LACRIMAL DISORDERS & DRY EYE

Question 1

DACRYOCYSTITIS

• Acute onset
• Infection of lacrimal sac
• More common in 50s/60s
• More common in women
• Can lead to pre-septal cellulitis

Symptoms

• Sudden onset
• Progressive worsening
• Redness
• Tenderness/pain
• Excess tearing
• Warm to touch

Answer 1

Signs

• Red focal elevated lesion
• Tearing
  Involves inner canthus,
  lacrimal sac, firm nodule

Management

• Warm compresses
• Topical ABs
• Oral ABs

Question 2

JONES TEST

Answer 2

• Checks patency/blockage between puncta and inferior meatus of nose
• Place fluorescein in eye, have pt blow nose after a few mins, look for staining on tissue
• Can’t entirely localize blockage, but gives vague indication
• Can also use q-tip along inferior meatus, look for staining

Question 3

REGURGITATION
TEST

Answer 3

• Checks patency between puncta and lacrimal sac
• Place fluorescein in eye, examine under slit lamp
• Pull lower lid, press on nasolacrimal sac
• Look for stained tears coming back out of inf puncta

Question 4

SCHIRMER’S 1

Answer 4

• Tests for quantity of reflex and basic tears
• Fold paper while still in packaging, hook it into lower
  lid on lateral side
• Leave it in for 5 mins, record how many mm of tears
  soaked into paper

Question 5

SCHIRMER’S 2

Answer 5

• Tests for quantity of basic tears
• Fold paper while still in packaging, hook it into
  lower lid on lateral side
• Leave it in for 5 mins, record how many mm
  of tears soaked into paper

NORMS

• Greater than 15mm: normal
• Less than 10mm: significant dry eye
• Less than 5mm: severe dry eye

Question 6

PHENOL RED THREAD

Answer 6

• 70mm long thread
• Use 1 thread each eye
• Avoid cornea, insert folded end into lower lid
• Wait 15 seconds, measure amount of red from bend
• Less risk of damage to surface upon removal

NORMS

• Less than 10mm = severe dry eye
• Less than 19mm = borderline dry eye
• Greater than 19mm = normal

Question 7

TEAR FILM STABILITY

• Helps to evaluate quality of mucin layer
• Give fluorescein, examine under cobalt blue filter
• Have pt close eye, open, and don’t blink
• Count seconds until black spots appear
• Wider staining strips add too much volume to tears
• Smaller strips give more accurate measure of
  stability

Answer 7

• 20-30s: normal
• 10-15s: borderline
• less than 10s: abnormal

Question 8

PUNCTAL STENOSIS

• Occurs due to age, inflammation, entropion/inversion
• Indicates inflammation, use oral ABs
  (topical not as effective due to poor
  drainage)

Answer 8

• Use dilator to poke inside puncta,
  loosen up occlusion

Question 9

NASOLACRIMAL
DUCT OBSTRUCTION

• Common in infants
• Lack of canalization of nasolacrimal duct

Answer 9

Management

• massage, warm compresses several times/day for several wks
• If infection, treat with oral ABs
• Refer to surgery after 1y/o
  Dacrycystorinostomy (DCR)

Question 10

DRY EYE

• Prevalence: 7.8%-14.4% (~1 in 10)
  
  • Higher prevalence in older pop, CL wearers
  • Affects women more than men
• • Lipid layer: produced by mb glands, Zeiss
  
  • Deficiency: lid problems, CLs
• Aqueous layer: produced by lacrimal gland, Krause, & Wolfring
  
  • Deficiency: decreased activity of lacrimal gland
• Mucin layer: produced by goblet cells in conj, crypts of Henle, glands of Manz
  
  • Deficiency: vitamin A, trachoma, lasik
• Glycocalyx: produced by k epithelum
  
  • Composed of mucins 1, 4, 16

Answer 10

Risk factors

• Prolonged near work, air travel, arid conditions, poor air quality
• Rheumatiod Arthritis
• Sjogren’s Syndrome: autoimmune disease, lacrimal gland is destroyed
  
  • 90% affected are women
  • 3 signs: severe dry eye, severe dry mouth
    (inactive parotid), RA
• Grave’s disease
• Acne rosacea
• Systemic medications: antihistamines (dry up moucous membs), oral contraceptives, antidepressants, hypertension meds, alcohol derived meds
• Ocular medications: preservatives can be cytotoxic
  
  • Damage to goblet cells
  • Long term IOP drops = higher risk
  • BAK preservative = cytotoxic
• Contact lens wear
• LASIK: worse 3-6 mos post op
  
  • Suction ring around limbus destroys goblet cells
  • Treat w/non-preservative gtts
  • Decreased corneal sensitivity results in less sensory input to lacrimal gland, less tearing
• Allergies
• Anterior seg disorders

Symptoms

• Burning/stinging
• Foreign body sensation
• Grittiness/irritation
• Increased reflex tearing: overproduction of aqueous
  tears from lacrimal gland that washes away lipid
  layer, no protection from evaporation
• Blurred vision (intermittent, improves with blinking)