Lacrimal Apparatus Lecture 3 PDF

1  Almond sized gland situated at upper-outer angle of orbit, in depression known as lacrimal fossa.  Ducts of lacrimal gland: about 12 in number & open in upper fornix. ① LACRIMAL  Arterial supply: GLAND ① Lacrimal branch of ophtha...

1  Almond sized gland situated at upper-outer angle of orbit, in depression known as lacrimal fossa.  Ducts of lacrimal gland: about 12 in number & open in upper fornix. ① LACRIMAL  Arterial supply: GLAND ① Lacrimal branch of ophthalmic artery. ② Infraorbital branch of maxillary artery.  Venous drainage:  Lacrimal vein which opens into the superior ophthalmic vein.  Very small glands with the same structure as lacrimal glands. ① Glands of Krause:  About 20 in UL & 8 in LL  Situated within the conjunctival stroma mainly near the fornices. ② ACCESSORY ② Glands of Wolfring: LACRIMAL  Few in number GLANDS  Situated near upper border of tarsal plate. ③ Sebacious Zeis glands ④ Mebomian glands ⑤ Conjunctival goblet cells 2 ① LACRIMAL  These are two small openings situated on a small elevation called lacrimal PUNCTI papilla, about 6 mm from the inner canthus on each lid margin. ② LACRIMAL  Two narrow tubular passages which lie→ (one above the other) being CANALICULI separated by a small body, the caruncle.  Situated in the (lacrimal fossa formed by the lacrimal bone and the frontal process of the maxilla). ③ LACRIMAL SAC  It is about 15 mm in length and 5 mm wide when distended. It is connected to the nasolacrimal duct inferiorly.  It is a membranous canal approximately 2 cm long extending from lower ④ NASOLACRIMAL part of the sac to the inferior meatus of the nose. The opening is covered DUCT by mycosal fold→ Hasner’s Valve  Part of the orbicularis, inserted into the lacrimal fascia surrounding sac. ⑤ HORNER'S  It contracts with normal orbicularis contraction during lid closure and MUSCLE creates –ve pressure in the sac leading to suction of tears from the conjunctival sac.  The tear film spreads over the ocular surface by gravity, capillary action & blinking of the eyelids. LAYER SECRETED BY FUNCTION ① OUTER LIPID  Prevent rapid evaporation of tears.  Meibomian glands. LAYER  Lubricates eyelids movement over globe.  Moisturizing corneal & conjunctival surfaces ② MIDDLE AQUEOUS  Lacrimal & accessory  Supplies oxygen needed for corneal LAYER lacrimal glands. metabolism.  Antibacterial as it contains lysozymes.  It washes away foreign particles.  Makes corneal epithelium →hydrophilic &  Goblet cells ③ INNER MUCINOUS fills irregularities between corneal epithelial  Crypts of Henle LAYER cells thus obtaining→ a smooth corneal  Glands of Manz. surface which is optically important.  ① ②  Inflammation of lacrimal gland  Cystic swelling in the upper fornix due to ① Acute: common complication of mumps. retention of lacrimal secretion.  The gland is enlarged & tender  Any Lacrimal gland swelling gives the ② Chronic: usually with trachoma. Signs & characteristic S-shaped deformity of lid. symptoms of inflammation are mild.  PUNCTAL EVERSION PUNCTAL OBSTRUCTION Moving it away from the lacus lacrimalis Epiphora is the main symptom EPIPHORA → ↓ tear drainage → epiphora  Congenital atresia CAUSE  Ectropion  Chronic blepharitis  Acquired (trauma or trachoma)  Punctal dilatation (simple TTT  Treat ectropion whatever the cause punctoplasty) with punctal dilators  Three snip punctoplasty CANALICULITIS CANALICULAR OBSTRUCTION  Actinomyces Israeli shows discharge  Congenital atresia CAUSE containing sulphur granules.  Acquired (trauma or trachoma)  Stent cannulation  Primary repair with silicon intubation TTT  Excision of the occluded part & resuturing.  If all procedures failed to obtain a patent canaliculus the end stage solution is conjunctivo-dacryocysto-rhinostomy 1 DEFINITION  Acute suppurative inflammation of the lacrimal sac.  