Dacryocystitis

For students and teachers in the medical field of opthalmology

1. Dacryocystitis – Acute and chronic Dr. K. Vasantha M.S., F.R.C.S. Edin Director RIO Chennai (Rtd)

2. Production of tears by the lacrimal gland Spread by the lids Transport of tears through the puncta, canaliculi, lacrimal sac and nasolacrimal duct Anatomy of the lacrimal system

3. Lacrimal puncta: These (one in the upper lid and one in the lower lid) are located at the junction of ciliary and the lacrimal portion of the lid margin. There is a slight elevation around the puncta – called papilla The upper is 6mm and the lower 6.5mm away from the inner canthus When we blink the puncta will move towards the groove near the plica semilunaris Lacrimal passages

4. This has two parts – vertical 2mm and horizontal about 8mm. At the junction of the two there is a slight dilatation called the ampulla The canaliculi pierce the lacrimal fascia and then unite to form a common canaliculus The common canaliculus then opens in to a small diverticulum in the sac called the lacrimal sinus of Maier at about 2.5mm from the apex of the sac The valve of Rosenmuller prevents reflux of tears back in to the canaliculus Lacrimal canaliculi

5. The sac is located in the lacrimal fossa formed by the lacrimal bone and the frontal process of the maxilla. The fossa is bounded by the anterior and posterior lacrimal crest The periorbita splits in to two and surrounds the sac to form the lacrimal fascia. There is venous plexus in between the two layers Lacrimal sac

6. The lacrimal sac is 15/5mm in size The part above the point where the canaliculi enter the sac is called the fundus. It is 3-5mm in size The body of the sac is 10-11 mm and the junction forms the neck of the sac Lacrimal sac

7. Antero lateral- Next to skin the angular vein is situated 8mm from the medial canthus. The palpebral fibers of the Orbicularis oculi which are present next are needed to squeeze the tears in to the nasolacrimal duct into the nose The medial palpebral ligament covers the upper part of the sac The lacrimal fibers of the Orbicularis and lacrimal fascia cover the sac Sac

8. Medial to the sac the Ethmoidal sinus is situated superiorly and the middle meatus is present inferiorly Posterior to the sac the lacrimal fibers of the Orbicularis, lacrimal fascia and the septum orbitale are present

9. Course downwards, backwards and laterally and opens into the inferior meatus about 30mm from the openings of the nose About 20/3mm in length and diameter The intraosseous part is 12.5mm in length. It lies in the nasolacrimal canal formed by the maxilla and the nasal concha and is lateral to the middle meatus The intrameatal part is 5.5mm in length Nasolacrimal Duct

10. The opening of the nasolacrimal duct into the inferior meatus occurs just before or after birth. If this does not occur it is called congenital nasolacrimal duct obstruction Often this will get canalized on its own in a few weeks Criggler’s massage also will help Rarely probing will be needed

11. If there is overflow of ears due to excessive production it is called watering Only when the overflow is due to obstruction it is called epiphora This is more common in women due to narrow NLD In Africans as the duct is short and straight, it is rare Epiphora

12. Primary acquired NLD in which no cause is found Secondary obstruction due to Injuries to the bone Infections causing canaliculitis Neoplasms like papilloma, squamous cell ca, mucoepidermoid ca, lymphomas, hemangiomas Autoimmune diseases, chemotherapy and radiotherapy causing inflammation Types of nasolacrimal duct obstruction

13. Location, dimension and direction of the puncta must be checked first The lower punctum will be directed away from the eyeball in Centurian syndrome Constant rubbing in old age while wiping off the tears also adds to this problem as the lower punctum will be directed away due to laxity of the lids Pouting of the punctum is seen in canaliculitis which is often due to Actinomyces infection Clinical examination in a case of watering of the eye

14. Chronic infection like conjunctivitis and blepharitis can cause fibrosis around the puncta appearing like a white ring around the puncta – punctoplasty will be effective in these cases In a stenosed punctum this white ring will not be there. Here punctoplasty will not help. This occurs with prolonged usage of 5 fluorouracil and miotics Foreign bodies in the punctum also can cause watering. I have seen a patient with an eye lash obstructing the punctum

15. Trichiasis Entropion Symblepharon Lid margin keratinization All of the above can be seen together in Stevens Johnson’s syndrome Reflex tearing will occur due to the presence of foreign bodies in the eye and other corneal lesions

16. This is the first test performed if watering is noticed. Important test to be performed in case of corneal ulcer When pressure is applied medial to the medial palpebral ligament normally no regurgitation is seen A clear watery fluid is seen in atonic sac. Sometimes this fluid may get ejected through the NLD also Reflux of mucoid fluid shows there is only obstruction and no infection ROPLAS test

