Epiphora

epiphora watering hyper lacrimation

1. EPIPHORA EVALUATION SIVA TEJA CHALLA

2. Epiphora implies overflowing of tears due to impairment lacrimal drainage . due to a disruption in the balance between tear production and tear loss.

3. CAUSES

4. Anatomical  complete or partial punctal canalicular or NLD obstruction Functional  Lacrimal pump failure due to Anatomical deformity (Laxity, orbicularis weakness )

5. Eyelids Horizontal laxity and floppy lids Lower lid entropion with orb.oculi overriding Lower lid ectropion with ineffective orb.oculi Loss of skin / orbicularis

6. Punctal Causes Congenital agenesis/imperforate Acquired : OcclusioN I nfection/radiation Systemic: phemphigoid,SJS,Burns Tumors Mal position Medial displacement Medial ectropion

7. Canalicular Congenital absence/fistula Acquired Intrinsic Canaliculitis Trauma/ Post radiation Trauma/ Post radiation Tumours Extrinsic Compression by adjacent tumours

8. Lacrimal Sac Abnormality o Sac inflammation o Perilacrimal fibrosis o Dacryolith o Sac tumors (rare in pediatric age group) o Adnexal tumors pressing on lacrimal sac or drainage pathway

9. NASOLACRIMAL DUCT OCCLUSION Congenital: NLD obstruction Delayed opening of Hasner’s valve, Cranio facial anomalies Agenesis. Acquired: Primary obstruction Secondary obstruction: tumour, trauma NASAL CONDITIONS o Severe Deviated Nasal Septum or Turbinate Hypertrophy

10. Excessive tears production Reflex lacrimation in response to various factors  Trichiatic cilia  severe entropion ,  raised IOP  allergic conjunctivitis ,  corneal exposure ,  drug irritation  environmental irritants like pollution

11. OTHERS Ocular surface disorders like chronic KCS, conjunctivochalasis , cicatricial ocular surface pemphigoid , symblephron . Neurogenic hypersecretory disorders like compressive irritation of parasympathetic lacrimal fibres, Aberrant regeneration of facial nerve following trauma . Facial palsy

12. CLINICAL EVALUATION OF A PATIENT WITH EPIPHORA

13. Careful history External examination Slit lamp biomicroscopy Syringing and probing Imaging

14. HISTORY constant versus intermittent tearing periods of remission versus no remission unilateral or bilateral condition subjective ocular surface discomfort history of allergies use of topical medications history of probing during childhood prior ocular surface infections prior sinus disease or surgery, midfacial trauma, or nasal fracture previous episodes of lacrimal sac inflammation clear tears versus tears with discharge or blood

15. EXTERNAL EXAMINATION The eyelids : malpositions , entropion , ectropion,or lid laxity The puncta : malpositions , stenosis, agenesis,atresia or accessory puncta .

16. SLIT LAMP BIOMICROSCOPY: abnormalities of eyelids, position of punctas,size and patency,discharge , size of caruncle , eyelid laxity, blinking mechanism , marginal tear strip , Tearfilm debris, papillae or follicles pinguecula , pterygium , conjunctival chelosis. Ocular cicatricial pemphigoid .

17. Nasal Examination Anatomic Abnormalities Hypertrophied turbinates Nasal polyps Deviated septum Atrophic rhinitis

18. DIAGNOSTIC TESTS

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

20. 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

21. DYE DISAPPERANCE TEST heavily relied upon in children , in whom lacrimal irrigation is impossible without deep sedation Instillation of fluorescein drops 2% into the conjunctiva of both eyes then examine after 5 minutes . Normally , very little or no dye present significant residual dye or prolonged retention is an indication of inadequate drainage of the dye

22. Fluorescein dye disappearance test

23. Dye test 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

24. JONES DYE TESTING J ones I test, or primary dye test: Differentiates partial obstruction from hypersecretion of tears. Fluorescein 2% drops instilled into the conjunctiva. After about 5 minutes, cotton tipped applicator inserted under the inferior turbinate. Positive : Detection of fluorescein from the nose means patency of the system. Negative : No dye detected, means either a partial or absolute obstruction or failure of the lacrimal pump.

25. Jones II test, or secondary dye test: the residual fluoresce in is flushed from the conjunctival sac following an negative jones 1 test. clear saline is placed in to the inferior canaliculus using syringe/cannula irrigant is retreived from nasal cavity Positive : Recovery of dye stained saline from the nose meaning a partial obstruction of the NLD. Negative : Recovery of unstained saline through the nose means total obstruction of the upper drainage system or a defective lacrimal pump mechanism.

26. Probing After topical anaesthesia , curved lacrimal cannula on a saline filled syringe is gently inserted into lower punctum & advanced Canula comes to either hard or soft stop

27. 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: it comes to stop at junction of common canaliculus & lacrimal sac(lateral wall)…. it indicates common canalicular block

28. Lacrimal Sac Syringing most frequently performed immediately after a DDT to determine the level of lacrimal drainage system occlusion After instil­lation of topical anesthesia , the lower eyelid punctum is dilated The irrigating cannula is placed in the canalicular system. To prevent canalicular kinking and difficulty in advancing the irrigating cannula ,lateral traction of the lower eye lid clear saline is injected and the results noted

29. Complete canalicular obstruction. The cannula is advanced with difficulty, and irrigation fluid refluxes from the same canaliculus

30. Com­plete common canalicular obstruction. A "soft stop" is encountered at the level of the lacrimal sac , and irrigated fluid ref luxes through the opposite punctum . Soft stop is a spongy feeling due to canalicular obstruction

31. Complete nasolacrimal duct obstruction . The cannula is easily advanced to the medial wall of the lacrimal sac, then a "hard stop " is felt, and irrigation fluid ref luxes through the opposite punctum . If the probe touches the medial orbital wall, this means Hard Stop .

32. Partial nasolacrimal duct obstruc­tion . The cannula is easily placed, and irrigation fluid passes into the nose as well as refluxing through the opposite punctum .

33. Patent la crimal drainage system. The cannula is placed with ease , and most of the irrigation fluid passes into the nose .

34. IMAGING TECHNIQUES

35. 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.

36. 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.

37. CT/MRI Epiphora foll . Trauma with NLD obst . R/o orb. Rim/ max. # Infant with cystic mass at med. Can. Amniocele v/s meningocele Suspected malignancy

38. 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 .

39. Epiphora in children

40. CAUSES Eye lid problems Blepharitis Distichiasis Poor lid closure entropion Surface abnormalities Conjunctivitis Corneal abrasioN Foreign body keratitis Lacrimal outflow abnormalities  Punctal agenesis/stenosis  congenital dacryocele  Canalicular obstruction  nasolacrimal duct obstruction

41. WATERING IN ADULTS

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