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Ophthalmology > Day 2 (3): Basic Clinical Evaluation of the Lacrimal Drainage System > Flashcards

Day 2 (3): Basic Clinical Evaluation of the Lacrimal Drainage System Flashcards

1
Q

What are the parts of the lacrimal system?

A
  1. Secretory system: main lacrimal gland, accessory lacrimal glands (of Krause and Wolfring)
  2. Drainage system: puncta, canaliculus, lacrimal sac, NLD
  3. Lid-Globe apposition: tendons
  4. Lacrimal pump mechanism: OO
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2
Q

What are the general causes of excessive tearing?

A
  1. Increased production: hypersecretion overwhelms drainage
  2. Decreased drainage: anatomically compromised drainage system
  3. Poor lid-globe apposition: tear lake does not align with the puncta
  4. Dysfunctional lacrimal pump mechanism: OO palsy
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3
Q

Why is lid-globe apposition important for tear drainage?

A
  1. Directs tears across the ocular surface into the puncta
  2. Prevents excessive exposure of ocular surface and minimizes tear film evaporation
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4
Q

Differentiate epiphora from lacrimation.

A

Lacrimation:
- aka Hypersecretion/Hyperlacrimation/Reflex Tearing
- increased tear production WITH normal tear transport or drainage
- produced tears overwhelm drainage system
- causes: corneal or conjunctival irritation, emotions

Epiphora:
- tear production is normal BUT tear transport or drainage is impaired
- overflowing tears (tears on the cheeks)

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5
Q

Differentiate anatomic from functional lacrimal drainage dysfunction

A

Anatomic:
- (+) gross STRUCTURAL abnormality
- partial (stenosis) OR complete blockage

Physiologic:
- failure of FUNCTIONAL mechanisms BUT lacrimal drainage system remains patent

  1. Poor lacrimal pump mechanism
    - OO weakness due to CN 7 palsy
  2. Poor lid-globe apposition
    - lower lid laxity due to aging or CN 7 palsy
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6
Q

What are the causes of lacrimation?

A

INCREASED TEAR PRODUCTION

  1. Trigeminal nerve stimulation (reflex tearing): due to ocular surface irritation
    - blepharitis, trichiasis
    - conjunctival and cornea inflammatory diseases
    - foreign bodies, contact lens use
    - dry eye syndrome
    - neuralgia
    - ocular inflammation (uveitis)
    - allergies
  2. Supranuclear: psychogenic (emotion)
  3. Infranuclear:
    - CN 7 aberrant innervation: goes to lacrimal nerve instead
    - lacrimal gland stimulation
  4. Bright lights, sneezing
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7
Q

What are the causes of epiphora?

A

DECREASED TEAR DRAINAGE

  1. Anatomic (stenosis or complete)
    - congenital
    - inflammatory +/- infectious
    - traumatic +/- burns
    - neoplastic
    - idiopathic
    - chronic ectropion
    - iatrogenic
    - nasal factors: allergic, iatrogenic, neoplastic
  2. Functional
    - incorrect lid closure: lid laxity, lagophthalmos, traumatic, iatrogenic
    - eyelid malposition
    - punctal eversion or medialization
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8
Q

What are the causes of combined lacrimation and epiphora?

A
  1. Facial nerve palsy:
    - lacrimal pump failure from OO dysfunction (E)
    - lagophthalmos –> exposure keratitis/corneal irritation (L)
  2. Lower lid ectropion:
    - punctal eversion (E)
    - conjunctival irritation (L)
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9
Q

Parts of the evaluation of a tearing patient?

A
  1. History
  2. Comprehensive ophthalmic exam including:
    - eyelids
    - lacrimal system
    - nasal cavity
    - anterior segment
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10
Q

Why is it important to differentiate lacrimation from epiphora?

A

Management:
Lacrimation - usually MEDICAL
Epiphora - usually SURGICAL

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11
Q

What are the pertinent points to elicit in the history of a tearing patient?

