Anatomy of lacrimal apparatus

Dr.Siddharth Gautam & Dr.Pavitra Patel
Resident Ophthalmology
JNMC,Wardha

1. ANATOMY OF LACRIMAL APPARATUS DR.SIDDHARTH GAUTAM

2. The lacrimal apparatus comprises the structures concerned with formation of tears i.e the main lacrimal gland and accessory lacrimal glands and its transport Components of lacrimal apparatus Lacrimal gland Lacrimal puncta Lacrimal cannaliculi Lacrimal sac Naso lacrimal duct

3. COMPONENTS OF LACRIMAL APPARATUS

4. LACRIMAL GLAND It is situated in the fossa for lacrimal gland,formed by the orbital part of frontal bone,in the anterolateral part of orbit.The gland is divided in its anterior aspect by the lateral horn of aponeurosis of the levator muscle into two parts : Superior Orbital Inferior Palpebral,which are continuous with each other posteriorly

5. PARTS OF THE LACRIMAL GLAND The larger Orbital part is in a depression, the lacrimal fossa, in the frontal bone; The smaller Palpebral part is inferior to levator palpebrae superioris ,in the superolateral part of the eyelid

6. ORBITAL PART OF LACRIMAL GLAND It is large about the size and shape of a small almond. It has: Two Surfaces : Superior & Inferior Two Borders : Anterior & Posterior Two Extremities : Medial & Lateral

7. Superior surface Convex Lies in contact with the periorbita lining the part of the frontal bone forming the fossa for lacrimal gland Attached to periorbita by fine trabeculae . Inferior surface Concave Lies on the levator palpebrae superioris muscle and the lateral horn of the levator aponeurosis .

8. Anterior border Sharp Within and parallel to the orbital margin,upto the zygomatico -frontal suture Lies in contact with the septum orbitale . Posterior border Round Continuous with the palpebral part of the gland Lies in contact with orbital pad of fat.

9. Lateral extremity Rests on the lateral rectus muscle . Medial extremity Related to levator palpebrae superioris muscle. 10

10. PALPEBRAL PART OF LACRIMAL GLAND One-third the size of orbital part Consists of only 2-3 lobules. Situated upon the course of the ducts of orbital part from which it is separated by the levator palpebrae superioris muscle, which is related to it superiorly .

11. Inferiorly the gland lies in relation to the superior fornix . Gland is compressed from above downwards and can be seen through the conjunctiva when the lid is everted . Posteriorly it is continuous with the orbital part. 12

12. Lacrimal gland is drained by a series of 8-12 small ducts. D ucts open into the lateral part of the superior conjunctival fornix.1-2 ducts also open into the lateral part of the inferior fornix. Since all the ducts pass through the palpebral part of the gland, therefore excision of the palpebral part alone amounts to excision of the entire gland as far as secretory function of the gland is concerned. The secretions from the gland is spread over the surface of the eye by the action of the lids.

13. STRUCTURE OF LACRIMAL GLAND Lacrimal gland is a branched tubulo -alveolar (serous acinous ) gland , similar in structure to the salivary glands. Microscopically , it consists of glandular tissue, stroma and septa. It is lined by a capsule as the outermost limit. Glandular tissue consists of acini and ducts arranged in lobes and lobules separated from each other by the fibrovascular septa .

14. Acini are lined by a single layer of pyramidal cells mounted on a basement membrane. These cells are surrounded by a layer of flattened myoepithelial cells. The pyramidal cells are of the serous type with eosinophilic secretory granules and a round nucleus situated towards the base. 15

15. These cells secrete the tears , expelled by the contraction of myofibrils. The secretion of the acinar units is drained by connecting channels which to begin with are intralobular , then these become extralobular and lastly open in the ducts. The stroma of the lacrimal gland is formed by mesodermal tissue which contains connective tissue, elastic tissue, lymphoid tissue, plasma cells, rich nerve terminals and blood vessels. 16

16. Blood supply Main lacrimal gland is supplied by lacrimal artery branch of ophthalmic artery. Sometimes a branch of the transverse facial artery may also supply the gland. The lacrimal veins draining the gland join the ophthalmic vein . Lymphatic drainage It is along the conjunctival drainage into the pre-auricular lymph nodes .

