Disorders Of Lacrimal Gland Tumours Flashcards
What are the features of the Lacrimal system
Where is the Lacrimal gland found?
Orbital lobe
Which is the main aqueous producer and accessory ducts to produce this?
Lacrimal gland- main
Krause and wolfring- 5-10%
What is the innervation of the lacrimal gland?
Ophthalmic division- Trigeminal nerve (lacrimal nerve branch)
What is secondary to the irritation of cornea and conjunctiva?
Reflex lacrimation
What is Bells palsy?
Lack of movement affecting 1 side of your face
Which muscle is effected in bells palsy?
Lavator muscle
What are the features of bells palsy?
What is dacryoadenitis?
Inflammation of the lacrimal gland
What are the features of dacryoadenitis?
What are the chronic systemic auses of dacryoadenitis?
Sarcoidosis
Thyroid eye disease
What are the presentations of lacrimal gland tumours?
What is the function of the tear film?
Lubrication Smooth pre corneal refracting surface Removes debris Microbial defence Regulate temperature
What is the total tear volume?
7-10 microletres
What aspects of the tears is a realisable predictor of tear volume insufficiency?
Tear meniscus
In an emotional state, which gland would produce tears?
Lacrimal gland
How many layers of the tear film from the inner to outer?
Mucin
Aqueous
Lipid
Which is the thickest layer?
Aqueous
Then mucin and lipid
Which glands produce mucin?
Goblet cells
Crypt of henle
Glands of manz
Where does the zeiss and moll glands secrete the lipids?
Zeiss= eyelash follicle Moll= b/w eyelash follicle and grey line
How many meibomian glands are there in the tarsal plate?
25 upper
20 lower
What in the tear film help defend against microbes?
Lysozyme…Enzyme, destroys gram +ve
Lactoferin…. bacteria nutrition
Immunoglobulins…MAIN, protein
Beta-lysin… protein, destroys invading bacteri
What can cause loss of goblet cells in mucin deficiency?
Steven Johnson syndrome Pemphigoid Burns Trachoma Vit- A deficiency
What causes Steven Johnson syndrome?
Adverse drug reaction… hypersensitivity to mucous membrane
What is a pemphigoid?
Blister!- unable to make mucins
… prevelant in females and in 7th decade
How can chlamydial trachomitis spread?
Direct contact with others or objects
Spread by flies
What is being presented in this image and how does it occur?
Bitots dot…. keratin debris and assoc with vit A deficiency
What are the key elements in Dry eye disease?
Tear film instability
Hyperosmalarity
Inflammation
Damage
What aietiological resons are there for dry eye?
Deficiency in volume and quality Abnormal eyelid Systemic Environmental CLs Medication Reftactive surgery
What is ADDE
Aqueous deficient dry eye
What can ADDE lead to?
Keratoconjunctivtis sicca
What can cause ADDE?
LG atrophy
Reduced neural input
Elevated evap rate
What systemic problem can cause lipid layer deficiency?
Menopause- hormonal changes?
Prostrate disease- androgen tx needed
How can MG dystrophy viewed?
Shown on infra red
How are meibomian cysts managed?
Antibiotics and warm compress
What can abnormal eyelid function result in?
Poor post blink
Poor tear pump mechanism
Large palpebral aperture
Elevated tear secretion rate
What are the 2 common eyelid abnormalities?
Ectropian
Entropian
What different systemic diseases link with tear dysfunction?
Steven-Johnson syndrome (mucotaneous disease)
Sjogrens syndrome (effects salivary/fluid secretions)
Systemic lupus erythematous (chronic inflamm in connective tissue)
Hyperthyroidism
Rheumatoid arthritis
What can cause Steven Johnson syndrome?
(ACUTE/SEVERE)
Hypersensitive reaction to:
Drugs HSV Epstein bar virus Enteroviruses Mycoplasma pneumonia
What ocular signs can be presented in Steven Johnson syndrome?
Papillary conjunctivitis
Dry Eye
Epiphora
(NB- MALES!)
Which sytemic disease can cause dry eye?
Sjogrens syndrome
Systemic lupus erythmetous
Which parts of the body can sjogrens syndrome effect?
Skin
LG
Airways
(NB- Females!)
What is considered a major impact on rheumatoid arthritis?
Climate urbanisation
What potential ocular manifestation maybe presented in RA?
KCS!
Episcleritis
Scleritis
How is dry eye treated in rheumatoid arthritis?
Lubricating ointments and artificial tears
If no response…. medical intervention (topical steroid)
What ocular signs maybe presented in hyperthyroidism?
EOM swelling
Proptosis
What environmental factors can cause dry eye?
Humidity- air conditioning
Blink rate- VDU
Pollution
What drugs could cause tear dysfunction?
Antimuscrinic/ anticholinergic (parkinsons disease)
Antihypertensives (beta blockers/diuretics)
Acrivistine (Antihistamines)
Oral contraceptives (Femodette/ locstrin)
How can refractive surgery cause reduced lacrimation?
Sensory corneal nerve plexus damaged during surgery
Damage to corneal epithelium- mucin layer disrupted
What symptoms would u experience with wet and dry eye?
Wet- excessive tearing, itching, soreness
Dry- FB sensation, gritty eye, photophobia
What signs are seen in wet and dry eye?
Wet- epiphora
Dry- hypereamia, corneal dessication
What potential test can be performed to assess tear volume?
Schirmir test Colour bar test Phenol red thread test Tear prism Ocular surface ass
What’s the difference between schirmir test 1 and 2?
