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Investigations > Nasolacrimal system examination > Flashcards

Nasolacrimal system examination Flashcards

1
Q

What are 11 steps to the examination of the nasolacrimal system?

A
  1. observe face
  2. observe/palpate lacrimal sac
  3. observe lids
  4. assess lid laxity
  5. examine puncta
  6. examine conjunctiva/cornea
  7. measure tear meniscus
  8. assess dye disappearance
  9. check dye recovery from nose
  10. cannulate and probe puncta/canaliculi
  11. irrigate with saline to estimate flow/regurgitation
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2
Q

What are 3 things to look for in the observation part of the NL system examination?

A
  1. asymmetry
  2. scars
  3. nasal bridge
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3
Q

What are 3 things to assess for when observing/palpating the lacrimal sac?

A
  1. check for regurgitation fro canaliculi on pressing sac
  2. mass
  3. inflammation
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4
Q

In what 2 states should the lids be observed?

A

eyes open and closed

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5
Q

What are 3 things to look for in the eyelids?

A
  1. contour
  2. position
  3. chronic lid disease
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6
Q

What are 3 ways you should draw the lids when assess lid laxity?

A
  1. laterally
  2. medially
  3. anteriorly
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7
Q

What are 3 things to assess for when examining the puncta?

A
  1. position
  2. calibre
  3. discharge
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8
Q

How should dye appearance be assessed in the nasolacrimal examination?

A

instil 2% fluorescein in lower fornix

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9
Q

How can you check dye recovery from the nose in the nasolacrimal examination?

A

use nasendoscope or cotton bud

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10
Q

How is the nasolacrimal system cannulated and the puncta/canaliculi probed?

A

lacrimal cannula attached to a syringe of saline (+ fluorescein)

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11
Q

What are you assessing for when cannulating and probing the puncta/ canaliculi?

A

patency of puncta, hard or soft stop

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12
Q

Why should you irrigate the nasolacrimal system with saline?

A

to estimate flow/regurgitation of upper and lower systems

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13
Q

How is the dye disappearance test formed?

A

instil drop of fluorescein 2% into each lower fornix; reassess at 2min, by which time (almost) complete clearance should have occurred

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14
Q

What does prolonged retention of fluorescein in the dye disappearance test indicate?

A

inadequate drainage

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15
Q

Explain how probing is performed?

A
  • under topical anaesthesia, straight lacrimal cannula inserted into lower canaliculus
  • guide towards medial wall of lacrimal sac whilst exerting gentle lateral traction on lower lid
  • assess for hard/soft stop
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16
Q

What does a hard (abrupt) stop when performing probing indicate?

A

indicates a patent system as far as the lacrimal sac

17
Q

What does a soft (spongy) stop when performing probing indicate?

A

canalicular block

18
Q

What is the valve of Rosenmuller?

A

valve, fold of mucosa between lacrimal sac and canalicular system preventing reflex of tear

19
Q

What is the valve of Hasner?

A

valve between nasolacrimal duct and inferior concha, prevents reflux of nasal secretions into nasolacrimal system during noseblowing

20
Q

How is irrigation of the nasolacrimal system performed?

A
  • under topical anaesthesia, insert lacrimal cannula into lower canaliculus and palce finger against the lacrimal sac
  • irrigate with saline - assess flow, quality of reurgitated fluid and sac distension
21
Q

What are 3 things to assess for when performing irrigation?

A
  1. flow
  2. quality of regurgitated fluid
  3. lacrimal sac distension
22
Q

How can flow be determined from nasolacrimal irrigation?

A

estimate flow (e.g. in %) conducted (i.e. down nose/back of the throat) vs. regurgitated; if regurgitated, note from which canaliculus

23
Q

What is meant by the quality of regurgitated fluid when performing nasolacrimal irrigation?

A

whether clear or purulent

24
Q

What will be the outcome of a) probing and b) irrigation with nasolacrimal blockage at the level of the punctum?

A
  • a) cannot cannulate
  • b) not possible
25
Q

What will be the outcome of a) probing and b) irrigation with nasolacrimal blockage at the level of the canaliculus (lower/upper)?

A
  • a) soft stop
  • b) regurgitates through same canaliculus only (high pressure)
26
Q

What will be the outcome of a) probing and b) irrigation with nasolacrimal blockage at the level of the common canaliculus?

A
  • a) soft stop
  • b) may regurgitate through either canaliculus
27
Q

What will be the outcome of a) probing and b) irrigation with nasolacrimal blockage at the level of the nasolacrimal duct?

A
  • a) hard stop
  • b) lacrimal sac dilates - may reurgitate (+- mucus) through either canaliculus
28
Q

When is Jones testing considered in the nasolacrimal examination?

A

in cases of partial obstruction, to ascertain th elevel fo the block

29
Q

What is the primary test in Jones testing?

A
  • instil fluorescein 2% into lower fornix
  • after 5 min assess for dye recovery with a cotton bud (can be moistened with 4% cocaine) placed at nasolacrimal duct opening (below inferior turbinate) or with nasendoscope
  • alternative way of looking for dye recoery is ask pt to blow one nostril at a time onto tissue
30
Q

What is the secondary test in Jones testing?

A
  • wash out fluorescein from the lower fornix
  • under topical anaesthesia, insert lacrimal cannula into lower canaliculus and irrigate
  • assess dye recovery from nose as before
31
Q

How can you interpret dye recovered from the primary test of Jones test?

A

result = positive, normal patency

32
Q

How can you interpret dye not recovered from the primary test of Jones test?

A

result = negative, partial obstruction or lacrimal pump failure

33
Q

How can you interpret dye recovered from the secondary test of Jones test?

A

result = positive, partial ostruction of nasolacrimal duct

34
Q

How can you interpret dye not recovered from the secondary test of Jones test?

A

result = negative, partial obstruction above the lacrimal sac

Investigations (29 decks)

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