17. Nerve supply Sensory nerve supply comes from the lacrimal nerve, a branch of ophthalmic division of the fifth cranial nerve . Sympathetic nerve supply comes from the carotid plexus of the cervical sympathetics . Secretomotor fibres are derived from the superior salivary nucleus . 18

18. ACCESSORY LACRIMAL GLANDS Same structure as main lacrimal gland Very small in size Glands of Krause: Upper lid-40-42 Lower lid-6-8 Deeply situated in the conjunctiva near the fornix on lateral side

19. Glands of Wolfring : Few in number Situated near the upper border of the tarsal plate Rudimentary accessory lacrimal glands: Present in the caruncle,plica semilunaris and infraorbital region. 20

20. LACRIMAL DRAINAGE SYSTEM Comprises of : The Puncta : Small, round to oval orifices of 0.2 mm in diameter. Situated on the summit of an elevation, the Papilla Lacrimalis that lies near the medial end of eyelid margins at the junction of its ciliated & non-ciliated parts. The puncta being avascular is paler than its surrounding structures. The puncta are surrounded by a ring of dense fibrous tissue which keeps them patent. 21

21. 2 . The Canaliculi : Hollow tubes of 0.5 mm in diameter connecting the puncta to the Lacrimal sac. It has : i ) Vertical Part - 2mm in length ii) Horizontal part - 8-10 mm in length Upper canaliculi is slightly shorter than the lower. There is a dilatation at the junction of these 2 parts- called AMPULLA . 23

22. The canaliculi unite at an angle of 25 degrees to form common canaliculus (0.5mm). The common canaliculus is directed an angle of 45 degrees with the sac before entering it. This acute entry into the Lacrimal Sac creates a potential mucosal flap or valve across the opening, The Valve of Rosenmuller . The point of entry of common canaliculus into the Lacrimal sac is called the Lacrimal sinus of Maier. The canaliculi are lined by stratified squamous epithelium .

23. 3. THE LACRIMAL SAC: Dimensions : 12-15 mm in length 4-6 mm anteroposteriorly 2-3 mm wide Situation : Lies in the lacrimal fossa formed by the lacrimal bone & frontal process of maxilla in the anterior part of the medial wall of the orbit which is continuous below with the Nasolacrimal duct.

24. RELATIONS OF LACRIMAL SAC Medially - Lacrimal sac is related to anterior ethmoid sinus in the upper part and middle meatus of the nose in the lower part. Anterolateral relations of the sac from deep to superficial include: Lacrimal fascia and few fibres of the inferior oblique muscle which arise from it. Lacrimal fibres of the orbicularis muscle (Horner's muscle ). 27

25. Medial palpebral ligament , which covers only the upper part of the sac. Therefore, distension of the sac always occurs in lower part which is covered by few fibres of the orbicularis and skin. Lacrimal abscess and fistula also open in the lower part owing to less resistance. Palpebral fibres of orbicularis . 28

26. Angular vein which crosses the medial palpebral ligament about 8 mm from the medial canthus . Many a time a tributary of the angular vein runs between it and the medial canthus . Therefore, to avoid profuse bleeding during sac surgery the shouldnot be made more than 3 mm medial to the medial canthus . Skin is the most anterior relation of the lacrimal sac.

27. Posteriorly , i.e. behind the sac from anterior to posterior important structures are: Lacrimal fascia Fibres of lacrimal part of orbicularis Septum orbitale which separates the sac from the orbital fat and check ligament of the medial rectus muscle. 30

28. 4.NASOLACRIMAL DUCT: Continuation of Lacrimal sac.  It is divided into 2 parts : a) An I nterosseous Part : 12.5 mm b) An I ntermeatal Part : 5.5 mm  The opening of Nasolacrimal duct has a mucosal fold , the Valve of Hasner , which prevents air from entering the lacrimal sac on sudden blowing the nose.

