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Duke Elder exam > Lacrimal system > Flashcards

Lacrimal system Flashcards

1
Q

3 layers of the tear film

A

lipid (superficial)
aqueous
mucous (deep)

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2
Q

source of lipid, aqueous and mucus tear films

A 
lipid = meibomian glands
aqueous = lacrimal gland 
mucuous = conjunctival goblet cells
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3
Q

function of lipid tear film

A

prevent acqueous layer evaporation

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4
Q

function of aqueous tear film

A

antibacterial activity, washing out debris and suppying cornea with nutrients

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5
Q

function of mucous tear film

A

aids in spreading tears and stabilising tear film

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6
Q

thickness of lipid, aqueous and mucous tear film

A 
lipid = 0.1 um 
aqueous = 7.0 um 
mucus = 0.2 um
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7
Q

pathway of the lacrimal system

A

lacrimal gland - puncta - canaliculi - lacrimal sac - nasolacrimal duct - inferior nasal meatus

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8
Q

structure of lacrimal gland

A

tubule-alveolar gland with acini and ducts - 2 parts:

  • orbital (in frontal bone)
  • palpebral (superiorlaterally in eyelids inferior to levator palpebrae muscle)
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9
Q

function of lacrimal gland

A

forms aqueous layer of tear film

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10
Q

blood supply to lacrimal gland

A

lacrimal artery - branch of ophthalmic artery

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11
Q

sensory nerve supply to lacrimal gland

A

lacrimal nerve (CNVI)

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12
Q

parasympathetic secretomotor nerve supply to lacrimal gland

A

CNVII - pathway = preganglionic parasympathetic fibres originate from superior salivatory nucleus in the pons and travel with greater petrosal nerve (branch of CNVII) to synapse at pterygopalatine junction - postganglionic fibres then joins the lacrimal branch of CNV1 to supply lacrimal gland

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13
Q

afferent and efferent nerves for lacrimal reflex

A 
afferent = CNVI
efferent = CNVII
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14
Q

what do the accessory lacrimal glands do

A

sustain the basal secretory level of the aqueous layer of the tear film

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15
Q

2 types of accessory lacrimal glands

A

Krause glands - adjacent to conjunctival fornix, more numerous in upper eyelid

Wolfring glands - in upper border of tarsal plate, larger than Krause glands

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16
Q

what are puncta

A

small round opening located medially at the posterior edge of the upper and lower lid margins at the junction of the lid’s ciliated and non-ciliated parts

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17
Q

what are the superior and inferior canaliculi comprised of

A 
vertical part (ampulla - 2mm long) 
horizontal part (8mm long)
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18
Q

where do the superior and inferior canaliculi join together

A

common canaliculus

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19
Q

what does the junction of the lacrimal sac and common canaliculus contain

A

Rosenmuller valve - importnat in preventing tear reflux

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20
Q

where is the lacrimal sac located

A

lacrimal fossa - formed by lacrimal bone and frontal process of the maxilla

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21
Q

what is the nasolacrimal duct

A

continuation of the lacrimal sac, opens into the inferior meatus in the nose

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22
Q

what does the opening of the nasolacrimal duct contain

A

fold of mucus - valve of Hasner - prevents air entering the nasolacrimal system during nose blowing

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23
Q

main PC of acquired lacrimal duct obstruction

A

epiphora (excessive watering of eye)

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24
Q

2 causes of acquired lacrimal obstruction

A 
punctal stenosis (idiopathic or chronic blepharitis) 
nasolacrimal obstruction (idiopathic, trauma, surgery or tumours)
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25
Q

treatment for punctal stenosis

A

punctoplasty

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26
Q

treatment for nasolacrimal obstruction

A

dacryocystorhinostomy (anastomosis of lacrimal sac with mucosa of middle meatus)

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27
Q

where is congenital nasolacrimal duct obstruction usually located

A

at valve of Hasner

28
Q

2 features of congenital nasolacrimal duct obstruction

A

epiphora

mucopurulent discharge on pressure over lacrimal sac

29
Q

first, second and third line treatments for congenital nasolacrimal duct obstruction

A

first = observation and massaging of the lacrimal sac for the first 12 months of life

second = nasolacrimal duct probing

third = nasolacrimal duct stent insertion, balloon dilatation or dacryocystorhinostomy

