14. Lacrimal Pt. 2

Question 1

Acute infectious ... is the infection of lacrimal gland. This is more common in .... This has a ... onset and is typically .... Characteristic signs includes ..., resulting from ..., swelling and ... over the ... 1/3 of upper eyelid. There may be ... discharge, ..., ... temporally. This can be caused by ....

Answer 1

Acute infectious dacryoadenitis is the infection of lacrimal gland. This is more common in children and young adults. This has a rapid onset and is typically unilateral. Characteristic signs includes S-shaped ptosis, resulting from erythema, swelling and tenderness over the outer 1/3 of upper eyelid. There may be mucopurulent discharge, ipsilateral preauricular lymphadenopathy, ipsilateral conjunctival chemosis temporally. This can be caused by viral or bacterial infections.

Question 2

Orbital cellulitis is an ...and ... ophthalmic emergency. It is characterised by infections of the ....
Preseptal cellulitis is ... infection which is anterior to the .... If left untreated, preseptal cellulitis can ....
Orbital cellulitis involves ... and ..., which is not found in preseptal cellulitis. Orbital cellulitis is managed by ..., whereas preseptal is managed using ... for 7-10 days, and should start improving in ... days.

Answer 2

Orbital cellulitis is an extremely serious and life-threatening ophthalmic emergency. It is characterised by infections of the soft tissues behind the orbital septum. Preseptal cellulitis is much more common and far less serious infection which is anterior to the orbital septum. If left untreated, preseptal cellulitis can progress to orbital cellulitis. Orbital cellulitis involves reduced eye movements and diplopia, which is not found in preseptal cellulitis. Orbital cellulitis is managed by sending the patient to hospital ER, whereas preseptal is managed using oral antibiotics for 7-10 days, and should start improving in 1-2 days.

Question 3

Chronic dacryoadenitis is the .... It has a ... appearance than acute infective dacryoadenitis. It typically has ... pain. Characteristic signs includes ... ptosis and ..., ... lacrimal gland on .... This is usually not ..., but is ..., therefore related to ... conditions.

Answer 3

Chronic dacryoadenitis is the persistent or progressive swelling of the outer 1/3 of the upper eyelid. It has a less severe appearance than acute infective dacryoadenitis. It typically has no to minimal pain. Characteristic signs includes S-shaped ptosis and irregular, lumpy lacrimal gland on palpation. This is usually not infectious, but is inflammation, therefore related to systemic inflammation conditions.

Question 4

Lacrimal gland tumours are .... They can occur at .... Epithelial tumours usually ..., whereas ... occur later in life. Most lacrimal gland tumours are ... (80%). Overtime, lacrimal gland tumours will invovle ... with a ..., ... due to ..., ..., ... and reduced .... Any suspected mass requires ....

Answer 4

Lacrimal gland tumours are very rare. They can occur at any age. Epithelial tumours usually occur in mid-life, whereas lymphomas occur later in life. Most lacrimal gland tumours are non-epithelial (80%). Overtime, lacrimal gland tumours will involve upper eyelid swelling with a mass, facial asymmetry due to displacement of the globe, diplopia, ptosis and reduced ocular motility. Any suspected mass requires referral for further investigation.

Question 5

What is the valve of Rosenmüller and the valve of Hasner?

Answer 5

Valve of Rosenmüller sits at the junction between the superior and inferior canaliculi. It prevents reflux of tears;

Valve of Hasner sits near the inferior concha of the nose and prevents reflux of tears form the nose back into the eye.

Question 6

Tears are drained mostly through the ... (70%), and the rest through the .... With blinking, the attachment of the ... muscle creates a ..... This is why it is called the .... Gravity then helps ....

Answer 6

Tears are drained mostly through the inferior punctum (70%), and the rest through the superior punctum. With blinking, the attachment of the preseptal orbicularis muscle creates a pressure difference that draws tears into the lacrimal sac. This is why it is called the tear pump. Gravity then helps drain and empty the sac through the nose.

Question 7

What are the 3 main possible causes of a “wet eye”?