29. STRUCTURE OF THE LACRIMAL SAC AND NASOLACRIMAL DUCT Epithelium :The lacrimal sac and NLD are lined by 2 layers of cells.The superficial layer is of non-ciliated columnar cells.The deep layer is of flattened cells. Subepithelial tissue contains lymphocytes which may aggregate in pathological condition to form follicles. Fibroblastic tissue of the lacrimal sac becomes continuous wilh that of the canaliculi . 32

30. Plexus of vessels is well developed around the NLD, forming an erectile tissue resembling in structure with that on the inferior concha . Engorgement of these vessels is said to be sufficient lo cause obstruction of the NLD and produce epiphora . 33

31. Blood supply of the lacrimal passages: Arterial supply to the lacrimal passage is derived from superior and inferior palpebral arteries (branches of ophthalmic artery), angular branch of facial artery, infraorbital artery and nasal branches of sphenopalatine artery. Venous drainage occurs into the angular vein and infraorbital vein from above and into the nasal vein from below. Lymphatics drain into the submandibular and the deep cervical glands.

32. Nerve supply Sensory nerve supply to the lacrimal sac and NLD comes from the infratrochlear nerve and the anterior superior alveolar nerves. Probably, there is a reflex relation between the nerve supply of the lacrimal gland and the lacrimal sac, because extirpation of the latter greatly diminishes the tear production. 35

33. PHYSIOLOGY Tear drainage: Tears are drained from conjunctival sac by two mechanisms: 1. Gravity. 2. Active pump mechanism. 1. By G ravity : Gravity plays a small part and most of the tears are drained by active pump.

34. 2 . Active pump (Suction): 70% of the tears are drained through the lower punctum and 30% through the upper punctum Upper and lower marginal strips of tears go medially The tears enter the puncta by capillary action and suction. Pretarsal orbicularis oculi splits into superficial and deep heads around the ampulae and some fibres are attached to the sac.

35. During closure of the eye: * Ampulae is compressed. *Horizontal canaliculus shortens. * Puncta move medially. *Deep head of the orbicularis (attached to sac) causes dilatation of the sac. All these causes a negative pressure in the sac and tears are sucked into the sac . When the eye closes, the sac goes to its original volume, forcing the tears into the nasolacrimal duct, and the puncta move laterally sucking tear into it.

36. 40

37. THE WATERING EYE It is characterised by overflow of tears from the conjunctival sac.The condition may occur due to excessive secretion of tears ( hyperlacrimation ) or may result from obstruction to the outflow of normally secreted tears ( epiphora ). Hyperlacrimation 1. Primary hyperlacrimation : It is a rare condition which occurs due to direct stimulation of the lacrimal gland. It may occur in early stages of lacrimal gland tumours and cysts and due to the effect of strong parasympathomimetic drugs . 2. Reflex hyperlacrimation : It results from stimulation of sensory branches of fifth nerve due to irritation of cornea or conjunctiva. It may occur in multitude of conditions which include: 41

38. Affections of the lids: Stye , hordeolum internum , acute meibomitis , trichiasis, concretions and entropion . Affections of the conjunctiva: Conjunctivitis which may be infective, allergic, toxic, irritative or traumatic Affections of the cornea: These include corneal abrasions, corneal ulcers and non-ulcerative keratitis. Affections of the sclera: Episcleritis and scleritis. Affections of uveal tissue: Iritis , cyclitis , iridocyclitis . Acute glaucomas . Endophthalmitis and panophthalmitis . Orbital cellulitis . 42

39. 3. Central lacrimation (psychical lacrimation ): It is seen in emotional states, voluntary lacrimation and hysterical lacrimation . Epiphora Inadequate drainage of tears may occur due to physiological or anatomical (mechanical) causes. Physiological cause is 'lacrimal pump' failure due to lower lid laxity or weakness of orbicularis muscle. Mechanical obstruction in lacrimal passages may lie at the level of punctum , canaliculus , lacrimal sac or nasolacrimal duct. 43

40. 1. Punctal causes: Eversion of lower punctum : It is commonly seen in old age due to laxity of the lids. It may also occur following chronic conjunctivitis, chronic blepharitis and ectropion . Punctal obstruction :There may be congenital absence of puncta or closure following injuries, burns or infections. Rarely a small foreign body concretion and cilia may also block the punctum . Prolonged use of drugs like idoxuridine and pilocarpine is also associated with punctal stenosis . 44