A
  1. Laterality (uni- or bi-)
  2. Onset and duration (congenital or acquired)
  3. Frequency (constant or intermittent)
  4. History of masses or bleeding from punctum (malignancy)
  5. History of recurrent lacrimal sac inflammation (leading to NLDO)
  6. Associated burning, grittiness or FB sensation (DES)
  7. Previous trauma or surgeries to the eyes, nose or face
  8. Use of medications (ophthalmics, chemotherapy, radiotherapy)
  9. History of ocular surface infections (conjunctiva, cornea)
  10. Allergies
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12
Q

Pertinent findings to note in the FACE when doing external eye examination:

A

Facial asymmetry
- Brow ptosis (frontalis)
- Lagophthalmos (OO)

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13
Q

Pertinent findings to note in the EYELIDS when doing external eye examination:

A

Eyelid margin position
- Ectropion: outward turning of margin –> exposure keratopathy
- Entropion: inward turning of margin –> corneal and conjunctival irritation

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14
Q

Pertinent findings to note in the EYELASHES when doing external eye examination:

A

Eyelash position and dandruff-like scales
- Trichiasis: misdirected eyelashes towards ocular surface
- Distichiasis: eyelashes grow from Meibomian gland orifices
- Collarettes: dandruff-like scales at base of lashes (blepharitis)

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15
Q

Pertinent findings to note in the PUNCTUM when doing external eye examination:

A
  1. Size
  2. Malposition
    - Ectropion: punctum everted away from tear lake
    - Medialization: punctum more medial away from tear lake
  3. Stenosis/occlusion/overlying membrane
  4. Pouting or swelling
    - Canaliculitis +/- Concretions
  5. Abnormal surrounding structures
    - Conjunctivochalasis: loose, redundant, non-edematous conjunctiva occluding the lower punctum
    - Enlarged lacrimal caruncle
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16
Q

Pertinent findings to note in the MEDIAL CANTHAL AREA when doing external eye examination:

A
  1. Inflammation (swelling, redness, warmth, tenderness)
    - Does not cross horizontal midline
    - Acute dacryocystitis: inflammation of lacrimal sac and NLD due to obstruction
    - Dacryocystocele: congenital bluish cystic mass filled with mucoid material and amniotic fluid
  2. Masses
    - Lacrimal sac tumor: crosses horizontal midline
    - Frontoethmoidal Encephalocele
    - Ethmoidal Mucocele
17
Q

Pertinent findings to note in the OCULAR SURFACE when doing external eye examination:

A

Examine with slit lamp biomicroscopy and fluorescein dye.
- INCREASED fluorescein dye uptake on ABNORMAL surface
- abrasions, erosions, keratitis/keratopathy, foreign bodies

Remember:
Any conjunctival or corneal irritation, mechanical or inflammatory, causes lacrimation

18
Q

What is elicited with palpation/compression of the lacrimal sac?

A
  1. Pain/Tenderness: sign of ACUTE inflammation
  2. Expression of mucopurulent discharge from the puncta
    - (+) ROPLAS: Regurgitation On Pressure over the LAcrimal Sac
    - sign of CHRONIC and REPEATED inflammation causing NLDO

DDX:
1. Dacryocystitis: inflammation of the lower system
- punctum and canaliculus is NORMAL
- inflammation is more MEDIAL

  1. Canaliculitis: inflammation of the upper system
    - punctum and canaliculus is INFLAMED (more LATERAL)
19
Q

What are the different ANATOMIC excretory tests for epiphora?

A

Goal: Look for location of obstruction

  1. Lacrimal Apparatus Irrigation/Syringing
  2. Canalicular probing
  3. Jones II Test
  4. Nasal Endoscopy
20
Q

What are the different PHYSIOLOGIC excretory tests for epiphora?

A

Indication: To confirm diagnosis of epiphora, assess tear flow and for pts where anatomical tests are not possible (e.g. children)

  1. Fluorescein dye disappearance
  2. Jones I Test
  3. Saccharin Test
21
Q

What are the different SECRETORY tests to assess lacrimation?

