CAUSES AND EVALUATION OF EPIPHORA-DR.PRABHAT DEVKOTA.pptx

DR.PRABHAT KIRAN DEVKOTA
MBBS(TU), MD(NAMS)

1. CAUSES AND EVALUATION OF EPIPHORA DR. PRABHAT DEVKOTA MBBS(TU), MD(NAMS)

2. CONTENT Lacrimal System Anatomy Lacrimal System Physiology Lacrimal Pump Mechanism Tearing Hyperlacrimation Epiphora Causes Approach to a case of Epiphora Evaluation 2

3. Anatomy of Lacrimal System Secretory System: Lacrimal Glands The main lacrimal gland The accessory lacrimal gland Drainage System: Lacrimal Passage Puncta Lacrimal Canaliculi Lacrimal sac Nasolacrimal Duct 3

4. 10-20% of tear are eliminated by evaporation Remaining by drainage Most of the tear flow by blinking Capillarity and gravity also has role Physiology of Tear Drainage 4

5. Lacrimal Pump Theories Rosengren Döane Theory: Eyelid opening causes negative pressure inside the lacrimal sac Jones Theory: Eyelid closure causes negative pressure inside the lacrimal sac Tri-Compartment Theory of Becker: Eyelid closure causes negative pressure in superior aspect of the lacrimal sac & positive pressure in the inferior sac and nasolacrimal duct 5

6. Rosengren Döane Mechanism 6

7. Pre Blink/Eyes Open: In the relaxed state, the puncta lie in the tear lake Blink/Eyes Close: • With eyelid closure, the orbicularis oculi muscle contracts. • The pretarsal orbicularis squeezes and close the puncta and canaliculi . • The preseptal orbicularis , which inserts into the lacrimal sac, pulls the lacrimal sac open, creating a negative pressure. • This draws the tears into the sac Lacrimal Pump Mechanism 7

8. Post Blink/Eyes Open: With eyelid opening, the orbicularis relaxes. the puncta open the lacrimal sac collapses propelling tears down the duct. Simultaneously, with the puncta opened, the canaliculi refill, completing the cycle. 8

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10. Tearing/Watering • Characterized by overflow of tears from the conjunctival sac. • Can be caused by either hypersecretion of tears or decreased elimination called as Epiphora . It is important to distinguish between epiphora and pseudoepiphora / hyperlacrimation 10

11. Imbalance between Tear Production & Drainage Hyperlacrimation : Hypersecretion secondary to anterior segment disease such as dry eye (paradoxical watering) or inflammation. Epiphora : Defective drainage due to a compromised lacrimal drainage system. Caused by Malposition of the puncta , Obstruction at drainage system, Lacrimal pump failure. 11

12. Hyperlacrimation 1.Primary hyperlacrimation : lacrimal gland tumours /cysts, parasympathomimetic drugs. 2. Reflex hyperlacrimation :d /t stimulation of sensory branches of 5 th nerve • Lids : Stye , hordeolum internum , acute meibomitis , trichiasis , concretions and entropion / ectropion . • Conjunctiva : Conjunctivitis (infective, allergic, toxic, irritative or traumatic) • Cornea : These include, corneal abrasions, corneal ulcers and non-ulcerative keratitis . • Sclera : Episcleritis and scleritis . • Uveal tissue : Iritis , cyclitis , iridocyclitis . • Acute glaucomas , Endophthalmitis and panophthalmitis,Orbital cellulitis 3. Central lacrimation : emotional states, voluntary lacrimation and hysterical lacrimation . 12

13. EPIPHORA Epiphora is tearing caused by a reduced tear transport or defective tear drainage outflow Epiphora is caused by obstruction to the lacrimal drainage (Anatomical) or due to lacrimal pump failure (Functional). 13

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15. Causes • Anatomical → Complete Or Partial Punctal Canalicular Or NLD Obstruction • Functional → Lacrimal pump failure due to Anatomical deformity (Laxity, orbicularis weakness) 15

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17. Eyelids Temporal downslope of the lower lid Horizontal laxity and floppy lids Lower lid entropion with orbicularis oculi overriding Lower lid ectropion with ineffective orbicularis oculi Lower lid retraction Loss of skin / orbicularis Facial Nerve dysfunction can result in poor blink and impair the tear pump mechanism 17