41. Causes in the canaliculi : Canalicular obstruction may be congenital or acquired due to foreign body, trauma, strictures and canaliculus . Causes in the lacrimal sac: These include congenital mucous membrane folds, traumatic strictures, dacryocystitis, specific infections like tuberculosis and syphilis, dacryolithiasis , tumours and atony of the sac . Causes in the nasolacrimal duct: Congenital lesions include noncanalization , partial canalization or imperforated membranous valves. Acquired causes of obstruction are traumatic/inflammatory strictures, tumours and diseases of the surrounding bones. 45

42. CLINICAL EVALUATION OF A CASE OF ‘WATERING EYE’ Slit – Lamp Examination : It is done for the evidence of following conditions:  Punctum : Patency, size,position,discharge , obstruction by an eyelash, large caruncle , Pouting Punctum , Centurion Syndrome  Ectropion  Lesions of eyelid margins as papillomas , molluscum contagiosum,chalazia,nevi , carcinoma  Signs of Blepharitis , Dry eye syndrome .  Conjunctival lesions as Pinguecula ,Pterygium , Follicles , Papillae, allergic conjunctivitis.  Corneal Irregularities, Dystrophies  Volume of tear lake 46

43. ROPLAS TEST :  Regurgitation On Pressure Over Lacrimal Apparatus System.  Also called as Palpation of Lacrimal Sac .  Punctal reflex of mucopurulent material indicates mucocele with a patent canalicular system, but with an obstruction at or distal to the lower end of Lacrimal Sac. In acute dacryocystitis palpation & compression are painful & should be avoided .  Rarely it reveals the presence of a stone or tumor. 47

44. Fluorescein Dye Disappearance test :  It is a semiquantitaive test of delayed or obstructed tearflow .  It is of particular importance for evaluation of congenital dacryostenosis in infants & toddlers where lacrimal irrigation is impossible without anaesthesia or deep sedation.  1 drop of 2% fluorescein is instilled into the unanaesthesised conjunctival sac of both the eyes .  The volume of tear lake is then noted preferably under cobalt blue light .  The patient is instructed not to wipe the eyes & tear lakes are examined 5 mins . later & relative volume is determined . 48

45.  Persistance of significant dye & especially asymmetric clearance of the dye from the tear meniscus over a 5 minutes period indicates a relative obstruction of the side retaining the dye. 49

46. Diagnostic Probing : It provides information regarding the site of obstruction. It is performed only after obstruction is demonstrated by other tests After topical anaesthesia of conjunctival sac,the canaliculi are also irrigated by anaesthetics A probe of appropriate size is inserted into the punctum , turned medially & advanced untill it encounters the lacrimal bone. The probe is then withdrawn a few mm and rotated inferiorly & slightly posterolaterally untill the proximal part of NLD is felt. The probe is then passed untill it strikes the floor of the nose in the inferior meatus . 50

47. If in between any obstruction is felt, the site of obstruction is noted by grasping the probe with a forceps at its entrance before withdrawing. Obstruction can be felt as a “ Soft stop ” in case of canalicular stenosis or as a “ Hard stop ” as the probe hits the bone at the medial wall of lacrimal sac.  Obstruction < 8mm- canalicular obstruction 8-10mm-common canalicular obstruction >10 mm- distal part i.e. sac & NLD  Probing in children : It should be done through upper canaliculus . Upto 1 yr of age , the distance from punctum to NLD is 12mm & to the floor of nose is 20mm. 51

48. Syringing : Principle : It provides information regarding the patency of canalicular system. Procedure : 1-2 drops of topical anaesthesia is instilled into the conjunctival sac. The punctum is dilated gently by advancing the Nettleship dilator, first vertically for about 2mm & then horizontally with a twisting movement . Simultaneously lateral traction is applied to the eyelid . 52

49. With the eyelid stretched, dilator is withdrawn & the Lacrimal cannula attached with syringe filled normal saline is advanced horizontally through punctum & canaliculus . No resistance should be felt in its entire path. Irrigation is then done & the patient is asked to respond if fluid passes into the oropharynx or nose. 53