17. Reflux of mucopurulent material shows presence of infection Blood stained discharge shows presence of dacryoliths or malignancy While giving pressure one must also see whether the fluid comes out through both puncta Syringing will confirm the presence of canalicular obstruction and NLD obstruction If obstruction is at the level of common canaliculi the fluid will egress through the other punctum

18. This test will give as an idea about how fast the tear fluid gets drained out A drop of 2% fluorescein is placed in to the conjunctival cul de sac After 5 minutes if you don’t see any dye it means there is no problem in exit of tears Can be performed in people who do not co operate for syringing and in children But one cannot differentiate between obstruction, pump failure and location of obstruction Fluorescein dye disappearance test

19. ‘0’ size Bowman’s probe is used Done if any obstruction is noticed while doing syringing The probe is passed through the canaliculus till a stop is found If it is soft obstruction is at the level of the canaliculus either individual or common. The distance at which the stop occurs must be noted for planning the treatment If it is hard it means the probe has crossed the canaliculus and reached the sac Probe test

20. Three probe test is performed by passing three probes through both canaliculi and a fistula if present In congenital fistula it will meet all the probes will meet at a common point In an acquired fistula the probe will enter the sac and a hard stop will be felt. This is because acquired fistula follows drainage of pus following acute dacryocystitis

21. Endoscopic examination is done to rule out any nasal pathologies like hypertrophy of the mucosa, polyps or tumors. Any anatomical variation like deflected nasal septum are also ruled out Dacryocystography can be done in complicated cases to find out the exact location of the block. This will be needed following repeated surgeries, injuries and when tumors are suspected CT to assess the bones and Nuclear lacrimal scintigraphy to assess the pumping of tear fluid are rarely done Other tests

22. During olden days we used to excise the sac by making a curvilinear incision of about 12mm in length about 3 – 4 away from the medial canthus along the lacrimal crest. Care must be taken to avoid the angular vein After obtaining hemostasis the medial canthal tendon is separated or cut. The sac is separated well by blunt dissection and then cut from the nasolacrimal duct with a twisting action Complication - watering Treatment for chronic dacryocystitis

23. Even now in old people with dry eye it is better to do dacryocytectomy, as whatever tear secretion is there will stay in the eye. This is like a punctum plug When a person comes with a corneal ulcer and dacryocystitis it is again better to do a cystectomy as we have to remove the source of infection as early and thoroughly as possible

24. Here a by pass is made between the sac and the middle meatus, by making an opening in the intervening bone In external DCR the connection is more successful as the passage is lined by mucosa, since we suture the sac and nasal mucosa. The bony osteum is also large. Since this is membranous bone it will not fuse together again The sac region is anesthetized by blocking the infra trochlear nerve. The nasal mucosa is anesthetized by blocking it with 4% lignocaine soaked gauze Dacryocystorhinostomy

25. A Freer’s elevator is used to separate the periosteum. After exposing the lacrimal fossa like this the bone is punched with the blunt dissector and extended with the sphenoidal punch. The lacrimal bone is very thin and can be easily punched Then the sac and the nasal mucosa are cut to make two flaps, which are then sutured It is better not to cut the medial canthal tendon here The wound is then sutured in layers

26. Endoscopic endonasal DCR has the advantage of absence of an incisional scar over the face. Besides that the medial canthal tendon is not touched and the lacrimal pump is not disrupted. Can be done even when acute dacryocystitis is present as the skin is not touched. But the success rate is less than external DCR as the bony opening is small Endonasal DCR

27. The bony opening in endonasal DCR is made with Hajek Kopfler forward punch and extended with a diamond burr Other method is to use a Ruggles’s rongeur to make a opening in the lacrimal bone and extend it manually The sac is filled with fluorescein stained visco elastic material. A cut is made in the sac wall and they are placed far fro each other so that they will not fuse again Mitomycin C can be used to reduce fusion Silicone stents also can be placed in the canaliculi

28. Normally though the tear fluid and the nasal mucosa contain a large number of micro organisms the sac wall is resistant to infection But when the duct is obstructed it can lead on to infection of the sac wall and the surrounding tissues. Then it is called acute dacryocystitis Acute dacryocytitis

29. Pain, swelling and redness over the sac region and watering In the initial stages there will be only induration. Later pus formation will be seen It should be differentiated from preseptal cellulitis and orbital cellulitis, esp. because this can occur in children If mucocele is there one can see swelling in the sac region. Here there will not be any inflammation In children encephalocele also must be ruled out Signs and symptoms

30. The infection may spread and cause preseptal and orbital cellulitis Sub periosteal abscess Cavernous sinus thrombosis Fistula Complications

31. If the patients come in the induration stage itself, most often the infection will come under control and we can do DCR at a later date If pus formation has occurred it has to be drained by making an incision in the dependant area. DCR has to be done later once the inflammation subsides Treatment