18. Punctum Congenital atresia or hypoplasia or stenosis Acquired: Trauma, Punctal plugs, Infection,Surgery , Burns/ Chemical Injury, Dermatitis, Medications (topical AGM, idoxuridine , systemic 5-fluorouracil, docetaxel ) Autoimmune conditions (SJS, TEN and pemphigoid ) Punctal Ectropion & Entropion Mechanical obstruction (ocular surface neoplasm or Conjunctivochalasis ) Medial lid laxity (“kissing puncta ”) 18

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20. Canaliculus Congenital absence/fistula Stenosis Canaliculitis ( actinomyces ) Scarring (herpes simplex) Direct Trauma/Post radiation Trauma Compression by adjacent tumours Foreign bodies (Herrick plugs, Dacryoliths ) Medications (anti-glaucoma drops, systemic drugs used for carcinoma like 5-fluorouracil, docetaxel ) 20

21. Lacrimal Sac Congenital Dacryocoele Lacrimal Sac Atony Sac inflammation ( Dacryocystitis ) Traumatic stricture Perilacrimal fibrosis Dacryolithiasis Mucocele Sac tumors (rare in pediatric age group) Adnexal tumors pressing on lacrimal sac or drainage pathway 21

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23. Nasolacrimal Duct Congenital: Agenesis or Atresia of the entire canal or duct a/w Craniofacial Or Clefting Disorders Imperforate Valve Of Hasner Acquired: Idiopathic Recurrent inflammation leading to scarring and stenosis Surgery/ Trauma, Neoplasms Papillomas , Squamous Cell Carcinoma, Lymphoma, Hemangiopericytoma , Adenocarcinoma etc 23

24. Nasal & Sinus disease Anatomical Abnormalities Severe Deviated Nasal Septum (DNS) Turbinate Hypertrophy Nasal Polyps Nasal Tumors Sinus surgery Allergic rhinitis Atrophic rhinitis 24

25. Evaluation of a Patient with Epiphora Careful history External examination Slit lamp biomicroscopy Syringing and probing Imaging 25

26. Mcnab's Logical Sequence Directed history Exclude causes of reflex tearing Make sure puncta are normal Assess lid laxity Palpate the lacrimal sac Syringe the lacrimal system If patent perform FDDT and Jones tests Examine the patient's nasal cavity 26

27. History Ask for onset, frequency, discharge, pain, swelling, intermittency, laterality of the symptoms, trauma, previous interventions, Constant Vs Intermittent Tearing Remission Vs No Remission Unilateral Or Bilateral Clear Tears Vs Tears with Discharge/Blood Subjective Ocular Surface Discomfort History Of Allergies Use Of Topical Medications ( Eg . Glaucoma Medication) History Of Probing During Childhood 27

28. Prior ocular surface infections (conjunctivitis or herpes simplex) Prior sinus disease or lid surgery, trauma or nasal fracture Previous episodes of Dacryocystitis Systemic disorders such as Sjogren’s syndrome, Facial nerve palsy, Treatment h/o chemotherapy or radioactive iodine, 28

29. External examination Inspection of the facial and eyelid anatomy, symmetry and function Skin of the eyelid, eyelid position blink rate and strength of the facial muscles. Presence of lagophthalmos , lid laxity , entropion or ectropion , punctal apposition with globe, any signs of inflammation, discharge or fistulas Tear film height, medial canthal fullness, ROPLAS test. 29

30. Slit Lamp Biomicroscopy : • Abnormalities of eyelids, Position of puncta , size and patency, discharge, • Size of caruncle , • Eyelid laxity, blinking mechanism, • Marginal tear strip ( tearfilm height). • Tearfilm debris. • Papillae or follicles • Pinguecula , Pterygium , conjunctivochalasis . • Ocular cicatricial pemphigoid . 30

31. Examination Of Eyelids Position Tone Aberrant regeneration Blepharitis Trichiasis Lacrimal sac swelling/tenderness/erythema 31

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34. Puncta : Size Position Patency Discharge/Swelling Tear Film: Height Volumn Quality 34