50. Inference :  If there is resistance to irrigation: obstruction is partial.  Regurgitation of fluid from same punctum indicates that there is a canalicular block .  Regurgitation of fluid from upper punctum indicates blockage at the level of common canalicular duct, lacrimal sac or nasolacrimal duct.  Immediate regurgitation of clear fluid usually suggests a common canalicular obstruction .  Relatively delayed regurgitation of fluid mixed with mucous or pus usually indicates NLD blockage. 54

51. JONES DYE TESTING :  It is rarely needed.  Indication : Patients with suspected partial obstruction of drainage system. It is of no value in context with total obstruction  These are the Dye tests for functional epiphora where the lacrimal drainage system is found to be patent on syringing.  Types : These are of 2 types : a) Jones test I b) Jones test II 55

52. a) Jones test 1 :  It investigates the Lacrimal outflow under normal physiological conditions.  It is also called as Primary test .  It differentiates the partial obstruction of lacrimal passage from primary hypersecretion of tears  Procedure : First a drop of 2 % fluorescein is instilled into the conjunctival sac. After about 5 minutes a cotton tipped bud moistened in a local anaesthetic is inserted under the inferior turbinate at the nasolacrimal duct opening. 56

53. Inference : i )Positive test : If fluorescein is recovered from the nose ( presence of dye in cotton ) it indicates patency of drainage system.Watering is due to primary hypersecretion & no further tests are necessary. ii ) Negative test : No dye recovered from nose indicates a partial obstruction (site unknown ) or failure of lacrimal pump mechanism.  In this case Jones Test II is performed immediately.

54. b) Jones Test II: Also called Irrigation or secondary test  It is a non-physiological test.  Principle :It identifies the probable site of partial obstruction , on the basis of whether the fluorescein dye instilled for primary/Jones test 1 entered the Lacrimal sac  Procedure :Topical anaesthetic is instilled & any residual fluorescein is washed out instilled during Jones test 1.The drainage system is then irrigated with saline with the cotton bud under inferior turbinate. 58

55. Inference : a)Positive test : Fluorescein stained saline recovered from the nose indicates that fluorescein entered the lacrimal sac, thus confirming functional patency of upper lacrimal passages ( punctum , canaliculi ). Partial obstruction of Naso-lacrimal duct is inferred. b)Negative test : Unstained saline recovered from the nose indicates that fluorescein did not enter the lacrimal sac. This implies partial obstruction of puncta , canaliculi , common canaliculi or defective lacrimal pump mechanism. 59

56. Ancillary Radiological Investigations :  Radiological tests help in confirming the site of obstruction or stenosis in case of blocked syringing , confirm a functional cause of epiphora & delineate the anatomical as well as the pathological process pertaining to the problem. a ) Dacryocystography : DCG involves injection of radio-opaque dye into the canaliculi & taking magnified images. 60

57. Indications of DCG :  To confirm the site of obstruction,especially prior to lacrimal surgery.  To aid diagnosis of diverticula , fistulae & filling defects caused by stones & tumours . 61

58. Technique :  The inferior puncta are dilated with a Nettleship punctum dilator.  Plastic catheters are inserted into canaliculi on both sides after instillation of anaesthesia .  Contrast medium, usually 1-2ml Lipiodol,0.5-2ml of water soluble iodinated contrast medium is injected simultaneously on both the sides & postero -anterior radiographs are taken.  10 mins later an erect oblique film is taken to assess the effect of gravity on tear drainage 62

59. Interpretation :  Failure of dye to reach the nose indicates an anatomical obstruction, the site of which is usually evident .  A normal DCG in the presence of epiphora indicates either lacrimal obstruction or lacrimal pump failure, especially if contrast is retained on the late film.  IN DCG both the sides are usually interpreted simultaneously.

60. B)Nuclear Lacrimal Dacryoscintigraphy :  It is a sophisticated test which assesses tear drainage under more physiological condition than a DCG.  The disadvantage as compared to DCG is that it fails to show finer anatomical details.  Apart from being a non-invasive procedure,radiation exposure to lens is minimal compared to DCG.  It is more sensitive in assessing incomplete blocks.

61. Technique : Radionuclide technitium 99 is delivered by a micropipette to the lateral conjunctival sac as a 10 micro litre drop.The tears are thus labelled with this gamma-emitting radioactive substance. The tracer is imaged by a gamma camera focussed on the inner canthus & a sequence of images is recorded over 20 minutes.