Answer 7

• Tear overproduction (including reflex tearing BUT not epiphora)
• Poor tear support/ movement across surface
• Impaired tear drainage

Question 8

What are the possible symptoms and signs of a “wet eye”?

Answer 8

Symptoms:
Watery eye (unilateral or bilateral) with fluid escape onto cheek, slight discomfort, blurred vision, watery eye worse in cold/ windy (usually anatomical/ obstructive); hot/ dry (usually overproduction/ dry eye) conditions.

Signs:
Increased tear meniscus, eyelid anomalies, drainage blockage, dry eye, stenosed puncta

Question 9

What are the history work-up questions for a “wet eye”?

Answer 9

• Px age
• True tear spillage or just poor vision?
• When/ where are symptoms worst?
• Chronic or acute?
• Associated discomfort?
• Previous therapy for thses symptoms?
• Previous CN VII-related events?

Question 10

What are the examination techniques for a “wet eye”?

Answer 10

• BCVA
• Pupil function & ocular motility
• Facial characteristics for any palsies
• Slit lamp examination: eyelid & puncta positioning (entropion/ ectropion) & eyelid laxity
• Eyelid movement
• Lagophthalmos?
• Eyelash anomalies (trichiasis)
• Lacrimal gland swelling
• Ocular surface assessment (tear film, cornea, conjunctiva etc.) - TBUT, TMH, tear secretion
• Lacrimal sac expression using ROPLAS test
• Lacrimal lavage (irrigation)
• Fluorescein-based test (dye disappearance, Jones I & II)

Question 11

ROPLAS test stands for .... This is a first line test for .... This involves applying ... over the lacrimal sac using an index finger.
If there is ...., it suggests .... There is very high ..., therefore a positive ROPLAS test ....

Answer 11

ROPLAS test stands for Regurgitation on Pressure over LAcrimal Sac. This is a first line test for nasolacrimal duct obstruction. This involves applying steady pressure over the lacrimal sac using an index finger. If there is regurgitation of mucopurulent or watery discharge from the punctum, it suggests nasolacrimal duct obstruction. There is very high speificity, therefore a positive ROPLAS test will almost always confirm a nasolacrimal duct obstruction.

Question 12

Lacrimal lavage is the process of .... This process is used to assess ...; flush ... (can improve epiphora symptoms); determine the level of any ....
Equipment required for the procedure includes gloves, ..., ..., ..., ..., topical anaesthetic eyedrop, cue tip and towel.
Optom should first .... Then, Optom should wash their hands and put on gloves. A towel should be placed across px’s neck to .... Then, prepare flush by drawing up a small volume (~...) into the syringe, and attach the ...). ... the punctum. Ask px to look ... and ... and to maintain this gaze. Gently pull down the ... to expose the .... Then, with the other hand, insert the ... into the punctum, following the direction of the .... Gently rotate the ... between your fingers (clockwise/ anticlockwise) in order to open the drainage a little. With the dilator in situ, apply slight ... on the lower eyelid to straighten the ampulla of the lower canaliculus. Then continue to gently insert the dilator into a more ... position to continue following the direction of the canaliculus. Take the syringe with attached ... and insert tip into the .... Insert the cannula until a .... Determine whether the stop is ... or ..., in order to determine the level of the .... Withdraw the cannula 2mm from the stop point and .... Explain to px that they may ... at the back of their mouth and to let you know if this occurs. If px can, it indicates that the lacrimal drainage system is .... This therefore does not exclude ..., further testing are needed to confirm. If not, it indicates that lacrimal drainage system is .... Optom should assess the ... and also observe the ... to assess for potential ....