35. 3. Conjunctiva Congestion/ Chemosis Caruncle Conjuctivochalosis Foreign body Keratinization 4. Cornea Corneal abrasion Foreign body 5. Anterior chamber Uveitis 35

36. Nasal Examination Mass/ Nasal polyps Inflammation Adhesions Anatomic abnormalities Hypertrophied nasal turbinates Deviated septum Atrophic rhinitis 36

37. CLINICAL TESTS 37

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40. Tear Meniscus Indicates the tear volume Normal meniscus height ~ 0.3mm A tear meniscus height <0.25 mm is suggestive of dry eye The size and asymmetry of the lacrimal lake and presence of precipitated proteins and stringy mucus may indicate an abnormal tear film or outflow obstruction. 40

41. Flourescein Dye Disappearance Test (FDDT) Evaluation of the residual fluorescein following instillation of one drop of fluorescein into the unanesthetized conjunctival sac Normal eyes entire fluorescein is washed off in 5 minutes A prolonged retention of dye in conjunctival sac indicates inadequate drainage which may be due to atonia of sac or mechanical obstruction 41

42. FDDT Grading: 0=No fluorescein in the conjunctival sac 1=Thin flurescing marginal tear drop persists 2=More fluorescein persists somewhere between 1 and 3 grades 3=Wide brightly fluorescein tear strip Grades 0 and 1 are considered normal 42

43. ROPLAS Test: Regurgitation On Pressure Over Lacrimal Sac Easy, noninvasive, and effective clinical test. Apply steady pressure with index finger over the lacrimal sac area. Look for regurgitation of mucopurulent discharge from the puncta . Highly sensitive and specific test for diagnosing NLDO. 43

44. ROPLAS Possible Interpretation 1. Mucoid , mucopurulent , purulent, or watery discharge regurgitation on pressure Distal NLDO 2. Bloody discharge Dacryolith Or Lacrimal Sac Malignancy Or Rhinosporidiosis 3. No discharge from punctum but contents emptying into the nose and mouth Atonic Sac 4. No regurgitation and no reduction in size of the lacrimal sac swelling Encysted Mucocele Or Lacrimal Sac Mass 44

45. SYRINGING: It is one of the most important test for evaluation of lacrimal system. It is minimally invasive, can be easily performed and does not require sophisticated instruments. It provides information on both - confirms the presence of obstruction in the lacrimal drainage system as well as the location of the obstruction. 45

46. Indication: 1. In epiphora - to rule out any blockage in lacrimal drainage system 2. Helps in identifying the site of blockage 3. Before intraocular surgeries (cataract/ glaucoma)- to rule out any previously undiagnosed block 4. To administer antibiotics & steroids into the lacrimal system (post- DCR surgery) 5. In DCG ( dacryocystography )- to inject dye for imaging of lacrimal drainage system 6. To flush & clean the lacrimal passages of debris in patients with epiphora 46

47. Prerequisite • Wash your hands (and afterwards too). • Position the patient comfortably with head supported. • Ensure good lighting. • Always explain to the patient (and any companion, if appropriate) what you are going to do. 47

48. Instruments Normal saline Sterile 1cc syringe Punctum dilator Lacrimal Cannula (26G) Local anaesthetic eye drops Clean cotton wool or gauze swabs Gloves Scale 48

49. Lacrimal Dilation The process of dilating the puncta Indication:- • Used to dilate puncta in small puncta before syringing • Used in Punctal stenosis • Canalicular repair with monoka stent 49

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51. Vertical insertion of the dilator • Sterilize the dilator • Insert dilator vertically downwards for 2 mm gently rotating clockwise and anticlockwise Horizontal insertion of the dilator • Pull the lower lid temporally to straighten the ampulla • Also this line up the vertical and horizontal canaliculi • Rotate the dilator horizontally and insert the dilator 51

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53. STEPS Use a towel, to avoid spillage Check the Punctum dilator and do not use if there is any damage to the tip. With the syringe, draw up about 1 ml of saline and then attach it to the cannula Flush the cannula with a small amount of saline to ensure it is patent. Instill the local anesthetic eye drops and wait about 30 seconds. 53

