Day 2 (3): Basic Clinical Evaluation of the Lacrimal Drainage System Flashcards
What are the parts of the lacrimal system?
- Secretory system: main lacrimal gland, accessory lacrimal glands (of Krause and Wolfring)
- Drainage system: puncta, canaliculus, lacrimal sac, NLD
- Lid-Globe apposition: tendons
- Lacrimal pump mechanism: OO
What are the general causes of excessive tearing?
- Increased production: hypersecretion overwhelms drainage
- Decreased drainage: anatomically compromised drainage system
- Poor lid-globe apposition: tear lake does not align with the puncta
- Dysfunctional lacrimal pump mechanism: OO palsy
Why is lid-globe apposition important for tear drainage?
- Directs tears across the ocular surface into the puncta
- Prevents excessive exposure of ocular surface and minimizes tear film evaporation
Differentiate epiphora from lacrimation.
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)
Differentiate anatomic from functional lacrimal drainage dysfunction
Anatomic:
- (+) gross STRUCTURAL abnormality
- partial (stenosis) OR complete blockage
Physiologic:
- failure of FUNCTIONAL mechanisms BUT lacrimal drainage system remains patent
- Poor lacrimal pump mechanism
- OO weakness due to CN 7 palsy - Poor lid-globe apposition
- lower lid laxity due to aging or CN 7 palsy
What are the causes of lacrimation?
INCREASED TEAR PRODUCTION
- 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 - Supranuclear: psychogenic (emotion)
- Infranuclear:
- CN 7 aberrant innervation: goes to lacrimal nerve instead
- lacrimal gland stimulation - Bright lights, sneezing
What are the causes of epiphora?
DECREASED TEAR DRAINAGE
- Anatomic (stenosis or complete)
- congenital
- inflammatory +/- infectious
- traumatic +/- burns
- neoplastic
- idiopathic
- chronic ectropion
- iatrogenic
- nasal factors: allergic, iatrogenic, neoplastic - Functional
- incorrect lid closure: lid laxity, lagophthalmos, traumatic, iatrogenic
- eyelid malposition
- punctal eversion or medialization
What are the causes of combined lacrimation and epiphora?
- Facial nerve palsy:
- lacrimal pump failure from OO dysfunction (E)
- lagophthalmos –> exposure keratitis/corneal irritation (L) - Lower lid ectropion:
- punctal eversion (E)
- conjunctival irritation (L)
Parts of the evaluation of a tearing patient?
- History
- Comprehensive ophthalmic exam including:
- eyelids
- lacrimal system
- nasal cavity
- anterior segment
Why is it important to differentiate lacrimation from epiphora?
Management:
Lacrimation - usually MEDICAL
Epiphora - usually SURGICAL
What are the pertinent points to elicit in the history of a tearing patient?
- Laterality (uni- or bi-)
- Onset and duration (congenital or acquired)
- Frequency (constant or intermittent)
- History of masses or bleeding from punctum (malignancy)
- History of recurrent lacrimal sac inflammation (leading to NLDO)
- Associated burning, grittiness or FB sensation (DES)
- Previous trauma or surgeries to the eyes, nose or face
- Use of medications (ophthalmics, chemotherapy, radiotherapy)
- History of ocular surface infections (conjunctiva, cornea)
- Allergies
Pertinent findings to note in the FACE when doing external eye examination:
Facial asymmetry
- Brow ptosis (frontalis)
- Lagophthalmos (OO)
Pertinent findings to note in the EYELIDS when doing external eye examination:
Eyelid margin position
- Ectropion: outward turning of margin –> exposure keratopathy
- Entropion: inward turning of margin –> corneal and conjunctival irritation
Pertinent findings to note in the EYELASHES when doing external eye examination:
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)
Pertinent findings to note in the PUNCTUM when doing external eye examination:
- Size
- Malposition
- Ectropion: punctum everted away from tear lake
- Medialization: punctum more medial away from tear lake - Stenosis/occlusion/overlying membrane
- Pouting or swelling
- Canaliculitis +/- Concretions - Abnormal surrounding structures
- Conjunctivochalasis: loose, redundant, non-edematous conjunctiva occluding the lower punctum
- Enlarged lacrimal caruncle
Pertinent findings to note in the MEDIAL CANTHAL AREA when doing external eye examination:
- 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 - Masses
- Lacrimal sac tumor: crosses horizontal midline
- Frontoethmoidal Encephalocele
- Ethmoidal Mucocele
Pertinent findings to note in the OCULAR SURFACE when doing external eye examination:
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
What is elicited with palpation/compression of the lacrimal sac?
