1) approach to watery eyes -lacrimal gland

h h h h h h

1. Approach To Watery Eye

2. Introduction Watering eye is an extremely common ocular symptom. Watering eye lacrimation epiphora Failure to differentiate these two conditions can result in unwarranted and improper medication of a large number of patients.

3. Epiphora , is due to a disruption in the balance between tear production and tear loss. Lacrimation is watering that occurs secondary to excessive tear production in the presence of a normal excretory system

4. Causes of watering eye Lacrimation (hypersecretion ): Secondary to ocular inflammation or surface disease . Emotional distress Irritation of the eyes ( smoke, dust, foreign bodies, injury )

5. Causes of watering eye Epiphora : ( defective drainage ): compromise of the lacrimal drainage system: a) malposition of the lacrimal puncta (e.g. ectropion ) b) obstruction (anywhere along the lacrimal drainage system, from puncta to the nasolacrimal duct ) c) lacrimal pump failure (lower lid laxity or weakness of the orbicularis muscle )

6. Evaluation of watering from the eye History Watering due to epiphore is usually unilateral and is not associated with irritation On the other hand lacrimation is usually bilateral and associated with irritation,itching or photophobia

7. Evaluation External examination : The puncta and eyelids (ectropion, punctal obstruction – eyelash, conjunctivochalasis, eversion of punctum by large caruncle, canaliculitis, canturion syndrome – prominent nasal bridge ) The lacrimal sac (palpation )

8. Anatomical tests These tests helps in localization of obstruction ● Syringing / irrigation ● Diagnostic probing ● Dacryocystography ● CT/MRI

9. Functional tests To access functioning of lacrimal apparatus under physiologic conditions Performed only when there is no evidence of obstruction in anatomical tests Flourescein dye disappearance test Scintigraphy Jones dye test I

10. Evaluation tests Fluorescein disappea r Functional tests

11. Jones dye testing : a) primary , b) secondary

12. Probing : a) hard stop, b) soft stop

13. Contrast Dacryocystography (DCG) • Technique: Plastic catheters are placed into one canaliculus in both eyes, 1ml lipidol is simultaneously injected through both catheters Water's view radiographs are taken, 5 minutes later, an erect oblique film is taken. Results: The site of obstruction is usually evident. Diverticula, filling defects due to stones and strictures can be diagnosed.

14. Lacrimal scintillography • Scintillography is used to assess the lacrimal drainage system under physiological conditions. • Technique: Tchnetium-99 is delivered by a micropipette to the inferior conjunctival sac. The tracer is imaged using a gamma camera.

15. Dacryocystitis Dacryocystitis is an infection of the lacrimal sac secondary to obstruction of the nasolacrimal duct at the junction of lacrimal sac. Dacryon= tear, cyst= sac Simply dacryocystitis is an inflammation of lacrimal sac. Dacryocystitis may be congenital oracquired.

16. acute daryocystitis - presentation of subacute onset of pain in the medial canthal area , associated with epiphora. signs : very tender tense red swelling at the medial canthus abscess fomation may occur

17. Treatment initial treatment involves the application of local warm compresses and oral antibiotics such as cloxacillin or augmentin , irrigation and probing should not be performed . incision and drainage maybe considered if pus points and absess is about to drain spontaneously. DCR is usually necessary after the acute infection has been controlled .

18. chronic dacryocystitis presentation is with epiphora , which may be associated with a chronic or recurrent unilateral conjunctivitis sign : 1. a painful swelling at the inner canthus caused by mucocele 2. obvious swelling may be absent , although pressure over the sac commonly dtill esults in refluc of mucopurulent material through the canaculi treatment involves DCR.

19. Lacrimal surgery Conventional dacryocystorhinostomy Lester Jones tube Endonasal surgery Endocanalicular laser DCR Balloon dacryocystoplasty

20. ENDOSCOPIC DCR Advantages : lack of a skin incision , shorter operating time , min blood loss and less risk of cerebrospinal fluid leakage. Disadvantages lower success rate , difficulty in examining the common canacular opening

21. 1. Insertion of light probe into lacrymal sac . 2. Transillumination of nasal bone. 3. Cauterization of mucosa. 4.Osteotomy and opening of lacrymal sac

22. 5. Insertion & fixation of stents . 6. Haemostasis & tamonade . 7. Osteotomy with stents at end . 8. Open osteotomy 1 mo post-op.