54. Ask the patient to look upwards and outwards (away from the nose) and to maintain this gaze until the procedure is over. With cotton wool or a gauze swab, gently pull down the lower eyelid expose the lower punctum . Inject the fluid slowly Ask if the patient experiences a salty taste at the back of the throat? If no → there is a blockage in the nasolacrimal apparatus Check for the regurgitation of fluid through puncta 54

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57. INTERPRETATION 57

58. Finding Interpretation Soft stop, clear regurgitation from the same puncta Individual canalicular obstruction Soft stop, clear regurgitation from the opposite puncta Common canalicular obstruction Hard stop, with clear, mucoid , or mucopurulent regurgitation from opposite puncta NLDO Hard stop, with clear, mucoid , or mucopurulent regurgitation from same puncta NLDO with canalicular obstruction of the opposite side Hard stop with no regurgitation but sac swelling Atonic lacrimal sac Hard stop with partial regurgitation of clear or mucoid fluid from opposite punctum Partial NLDO 58

59. SITUATION 1 100% regurgitation of fluid through same puncta Clear regurgitate Probing → soft stop Proximal obstruction Canalicular Block 59

60. SITUATION 2 100% regurgitation of fluid through opposite puncta . - Common canaliculus or nasolacrimal duct Mucoid regurgitate: Hard stop Clear regurgitate: Soft stop 60 Complete NLDO Common Canalicular Block

61. SITUATION 3 Less than 100% (Partial regurgitation of fluid through opposite puncta and patients responds yes to taste sensation. -Common canaliculus stenosis or, partial nasolacrimal duct Mucoid regurgitate Hard stop Clear regurgitate Soft stop 61 Partial NLDO Common Canalicular Stenosis

62. SITUATION 4 • Freely patent pathway → Syringing positive • Probing also normal • Still patient complaints of epiphora ! No anatomical problem functional/physiological problem “ Lacrimal Pump Failure” 62

63. SITUATION 5 Fluid freely injectable but no sensation felt in the throat Painful probing Internal Fistula Or False Passage 63

64. Contraindications Of Syringing • Acute dacryocystitis • Lacrimal abscess • Acute conjunctivitis • Chronic dacryolithiasis 64

65. LACRIMAL PROBING The process of passing a thin metal instrument Bowmans Lacrimal Probe into the lacrimal sac and down the duct to diagnose and if possible open the blockages. 65

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67. • Hard stop: it comes to stop at medial wall of sac through which rigid lacrimal bone is felt. this indicates obstruction of nasolacrimal duct • Soft stop: spongy feel against the probe anywhere along the canaliculus . Proximal: <3 mm Mid: 3-8 mm Distal: >8 mm 67

68. Indications: • To diagnose upper lacrimal system blockage • Canalicular Obstruction 68

69. Hyperlacrimation • Epiphora due to excessive tearing • Lacrimal pump is normal so tears will reach the lacrimal sac normally • Pathway is patent so syringing is also positive • Probing also is normal (no obstruction ) Pump Failure • Epiphora due to failure of lacrimal pump mechanism • So tears will not reach the lacrimal sac normally • Pathway is patent so syringing is also positive • Probing also is normal (no obstruction) Partial obstruction in Lacrimal passage • Epiphora due to failure of complete drainage • Some fluid reaches the throat but most overflows • Lacrimal pump normal so tears reach the sac normally • Pathway is partially patent so syringing will be normal with some regurgitation. 69

70. JONES Test 1: Primary Jones Test • Instill one drop of fluorescein into the conjunctival sac • Put a cotton bud soaked in anesthetic in the inferior meatus . • If fluorescein is detected on bud after five minutes, the system is patent 70

71. Positive Primary Jones Test: • Dye reached the sac → pump normal • Dye reached the bud → patent system • The cause of tearing is probably hypersecretion Negative Primary Jones Test: • If no fluorescein is discovered on bud! • Either pump problem? • Or obstruction? 71

72. JONES II Test: Secondary Jones • If JONES 1 is negative • Perform syringing Positive Secondary Jones Test: -If fluorescein is detected, then this shows it had entered the sac normal lacrimal pump -Suggests a partial obstruction of the nasolacrimal duct 72

73. Negative Secondary Jones Test: -If no dye is found on the cotton bud after syringing. -Because fluorescein had not entered the sac→ lacrimal pump failure Or there is Stenosis of the puncta or canalicular system 73

