Lacrimal Disorders

Question 1

What is Dacryoadenitis?

Answer 1

Lacrimal gland disorder

Question 2

What does the prefix ‘dacryo’ indicate?

Answer 2

Generally indicates a disorder of the lacrimal system

Question 3

What does one experience with Dacryoadenitis?

Answer 3

Acute discomfort of the upper temporal quadrant.

Question 4

What are the clinical signs of Dacryoadenitis?

Answer 4

Ptosis with hyperaemia and oedema (most pronounced in the upper temporal quadrant - i.e. where the lacrimal gland is located).

Question 5

What is Ptosis?

Answer 5

Drooping or falling of the upper eyelid.

Question 6

What is Hyperaemia?

Answer 6

an excess of blood in the vessels supplying an organ or other part of the body.

Question 7

What is epiphora?

Answer 7

A clinical term for a watery eye

Question 8

What can epiphora occur as a result of?

Answer 8

Punctal Stenosis - narrowed or closed puncter Canalicutitis - infection of the canaliculi Congenitally - born with it In all three of these cases its to do with an outflow obstruction.

Question 9

What can Punctal Stenosis arise as a result of?

Answer 9

Ca arise following conjunctival scarring from trauma or inflammation (e.g. herpes simplex). Drug therapy (e.g. anti-virals) - although rare certain drugs are known to be associated with Punctal Stenosis.

Question 10

What is Punctal Stenosis?

Answer 10

A condition in which the puncters (a.k.a where drainage happens from) are closed or narrowed.

Question 11

What is canaliculitis?

Answer 11

Infection of canaliculus, e.g. by Actinomyces israelii (a bacterium) - the course of the infection blocks the canaliculi - causing outflow obstruction. (This happens in 2% of cases)

Question 12

Describe congenitally caused Epiphora.

Answer 12

20% ( 1 in five babies) of neonates (newborn children) show evidence of symptomatic outflow obstruction (basically tear outflow system isn’t fully formed yet). :( 70% of babies are symptom free by three months and over 90% of babies are symptom free by 1 year. :)

Question 13

What do symptoms of congenital epiphora include?

Answer 13

Obviously epiphora itself and mucopurulent discharge. (mucus-pus dicharge)

Question 14

What does congenital outflow obstruction often get mistaken for?

Answer 14

That mucus pus discharge often means it gets mistaken for bacterial conjunctivitis.

Question 15

What is dacryocystitis?

Answer 15

An infection of the lacrimal sac

Question 16

What might the treatment for Dacryocystitis include?

Answer 16

Systemic Antibiotics

Warm compress

Incision and drainage where appropriate

If still not gone (i.e. the dacryocystitis becomes chronic) follow-up treatment may include Dacryocystogram (DCG) (to see where the problem exactly is) then surgical procedure Dacryocystorhinostomy (DCR) occurs - this establishes a new drainage route.

Question 17

What does it mean to be multifactorial?

Answer 17

dependent (or caused by) a number of factors, especially genetic or environmental factors.

Question 18

What is dry eye disease?

Answer 18

Dry eye is a multifactorial disease of the ocular surface characterised by a loss of homeostasis of the tear film and accompanied by ocular symptoms, in which tear film instability and hyperosmolarity (increase in osmolarity), ocular surface inflammation and damage, and neurosensory abnormalities play an aetiological role

Question 19

What are the two classic classifications of dry eye disease?

Answer 19

Tear deficient dry eye disease

and

Evaporative dry eye disease

Question 20

What are the two causes of tear deficient dry eye disease?

Answer 20

Sjogren’s Syndrome (SS)

Non-Sjogren’s Syndrome - e.g. things such as age

Question 21

What is the link between age and dry eye disease?

Answer 21

As you get older the ability of the lacrimal gland to secrete an adequate volume of tears declines.

Question 22

What are the causes of evaporative dry eye disease?

Answer 22

Tears are unstable as Meibomian gland oil is either insufficient or of the wrong composition to retard tear evaporation.

Lid related

Surface change

Contact lens-related

Question 23

Why is dry eye disease classification (i.e. whether its tear deficient or evaporative) an iffy concept?

Answer 23

Rather than being separate groups, the distinction is more like that of a scale with many patients showing evidence of not producing enough tears as well as having something wrong with meibomian gland oil composition and so they would be in the middle of the scale.

Question 24

What is Sjorgen’s Syndrome and what is it associated with?

Answer 24

• Sjogren’s Syndrome is an autoimmune disorder consisting of dry eye (KCS) and dry mouth (xerostomia), which often involves nasal and vaginal mucous membranes too.
• SS is commonly associated with systemic diseases such as rheumatoid arthritis and systemic lupus erythematosus

Question 25

What is the most common cause of tear deficient dry eye?

Answer 25

Acquired primary lacrimal disease.

Question 26

What is affected in acquired primary lacrimal disease?

Answer 26

Only the lacrimal glands.

Question 27

What are the symptoms of acquired primary lacrimal disease?

Answer 27

• Patients with mild dry eye syndrome may have symptoms of irritation, itching, soreness, burning, or intermittent blurred vision
• Patients with moderate dry eye syndrome have increased discomfort and frequency of symptoms, and visual effects may become more consistent
• Patients with severe dry eye syndrome have increasing frequency of symptoms or constant symptoms, and visual symptoms may be disabling

Question 28

What are the signs of acquired primary lacrimal disease?

Answer 28

evidence of the following:

-Conjunctival injection

• Conjunctival staining (using fluorescin or lissamine green)
• Corneal staining - to look for superficial punctate keratitis (an indication/side problem).
• Reduced tear meniscus (see attached image for an explanation of what this is.
• Filaments
• Reduced TBUT (tear break up time)
• Reduced Schirmer score
• Meibomian gland disease

Question 29

What is conjunctival injection?

Answer 29

Conjunctival injection or hyperemia is a nonspecific response with enlargement of conjunctival vessels induced by various diseases.

Question 30

How is acquired primary lacrimal disease managed?

Answer 30

• Lubricants
• Tear preservation treatments - using puncter plugs to stop drainage of tears happening as fast (for dry eye disease associated with tear deficiency).
• Lid hygiene
• Oral antibiotics
• Immunosuppresants
• Alternative therapies

Question 31

In what form do ocular lubricants exist?

Answer 31

Ocular lubricants can exist in the form of eye drops, gels and ointments in order to treat the discomfort associated with conditions in which the tear film is reduced or unstable