Lacrimal drainage system

Question 1

What are the causes of a watering eye

Answer 1

Hyper secretion secondary to ocular inflammation or surface disease

Defective drainage due to compromise of lacrimal drainage system
- malposition of lacrimal puncta
- obstruction anywhere along lacrimal drainage system
- lacrimal pump failure, which may occur secondarily to lower lid laxitiy/ weakness of the orbicularis oculi

Question 2

What are the external examination with slit lamp for

Answer 2

• punctal stenosis (narrowing)
• ectropion causing malposition of punctum
• punctal obstrucion
• large caruncle displacing puncta away from eyeball
• pouting punctume (typical of canaliculitis)
• centruion syndrome: anterior malposition of medial lid, resulting in displacement if puncta, due to prominent nose bridge

Question 3

state the evaluation that a opthalmologist can carry out and why

Answer 3

Fluorescein disappearance test. As it does not require anaesthesia

Question 4

Describe how the flourescein disappearance test is carried out and how the positive and negative results are derived

Answer 4

• Instil fluorescein 2% into both eyes

Negative: Little or no dye should remain at tear meniscus after 5 minutes

Positive: Prolonged retention, indicative of inadequate drainage

Question 5

State two test that cannot be carried out by an optometrist to test the lacrimal drainage system and why

Answer 5

Probing an irrigation, and Jones dye Testing (secondary and primary) as both require anaesthesia

Question 6

State the procedure of probing and irrigation as well a interpretation of the results

Answer 6

With topical anaesthesia, use a blunt tip lacrimal cannula with 2ml saline filled syringe and insert it into the punctum to reach the lacrimal sac

• if cannula comes to ‘hard stop’, it has reached medial wall. Irrigation performed to test if nasolarimal duct is blocked. Patiet with normal drainage will feel and taste the saline
• if cannula comes to ‘soft’ stop, the sac is not entered, Thus canaliculi may be blocked. Irrigation results in reflux

Question 7

Why is Jones dye testing carried out

Answer 7

To differentiate partial obstruction of lacrimal passage to primary hypersecretion of tears

Question 8

State the Jones Dye testing primary test procedure and results

Answer 8

Fluorescein is instilled and cotton bud mositened with topical anaesthetic placed under inferior turbinate at the nasolacrimal duct

• fluorescein observed on cotton bud: normal drainage system
• no fluorescein observed: partial obstruction or failt of lacrimal pump as flourescein did not drain off successfully. Perfrom secondary test to determine if obstruction is of the canaliculus or the nasolacrimal duct

Question 9

State the procedure of Jones Dye testing secondary test

Answer 9

cannula inserted into lacrimal sac to irrigate
- positive: indicates obstruction is of nasolacrimal duct
- negative: indicates partial obstruction of the upper lacrimal passages or a defective lacrimal pump

Question 10

What are the acquired obstructions in the lacrimal drainage system

Answer 10

Primary punctal stenosis

Secondary punctal stenosis

Canalicular obstruction

Nasolacrimal duct obstruction

Question 11

name two acquired obstructions of the punctum

Answer 11

Primary punctal stenosis
- punctum is narrowed or occluded

Secondary punctal stenosis
- caused by punctal eversion, and susbsequent narrowing and occlusion

Question 12

What is the management of pri/sec punctal stenosis

Answer 12

dilation or punctoplasty

Question 13

What is the management for canalicular obstruction

Answer 13

REFER
- For partial obstruction, intrubation to open up canaliculus

• for total canalicular obstruction, surgery to anastomose the working part of canaliculus to the lacrimal sac

Question 14

What is the mangament for nasolacrimal duct obstruction

Answer 14

REFER
- DCR surgery (Dacryocystorhinostomy) to anastomose lacrimal sac to nasal mucosa

Question 15

Name the two congenital obstructions of the lacrimal drainage system

Answer 15

Nasolacrimal duct obstruction

Congenital dacryocele

Question 16

What are the signs of nasolacrimal duct obstruction (in baby)

Answer 16

Epiphora and matting of lashes

Gental pressure over lacrimal sac cause reflux of purulent material from the puncta

Question 17

What is the mangament of nasolacrimal duct obstruction (in baby)

Answer 17

• massage of lacrimal sac to attempt to rupture the membraneous obstruction
• refer for probing of lacrimal system at 12-18 mths of age if spontaneous canalisation does not occur

Question 18

What is the cause of congential dacryocele

Answer 18

Collection of amniotic fluid or mucus in the lacrimal sac

Question 19

What are the signs of congenital dacryocele

Answer 19

bluish cystic swelling at or below the medial canthus area, accompanied by epiphora at around the birth period

Question 20

What are the mangament of congenital dacryocele

Answer 20

resolution is commone with only convervative treatment, if it fails probing is usually adequate

Question 21

What is the infection of the lacrimal drainge system

Answer 21

Dacryocystitis

Question 22

What is the cause of acute dacryocystitis

Answer 22

Infection of lacrimal sac, usually secondary to obstruction of the nasolacrimal duct

Question 23

What are the signs of acute dacryocystitis

Answer 23

• very tender, red, tense swelling at medial canthus w epiphora
• abscess formation in severe cases

Question 24

What is the management for acute dacryocystitis

Answer 24

• warm compress
• refer to ophthalmologist for antibiotics or surgical drainage

Question 25

What is the signs of chronic dacryocystitis

Answer 25

• Painless swelling at inner canthus with epiphora
• pressure on lacrimal sac commonly casue mucopurulent material refluc through canaliculi
• may present with chronic or recurrent unilateral conjunctivitis

Question 26

What is the treatment of chronic dacryocystitis

Answer 26

refer for surgical treatment (DCR)