1 measures basal reflex tear secretion
2 direct measure of reflex tear lacrimation
How is schirmir test done briefly?
Fold schirmir strip
Hook over temporal lower lid
Leave 5 minutes
Encourage normal blinking
What is normal results in the schirmir test?
More 10mm
How is using anesthesia change the results?
Results will be lower as levels of secretion are lowered
Less than 5mm in 5 minutes= borderline dry eye
What anesthesia is used for the schirmir tests?
1 drop of 0.5% proxy
What are normal results for schirnir test 2?
More than >15mm of tear secretion in 2 minutes
Whats another variation to the schirmir test?
Colour bar test… uses line of soluble strip and dye is carried along strip by tears (mm scale visible)
What dyes are seen when wet or dry on a 70mm phenol red thread test?
Yelloe when dry
Red when wet
What techniques can be used for a NITBUT?
Keratometer mires
Slit lamp
Heat absorbing filter and grid pattern
What diagnostic agents can be used to assess ocular surface damage?
Nafl
Rose bengal
Lissamine Green
Where is the 1st stain located in KCS?
Bulbar conj
Progresses to temporal inferior
What staining signs would be seen in bacterial conjunctivitis?
Diffuse punctuate staining
What is the gold standard agent for detecting ocular surface damage?
Rose bengal
Whats the difference b/w LG and RB?
More comfortable!
Fades quickly
Assess 1 eye at a time b/w 1-4 mins after instillation
Stain enhanced with wratten25
What are the 4 requirements for artificial tear substitutes?
Non irritant
Good ocular lubricating
Long retention time within conj sac
Not interefe with visual performance
Wht are the pH levels of artifical tears?
7.4 alkaline
What part of the formulation in tear subs increases retention?
Viscolizing agent (substitute for mucin)
What are the names of some tear substitute?
Systane
Artelac
Hyabak
Clinitas soothe
What foods may improve tear dysfunction/dry eye)?
Omega 3 fatty acids Flaxseed oil Fish oil Oily fish Increase water intake
What are the different types of occlusion?
Temporary- collegen plugs
Partial- PVP perforated plug
Permanent- cauterization/argon laser/silicone punctual plug
What is the punctal plug procedure?
Topical anesthesia around puntum Dilate punctum c dilator Select appropriate diam plug Insert c forceps Push down below mouth of punctum
What is small lateral tarsorrhaphy?
Surgery to reduce palpebral apature
In what ways can you reduce the rate of evap?
Use room humidifier Reduce room temp Computer breaks Surgery Everset Harris- side shields reduce evap
What tests can be done to investigate drainage system?
Jones dye test 1 and 2
Dilation and irrigation
What briefly is the procedure for dilation and irrigation?
Anesthesia
1 drop proxy into inf conj and directly inf punctum
OR inf conj sac then wet bud and apply inf punctum for 2 minutes
Dilation: pull lower lid taut Place dilator into punctum Rotate dilator Advance dilator 2mm in
Not permanent due to tissue elasticity
Irrigation: Insert cannula vz Advance 2mm into ampulla Rotate 90 degrees towards nose Pull lower lid laterally Advance cannula Hard stop= cannula hits bone ✔ Inject saline At hard stop= retract 3mm and add 2-3ml saline into nasolacrimal syst Withdraw cannula
How do we interpret the results from the dilation and irrigation?
Fluid regurgitates UPPER punctum-
Blockage beyond common canaliculus
Fluid regurgitates LOWER punctum-
Blockage b/w inf punctum and common canaliculus
When is a Jones dye performed?
Suspect obstruction and a lacrimal drainage suspected
What can JD test differential dx that D+I cannot?
Location and degree
How is the JD 1 performed?
Instill nafl Wait 5 minutes Insert bud into nostril (10mm) Check Nafl presence on bud (BL) No nafl?- massage Px occluded contralateral nostril Blows nose into white tissue Check nafl presence
When is JD 2 indicated?
When no dye is present in tissue from JD 1
What is the procedure to JD 2?
Prep syringe and lacrima cannula Fill c saline Inject 2-3ml saline into inf canaliculus Px leans forward Kidney dish held beneath nostril Collect fluid Examine for Nafl presence
How would the results be interpreted in a JD 2 test?
Fluid c Dye= functional block, duct narrow or lower system block
Fluid s dye= functional block, upper system blockage- near punctum
What techniques can be used to increase tear drainage?
D+I
Nasolacrimal probing
Dacryocystorhinostomy (only of the above 2 fail)
What is the procedure for Dacryocystorhinostomy?
Hole drilled in nasal cavity at medial wall of lacrimal sac
Silicone tube inserted to main drainage
What are the signs of canaliculitis?
Chronic Unilateral Red eye Epiphora "Pouting punctum" Mucopurelent discharge
What types of infection are there in canaliculitis?
Actinomyces Israeli
Candida albicans
Aspergillus
Herpetic
What are dacryoliths?
Concretions if lacrimal sac.
Pockets in drainage, needs to be removed through punta direct manipulation
Surgically- canaliculotomy
What is dacrocyctitis and how is it caused?
Bacterial infection in the nasolacrimal sac
Occurs when nasolacrimal duct blocked
What are the signs/sxs of dacryocyctitis?
Acute- Painful, Pus in sac
Chronic- conjunctivitis c epiphora, sac filled with mucoid material
What are the possible tx for dacryocyctitis?
Warm compress
Systemic antibiotics
Dacryocystorhinostomy
What are the tx for naslacrimal tumours?
Excision and radiation
