Lacrimal System Disorders III- lacrimal duct

What are causes of watery eyes?

> Hypersecretion → excessive secretion of tears

• Inadequate drainage

What are the causes of hypersecretion?

• primary (rare)

• central hyper lacrimation (crying)

• secondary to anterior segment conditions

- Allergic/infective/irritative conjunctivitis

- Trichiasis , distichiasis

- Corneal disease

what are the causes of inadequate drainage?

• Malposition of lids

• Lacrimal pump failure

• Nasolacrimal duct obstruction:

—> congenital + acquired

What are the 5 Drainage obstructions?

1) Punctual Stenosis

2) Canalicular obstruction → inferior or superior

3) Common canalicular obstruction

4) Nasolacrimal duct obstruction

5) Congenital nasolacrimal duct obstruction

What is punctual stenosis + what are the symptoms?

• narrowing of puncta → can be age-related

Symptoms:

• Epiphora

• Irritation

• Blurred vision → downgaze

What is the Management of punctual stenosis?

• saline syringing

• do probing at same time to remove blockage

What is the secondary Care of Punctual stenosis?

• Lacrimal syringing +probing

• canalicular curettage → incision

• Punctual dilation (stenosis) → same time as syringing + probing

• surgery (DCR, Lester-Jones tube)

What is Canaliculitis (caused by canalicular obstruction)?

• infection/inflammtion of canaliculi

What are the symptoms of Canalicular obstruction?

• epiphora

• chronic + refractory mucopurulent conjucntivitis

• peri canalicular redness + oedema

• mucopurulent discharge on pressure over canaliculus

• ‘pouting’ punctum

• no lacrimal sac involvement → dacryocystitis

What is the treatment of Canaliculitis?

• topical antibiotic

• canaliculotomy usually required → incision to remove blockages

What are Dacryoliths?

• Lacrimal stones → solid material

• concretion of material in any part of lacrimal system

• unclear pathogenesis

• present in late adulthood

• epiphora

• recurrent attacks of acute dacryocystitis + lacrimal sac distension

what is the treatment for dacryoliths?

• surgery

What is the Aetiology for Nasolacrimal duct obstruction?

• idiopathic → no known cause

• Age-related stenosis

• secondary causes:

- Injury/trauma

- systemic inflammatory conditions

- Eye drops

- Cancer treatment

• Infection:

> dacryocystitis

> Canaliculitis

• Tumour of lacrimal sac or canaliculi → rare

What is the Aetiology for congenital obstruction?

• persistent membrane at opening of nasolacrimal duct (uni or bilateral)

• common ~20% of babies

What are the signs of congenital obstruction?

• Epiphora + mucous dsicharge

• Mucopurulent discharge if infected

• Pressure over lacrimal sac may cause mucous reflex

What are the differential diagnosis of congenital obstruction?

• Congenital glaucoma

• Punctual atresia (congenital)→ absence or narrowing of puncta

What is the management of congenital obstruction ?

• Reassure → 95% resolve by 1yr

• parent massage 2x day

• clean lids

• Treat infections

• Probe > 12months

What is Dacryocystitis?

• infection/ inflammation of lacrimal sac

• usually secondary to nasolacrimal duct obstruction

• acute or chronic

What are the signs of Chronic Dacryocystitis?

• Lacrimal sac mucocele (fluid filled)

• ± chronic /recurrent unilateral conjunctivitis

• Mucocele usually evident → painless swelling at inner canthus

• mucopurulent canalicular reflex → when you press pus comes out of puncta

What is the treatment for Chronic Dacryocystitis?

> optometric management:

• warm compress

• refer routinely if symptoms persist or recur

What is acute Dacryocystitis + when is it most common?

• infection of lacrimal sac

• commonest in infants + post menopausal women

What are the Signs and Symptoms of Acute Dacryocystitis?

• sudden onset

• epiphora

• painful, red, tender swelling over lacrimal sac

• may discharge to skin surface

• fever

What is the treatment for Acute Dacryocystitis?

• emergency or urgent referral

• antibiotics

Lacrimal sac tumours

• rare

• Painless swelling

• Punctual reflex of pus + blood

image: swelling at inner corner of eye biopsy, revealing a rare tumour of lacrimal sac → vast majority of swelling in this area due to being expansions of lacrimal sac