A

Goal: Test secretory function of the lacrimal glands and integrity of the tear film

  1. Tear Break-up Time
  2. Schirmer’s Test
  3. Rose Bengal Test
  4. Tear Lysozyme Test
22
Q

How is the Saccharin test done?

A
  1. A drop of 2% saccharin is placed in the conjunctival fornix.
  2. 90% of patients with a patent lacrimal system will taste it in 15 minutes.
23
Q

How is the Fluorescein Dye Disappearance Test done?

A
  • Evaluation of the residual fluorescein in the eye following instillation into the UNANESTHETIZED conjunctiva.
  • High sensitivity
  • Usually done in CHILDREN
  • DOES NOT localize the obstruction
  1. A drop of 2% fluorescein is placed in the fornix
  2. The volume of the tear meniscus and fluorescein remaining in the conjunctival cul-de-sac is examined with the cobalt blue light after FIVE minutes.
  3. The amount of remaining fluorescein can be graded using a scale from 0 to 4:
    - 0: no remaining dye [+ FDDT/Normal]
    - 1: minimal dye remaining [+ FDDT/Normal]
    - 2/3: subjective [- FDDT/Abnormal]
    - 4: all the dye remains [- FDDT/Abnormal]
  4. Compare both sides simultaneously.

Result:
+ FDDT: lacrimal drainage dysfunction unlikely
- FDDT/Retention: delay in tear flow

24
Q

Describe how lacrimal apparatus irrigation test is done.

A
  • Performed immediately AFTER a NEGATIVE FDDT to localize level of obstruction
  • Not a physiologic test because it uses higher hydrostatic pressure than normal tear outflow
  • CONTRAINDICATIONS: acute infection (dacryocystitis or canaliculitis)
  1. Instillation of topical anesthetic
  2. Dilation of punctum with lacrimal dilator
  3. Blunt cannula attached to a 3 cc syringe is placed into the inferior punctum (vertically for 2 mm then horizontally with the eyelids stretched to straighten the canaliculus)
  4. Advance cannula for 3-7 mm into canaliculus and irrigate with sterile water or normal saline.
25
Q

How is canalicular probing done?

A
  • INDICATION: LAI demonstrates obstruction and determination of location/extent of block
  • CONTRAINDICATION: Acute infection (dacryocystitis/canaliculitis)
  1. Instillation of topical anesthetic and dilation of punctum done during LAI
  2. Lacrimal probe is advanced 2 mm vertically then horizontally while keeping the eyelid stretched laterally.
  3. Advance probe until obstruction OR lacrimal bone is encountered.

Result:

Hard Stop: lacrimal bone; obstruction in the NLD
Soft Stop: spongy feeling; obstruction in CC or kinking of canaliculus (always maintain traction on eyelids to straighten)

RUC/RLC/LUC/LLC: ___ mm hard/soft stop

Note: if > 10 mm of probe advanced, already in lacrimal sac

26
Q

Interpretation of LAI and Lacrimal Probing test results.

A

(+) Fluid in nose/pharynx, (-) Reflux, Hard stop:
PATENT (normal or physiologic dysfunction)

(+) Fluid in nose/pharynx, (+) Reflux in OPPOSITE PUNCTUM, Hard stop:
INCOMPLETE BLOCK/STENOSIS anywhere in the system

(-) Fluid in nose/pharynx, (+) Reflux in SAME PUNCTUM, Soft stop:
COMPLETE CANALICULAR BLOCK

(-) Fluid in nose/pharynx, (+) Reflux in OPPOSITE PUNCTUM –> PROBING –>
Hard stop: COMPLETE NLDO
Soft stop: COMPLETE COMMON CANALICULAR BLOCK

27
Q

When is PHYSIOLOGIC DYSFUNCTION or FUNCTIONAL DISORDER of lacrimal drainage system suspected?