30
Q

what is canaliculitis

A

infection of canaliculi - most commonly due to Actinomyces israelii

31
Q

3 features of canaliculitis

A

epiphora
red eye
discharge on pressure over the canaliculus

32
Q

management of canaliuclitis

A

topical Abx

33
Q

what is dacryoadenitis

A

idiopathic lacrimal gland inflammation

34
Q

main risk factor for dacryoadenitis

A

tear stasis, secondary causes include viral infections e.g. mumps

35
Q

potential cause of bilateral dacryoadenitis

A

sarcoidosis

36
Q

potential cause of persistence/presence of paraesthesia with dacryoadenitis

A

carcinoma

37
Q

4 features of dacryoadenitis

A

painful/tender/red/swollen lacrimal gland (superolateral upper eyelid)
disturbed tear production
s-shaped ptosis of upper eyelid
downward and inward displacement of the globa

38
Q

what is dacryocystitis

A

infection of lacrimal sac due to obstruction in nasolacrimal duct

39
Q

4 bacteria causing bacryocystitis

A

s. aureus
s. epidermidis (adults)
s. pneumoniae
h. influenzae (children)

40
Q

features of acute dacryocystitis

A

erythematous tender swelling over lacrimal sac with associated epiphora

41
Q

management of acute dacryocystitis

A

warm compresses, systemic abx and dacryocystorhinostomy after the acute phase has completely resolved

42
Q

features of chronic dacryocystitis

A

epiphora and recurrent unilateral conjunctivitis

43
Q

management of chronic dacryocystitis

A

dacryocystorhinostomy

44
Q

most common lacrimal gland tumour

A

pleomorphic adenoma of lacrimal gland (benign but can transform to malignant)

45
Q

featrures of pleomorphic adenoma of lacrimal gland

A

progressive painless enlargement of upper eyelid with inferonasal dystopia

46
Q

investigation and treatment of pleomorphic adenoma of lacrimal gland

A

CT

surgery

47
Q

main type of lacrimal gland carcinoma

A

adenoid cystic carcinoma

48
Q

histopathology of adenoid cystic carcinoma

A

cribriform (‘Swiss cheese’) growth pattern

49
Q

2 other types of lacrimal gland carcinoma

A

pleomorphic adenocarinoma

mucoepidermoid carcinoma

50
Q

5 features of lacrimal gland carcinoma

A 
rapidly growing and painful lacrimal gland mass
inferonasal dystopia
optic disc swelling 
choroidal folds 
perineural invasion?
51
Q

what is perineural invasion

A

spreading of a cancer around a nerve - causing a neurological deficit

52
Q

4 ways to manage lacrimal gland carcinoma

A

biopsy
orbital exenteration (surgical removal of globe and surrounding tissue)
radical orbitectomy
radiotherapy

53
Q

what is Sjogren syndrome

A

autoimmune condition - salivary and lacrimal glands become infiltrated with lymphocytes and acini are progressively destroyed

54
Q

triad of features of Sjogren syndrome

A

xerostomia
keratoconjunctivitis sicca
parotid gland enlargement

55
Q

other condition commonly present with Sjogren syndrome

A

posterior blepharitis

56
Q

type of erosions in Sjogren syndrome

A

corneal punctate epithelial erosions (stains with fluorescein)

57
Q

4 investigations for Sjogren syndrome

A

anti-Ro and anti-La antibodies
reduced tear film breakup time
Schirmer test
ocular staining

58
Q

what does the schirmer test do

A

determines whether the eye produces enough tears to keep it moist

59
Q

what does ocular staining show in Sjogren syndrome

A

interpalpebral staining of cornea and conjunctiva, rather than a superior or inferior stain pattern (seen in superior limbic keratoconjunctivitis or exposure keratopathy respectively)

60
Q

first line treatment of Sjogren syndrome

A

ocular lubricants and artificial tears - including hypromellose (lowest viscosity) carbomer and paraffins (highest viscosity)

61
Q

second line treatment of Sjogren syndrome

A

topical corticosteroids and/or oral pilocarpine (increases lacriaml gland secretion)

62
Q

third line treatment of Sjogren syndrome

A

punctal occlusion or low-water content bandage contact lenses (e.g. silicone hydrogel)

63
Q

what is xerophthalmia caused by

A

severe vitamin A deficiency

64
Q

5 features of xerophthalmia

A 
nyctalopia
xerosis 
Bitot's spots
punctate corneal epithelial erosions
keratomalacia in severe cases
65
Q

what is xerosis

A

severe conjunctival dryness and keratinization

66
Q

what are Bitot’s spots

A

triangular keratinized build up on the conjunctiva

67
Q

management of xerophthalmia

A

vit A supplementation and topical lubrication

Duke Elder exam (5 decks)

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