Nasolacrimal System Disorders Flashcards
list the order of the nasolacrimal drainage system
superior & inferior canaliculi → common canaliculus → Valve of Rosenmuller → lacrimal sac → lacrimal duct → valve of Hasner → inferior meatus
what is lacrimal pump action?
what happens when the eyes are open?
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
the overflow of tears at the eyelid margin
epiphora
what causes epiphora?
hypersecretion, defective drainage
e.g: conjunctivochalsis, punctal stenosis, canalicular obstruction (canaliculitis), acute dacryocystitis, nasolacrimal duct obstruction (congenital/acquired)
what is caused by anterior segment disease?
involves:
- dry eye: paradoxical watering
- inflammation
hypersecretion
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?
defective drainage
what is one or more folds of redundant conjunctiva prolapsing over lower eyelid margin called?
conjunctivochalsis
what causes conjunctivochalsis?
loss of conjunctival adhesion to underlying Tenon’s capsule & episclera –> frequently results in epiphora
which age group does conjunctivochalsis usually affect?
elderly pts
what is the management of conjunctivochalsis?
topical lubrication or surgery (conjunctiva secured to underlying sclera)
what causes punctal stenosis?
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
what causes canalicular obstruction? what can it lead to?
congenital, trauma, medications (taxotere), radiation, infection
lead to canalculitis
what bacteria causes canalculitis?
Actinomyces israelli
unilateral epiphora w/ chronic mucopurulent conjunctivitis
canalicular redness & edema
mucopurulent discharge on pressure over canaliculus (“pouting punctum”)
what condition are these signs & symptoms for?
canaliculitis
what forms within canaliculus (sulfur granules) leading to further obstruction (dacryolith)?
concretions
what is the management of canaliculitis?
requires surgical removal of concretions
topical antibiotics are not curative
what is the management of punctal stenosis?
dilation, punctoplasty, perforated punctal plug
what is infection of the lacrimal sac, usually due to nasolacrimal duct obstruction called?
acute dacryocystitis
what are symptoms of acute dacryocystitis?
pain & redness below the medial canthal area, epiphora
what are signs of acute dacryocystitis?
tense red swelling below the medial canthal area
tender to touch
pressure on swollen tissue → mucopurulent reflux from canaliculi
what are treatments of acute dacryocystitis?
hot compresses over affected area
oral antibiotics:
augmentin 500mg PO q8h x 7-10 days
keflex 500mg PO q6h x 7-10 days
what are complications of acute dacryocystitis?
preseptal cellulitis, orbital cellulitis
what is it called when Valve of Hasner fails to open up?
congenital (primary) nasolacrimal duct obstruction (NLDO)
exacerbated during upper respiratory tract infections —
epiphora, mucus discharge, matting of eyelashes, bacterial conjunctivitis
what are these signs of?
congenital (primary) NLDO
what is the differential diagnosis of congenital (primary) NLDO?
congenital glaucoma, corneal abrasion, corneal ulcer
what are treatments of congenital (primary) NLDO?
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
what is acquired (secondary) nasolacrimal duct obstruction (NLDO)?
trauma, infection, inflammation, neoplasm
what are the diagnostic & treatment procedures for nasolacrimal system disorders?
external examination, lacrimal dilation & irrigation, NaFl disappearance test, Jones test, contrast dacryocystography, dacryocystorhinostomy (DCR)
explain the purpose of external examination
what is the most common cause of lacrimal drainage failure?
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
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?
hard stop
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?
soft stop
what is the range of normal tear meniscus?
0.2-0.4mm
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
NaFl disappearance test
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
contrast dacryocystography
what are indications of contrast dacryocystography?
confirms precise site of obstruction for surgery guidance
aids in diagnosis of diverticuli, fistulae, & filling defects due to presence of a mass (stone, tumor)
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
dacryocystorhinostomy (DCR)
what age group is DCR usually performed on?
adults
