Nasolacrimal system examination

Question 1

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

Answer 1

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

Question 2

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

Answer 2

1. asymmetry
2. scars
3. nasal bridge

Question 3

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

Answer 3

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

Question 4

In what 2 states should the lids be observed?

Answer 4

eyes open and closed

Question 5

What are 3 things to look for in the eyelids?

Answer 5

1. contour
2. position
3. chronic lid disease

Question 6

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

Answer 6

1. laterally
2. medially
3. anteriorly

Question 7

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

Answer 7

1. position
2. calibre
3. discharge

Question 8

How should dye appearance be assessed in the nasolacrimal examination?

Answer 8

instil 2% fluorescein in lower fornix

Question 9

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

Answer 9

use nasendoscope or cotton bud

Question 10

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

Answer 10

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

Question 11

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

Answer 11

patency of puncta, hard or soft stop

Question 12

Why should you irrigate the nasolacrimal system with saline?

Answer 12

to estimate flow/regurgitation of upper and lower systems

Question 13

How is the dye disappearance test formed?

Answer 13

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

Question 14

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

Answer 14

inadequate drainage

Question 15

Explain how probing is performed?

Answer 15

• 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

Question 16

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

Answer 16

indicates a patent system as far as the lacrimal sac

Question 17

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

Answer 17

canalicular block

Question 18

What is the valve of Rosenmuller?

Answer 18

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

Question 19

What is the valve of Hasner?

Answer 19

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

Question 20

How is irrigation of the nasolacrimal system performed?

Answer 20

• 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

Question 21

What are 3 things to assess for when performing irrigation?

Answer 21

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

Question 22

How can flow be determined from nasolacrimal irrigation?

Answer 22

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

Question 23

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

Answer 23

whether clear or purulent

Question 24

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

Answer 24

• a) cannot cannulate
• b) not possible

Question 25

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

Answer 25

* a) soft stop * b) regurgitates through same canaliculus only (high pressure)

Question 26

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

Answer 26

* a) soft stop * b) may regurgitate through either canaliculus

Question 27

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

Answer 27

* a) hard stop * b) **lacrimal sac dilates** - may reurgitate (+- mucus) through either canaliculus

Question 28

When is Jones testing considered in the nasolacrimal examination?

Answer 28

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

Question 29

What is the primary test in Jones testing?

Answer 29

* 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

Question 30

What is the secondary test in Jones testing?

Answer 30

* 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

Question 31

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

Answer 31

result = positive, normal patency

Question 32

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

Answer 32

result = negative, partial obstruction or lacrimal pump failure

Question 33

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

Answer 33

result = positive, partial ostruction of nasolacrimal duct

Question 34

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

Answer 34

result = negative, partial obstruction above the lacrimal sac