- Pain/Tenderness: sign of ACUTE inflammation
- 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
- Canaliculitis: inflammation of the upper system
- punctum and canaliculus is INFLAMED (more LATERAL)
What are the different ANATOMIC excretory tests for epiphora?
Goal: Look for location of obstruction
- Lacrimal Apparatus Irrigation/Syringing
- Canalicular probing
- Jones II Test
- Nasal Endoscopy
What are the different PHYSIOLOGIC excretory tests for epiphora?
Indication: To confirm diagnosis of epiphora, assess tear flow and for pts where anatomical tests are not possible (e.g. children)
- Fluorescein dye disappearance
- Jones I Test
- Saccharin Test
What are the different SECRETORY tests to assess lacrimation?
Goal: Test secretory function of the lacrimal glands and integrity of the tear film
- Tear Break-up Time
- Schirmer’s Test
- Rose Bengal Test
- Tear Lysozyme Test
How is the Saccharin test done?
- A drop of 2% saccharin is placed in the conjunctival fornix.
- 90% of patients with a patent lacrimal system will taste it in 15 minutes.
How is the Fluorescein Dye Disappearance Test done?
- 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
- A drop of 2% fluorescein is placed in the fornix
- 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.
- 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] - Compare both sides simultaneously.
Result:
+ FDDT: lacrimal drainage dysfunction unlikely
- FDDT/Retention: delay in tear flow
Describe how lacrimal apparatus irrigation test is done.
- 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)
- Instillation of topical anesthetic
- Dilation of punctum with lacrimal dilator
- 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)
- Advance cannula for 3-7 mm into canaliculus and irrigate with sterile water or normal saline.
How is canalicular probing done?
- INDICATION: LAI demonstrates obstruction and determination of location/extent of block
- CONTRAINDICATION: Acute infection (dacryocystitis/canaliculitis)
- Instillation of topical anesthetic and dilation of punctum done during LAI
- Lacrimal probe is advanced 2 mm vertically then horizontally while keeping the eyelid stretched laterally.
- 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
Interpretation of LAI and Lacrimal Probing test results.
(+) 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
When is PHYSIOLOGIC DYSFUNCTION or FUNCTIONAL DISORDER of lacrimal drainage system suspected?
- Presents with epiphora
- (-) FDDT: delayed/abnormal
- LAI: (+) Fluid in nose or pharynx, (-) Reflux
- Probing: Hard stop on probing
Suspect: Lacrimal Pump Insufficiency/Dysfunction
Describe the Jones I Test
- 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)
- 2% Fluorescein instilled into UNANESTHETIZED conjunctiva
- 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
Describe the Jones II Test
- Performed after a (-) Jones I test (anatomic or functional problem)
- Almost similar to LAI
- Residual fluorescein in flushed from ANESTHETIZED conjunctiva by irrigation with normal saline through one canaliculus using a lacrimal cannula.
- 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
Interpretation of results of the Jones I and Jones II Tests
(+) 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
Why do nasal endoscopy in cases of lacrimal drainage system obstruction?
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
What are the goals when examining a tearing patient?
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.
Most clinically useful tests in lacrimal drainage dysfunction?
- Fluorescein Dye Disappearance Test: establish diagnosis of epiphora and estimate of severity
- Lacrimal Apparatus Obstruction and Canalicular Probing: localize level of obstruction once diagnosis is established