A
  1. Presents with epiphora
  2. (-) FDDT: delayed/abnormal
  3. LAI: (+) Fluid in nose or pharynx, (-) Reflux
  4. Probing: Hard stop on probing

Suspect: Lacrimal Pump Insufficiency/Dysfunction

28
Q

Describe the Jones I Test

A
  • Evaluates lacrimal outflow under PHYSIOLOGIC conditions (normal hydrostatic pressure) similar to FDDT
  • only an ANATOMICALLY and FUNCTIONALLY PATENT system will produce a (+) result
  • Rarely performed due to HIGH FALSE NEGATIVE (dye may be difficult to retrieve since procedure is somewhat blind)
  1. 2% Fluorescein instilled into UNANESTHETIZED conjunctiva
  2. Cotton-tipped applicator inserted beneath the inferior turbinate at the level of the NLD ostium at 2 MINUTES then at 5 MINUTES.

(+): dye in applicator –> similar to (+) FDDT –> patent and functionally adequate

(-): no dye –> similar to (-) FDDT –> delayed transit time –> anatomic or physiologic problem

29
Q

Describe the Jones II Test

A
  • Performed after a (-) Jones I test (anatomic or functional problem)
  • Almost similar to LAI
  1. Residual fluorescein in flushed from ANESTHETIZED conjunctiva by irrigation with normal saline through one canaliculus using a lacrimal cannula.
  2. Pt to blow or spit any fluid that passes into the nose or pharynx into a clean tissue

(+): recovery of saline + some reflux
- if dye-stained: STENOSIS of lacrimal sac or NLD (pooling of fluorescein within the sac)
- if clear: STENOSIS of puncta or canaliculus (most fluorescein from Jones I was not able to enter drainage system)

(-): no saline recovered + reflux; COMPLETE obstruction but CANNOT LOCALIZE

30
Q

Interpretation of results of the Jones I and Jones II Tests

A

(+) Jones I, (+) Jones II - DYE: Patent (Normal vs Low-grade Stenosis)

(-) Jones I, (+) Jones II - CLEAR: Punctal or Canalicular stenosis vs Functional

(-) Jones I, (+) Jones II - DYE: Lacrimal Sac or NLD stenosis vs Functional

(-) Jones I, (-) Jones II, (+) Reflux of SALINE in OPPOSITE punctum:
Complete Common Canalicular Obstruction

(-) Jones I, (-) Jones II, (+) Reflux of SALINE in SAME punctum:
Complete Canalicular Obstruction

(-) Jones I, (-) Jones II, (+) Reflux of DYE in OPPOSITE punctum:
Complete NLDO

(-) Jones I, (-) Jones II, (+) Reflux of DYE in SAME punctum:
Complete NLDO + Complete Opposite Canalicular Obstruction

In summary:

Patent and Functional: (+) Jones I, (+) Jones II
Partial/Stenosis or Dysfunctional: (-) Jones I, (+) Jones II
Complete/Obstruction: (-) Jones I, (-) Jones II

31
Q

Why do nasal endoscopy in cases of lacrimal drainage system obstruction?

A

To rule out nasal pathologies causing lacrimal symptoms:
1. Nasal/paranasal tumors
2. Hypertrophy of inferior turbinate
3. Septal deviations

Steps:
1. Pharmacologic decongestion with Oxymetazoline
2. Insertion of rigid 4 mm or 3.7 mm endoscope

Note: poor view from speculum and headlight

32
Q

What are the goals when examining a tearing patient?

A

Differentiate between:

Epiphora: lacrimal drainage dysfunction VS
Lacrimation: ocular surface irritation

AND

Anatomic: mechanical obstruction
Physiologic: lacrimal pump failure

In most: HX and PE are enough.

33
Q

Most clinically useful tests in lacrimal drainage dysfunction?

A
  1. Fluorescein Dye Disappearance Test: establish diagnosis of epiphora and estimate of severity
  2. Lacrimal Apparatus Obstruction and Canalicular Probing: localize level of obstruction once diagnosis is established

Ophthalmology (44 decks)

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