Nasolacrimal system examination Flashcards
What are 11 steps to the examination of the nasolacrimal system?
- observe face
- observe/palpate lacrimal sac
- observe lids
- assess lid laxity
- examine puncta
- examine conjunctiva/cornea
- measure tear meniscus
- assess dye disappearance
- check dye recovery from nose
- cannulate and probe puncta/canaliculi
- irrigate with saline to estimate flow/regurgitation
What are 3 things to look for in the observation part of the NL system examination?
- asymmetry
- scars
- nasal bridge
What are 3 things to assess for when observing/palpating the lacrimal sac?
- check for regurgitation fro canaliculi on pressing sac
- mass
- inflammation
In what 2 states should the lids be observed?
eyes open and closed
What are 3 things to look for in the eyelids?
- contour
- position
- chronic lid disease
What are 3 ways you should draw the lids when assess lid laxity?
- laterally
- medially
- anteriorly
What are 3 things to assess for when examining the puncta?
- position
- calibre
- discharge
How should dye appearance be assessed in the nasolacrimal examination?
instil 2% fluorescein in lower fornix
How can you check dye recovery from the nose in the nasolacrimal examination?
use nasendoscope or cotton bud
How is the nasolacrimal system cannulated and the puncta/canaliculi probed?
lacrimal cannula attached to a syringe of saline (+ fluorescein)
What are you assessing for when cannulating and probing the puncta/ canaliculi?
patency of puncta, hard or soft stop
Why should you irrigate the nasolacrimal system with saline?
to estimate flow/regurgitation of upper and lower systems
How is the dye disappearance test formed?
instil drop of fluorescein 2% into each lower fornix; reassess at 2min, by which time (almost) complete clearance should have occurred
What does prolonged retention of fluorescein in the dye disappearance test indicate?
inadequate drainage
Explain how probing is performed?
- 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
What does a hard (abrupt) stop when performing probing indicate?
indicates a patent system as far as the lacrimal sac
What does a soft (spongy) stop when performing probing indicate?
canalicular block
What is the valve of Rosenmuller?
valve, fold of mucosa between lacrimal sac and canalicular system preventing reflex of tear
What is the valve of Hasner?
valve between nasolacrimal duct and inferior concha, prevents reflux of nasal secretions into nasolacrimal system during noseblowing
How is irrigation of the nasolacrimal system performed?
- 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
What are 3 things to assess for when performing irrigation?
- flow
- quality of regurgitated fluid
- lacrimal sac distension
How can flow be determined from nasolacrimal irrigation?
estimate flow (e.g. in %) conducted (i.e. down nose/back of the throat) vs. regurgitated; if regurgitated, note from which canaliculus
What is meant by the quality of regurgitated fluid when performing nasolacrimal irrigation?
whether clear or purulent
What will be the outcome of a) probing and b) irrigation with nasolacrimal blockage at the level of the punctum?
- a) cannot cannulate
- b) not possible
What will be the outcome of a) probing and b) irrigation with nasolacrimal blockage at the level of the canaliculus (lower/upper)?
- a) soft stop
- b) regurgitates through same canaliculus only (high pressure)
What will be the outcome of a) probing and b) irrigation with nasolacrimal blockage at the level of the common canaliculus?
- a) soft stop
- b) may regurgitate through either canaliculus
What will be the outcome of a) probing and b) irrigation with nasolacrimal blockage at the level of the nasolacrimal duct?
- a) hard stop
- b) lacrimal sac dilates - may reurgitate (+- mucus) through either canaliculus
When is Jones testing considered in the nasolacrimal examination?
in cases of partial obstruction, to ascertain th elevel fo the block
What is the primary test in Jones testing?
- 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
What is the secondary test in Jones testing?
- 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
How can you interpret dye recovered from the primary test of Jones test?
result = positive, normal patency
How can you interpret dye not recovered from the primary test of Jones test?
result = negative, partial obstruction or lacrimal pump failure
How can you interpret dye recovered from the secondary test of Jones test?
result = positive, partial ostruction of nasolacrimal duct
How can you interpret dye not recovered from the secondary test of Jones test?
result = negative, partial obstruction above the lacrimal sac