Predisposing factor: ETIOLOGY  Naso-lacrimal duct obstruction or chronic dacryocystitis.  Causative agent: Pneumococci, Staphylococci and Streptococci. SYMPTOMS ① Severe pain. ② Fever. ③ Epiphora. ① Marked edema and redness of skin over the sac below medial canthus. ② Regurgitation test: -ve due to congestion of epithelium of canaliculi. SIGNS ③ Tender swelling of lacrimal sac. ④ Abscess formation with fluctuation. ① Lacrimal fistula: The sac may burst anteriorly through the skin. ② Pyocele: Canaliculi may become obstructed. COMPLICATIONS ③ Orbital cellulitis and cavernous sinus thrombosis. ④ Turn into chronic dacryocystitis. ① During the acute phase: a. Antibiotics: Systemic and topical. b. Hot fomentations. TREATMENT c. Lotions: To clean the pus. d. Incision and drainage if abscess isformed. ② After the acute attack subsides:  Dacryocystorhinostomy (DCR) with fistulectomy if needed.  2  Chronic inflammation of lacrimal sac. DEFINITION  It is the commonest lacrimal sac disorder.  Predisposing factor:  Naso-lacrimal duct obstruction (duct itself or its opening in the nose).  Causative agent: ETIOLOGY  Pneumococci in 80%.  Staphylococci, Streptococcus, & fungi.  TB and Syphilis: Rare. ① Watery eye. SYMPTOMS ② Discharge. ① Swelling of lacrimal sac below the medial palpebral ligament. ② Regurgitation test: +ve Pressure on the swelling causes regurge of mucous or pus. SIGNS ① Chronic conjunctivitis. ② Epiphora, eczema and ectropion (vicious circle of cicatricial ectopion). ③ Hypopyon ulcer (d.t pneumococci) COMPLICATIONS ④ Risk factor for endophthalmitis following intraocular operation. ⑤ Mucocele and pyocele: if the canaliculi are obstructed. ⑥ Fulmination of inflammation into acute form with lacrimal abscess or fistula formation.  Culture & sensitivity of the regurgitated discharge INVESTIGATIONS  Epiphora investigations.  ① Treatment of the cause of obstruction:  e.g. relieve congestion, removal of a nasal polyp. ② Dacryocystorhinostomy: Operation of choice.  To create a surgical opening between the lacrimal sac and the nasal mucosa of the middle meatus, allowing drainage PRINCIPLE of tears directly into the nose bypassing the obstructed naso-lacrimal duct. ① Chronic dacryocystitis. INDICATIONS ② Mucocele of the lacrimal sac. ③ Lacrimal fistula (DCR and fistulectomy). ① Bad lacrimal sac: Extensive adhesions & neglected cases. ② Bad nasal mucosa: Atrophic rhinitis and polypi. C/I ③ T.B and tumors of the sac. TREATMENT ④ Hypopyon ulcer. ③ Dacryocystectomy: PRINCIPLE  Removal of the lacrimal sac. INDICATIONS  In cases where DCR can't be done.  3 DEFINITION  Chronic inflammation of lacrimal sac in newborn.  Naso-lacrimal duct obstruction d.t  Incomplete→ canalization ETIOLOGY  Membrane  Accumulation of→ epihelial debris  There is continuous watering of the eyes usually evident in 2nd week of SYMPTOMS life (normally, tears are secreted 3-4 weeks after birth).  There may be purulent discharge or conjunctivitis in infected cases.  Sticky mucopurulent discharge filling conjunctival sac & +ve regurgitation SIGNS test.  persistent epiphora ① Ophtalmia neonatorum: D.D.  Acute conjunctivitis in the 1st 2 weeks of life (but –ve regurgitatin). ② Congenital glaucoma (buphthalmus): the IOP is elevated ① Conservative (dating from diagnosis & until 6 months of life)  Lacrimal sac massage: mother is taught to massage the sac contents towards the nose to rupture any membranes & this is carried out 4 times/15 presses/daily.  Frequent anti-biotic drops after the massage (avoid quinolones & chloramphenicol) ② Surgical treatment (aim to re-canalise the nasolacrimal duct). a. Probing of the NLD (following failed conservative treatment until age of 6 months)  Undergone through the upper punctum (to spare the lower) & under TREATMENT general anesthesia. Great care is taken to avoid injury to the walls of the duct as it may cause fibrosis or infection.  