Lecture 6 - Obstructive Disorders of the Orbit and Adnexa

What are the obstructive disorders of the adnexa/orbit discussed in this lecture?

Nasolacrimal duct obstruction and punctal stenosis

What is nasolacrimal duct obstruction (NLDO)?

Anatomical obstruction occurring somewhere along the lacrimal drainage pathway

Where can blockage occur in nasolacrimal duct obstruction?

Anywhere from the punctum to the valve of Hasner

Can nasolacrimal duct obstruction be congenital or acquired?

Yes, it may be congenital or acquired

When do congenital nasolacrimal duct obstructions produce symptoms?

During the neonatal period

At what age can acquired nasolacrimal duct obstruction occur?

At any age

What is epiphora?

Excessive tearing due to impaired tear drainage

What symptoms may occur with nasolacrimal duct obstruction?

Epiphora and chronic or recurrent conjunctivitis

What is the most common complaint in nasolacrimal duct obstruction?

Tearing with chronic wiping of the eye

How common is congenital nasolacrimal duct obstruction in newborns?

It occurs in up to 30% of newborns

When do symptoms of congenital nasolacrimal duct obstruction typically appear?

Within the first 1 to 2 months of life

What causes congenital nasolacrimal duct obstruction?

A congenitally imperforate membrane covering the distal end of the nasolacrimal duct over the valve of Hasner

What eyelash findings are associated with congenital nasolacrimal duct obstruction?

Morning crusting and matting of the lashes causing them to stick together

What discharge may occur with congenital nasolacrimal duct obstruction?

Mucopurulent discharge when the lacrimal sac is palpated

What infection most commonly develops from congenital nasolacrimal duct obstruction?

Conjunctivitis

What less common infections can occur from congenital nasolacrimal duct obstruction?

Preseptal cellulitis and dacryocystitis

What does PANDO stand for?

Primary acquired nasolacrimal duct obstruction

In what population is PANDO most common?

Middle-aged and elderly females

What factors may contribute to PANDO?

Hormonal fluctuations and nasolacrimal structural changes

What type of change is PANDO considered?

An involutional change associated with aging

What is another term for involutional PANDO?

Dacryostenosis

What is another term for involutional PANDO?

Punctal stenosis

What does SALDO stand for?

Secondary acquired nasolacrimal duct obstruction

What causes SALDO?

An identifiable underlying cause or condition

What infectious causes can produce SALDO?

Dacryocystitis and herpes virus infection

What medication-related mechanism can produce SALDO?

Medication-induced obstruction

What inflammatory conditions can produce SALDO?

Dry eye disease (DED) and chronic blepharitis

What types of occult matter can produce SALDO?

Plugs, makeup, dirt, and eyelashes

What neoplastic or traumatic factors can produce SALDO?

Neoplasms and repeated probing trauma

What disease process can produce SALDO?

Ocular pemphigoid

What mechanical factors can produce SALDO?

Mechanical obstruction of the drainage system

What sinonasal condition can produce SALDO?

Nasal or sinus disease

How is congenital nasolacrimal duct obstruction tested with fluorescein?

Place NaFl dye in both eyes and look for retained dye after 10 minutes

What does retained fluorescein after 10 minutes indicate in infants?

Congenital nasolacrimal duct obstruction

What dye test is congenital NLDO testing similar to?

Jones Dye testing

What is the standard test for acquired nasolacrimal duct obstruction?

Jones Dye testing

What is the normal Jones Dye testing result?

Fluorescein drains very quickly

How can fluorescein be detected during Jones Dye testing?

Swab the inside of the nose with a cotton swab

What patient action may demonstrate fluorescein drainage during Jones Dye testing?

Blowing the nose

What is the purpose of dilation and irrigation (D&I) in nasolacrimal duct obstruction?

To attempt to flush out the blockage

How does blockage affect dilation and irrigation?

Irrigation becomes difficult when blockage is present

What is the purpose of probing with a Bowman's probe?

