2: Lacrimal System Flashcards
1
Q
punctal stenosis
A
narrowing of the punctum
2
Q
punctal stenosis etiology
A
- most commonly age (tissue atrophy makes the punctum more flaccid)
- less commonly chronic blepharitis
3
Q
punctal stenosis demograpics
A
more common in elderly
4
Q
punctal stenosis laterality
A
unilateral or bilateral
5
Q
punctal stenosis symptoms
A
- asymptomatic
- tearing
6
Q
punctal stenosis signs
A
- narrowing of the punctum
- epiphora
7
Q
punctal stenosis management
A
- punctal dilation provides temporary benefit
- perforated punctal plugs
- refer for surgery: punctoplasty and/or silicone intubation
8
Q
canaliculitis
A
inflammation/infection of the lacrimal sac
9
Q
canaliculitis etiology
A
- 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
10
Q
canaliculitis demographics
A
no predilection
11
Q
canaliculitis laterality
A
unilateral
12
Q
canaliculitis symptoms
A
- tenderness nasally
- mild to severe redness of the upper or lower eyelid nasally
- ocular redness nasally
- mucous discharge
13
Q
canaliculitis signs
A
- 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
14
Q
canaliculitis management
A
- 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
15
Q
canaliculitis clinical pearls:
- often presents as _____
- many patients will end up needing _____
A
a chronic mucopurulent conjunctivitis that does not respond to topical antibiotics (many differential diagnoses and etiologies);
a canaliculotomy
16
Q
dacryocystitis
A
bacterial infection of the lacrimal sac
17
Q
dacryocystitis etiology
A
- most commonly Staph aureus, Staph epidermis, and Haemophilus influenzae
- may be an extension of a sinus infection or complication from a nasolacrimal duct obstruction
18
Q
dacryocystitis demographics
A
no predilection
19
Q
dacryocystitis laterality
A
unilateral
20
Q
dacryocystitis symptoms
A
- pain nasally
- redness and swelling in the area of the lacrimal sac
- mucous discharge
21
Q
dacryocystitis signs
A
- 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
22
Q
dacryocystitis complications
A
- orbital cellulitis
- dacryocele (cyst of the lacrimal sac) in chronic cases- appears as bluish mass in the area of the lacrimal sac
23
Q
dacryocystitis management
A
- 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
24
Q
nasolacrimal duct obstruction (NLDO)
A
obstruction of the nasolacrimal duct
25
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
26
nasolacrimal duct obstruction (NLDO) laterality
unilateral or bilateral
27
nasolacrimal duct obstruction (NLDO) symptoms
- tearing**
| - mucous discharge
28
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
29
nasolacrimal duct obstruction (NLDO) complications
- dacryocele (cyst of the lacrimal sac): appears as a bluish mass in the area of the lacrimal sac
- dacryocystitis
30
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
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, _____
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)