The punctum & canaliculus are dilated by a Nettleship’s dilator then a No.1 or No. 2 probe is directed 2mm vertically then the upper lid is stretched laterally & the probe is directed 6mm horizontally until reaching a bony stop. The brobe then is rotated & directed downwards postero-lateraly targeting the 1st canine teath b. Intubation with silicone tube :This may be performed with repeated probing failure. The silicone tube should be kept in the nasolacrimal duct for 6-12 months. c. DCR (when the condition fails to respond up to 4 years of age) INFANTILE DACRYOCYSTITIS PROBING OF THE NLD   Common condition that occurs when tears aren't able to provide DEFINITION adequate lubrication for the eye.  Aqueous deficient dry eye: deficient→ tear secretion TYPES  Evaporative dry eye: meibomian gland dysfunction leads to defective oily layer resulting in increased evaporation and tear film instability ① Congenital absence of the lacrimal gland. ② Inflammation of lacrimal gland e.g. sarcoidosis. ③ Tumors of lacrimal gland: e.g. mixed lacrimal gland tumor (most common) ④ Keratoconjunctivitis sicca:  Autoimmune disease leading to atrophy and fibrosis of lacrimal gland ETIOLOGY  Occurs usually in females and may be associated with arthritis and dry mouth (Sjogren's syndrome). ⑤ Conjunctival scarring:  Due to trachoma, chemical burns, Stevens-Johnson syndrome and ocular cicatricial pemphigoid. ① Irritation & foreign body sensation. ② Deficient tear production measured by→ filter paper (Schirmer’s test). ③ Rose Bengal staining of (degenerated epithelium of conjunctiva, cornea) & (mucous) ④ Punctate epithelial erosion of the cornea. ⑤ Tear film break - up time (BUT) is diminished.  Time taken for 1st dry spot to appear on cornea after complete blink. CLINICAL PICTURE  TFBUT measurement is easy and fast method used to assess stability of tear film. It is a standard diagnostic procedure in the dry eye clinics. ① Protective glasses and contact lenses. ② Tear substitutes (eye drops, eye gel). TREATMENT ③ Occlusion of the puncti to reduce tear drainage. ④ Systemic steroids (autoimmune cases).  1 Excessive Lacrimation:  Emotional conditions.  Reflex lacrimation due to foreign body impaction or blepharitis, conjunctivitis, keratitis, irido-cyclitis, or glaucoma. 2 Epiphora: Watering is due to defective tear drainage.  Lacrimal pump failure: ① Lid margin: Abnormality in posterior border of the lid margin. ETIOLOGICAL ② Ectropion. CLASSIFICATION ③ Orbicularis muscle: Facial palsy.  Obstructive epiphora: ① Congenital e.g. punctual atresia, NLD obstruction. ② Inflammatory (trachoma, herpes, fungal) e.g dacryocystitis or canaliculitis. ③ Traumatic e.g. bony fractures, surgical trauma. ④ Tumors e.g. nasal polyps, maxillary tumors. 1 Treatment of the cause: e.g. Ectropion and nasal causes of epiphora. 2 Stenosis of puncti and canaliculi: Dilatation and probing. 3 Obstruction of Naso-lacrimal duct: TREATMENT OF CONGENITAL OBSTRUCTION ACQUIRED OBSTRUCTION EPIPHORA  Hydrostatic massage.  Dilatation & probing usually fails.  Dilatation and probing.  Dacryocystorhinostomy.  Dacryocystorhinostomy.  Dacryocystectomy. ① The syndrome consisting of atrophy & fibrosis of lacrimal and salivary gland is a. Sjögren’s syndrome b. Mikulicz’s syndrome c. Sturge-Weber syndrome d. Vogt-Koyanagi syndrome ② Epiphora occurs in a. Iritis b. trachoma c. chronic dacryocystitis d. acute congestive glaucoma ③ The most common tumour of the lacrimal gland is a. basal cell carcinoma b. squamous cell carcinoma c. mixed tumour d. malignant melanoma ④ Tears are produced in the newborn after a. 1 week b. 2 weeks c. 3 weeks d. 4 weeks ⑤ The nasolacrimal duct opens in the nose at a. superior meatus b. middle meatus c. inferior meatus d. nasal septum