Day 2 (2): Obstruction of the Lacrimal Drainage System Flashcards
Classification of Lacrimal Drainage System Obstruction
- Age of Onset: Congenital or Acquired
- Degree of Obstruction: Partial (Stenosis) or Complete
- Location
- Upper system: Puncta, Canaliculi
- Lower system: Lacrimal sac, NLD
Pertinent points in the history of CONGENITAL LS Obstructions
- CONSTANT tearing since BIRTH or shortly thereafter: COMPLETE blockage
- upper system: minimal mucopurulent material
- lower system: frequent mucopurulent material + matting or crusting of the eyelashes - INTERMITTENT tearing with mucopurulence: PARTIAL blockage of lower system
- e.g. swelling of inferior turbinate and mucosa with URTI or allergies
Pertinent points in the PE of Congenital LS Obstructions.
Reflex Tearing (Lacrimation) or Non-Obstructive Functional (Epiphora)
- Facial asymmetry, lagophthalmos: congenital CN 7 palsy –> paralysis of OO –> exposure keratopathy (lacrimation) + lacrimal pump failure (epiphora)
- Eyelid malpositions: ectropion, entropion
- Punctal position: medial
- Lash abnormalities: trichiasis
- Enlarged cornea + thinned sclera: buphthalmos
Pertinent points in the PE of Congenital LS Obstructions
Obstructive (Epiphora)
- Tear meniscus height
- (+/-) Puncta
- Matting of lashes +/- mucopurulent discharge
- Medial canthal mass
- above MCT: tumor, nasofrontal encephalocele, anterior ethmoidal mucocele
- below MCT: dacryocystocele - (+/-) Retrograde discharge of mucoid material on firm palpation of lacrimal sac
- Fluorescein Dye Disappearance Test: children
Discuss punctal dysgenesis.
- Incomplete canalization with membranous occlusion of punctum
- Cause:
- Failed dehiscence of epithelium overlying normal canaliculi
- Failed canalization of most proximal canaliculi - HX: Epiphora since birth or infancy
- PE: Translucent white membrane over punctum
- TX: Membranotomy with sharp punctal dilator
Discuss punctal agenesis
- Absence of punctum
- Cause: Failure of canaliculi outbudding from upper end of solid lacrimal cord
- HX: Epiphora since birth or infancy
- PE: (-) punctal papilla
- TX: Observe if minimal symptoms;
Conjunctivodacryocystorhinostomy with Jones Tube if severe
Discuss canalicular dysgenesis and agenesis.
Agenesis: Failure of canaliculi outbudding from upper end of solid lacrimal cord
Dysgenesis: Incomplete canalization of cord
Symptoms dependent on severity and location of abnormality.
HX: Epiphora since birth or infancy
PE:
- agenesis: (-) punctal papilla
- dysgenesis: punctum ends blindly on probing
TX: Conjunctivodacryocystorhinostomy with Jones Tube (agenesis)
Most common etiology of congenital NLDO
Membranous obstruction at the valve of Hasner (between NLD and inferior turbinate)
- associated with premature birth
Pertinent HX and PE findings in Congenital NLDO
HX: Epiphora since birth or infancy + mucopurulent discharge and matting of eyelashes
PE:
1. Increased tear meniscus height
2. NEGATIVE fluorescein dye disappearance test: dye retention
3. Reflux of mucoid material upon firm pressure over the lacrimal sac
Interpretation of Fluorescein Dye Disappearance Test
POSITIVE FDDT
- dye coming out of nostrils
- PATENT lacrimal drainage
NEGATIVE FDDT
- dye retention
- OBSTRUCTED lacrimal drainage
Management of Congenital NLDO
Age: < 1 year old
- Conservative management
- 96% resolve spontaneously by the 1st year
- Erythromycin ointment + Crigler maneuver (lacrimal compression)
Age: > 1 year old
- Surgery: if still persistent
- Indications for EARLIER surgery:
1. Recurrent severe infection (dacryocystitis)
2. Dacryocystocele: proximal and distal block
Surgical Approaches:
1. NLD probing and irrigation
2. NLD intubation or balloon dacryoplasty
3. Dacryocystorhinostomy: create a new tear drainage system connecting the lacrimal sac and nasal cavity, bypassing the NLD
How does Crigler Maneuver or lacrimal sac compression work?
Digital compression of the lacrimal sac increases the hydrostatic pressure within the drainage system in an attempt to overcome the membranous obstruction of the distal end of the NLD
Remember: compress in a way that contents do no regurgitate from the puncta
What is a dacryocystocele?
- Cystic lesion in the medial canthal area usually BELOW the MCT noted at birth or early in infancy
- Contains trapped amniotic fluid and mucus produced by goblet cells in the lacrimal sac
- Formed when a distal blockage (usually membranous) of the lacrimal sac causes distention of the sac, which also kinks and closes off the entrance to the common canaliculus
- (+/-) intranasal component
- 2 sites of blockage:
1. Valve of Rosenmuller proximally (common canaliculi to lacrimal sac)
2. Valve of Hasner distally (NLD to inferior meatus)
What are the pertinent HX, PE and MX of dacryocystocele?
HX: Bluish, cystic mass or swelling in the medial canthus at BIRTH (usually BELOW the horizontal midline)
PE: Bluish cystic well-circumscribed non-mobile mass below the MCT
- if BILATERAL: do Nasal exam to r/o INTRANASAL CYST
- may cause airway obstruction (because infants are nasal breathers)
MX:
1. Conservative:
- Crigler Maneuver (lacrimal sac compression)
- Topical antibiotics
- NLD Probing: indications
- no resolution beyond 2 weeks of life
- minimal improvement with compression
- recurrent infection: allow inflammation to resolve first prior to doing surgery
- signs of acute respiratory distress - Marsupialization: for the intranasal cyst
- Dacryocystitis: systemic antibiotics
NOTE:
Decompression of an infected dacryocystocele with a skin incision should not be performed as this may cause a fistulous tract.
What are the common causes of ACQUIRED Punctal Stenosis (incomplete) or Occlusion (complete)
- Inflammation +/- Infection (Trachoma, Blepharitis)
- Allergic
- Chemotherapeutic agents: cicatrizing disease of the conjunctiva
- Tumors
- Iatrogenic injury
- Burn
- Traumatic
- Long-standing lid malposition
- Aging