Answer 12

Lacrimal lavage is the process of injecting saline into the inferior punctum. This process is used to assess potency of lacrimal drainage system; flush debris loosely sitting in the system (can improve epiphora symptoms); determine the level of any blockages. Equipment required for the procedure includes gloves, sterile saline, sterile syringe, sterile Punctal dilator, sterile lacrimal cannula, topical anaesthetic eyedrop, cue tip and towel. Optom should first explain the procedure to the patient and obtain consent. Then, Optom should wash their hands and put on gloves. A towel should be placed across px’s neck to absorb any fluid spillage. Then, prepare flush by drawing up a small volume (~2mL of sterile saline) into the syringe, and attach the sterile cannula). Anaethetise the punctum. Ask px to look upwards and outwards and to maintain this gaze. Gently pull down the lower eyelid to expose the lower punctum. Then, with the other hand, insert the dilator into the punctum, following the direction of the lower canaliculus. Gently rotate the dilator between your fingers (clockwise/ anticlockwise) in order to open the drainage a little. With the dilator in situ, apply slight lateral traction on the lower eyelid to straighten the ampulla of the lower canaliculus. Then continue to gently insert the dilator into a more horizontal position to continue following the direction of the canaliculus. Take the syringe with attached cannula and insert tip into the lower punctum. Insert the cannula until a stop is reached. Determine whether the stop is hard or soft, in order to determine the level of the blockage. Withdraw the cannula 2mm from the stop point and slowly inject fluid. Explain to px that they may taste a salty solution at the back of their mouth and to let you know if this occurs. If px can, it indicates that the lacrimal drainage system is patent under high pressure conditions. This therefore does not exclude functional duct obstruction, further testing are needed to confirm. If not, it indicates that lacrimal drainage system is blocked. Optom should assess the ease of fluid flush and also observe the upper punctum to assess for potential regurgitation.

Question 13

What does a hard stop and a soft stop indicate during lacrimal lavage?

Answer 13

Hard stop indicates a patient canaliculus system. This is because the cannula is within the lacrimal sac and touching against the lacrimal bone. Soft stop suggests blockage within the canalicular system, this is possibly due to cannula pushing against the spongy outer walls of the lacrimal sac.

Question 14

What does the following situations in a lacrimal lavage indicate:
• Reflux of saline through the same punctum
• Soft stop + reflux of saline from upper or both puncta
• Hard stop + reflux of saline from upper punctum
• Soft stop but px can taste salt water
• Minimal resistance & px can taste salt water

Answer 14

• Reflux of saline through the same punctum = obstruction within the same canaliculus
• Soft stop + reflux of saline from upper or both puncta = obstruction at common canaliculus
• Hard stop + reflux of saline from upper punctum = complete obstruction of nasolacrimal duct
• Soft stop but px can taste salt water = partial nasolacrimal duct obstruction
• Minimal resistance & px can taste salt water = complete patent lacrimal drainage system

Question 15

The Jones I and II tests are used to test ... during .... 1 drop of ... is placed into the .... A cotton bud soaked in ... is placed in the .... Optom should wait for ... mins .
System is deemed patent when ..., also known as a ....
Functional obstruction anywhere from the ... is indicated if ... also known as a .....
For Jones II, optom should then ... and syringe lacrimal drainage system with .... If fluorescein is detected from the nose, it is a .... test, indicating ... of the nasolacrimal duct. If fluorescein is not detected from the nose, it is a ... test, indicating ... of punctum or ... system. If saline is not detected from the nose at all, it indicates ... somewhere in the lacrimal drainage system.

Answer 15

The Jones I and II tests are used to test functional obstruction during physiological conditions. 1 drop of fluorescein is placed into the conjunctival sac. A cotton bud soaked in anaesthetics is placed in the inferior meatus. Optom should wait for 5 mins . System is deemed patent when fluorescein is detected, also known as a positive Jones I. Functional obstruction anywhere from the punctum to valve of Hasner is indicated if fluorescein is not detected also known as a negative Jones I. For Jones II, optom should then wash excess fluorescein from conjunctival sac and syringe lacrimal drainage system with saline. If fluorescein is detected from the nose, it is a positive Jones II test, indicating functional obstruction of the nasolacrimal duct. If fluorescein is not detected from the nose, it is a negative Jones II test, indicating stenosis of punctum or canalicular system. If saline is not detected from the nose at all, it indicates complete obstruction somewhere in the lacrimal drainage system.

