2: Lacrimal System

Question 1

punctal stenosis

Answer 1

narrowing of the punctum

Question 2

punctal stenosis etiology

Answer 2

• most commonly age (tissue atrophy makes the punctum more flaccid)
• less commonly chronic blepharitis

Question 3

punctal stenosis demograpics

Answer 3

more common in elderly

Question 4

punctal stenosis laterality

Answer 4

unilateral or bilateral

Question 5

punctal stenosis symptoms

Answer 5

• asymptomatic

- tearing

Question 6

punctal stenosis signs

Answer 6

• narrowing of the punctum

- epiphora

Question 7

punctal stenosis management

Answer 7

• punctal dilation provides temporary benefit
• perforated punctal plugs
• refer for surgery: punctoplasty and/or silicone intubation

Question 8

canaliculitis

Answer 8

inflammation/infection of the lacrimal sac

Question 9

canaliculitis etiology

Answer 9

• 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

Question 10

canaliculitis demographics

Answer 10

no predilection

Question 11

canaliculitis laterality

Answer 11

unilateral

Question 12

canaliculitis symptoms

Answer 12

• tenderness nasally
• mild to severe redness of the upper or lower eyelid nasally
• ocular redness nasally
• mucous discharge

Question 13

canaliculitis signs

Answer 13

• 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

Question 14

canaliculitis management

Answer 14

• 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

Question 15

canaliculitis clinical pearls:

• often presents as _____
• many patients will end up needing _____

Answer 15

a chronic mucopurulent conjunctivitis that does not respond to topical antibiotics (many differential diagnoses and etiologies);
a canaliculotomy

Question 16

dacryocystitis

Answer 16

bacterial infection of the lacrimal sac

Question 17

dacryocystitis etiology

Answer 17

• most commonly Staph aureus, Staph epidermis, and Haemophilus influenzae
• may be an extension of a sinus infection or complication from a nasolacrimal duct obstruction

Question 18

dacryocystitis demographics

Answer 18

no predilection

Question 19

dacryocystitis laterality

Answer 19

unilateral

Question 20

dacryocystitis symptoms

Answer 20

• pain nasally
• redness and swelling in the area of the lacrimal sac
• mucous discharge

Question 21

dacryocystitis signs

Answer 21

• 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

Question 22

dacryocystitis complications

Answer 22

• orbital cellulitis

- dacryocele (cyst of the lacrimal sac) in chronic cases- appears as bluish mass in the area of the lacrimal sac

Question 23

dacryocystitis management

Answer 23

• oral&raquo_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

Question 24

nasolacrimal duct obstruction (NLDO)

Answer 24

obstruction of the nasolacrimal duct

Question 25

nasolacrimal duct obstruction (NLDO) etiology

Answer 25

• 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

Question 26

nasolacrimal duct obstruction (NLDO) laterality

Answer 26

unilateral or bilateral

Question 27

nasolacrimal duct obstruction (NLDO) symptoms

Answer 27

• tearing**

- mucous discharge

Question 28

nasolacrimal duct obstruction (NLDO) signs

Answer 28

• 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

Question 29

nasolacrimal duct obstruction (NLDO) complications

Answer 29

• dacryocele (cyst of the lacrimal sac): appears as a bluish mass in the area of the lacrimal sac
• dacryocystitis

Question 30

nasolacrimal duct obstruction (NLDO) management

Answer 30

• 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

Question 31

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, _____

Answer 31

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)