To physically explore the nasolacrimal system and locate the obstruction

What imaging test may be used in serious cases of nasolacrimal duct obstruction?

Dacryocystorhinogram (x-ray)

What percentage of congenital nasolacrimal duct obstructions resolve spontaneously?

Approximately 90%

When do most congenital nasolacrimal duct obstructions resolve spontaneously?

Within the first year of life

How often should digital lacrimal sac massage be performed in congenital NLDO?

Four times daily (QID)

Why is digital massage used in congenital nasolacrimal duct obstruction?

It may speed the resolution process

When should surgical probing be considered for congenital nasolacrimal duct obstruction?

If there is no resolution after one year

When may surgical probing be considered earlier in congenital NLDO?

With persistent or recurrent infection or at parental request

What is the first procedural treatment often attempted for acquired nasolacrimal duct obstruction?

Dilation and irrigation (D&I)

Why is dilation and irrigation performed in acquired NLDO?

To establish patency of the lacrimal drainage system

What types of acquired obstruction may improve with D&I?

Small obstructions and subacute infections or inflammations

For what conditions is D&I ineffective?

Dacryostenosis and disease-related causes such as tumors or nasal/sinus disease

What adjunctive conservative treatment may be used in acquired NLDO?

Heat and digital massage

How should heat be applied in acquired NLDO?

Wrap the finger with a damp hot cloth

What probe may be used for acquired nasolacrimal duct obstruction?

Bowman's probe

To whom should patients with nasolacrimal duct obstruction be referred for advanced care?

An oculoplastic OMD

What is punctal stenosis?

A specific form of nasolacrimal obstruction involving narrowing of the punctum

What is a common cause of epiphora?

Punctal stenosis

Can punctal stenosis be congenital or acquired?

Yes

What term is often used for congenital punctal stenosis?

Atresia

What term is often used for congenital punctal stenosis?

Agenesis

What is the most common form of acquired punctal stenosis?

Involutional punctal stenosis in elderly patients

What causes involutional punctal stenosis?

Age-related tissue atrophy

How does tissue atrophy contribute to involutional punctal stenosis?

The densely fibrotic ring around the punctum becomes less taut and more flaccid

How do surrounding muscles contribute to involutional punctal stenosis?

They become atonic, producing additional punctal laxity and closure

Why is dilation and irrigation often unsuccessful in acquired punctal stenosis?

The punctum rapidly closes again after treatment

What symptom commonly returns after D&I in acquired punctal stenosis?

Epiphora

How quickly can epiphora return after D&I in acquired punctal stenosis?

Within days or weeks

Why should repeated D&I be avoided in acquired punctal stenosis?

It causes additional trauma to the punctal orifice and musculature

How can repeated D&I worsen punctal stenosis?

Trauma leads to atrophy, inflammation, scarring, and secondary acquired obstruction

What is the definitive treatment for punctal stenosis?

Mechanical opening of the punctum through implantation or surgical reconstruction

What are perforated punctal plugs?

A noninvasive treatment used to help patients with punctal stenosis

What is a limitation of perforated punctal plugs?

They do not create a very large channel

What is snip punctoplasty?

A procedure that enlarges the punctal opening

What is the goal of snip punctoplasty?

To make the punctal opening larger than its original size

When is a Crawford stent indicated?

When canalicular stenosis is also present

How is a Crawford stent inserted?

A guidewire is passed through the lower punctum and downward through the drainage system

Where is the Crawford stent guidewire brought out?

Through the nose

How long is the Crawford stent typically left in place?

For a few months

Why is the Crawford stent left in place?

To maintain patency of the drainage opening

Is Crawford stenting a permanent treatment?

No, it is temporary

What complication can occur with a Crawford stent?

Stent prolapse

What granulomatous complication can occur with a Crawford stent?

Granuloma formation

What punctal complication can occur with a Crawford stent?

Damage to the punctum from tension

What infectious complication can occur with a Crawford stent?

Infection