Question 16

Dye disappearance test is done by instilling ... into the ... of both eyes. After 5 mins, ... and ... are observed under a ... light for signs of .... In a healthy, patent lacrimal drainage system, the ... should .... Any amount of dye remaining after ... mins suggests complete or partial duct obstruction. ... between the eyes should also be noted.

Answer 16

Dye disappearance test is done by instilling fluorescein into the inferior fornix of both eyes. After 5 mins, tear film and meniscus are observed under a cobalt blue light for signs of dye retention. In a healthy, patent lacrimal drainage system, the fluorescein should completely disappear. Any amount of dye remaining after 5 mins suggests complete or partial duct obstruction. Asymmetry between the eyes should also be noted.

Question 17

What are the tertiary work up of a “wet eye”? (Not done by optometrists)

Answer 17

• Intranasal examination
• X-ray or CT scan
• Dacryocystography
• Dacryoscintigraphy

Question 18

Reflex tearing is the ... caused by .... This can be caused by ... abnormality with or without pain. With pain, it can be due to .... WIthout pain, it can be due to .... Can also be due to ..., asthenopia (...), nasal abnormalities, ..... Hypersecretion of tears is the ... (overall rare). Lacrimal gland hypersecretion is very rare, but can be caused by ... from a ..., aberrant ... regeneration, or with ... or certain ... medications.

Answer 18

Reflex tearing is the reactive tear production caused by ocular trauma or stimulation. This can be caused by corneal or conjunctival abnormality with or without pain. With pain, it can be due to abrasion, laceration, foreign body, recurrent erosion, trichiasis. WIthout pain, it can be due to allergy, DED, blepharitis, conjunctivitis. Can also be due to intraocular inflammation, asthenopia (uncorrected refractive error), nasal abnormalities, psychological/ emotional tearing. Hypersecretion of tears is the excess basal tear production (overall rare). Lacrimal gland hypersecretion is very rare, but can be caused by compression of parasympathetic lacrimal fibres from a tumour, aberrant CN VII regeneration, or with dacryoadenitis or certain cholinergic agonist medications.

Question 19

Poor tear support/ movement across the ocular surface can be due to disruptions to ... and/ or .... These include abnormal ..., e.g. ..., ..., other eyelid ...; obstruction of tear movement due to ... or ...; deficiency of eyelid "..." due to ... dysfunction e.g. ..., ..., .... Optom should conduct a full clincal work up to determine ... and assess ... of surface damage. The major priority is to .... Tear supplements may be needed to .... ... or limited ... may also be needed. Referral may be needed for ... management of lid position/ neural issues/ tumours/ scar tissue.

Answer 19

Poor tear support/ movement across the ocular surface can be due to disruptions to lid-globe apposition and/ or tear pump mechanism. These include abnormal eyelid position/ poor apposition of punctae, e.g. Entropion, entropion, other eyelid deformity; obstruction of tear movement due to conjunctival irregularity or scarring; deficiency of eyelid "pumping" due to neuromuscular dysfunction e.g. Bell's palsy, diabetes, lagophthalmos. Optom should conduct a full clincal work up to determine cause and assess extent of surface damage. The major priority is to protect ocular surface from further damage. Tear supplements may be needed to reduce/ /prevent exposure. Lid taping or limited epilation may also be needed. Referral may be needed for surgical management of lid position/ neural issues/ tumours/ scar tissue.

Question 20

Ectropion is ..., where the lid margin ... from the eye. This is commonly due to ... but also cicatricial (.../ .../ ...), paralytic (... palsy), mechanical (...), congenital and inflammatory (...).
Ectropion can cause ..., ..., ... eye, reduced ..., droopy ... exposing .... Treatment of ectropion includes protection of ocular surface with ..., temporary ..., or referral for ....

