Nasolacrimal System Disorders

Question 1

list the order of the nasolacrimal drainage system

Answer 1

superior & inferior canaliculi → common canaliculus → Valve of Rosenmuller → lacrimal sac → lacrimal duct → valve of Hasner → inferior meatus

Question 2

what is lacrimal pump action?

what happens when the eyes are open?

Answer 2

contraction of orbicularis oculi forces tears down the nasolacrimal duct

when the eyes are open → the canaliculus & sac expand → creating a negative pressure that draws tears from the canaliculus into the sac

Question 3

the overflow of tears at the eyelid margin

Answer 3

epiphora

Question 4

what causes epiphora?

Answer 4

hypersecretion, defective drainage

e.g: conjunctivochalsis, punctal stenosis, canalicular obstruction (canaliculitis), acute dacryocystitis, nasolacrimal duct obstruction (congenital/acquired)

Question 5

what is caused by anterior segment disease?

involves:

• dry eye: paradoxical watering
• inflammation

Answer 5

hypersecretion

Question 6

characteristics:
compromised lacrimal drainage system

• malposition of lacrimal puncta (ectropion)
• obstruction along drainage system: anywhere along pathway from punctum to valve of Hasner
• lower lid laxity or orbicularis oculi weakness: CN VII palsy

what is this called?

Answer 6

defective drainage

Question 7

what is one or more folds of redundant conjunctiva prolapsing over lower eyelid margin called?

Answer 7

conjunctivochalsis

Question 8

what causes conjunctivochalsis?

Answer 8

loss of conjunctival adhesion to underlying Tenon’s capsule & episclera –> frequently results in epiphora

Question 9

which age group does conjunctivochalsis usually affect?

Answer 9

elderly pts

Question 10

what is the management of conjunctivochalsis?

Answer 10

topical lubrication or surgery (conjunctiva secured to underlying sclera)

Question 11

what causes punctal stenosis?

Answer 11

idiopathic, blepharitis, trauma, prior radiation therapy

meds: taxotere (breast cancer), 5-fluororacil (various cancers)

chronic secondary to infection (Actinomyces irsraelii)

autoimmune disorders: ocular cicatrical pemphigoid, Stevens Johnson syndrome

Question 12

what causes canalicular obstruction? what can it lead to?

Answer 12

congenital, trauma, medications (taxotere), radiation, infection

lead to canalculitis

Question 13

what bacteria causes canalculitis?

Answer 13

Actinomyces israelli

Question 14

unilateral epiphora w/ chronic mucopurulent conjunctivitis

canalicular redness & edema

mucopurulent discharge on pressure over canaliculus (“pouting punctum”)

what condition are these signs & symptoms for?

Answer 14

canaliculitis

Question 15

what forms within canaliculus (sulfur granules) leading to further obstruction (dacryolith)?

Answer 15

concretions

Question 16

what is the management of canaliculitis?

Answer 16

requires surgical removal of concretions

topical antibiotics are not curative

Question 17

what is the management of punctal stenosis?

Answer 17

dilation, punctoplasty, perforated punctal plug

Question 18

what is infection of the lacrimal sac, usually due to nasolacrimal duct obstruction called?

Answer 18

acute dacryocystitis

Question 19

what are symptoms of acute dacryocystitis?

Answer 19

pain & redness below the medial canthal area, epiphora

Question 20

what are signs of acute dacryocystitis?

Answer 20

tense red swelling below the medial canthal area

tender to touch

pressure on swollen tissue → mucopurulent reflux from canaliculi

Question 21

what are treatments of acute dacryocystitis?

Answer 21

hot compresses over affected area

oral antibiotics:
augmentin 500mg PO q8h x 7-10 days
keflex 500mg PO q6h x 7-10 days

Question 22

what are complications of acute dacryocystitis?

Answer 22

preseptal cellulitis, orbital cellulitis

Question 23

what is it called when Valve of Hasner fails to open up?

Answer 23

congenital (primary) nasolacrimal duct obstruction (NLDO)

Question 24

exacerbated during upper respiratory tract infections —

epiphora, mucus discharge, matting of eyelashes, bacterial conjunctivitis

what are these signs of?

Answer 24

congenital (primary) NLDO

Question 25

what is the differential diagnosis of congenital (primary) NLDO?

Answer 25

congenital glaucoma, corneal abrasion, corneal ulcer

Question 26

what are treatments of congenital (primary) NLDO?

Answer 26

spontaneous resolution in over 95% of pts w/in first year

massage lacrimal sac to rupture membranous obstruction by hydrostatic pressure

surgical: probing of nasolacrimal duct
- typically delayed until after 1 yr; can be delayed up to 2 yrs
- requires general anesthesia

Question 27

what is acquired (secondary) nasolacrimal duct obstruction (NLDO)?

Answer 27

trauma, infection, inflammation, neoplasm

Question 28

what are the diagnostic & treatment procedures for nasolacrimal system disorders?

Answer 28

external examination, lacrimal dilation & irrigation, NaFl disappearance test, Jones test, contrast dacryocystography, dacryocystorhinostomy (DCR)

Question 29

explain the purpose of external examination

what is the most common cause of lacrimal drainage failure?

Answer 29

punctal abnormality is the most common cause of lacrimal drainage failure

examine the lid margins & puncta at the slit lamp → ectropion, punctal obstruction/stenosis, palpate the lacrimal sac

Question 30

cannula hits the medial wall of the sac that lies adjacent to the lacrimal bone

confirms pt canalicular system

saline irrigation is performed — if it cannot be tasted in throat → there is an obstruction of nasolacrimal duct

what is this called in lacrimal dilation & irrigation treatment?

Answer 30

hard stop

Question 31

cannula does not reach wall of lacrimal sac due to canalicular obstruction

if saline returns through the same punctum → the obstruction is in the canaliculus

if saline returns through the opposite punctum → the obstruction is in the common canaliculus (Valve of Rosenmuller)

what is this called in the lacrimal dilation & irrigation treatment?

Answer 31

soft stop

Question 32

what is the range of normal tear meniscus?

Answer 32

0.2-0.4mm

Question 33

Name this procedure:
instill NaFl drops into both conjunctival fornices → examine ocular surface after 5 minutes → minimal dye should remain

prolonged retention of dye indicates inadequate lacrimal drainage

Answer 33

NaFl disappearance test

Question 34

Name this procedure:

• radio-opaque contrast medium injected into canaliculi, followed by imaging of nasolacrimal drainage pathway
• should not be performed if active infection is present
• unnecessary if site of obstruction is obvious

Answer 34

contrast dacryocystography

Question 35

what are indications of contrast dacryocystography?

Answer 35

confirms precise site of obstruction for surgery guidance

aids in diagnosis of diverticuli, fistulae, & filling defects due to presence of a mass (stone, tumor)

Question 36

Name this treatment:
surgical procedure that connects the lacrimal sac to the middle nasal meatus (when probing not possible or can’t recreate pathway)

• creates a new drainage pathway for tears that bypasses the nasolacrimal ducct
• general anesthesia usually required

Answer 36

dacryocystorhinostomy (DCR)

Question 37

what age group is DCR usually performed on?

Answer 37

adults