74. IMAGING TECHNIQUES 74

75. Dacryocystography (DCG) Allows visualization of anatomic details of the lacrimal drainage system using contrast material and imaging with x-ray or CT or MRI. Determine the surgical plan, when the patient is symptomatic but the lacrimal system is patent after syringing. History • CDCG- Conventional Dacryocystography - Ewing-1909 • Bismuth subnitrate to visualize a lacrimal abscess • Larger radiation dose • Overlapping of structures 75

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77. Ideal Dye: 1. Radio-opaque 2. Homogenous 3. Non-irritant 4. Non-toxic 5. Optimal viscosity 6. Free of adverse reaction Oil soluble : Lipoidol Water Soluble : lohexol , lopamidol , Sinograffin , Omnipaque MR-DCG: 0.5% gadolinium solution, NS or NS + 0.5% lidocaine , balanced salt solution (BSS) 77

78. Purpose of DCG To visualize the lacrimal drainage system 1. Position and size of the lacrimal sac with respect to the bony landmarks 2. Abnormalities like Sac diverticula 3. Filling defects due to mucopeptide concretions ( Dacryolith ) 4. Functional flow of tears in the lacrimal system 5. Lacrimal Sac Mass lesions 6. Partial NLDO 78

79. • 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. 79

80. Dacryoscintigraphy • Rossomondo et al. in 1972 • Physiological test - mainly for functional epiphora • Non-invasive • Eye radiation exposure is lower- between 0.014 and 0.021 rads (may be between 0.4 and 0.6 rads in complete obstruction) • Technique: instill a drop of technetium-99m pertechnetate in the lateral cul-de-sac BE - patient sitting upright in front of a gamma camera • Images taken every minute for at least 20 minutes • Evaluation: based on the presence of delay of the radionuclide tracer at the level of lacrimal sac termed as either "pre- sac" or "post-sac" 80

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82. CT/MRI Epiphora following Trauma with NLD obstruction to rule out Orbital rim/maxillary fracture. Infant with cystic mass at medial canthus Amniocele v/s meningocele Suspected malignancy 82

83. Lacrimal Endoscopy -1.0 mm diameter rigid endoscope or fibroptic flexible endoscopes was inserted through the puncti and canaliculi to inspect the lining mucosa of lacrimal system, its contents and investigating DCR fistulae. 83

84. Secretory Test Schirmer’s Test Tear Breakup Time Rose Bengal Staining Lysozyme Lysis test 84

85. Schirmer’s Test It evaluates aqueous tear production. Whatman No. 41 filter paper is used which is 5mm wide and 35mm long. Filter paper is folded at 5 mm & inserted at the junction of the lateral 1/3 rd and medial 2/3 rd of the lower lid, patient is asked to keep their eyes closed for 5 minutes & amount of wetting is measured. Normal: >15mm Mild to Moderate: 5mm to 14mm Severe: <5mm 85

86. Schirmer 1 : It detects the basal as well as reflex tear secretion. A value <10 mm at 5 minutes is considered abnormal. Schirmer 2: It is done after anesthetizing the cornea with topical anesthesia medication ( proparacaine ). It measures only the basal secretion. -Some authors also describe it as a tactile reflex done after nasal stimulation with a cotton applicator. -A value <6 mm at 5 minutes is considered abnormal. 86

87. Schirmer 3 : aka photic reflex secretion. It is similar to Schirmer's 1 along with retinal stimulation by looking at the sun. It is no longer performed. 87

88. Tearfilm Break-up Time TBUT indicates tear film stability. One drop of fluorescein is instilled and the patient is instructed to blink once and then to keep his eyes open. time elapsed from last blink to appearance of the first random dry spot on cornea through a slit-lamp cobalt blue filter. TBUT of less than 10 seconds may indicate poor function of the mucin or meibomian layer despite a sufficient amount of tears 88

89. Rose Bengal Staining Similar to a break-up time test. One drop of rose bengal is placed in the eye and the patient blinks several times for 1 min. Interpalpebral staining with bengal rose areas are then found in the dry eye. With both tests, staining of cornea is sought as lagophthalmos or incomplete blinking may exist, leading to reflex epiphora . 89