Answer 20

Ectropion is lower lid eversion, where the lid margin rests away from the eye. This is commonly due to age-related CT degenerative changes but also cicatricial (checmial burn/ surgery/ skin disease), paralytic (CN VII palsy), mechanical (tumour), congenital and inflammatory (contact dermatitis). Ectropion can cause hyperaemic lower Palpebral conjunctiva, watery, gritty eye, reduced TBUT, droopy lower lid exposing lower Palpebral conjunctiva. Treatment of ectropion includes protection of ocular surface with tear supplements, temporary eyelid taping, or referral for surgical correction.

Question 21

Entropion is ..., where the lid margin ... the eye. This is commonly ...-related, but may be ..., ... (surgical trauma, ocular irritation or ...) or .... Entropion can cause ..., ... eyes, ... on lower eyelid, ... disturbances (SPK to ulcer), ... of .... Treatment includes protection of ocular surface with ..., ... CLs, temporary .... Patients may also be referred for ....

Answer 21

Entropion is lower lid inversion, where the lid margin rests against the eye. This is commonly age-related, but may be cicatricial, spastic (surgical trauma, ocular irritation or blepharospasm) or congenital. Entropion can cause gritty, watery eyes, no visible lashes on lower eyelid, epithelial disturbances (SPK to ulcer), hyperaemia of inferior bulbar conjunctiva. Treatment includes protection of ocular surface with tear supplement, bandage CLs, temporary lid taping. Patients may also be referred for surgical correction.

Question 22

Trichiasis refers to ... rubbing against the globe in a person without ... by definition. It may be idiopathic or caused by chronic ..., ... (eyelid ... from trauma or surgery). It causes ..., ... eyes, corneal ... disturbances, and ` … hyperaemia. This can be treated with …, which is the removal of misdirected lashes; … and to treat underlying …`.

Answer 22

Trichiasis refers to misdirected eyelashes rubbing against the globe in a person without entropion by definition. It may be idiopathic or caused by chronic blepharitis, cicatricial (eyelid scarring from trauma or surgery). It causes gritty, watery eyes, corneal epithelial disturbances, and bulbar hyperaemia. This can be treated with epilation, which is the removal of misdirected lashes; tear supplements and to treat underlying blepharitis.

Question 23

Distichiasis refers to growth of an ... of eyelashes, emanating from the .... This is relatively ..., and can be ... (mutation ... gene) or acquired through ..., ..., or ... burn. This is treated the same way as .... Patients should also be referred for ... evaluation due to the same mutation affecting ... and ... development.

Answer 23

Distichiasis refers to growth of an aberrant second row of eyelashes, emanating from the meibomian gland orifices. This is relatively rare, and can be congenital (mutation FOXC2 gene) or acquired through blepharitis, MGD, or chemical burn. This is treated the same way as trichiasis. Patients should also be referred for cardiac evaluation due to the same mutation affecting lymph and blood vascular development.

Question 24

Floppy eyelid syndrome is the eyelid ... with reactive .... Px with this condition can easily ... their eyelids even when .... This condition is ... and .... This can lead to ..., ... and redness, commonly worse in the ..., droopy ...; ... and ... lower lids; corneal ..., leading to ...; ... due to mechanical irritation. There are no specific .... This syndrome is commonly associated with ..., ..., ..., and .... This is managed by using ..., l... during sleep. Some px may be referred for ... if needed.

Answer 24

Floppy eyelid syndrome is the eyelid hyperlaxity with reactive Palpebral conjunctivitis. Px with this condition can easily evert their eyelids even when sleeping. This condition is common and underdiagnosed. This can lead to chronic eye irritation, tearing and redness, commonly worse in the morning, droopy upper lids; loose and unstable lower lids; corneal exposure, leading to ulceration; papillary conjunctivitis due to mechanical irritation. There are no specific diagnostic tests. This syndrome is commonly associated with obstructive sleep apnoea, keratoconus, obesity, and males. This is managed by using tear supplements, lid taping during sleep. Some px may be referred for surgery if needed.

