3. • Step 2: Observe tear film w/ Cobalt filter

4. • Step 3: Observe after 5 min for asymmetry of dye clearance between eyes.

Jones 1 TESt (Primary Dye test)

1. • Goal: Checks for lacrimal outflow under normal physiological conditions

2. • Step 1: Instill NaFl onto conjunctival fornices

3. • Step 2: @ 2-5 min mark; attempt to recover NaFl from inferior nasal meatus w/ cotton tip

trying to recover dye

swab up the nose

(+) recover y = no blockage

(-) recovery = functional deficit or mechanical block

Jones 2 Test

1. Goal: Determine if blockage is functional vs. anatomical

2. • Usually performed after (-) Jones 1 Test

3. • Step 1: Same up to Jones 1 Test

4. • Step 2: Lacrimal irrigation w/ cannula

5. • Step 3: Attempt to recover NaFl from inferior nasal meatus

flush saline thru

(+) recovery = functional deficit

(-) recovery = some kind of mechanical obstruction

lacrimal probing

1. • Goal: Help determine site of obstruction

2. • Step 1: Instillation of topical anesthesia

3. • Step 2: Probe passed through punctum

4. • Step 3: Feel for “stop” or resistance

hard stop = nasal bridge = blockage is more distal past canaliculus

soft stop = osbtruction at level of canaliculus or sac

dilation and irrigation test

1. (can forgo previous probing)

2. • Goal: Determine level of lacrimal drainage system occlusion

3. • Step 1: Instill topical anesthetic

4. • Step 2: Lower punctum is dilated (checks for punctal stenosis)

5. • Step 3: Irrigating cannula placed through canalicular system and saline is injected

usually on inferior bc its easir

normal result of dilation and irrigation

they test it

Dilation and irrigation cannula resistance w no fluid irrigation (they dont tate it)

total canalicular obstruction

fluid irrigation out of opposite canaliculus

blockage of common canalilculus

they dont taste it adn a lot of mucous comes thru opposite puncta

1. complete NLDO