Lacrimal System Diseases OPT 539 PDF

Lacrimal System Diseases OPT 539: Ocular Disease I Scott D. Klemens, O.D., F.A.A.O. October 15, 2024  Objective Introduce and review Lacrimal System Diseases Lacrimal System  Lacrimal System Lacrimal Gland: bilobed...

Lacrimal System Diseases OPT 539: Ocular Disease I Scott D. Klemens, O.D., F.A.A.O. October 15, 2024  Objective Introduce and review Lacrimal System Diseases Lacrimal System  Lacrimal System Lacrimal Gland: bilobed (palpebral/orbital) Secretes aqueous Lacrimal Punctum: opening on eyelids that pump tears away Canaliculus: short channels for tears to drain (2mm up/down 8-10mm horizontal) Valve of Rosenmuller: one-way valve to prevents reflux from lacrimal sac Lacrimal Sac: temporary reservoir for tears Nasolacrimal Duct: Inferior continuation of the lacrimal sac, eventually tears flow into nasal meatus/nasal cavity Valve of Hasner: prevents air from entering the nasolacrimal duct Congenital Lacrimal Anomaly  Congenital Dacryocele aka dacryocystocele, amniotocele, and mucocele Usually present at birth and unilateral Caused by concomitant obstruction below the lacrimal sac and at the level of the canalicular opening in the sac Etiology is debatable between amniotic fluid and mucus  Clinical Presentation Bluish gray cystic swelling of lacrimal sac Firm when palpated DDx: meningoencephalocele, capillary hemangioma, dermoid cyst  Tx / Pt. Ed. Conservative Management Warm Compresses w/ digital massage Antibiotics Probing and or surgery may be necessary in some cases Educate that they may be at higher risk for dacryocystitis, preseptal cellulitis, intranasal involvement  Congenital Nasolacrimal Duct Obstruction (NDO) aka dacryostenosis Approximately 6% of newborns (high as 20% may have symptoms) Usually a result of incomplete canalization (formation of NLD) Usually obstruction is at nasal end involving the valve of Hasner Infants are at increased risk for those with trisomy 21, EEC Syndrome, branchiooculofacial syndrome, CHARGE syndrome, Goldenhar Syndrome  Clinical Presentation Present with history of chronic or intermittent tearing and debris Eyelid erythema is not characteristic, but may present because of rubbing Increased tear meniscus Palpation of lacrimal sac may cause reflex of tears and or mucus  Tx / Pt. Ed. Warm Compresses bid to qid w/ nasolacrimal massage Parent places index finger over canaliculus and massages downward If mucopurulent discharge present consider topical antibiotic ung Erythromycin bid Spontaneous resolution in 70% of patients by age 3mos, and 90% by 12mos In cases that do not resolve by 6-10mos lacrimal duct probing Surgery is last option Educate on risk for secondary complications (infection)  Important Differential Always rule-out other causes of epiphora Patient has tearing and photophobia must rule-out presence of Congenital Glaucoma May or may not have enlarged cornea with corneal edema and or clouding (classic presentation) Check IOP and try and look at ON! Acquired Lacrimal Disease  Acquired NDO May also be referred to as PANDO/SANDO (primary vs secondary depending on etiology Blockage of the lacrimal outflow system usually caused by non-specific inflammation of the lacrimal sac and or duct Etiology: Infection, Inflammatory, Neoplastic, Traumatic, Mechanical Clinical Diagnosis: Dye disappearance, Dilation and Irrigation (D&I), Jones I/II  Clinical Presentation Increased lacrimal/tear lake Epiphora (tearing) Increased fluorescein pooling Discharge/crusting  Dilation and Irrigation (D&I) Insert dilator vertically (2mm) then horizontal (8mm), twist instead of forcing it in 3cc Syringe with Saline, use a blunt tipped needle or irrigation tip (21/23gauge lacrimal cannula) Push saline through at steady rate, if saline comes back through puncta and or can’t push through this would be positive for blockage (may need to repeat) Anesthetic warranted for smaller puncta and or less cooperative patients  D&I https://www.youtube.com/watch?v=n0XLP-96OEU  Tx/Pt.Ed. Try and determine etiology Warm Compresses If partial obstruction consider topical antibiotics/steroids to deter infection/inflammation Try opening with D&I If complete obstruction then will require imaging and surgery  Dacrocystorhinostomy (DCR) Requires patent puncta/canaliculus Surgically bypass nasolacrimal duct Fistula created from lacrimal sac to lateral nasal mucosa using silicone tube  Dacryocystitis Inflammatory state of the nasolacrimal sac, typically caused by obstruction within the nasolacrimal duct Can be acute vs chronic and acquired vs congenital Regardless of type almost always caused by obstruction in nasolacrimal system More often found in Caucasian adults, females 75% of cases  Acute Dacryocystitis Infection of the lacrimal sac Etiology: Nasolacrimal duct obstruction > Tears