2: Lacrimal System Flashcards
punctal stenosis
narrowing of the punctum
punctal stenosis etiology
- most commonly age (tissue atrophy makes the punctum more flaccid)
- less commonly chronic blepharitis
punctal stenosis demograpics
more common in elderly
punctal stenosis laterality
unilateral or bilateral
punctal stenosis symptoms
- asymptomatic
- tearing
punctal stenosis signs
- narrowing of the punctum
- epiphora
punctal stenosis management
- punctal dilation provides temporary benefit
- perforated punctal plugs
- refer for surgery: punctoplasty and/or silicone intubation
canaliculitis
inflammation/infection of the lacrimal sac
canaliculitis etiology
- most commonly Actinomcyes israelii
- less commonly Candida, Fusarium, and Aspergillus species, herpes simplex, and varicella zoster
- may also be non-infectious and caused by a punctal plug
canaliculitis demographics
no predilection
canaliculitis laterality
unilateral
canaliculitis symptoms
- tenderness nasally
- mild to severe redness of the upper or lower eyelid nasally
- ocular redness nasally
- mucous discharge
canaliculitis signs
- mild > severe erythema of the upper and/or lower eyelid nasally
- erythematous “pouting” of the punctum
- reflux of mucopurulent/purulent discharge from the punctum when pressure is applied to the canaliculus
- expression of dacryoliths from the punctum when pressure is applied to the canaliculues; if actinomyces isreaelii is the etiology, dacryoliths consist of sulfur granules (appear yellow)
- conjunctival injection nasally
- may have accompanied bacterial conjunctivitis and/or preseptal cellulitis
canaliculitis management
- warm compress qid (?)
- remove the concretions or punctal plug; if unable to remove all concretions or punctal plug, refer out for canaliculotomy (common for a patient to need this for definitive treatment)
- treat the pathogen: bacterial- oral and topical antibiotic, irrigation with an antibiotic; fungal- topical antifungal, irrigation with antifungal solution; viral- topical antiviral and silicone intubation to prevent stenosis from scarring, can consider oral antiviral if other signs of herpetic infection
canaliculitis clinical pearls:
- often presents as _____
- many patients will end up needing _____
a chronic mucopurulent conjunctivitis that does not respond to topical antibiotics (many differential diagnoses and etiologies);
a canaliculotomy
dacryocystitis
bacterial infection of the lacrimal sac
dacryocystitis etiology
- most commonly Staph aureus, Staph epidermis, and Haemophilus influenzae
- may be an extension of a sinus infection or complication from a nasolacrimal duct obstruction
dacryocystitis demographics
no predilection
dacryocystitis laterality
unilateral
dacryocystitis symptoms
- pain nasally
- redness and swelling in the area of the lacrimal sac
- mucous discharge
dacryocystitis signs
- erythema and edema of the skin overlying the lacrimal sac
- reflux of mucopurulent/purulent discharge from the punctum when pressure is applied to the lacrimal sac
- may have accompanied bacterial conjunctivitis and/or preseptal cellulitis
dacryocystitis complications
- orbital cellulitis
- dacryocele (cyst of the lacrimal sac) in chronic cases- appears as bluish mass in the area of the lacrimal sac
dacryocystitis management
- oral»_space; topical antibiotic (IV antibiotic for severe cases/orbital cellulitis/neonatal)
- warm compress with massage qid to prevent formation of a mucocele
- incision and drainage of the lacrimal sac may be necessary (if abscess forms and points)
- dacryocystorhinostomy (DCR): anastomosis between the lacrimal sac and nasal cavity through a bony ostium, after the acute infection has been controlled
nasolacrimal duct obstruction (NLDO)
obstruction of the nasolacrimal duct
nasolacrimal duct obstruction (NLDO) etiology
- congenital (evident in first 1-12 months of life)- incomplete canalization of the nasolacrimal duct with a membrane over the valve of Hasner
- acquired (more common in elderly)- with age, tissue atrophy makes the nasolacrimal duct more flaccid; may also be due to chronic sinus disease, dacryocystitis, naso-orbital trauma
nasolacrimal duct obstruction (NLDO) laterality
unilateral or bilateral
nasolacrimal duct obstruction (NLDO) symptoms
- tearing**
- mucous discharge
nasolacrimal duct obstruction (NLDO) signs
- epiphora**
- moist or dried mucopurulent material on the eyelashes (predominantly medially)
- reflux of mucous discharge from the punctum when pressure is applied to the lacrimal sac
- may have accompanied bacterial conjunctivitis and/or preseptal cellulitis
nasolacrimal duct obstruction (NLDO) complications
- dacryocele (cyst of the lacrimal sac): appears as a bluish mass in the area of the lacrimal sac
- dacryocystitis
nasolacrimal duct obstruction (NLDO) management
- dilation and irrigation
- congenital: most cases resolve spontaneously by 6-12 months of age; digital massage to qid to speed the process- start at the lacrimal sac and move inward and downward; topical antibiotic if needed to control the mucous discharge; refer if: no resolution within 1 year, persistent/recurrent infection of the lacrimal drainage system, or non-resolving dacryocele- probing and/or balloon dacryoplasty
- acquired: refer out for surgery: balloon dacryoplasty for partial obstruction; dacryocystorhinostomy (DCR) for complete obstruction
nasolacrimal duct obstruction (NLDO) clinical pearls:
- incomplete canalization with resultant NLDO occurs in ____% of infants
- examine patients carefully for ____
- once you determine the issue is lacrimal drainage obstruction, _____
2-4;
other causes of epiphora;
perform dilation and irrigation (if you suspect infective properties, treat with oral antibiotic first- don’t want to “push” something infectious further into the nasolacrimal system)