62. c ) Computerised Tomography :  Its role comes when anatomical or pathological abnormalities are suspected as the underlying cause of epiphora . E.g. Cranio -facial injury, congenital deformities, Lacrimal sac neoplasia .  The paranasal sinuses especially the maxillary sinuses are imaged for any abnormalities that might be affecting the NLD.  Preoperative assessment of cribriform plate to avoid possible cerebrospinal leak at the time of injury.

63. Newer Modalities : a) Chemiluminiscene test : Cyalume , a chemiluminiscent material is injected with a sialography catheter to demonstrate the patency of outflow passeges . b ) Dacryoscopy : Dacryoscope , a mini rigid endoscope allows the direct visualisation of the interior & lining of lacrimal passages. c) Standardised echography :Gross anatomical structural defects can be evaluated. d )Thermography : It is used in conjunction with routine lacrimal irrigation to visualise the tear ducts in normal subjects and in patients with obstructive epiphora .

64. Dacryocystitis Inflammation of the lacrimal sac. It may occur in two forms :  C ongenital dacryocystitis  Adult dacryocystitis 1)Acute 2)Chronic 70

65. Congenital Dacryocystitis I nflammation of the lacrimal sac occurring in newborn infants; and thus also known as dacryocystitis neonatorum . Clinical Picture: 1. Epiphora , usually developing after seven days of birth. It is followed by copious mucopurulent discharge from the eyes . 2. Regurgitation test is usually positive , i.e., when pressure is applied over the lacrimal sac area, purulent discharge regurgitates from the lower punctum . 3. Swelling on the sac area may appear eventually. 71

66. Complications: If not treated in time it may be complicated by recurrent conjunctivitis, acute on chronic dacryocystitis , lacrimal abscess and fistulae formation . Treatment: D epends upon the age at which the child is brought Massage over the lacrimal sac area and topical antibiotics constitute the treatment of congenital NLD block, up to 6-8 weeks of age. Lacrimal syringing (irrigation) with normal saline and antibiotic solution. It should be added to the conservative treatment if the condition is not cured up to the age of 2 months 72

67. 3. Probing of NLD with Bowman's probe. It should be performed, in case the condition is not cured by the age of 3-4 months . Some surgeons prefer to wait till the age of 6 months. 4. Intubations with silicone tube may be performed if repeated probings are failure. The silicone tube should be kept in the NLD for about six months . 5. Dacryocystorhinostomy (DCR) operations: When the child is brought very late or repeated probing is a failure, then conservative treatment by massaging, topical antibiotics and intermittent lacrimal syringing should be continued till the age of 4 years . After this, DCR operation should be performed. 73

68. Chronic Dacryocystitis M ore common than the acute dacryocystitis Clinical Picture: Stage of chronic catarrhal dacryocystitis Stage of lacrimal mucocoele Stage of chronic suppurative dacryocystitis Stage of chronic fibrotic sac 74

69. Complications: Chronic intractable conjunctivitis , acute on chronic dacryocystitis . Ectropion of lower lid , maceration and eczema of lower lid skin due to prolonged watering . Simple corneal abrasions may become infected leading to hypopyon ulcer . If an intraocular surgery is performed in the presence of dacryocystitis , there is high risk of developing endophthalmitis . Because of this, syringing of lacrimal sac is always done before attempting any intraocular surgery. 75

70. Treatment: Conservative treatment by repeated lacrimal syringing. Dacryocystorhinostomy (DCR ) - It should be the operation of choice as it re-establishes the lacrimal drainage. Dacryocystectomy (DCT ) - It should be performed only when DCR is contraindicated.  Indications of DCT : a)Too young(<4 yrs ) or too old(>60 yrs ) b)Markedly shrunken or fibrosed sac c) TB,syphilis,leprosy or mycotic infections of sac d) Tumours of the sac e)Gross nasal diseases Atrophic Rhinitis 4. Conjunctivodacryocystorhinostomy (CDCR ) - Performed in presence of blocked canaliculi 76