stagnate in lacrimal sac/bacteria > becomes infection Causes of obstruction: Long and narrow nasolacrimal ducts Lacrimal sac diverticulum (small pouch or bulge) Trauma Dacryoliths (concretion within nasolacrimal system) Inflammatory sinus and nasal problems  Clinical Findings Acute Dacryocystitis Tenderness (if palpated), erythema, and swelling over nasal portion of lower eyelid Epiphora Purulent punctal discharge particularly if pressure is applied to the lacrimal sac Fever and malaise may occur Secondary Complications Preseptal Cellulitis Conjunctivitis Less common, orbital cellulitis and sepsis Acute Dacryocystitis  Chronic Dacryocystitis Etiology Chronic Infection Chronic inflammation/granuloma Tumor (cancer) Clinical Findings Enlarged lacrimal sac without signs of acute inflammation Chronic Dacryocystitis  Treatment Warm Compresses and Crigler massage qid Antibiotics Oral (Augmentin 875mg bid/500mg tid) Topical prophylaxis and or conjunctivitis If draining may be helpful Febrile patients should be referred to hospital for i.v. antibiotics Probing in acute cases usually discouraged Could consider aspirating for culture Excision and drainage considered for pointing abscess  Treatment In chronic cases or after infection resolved D&I and or probing to relieve obstruction Nasal Exam, possible CT scan Surgery usually required for chronic cases (DCR)  Dacryoadenitis Inflammation of the lacrimal gland Unilateral or bilateral Acute or Chronic Lacrimal gland is located superior-temporally to the globe, within the extraconal orbital fat Can be secondary to infection, inflammation, and idiopathic  Acute Dacryoadenitis Most likely related to infection Bacterial: Staphylococcus aureus, Streptococcus pneumoniae Viral: Epstein-Barr, adenovirus, mumps, herpes simplex, herpes zoster More likely to be viral Children and young adults most commonly infected Less common than dacryocystitis  Clinical Presentation Temporal upper eyelid swelling Characteristic “S-shaped lid” Erythema Warmth Tenderness when palpated May have fever, discharge, tearing, conj chemosis, swollen preauricular nodes  Acute Dacryoadenitis Swollen palpebral lobe of the lacrimal gland can be easily visualized in the supratemporal fornix by elevating the upper lid while having the patient looking down  Additional Work-up Acute presentation in association with Labs viral illness does not require Complete CBC comprehensive evaluation Antinuclear antibody (ANA) Atypical features Possible culture of discharge Swelling does not improve with treatment Imaging Bilateral presentation CT or MRI Older adults Biopsy Associated systemic symptoms suggest malignant or autoimmune process  Chronic Dacryoadenitis Most likely inflammatory Large portion remain idiopathic Associated systemic condition Sjogren Syndrome Sarcoidosis Crohn disease Granulomatosis with polyangiitis (formerly called Wegener’s) Rare Vasculitis Tumor  Clinical Presentation Swelling is usually painless Do not have signs of acute presentation May have globe displacement and or restricted ocular motility May present bilaterally  DDx of Chronic Dacryoadenitis Dermoid Cyst Herniation of orbital fat Superior-temporal mass Weakening of tenon’s capsule due to age, trauma, infection Mobile and non-tender Usually present in childhood Superior-temporal on orbit Yellow, convex, soft with superficial blood vessels  Treatment Treat the underlying infection or inflammation Viral cases are self-resolving usually within 4-6wks Bacterial cases will require systemic antibiotics Corticosteroids will induce shrinking of an enlarged lacrimal gland from almost all sources of dacryoadenitis Imaging/biopsy for non-resolving conditions  Canaliculitis Classified into primary and secondary Primary: Inflammation of the lacrimal canaliculus, usually caused by infection Secondary: Inflammation of the lacrimal canaliculus, due to punctal canalicular plug insertion or canalicular intubation Organisms responsible: Actinomyces israelii, Staphylococcus, Streptococcus, Pseudomonas aeruginosa most commonly associated with plug-associated Commonly misdiagnosed  Clinical Presentation Usually presents unilaterally Pouting of punctum or medial canthal swelling (erythema) Watering, discharge Concretions (yellowish granules) associated with Actinomyces Secondary forms may present with blood-stained tears/discharge Canaliculitis  Treatment Warm Compresses w/ local massage Topical and Systemic Antibiotics 80% of cases have found conservative management to be ineffective Concretions may shield bacteria promoting resistence Surgical options Canalicultomoy: incision on posterior aspect of canaliculus remove debris and irrigate with antibiotic solution  Canaliculotomy https://oculoplastic.eyesurgeryvideos.net/canaliculotomy-for- canaliculitis/ Questions?