Question 25

Impaired tear drainage is due to obstruction of the ..., ..., ..., ... or part of the .... This can be caused by ... decvelopments, .../ ..., ..., ... related, infective e.g. ..., ..., or .... It is important to identify and ... as appropriate. ... under topical anaethesia may be conducted to help, unless contraindicated. ... is often required for ... surgery e.g. punctoplasty, ... (bypass canaliculi), ... DCR (bypass NLD).

Answer 25

Impaired tear drainage is due to obstruction of the punctae, canaliculae, lacrimal sac, nasolacrimal duct or part of the nose. This can be caused by congenital decvelopments, trauma/ scarring, inflammation/ infiltration/ scarring, drug related, infective e.g. canaliculitis, dacryocyctitis, or tumours. It is important to identify and treat underlying conditions as appropriate. Lacrimal irrigation under topical anaethesia may be conducted to help, unless contraindicated. Referral is often required for drainage surgery e.g. punctoplasty, Jones tube (bypass canaliculi), dacryocystorhinostomy DCR (bypass NLD).

Question 26

Canaliculitis is a ..., ... infection of the .... It is usually caused by ... or ... (G+). Symptoms of canaliculitis includes ... or ..., general ..., and mild ... over ... eyelid. Signs include ... and chronic ... that resist treatment,... and ... of punctum, ... of skin near punctum, ... from canaliculi. Canaliculus should be differentially diagnosed from
* ... → symptoms/ signs are more ...
* ... → does not have ..., more ...
* ... → no pouting of ... or ....
Patients should be .... ... from punctum should be removed. Warm compresses can help break up .... ... treatment is also needed.

Answer 26

Canaliculitis is a rare, unilateral infection of the canaliculis. It is usually caused by Actinomyces or Streptomyces (G+). Symptoms of canaliculitis includes tearing or discharge, general conjunctival hyperaemia, and mild tenderness over nasal eyelid. Signs include unilateral epiphora and chronic mucopurulent conjunctivitis that resist treatment,redness and pouting of punctum, redness of skin near punctum, chalky granules/ concretions from canaliculi. Canaliculus should be differentially diagnosed from dacryocystitis → symptoms/ signs are more severe , nasolacrimal duct obstruction → does not have erythema, more epiphora, conjunctivitis → no pouting of punctum or punctal discharge. Patients should be referred. Granules from punctum should be removed. Warm compresses can help break up granular concretions. Antibiotic treatment is also needed.

Question 27

Dacryocystitis is a ... infection of the .... This is often ..., but can also be .... Symptoms include ..., ... and ... over the innermost aspect of the ... (over the lacrimal sac); ..., ...; possible fever.
Signs of dacryocystitis includes:
* ..., ... swelling centred over ... aspect of lower eyelid;
* swelling extends to ... area ...;
* ... discharge expressed from ... when pressure is applied over lacrimal sac (... test);
* possible associated orbital cellulitis;
* Chronic form may have ... swelling and is often second to ....
Treatment includes ` … and … antibiotics and …. Due to risk of spreading infection, … and …` are contraindicated.

Answer 27

Dacryocystitis is a unilateral infection of the lacrimal sac. This is often acute, but can also be chronic. Symptoms include pain, redness and swelling over the innermost aspect of the lower eyelid (over the lacrimal sac); tearing, mucopurulent discharge; possible fever. Signs of dacryocystitis includes:
* erythematous, tender swelling centred over nasal aspect of lower eyelid;
* swelling extends to periorbital area nasally;
* mucopurulent discharge expressed from punctum when pressure is applied over lacrimal sac (ROPLAS test);
* possible associated orbital cellulitis;
* Chronic form may have painless swelling and is often second to nasolacrimal duct blockage.
Treatment includes ` topical and systemic antibiotics and warm compresses. Due to risk of spreading infection, lacrimal lavage and probing` are contraindicated.

Question 28

What is dacryocystorhinostomy (DCR)?

Answer 28

Surgical intervention to treat epiphora associated with nasolacrimal duct obstruction. It is a bypass procedure that creates a pathway from the canaliculus into the nose through bone cutting (osteotomy) and opening the nasolacrimal sac into the nose.