71. Acute Dacryocystitis Acute dacryocystitis is an acute suppurative inflammation of the lacrimal sac, characterised by presence of a painful swelling in the region of sac . Clinical Picture: Stage of cellulitis Stage of lacrimal abscess Stage of fistula formation 77

72. Complications: Acute conjunctivitis , Corneal abraision which may be converted to corneal ulceration , Lid abscess , Osteomyelitis of lacrimal bone , Orbital cellulitis , Facial cellulitis and acute ethmoiditis . Rarely cavernous sinus thrombosis and very rarely generalized septicaemia may also develop. 78

73. Treatment:  During cellulitis stage : It consists of systemic and topical antibiotics to control infection; and systemic anti- inflammatory analgesic drugs and hot fomentation to relieve pain and swelling.  During stage of lacrimal abscess : In addition to the above treatment when pus starts pointing on the skin , it should be drained with a small incision. The pus should be gently squeezed out, the dressing done with betadine soaked roll gauze. 79

74. Later on depending upon condition of the lacrimal sac either DCT or DCR operation should be carried out, otherwise recurrence will occur .  Treatment of external lacrimal fistula : After controlling the acute infection with systemic antibiotics , fistulectomy along with DCT or DCR operation should be performed 80

75. Surgical techniques of DCR Conventional external approach DCR Endonasal DCR 81

76. Conventional external approach DCR Anaesthesia Skin incision   Dissection of lacrimal sac Exposure of nasal mucosa Preparation of flaps of sac Fashioning of nasal mucosal flaps Suturing of flaps Closure 82

77. Endonasal DCR Preparation and anaesthesia Identification of sac area Creation of opening in the nasal mucosa, bones fossa and posteromedial wall s forming the lacrimal fossa and posteromedial wall. Stenting of rhinostomy opening Postoperative care and removal of sialistic lacrimal stents

78. SURGICAL TECHNIQUE OF DACRYOCYSTECTOMY (DCT) Anaesthesia Skin incision   Dissection of lacrimal sac Removal of lacrimal sac. After exposing the sac, it is separated from the surrounding structures by blunt dissection followed by cutting its connections with the lacrimal canaliculi . It is then held with artery forceps and twisted 3-4 times to tear it away from the nasolacrimal duct (NLD). Curettage of bony NLD. It is done with the help of a lacrimal curette to remove the infected parts of membranous NLD. Closure. It is done as for external DCR 84

79. 85 SWELLINGS OF THE LACRIMAL GLAND DACRYOADENITIS Dacryoadenitis may be acute or chronic. I. Acute dacryoadenitis Etiology . It may develop as a primary inflammation of the gland or secondary to some local or systemic infection. Dacryoadenitis secondary to local infections occurs in trauma,conjunctivitis (especially gonococcal and staphy­lococcal) and orbital cellulitis . Dacryoadenitis secondary to systemic infections is associated with mumps, influenza, infectious mononucleosis and measles.

80. Clinical picture . Acute inflammation of the palpebral part is characterised by a painful swelling in the lateral part of the upper lid. The lid becomes red and swollen with a typical S-shaped curve of its margin. Acute orbital dacryoadenitis produces some painful proptosis in which the eyeball moves down and in. A fistula in the upper and lateral quadrant of the upper lid may develop as a complication of suppurative dacryoadenitis . Treatment . It consists of a course of appropriate systemic antibiotic, analgesic and anti-inflammatory drugs along with hot fomentation. When pus is formed, incision and drainage should be carried out 86

81. II. Chronic dacryoadenitis It is characterised by engorgement and simple hypertrophy of the gland. Etiology . Chronic dacryoadenitis may occur: ( i ) as sequelae to acute inflammation; (ii) in association with chronic inflammations of conjunctiva and; (iii) due to systemic diseases such as tuberculosis, syphilis and sarcoidosis . Clinical features . These include ( i ) a painless swelling in upper and outer part of lid associated with ptosis ; (ii) eyeball may be displaced down and in; and (iii) diplopia may occur in up and out gaze. On palpation, a firm lobulated mobile mass may be felt under the upper and outer rim of the orbit. Differential diagnosis from other causes of lacrimal gland swellings is best made after fine needle aspiration biopsy or incisional biopsy. Treatment consists of treating the cause. 87

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