Epiphora

Eye watering- causes and treatment

1. EPIPHORA BY Dr. Lakshmi.K.S Moderator- DR. Rajani.K

2. Introduction to watering eye Causes op epiphora and their management Clinical evaluation of watering eye Management of traumatic disruption of lacrimal apparatus DCR- types and techniques

3. Introduction The watering eye- characterized by overflow of tears from the conjunctival sac. Can be due to Hyperlacrimation (excessive secretion of tears) Epiphora (obstruction to the outflow of normally secreted tears)

4. Hyperlacrimation Primary hyperlacrimation- direct stimulation of lacrimal gland Reflex hyperlacrimation- stimulation of sensory branches of 5 th nerve due to irritation of cornea or conjunctiva Central hyperlacrimation- emotional states, voluntary lacrimation and hysterical lacrimation

5. Epiphora Physiological- lacrimal pump failure due to lower lid laxity or weakness of orbicularis muscle

6. Anatomical- obstruction of lacrimal outflow system at any level from punctum to nasolacrimal duct opening in the inferior meatus

7. Punctal causes- obstruction Congenital absence or primary punctal stenosis Ciciatricial closure following injuries, burns or infections- punctal stenosis. Treatment- dilatation or puntoplasty(2 or 3 snip procedure ) Foreign body- eg: eye lash Treatment- removal Prolonged use of drugs like iodoxyuridine and pilocarpine. Prevention-using drugs judiciously

8. Punctoplasty- for primary punctal stenosis involves removal of the posterior wall of the ampulla by a two- or three-snip technique (video)

9. Malposition Punctal malposition- tear film is not in contact with the malpositioned punctum to drain. Old age due to laxity of lids causing punctal eversion Following chronic conjunctivitis, chronic blepheritis or ectropion Centurion syndrome- characterized by anterior malposition of the medial part of the lid, with displacement of puncta out of the lacus lacrimalis due to a prominent nasal bridge

10. Treatment Treatment- Ziegler cautery - Burns are applied to the palpebral conjunctiva, 5 mm below the punctum for punctal eversion Medial conjunctivoplasty: A diamond-shaped piece of tarsoconjunctiva is excised. approximation of the superior and inferior wound margins with sutures for punctal eversion. Lower lid tightening: with a lateral canthal sling with or without medial conjunctivoplasty

11. Canalicular causes Congenital stenois Acquired- trauma foreign body strictures canaliculitis - pouting of punctum

12. Treatment of canalicular obstruction Partial canalicular obstruction intubation using silicone stents through one or both canaliculi, which are left in situ for 3–6 months total canalicular obstruction conjunctivodacryocystorhinostomy and the insertion of a special (Lester Jones) tube

13. Management of traumatic damage to lacrimal apparatus Lesions of the lacrimal drainage system occur in up to 16% of all eyelid injuries. The main causes are road traffic accidents, animal bites and violence. Canalicular lacerations are the most common injury of the lacrimal drainage system because of their exposed location in the upper and lower lid. The lower canliculus is more frequently involved Lacerations of the lacrimal sac or nasolacrimal duct are often associated with severe head trauma and midface fractures and needs multidisciplinary treatment approach.

14. Procedure of canalicular repair First the punctum is dilated, then the medial (portion closest to nose) cut end of canalicular system is identified. The stent is then introduced through punctum . When silicon stent is used , the collar of stent is placed securely in punctum so that the top edge is flushed with the eyelid margin, stent is then cut to appropriate length to- bridge the laceration. The length of stent should be cut with excess remaining as a small amount of excess stent should extend to the nasolacrimal sac. The stent is then placed into the medial cut end of canaliculus .

15. The laceration is then re-approximated with fine suture like 6-0 vicryl . The sutures should not pass through the cut ends of the canaliculus , The pericanalicular tissues are meticulously approximated. In cases where IV intubation tubes are used, the technique is essentially the same but the difference is the lateral portion of the tube is sutured to eyelid margin to prevent extrusion. If the medial canthal tendon is disrupted, it is also repaired to re-establish anatomic position and lid function.

16. Associated lid injuries are promptly repaired. In any patient with suspected orbital or mid face fractures, orbital computed tomography is advised. Even though the patient has nil visual prognosis after globe rupture the lid and canalicular suturing should be meticulous because a good lid contour is essential for fitting a custom artificial eye later. Patients should be reviewed at regular intervals, at 2 weeks when the sutures are removed, one month when the IV Cannula is removed, 3 months when the monocanalicular stent is removed

17. Lacrimal sac causes Congenital mucous membrane folds Traumatic strictures- post perforating trauma, chemical injuries Dacryocystitis Dacryolithiasis Tumours 1. Meyer sinus, 2. rosenmuller valve3. Arlt sinus, 4. krause valve, 5. spiral valve of Hyrtl , 6. Taillefer valve, 7. valve of hasner Acute dacryocystitis Chronic dacryocystitis

18. Acute dacryocystitis Stages: Stage of cellulitis Stage of lacrimal abscess Stage of fistula formation

19. Treatment of acute dacryocystitis Topical antibiotic eye drops oral antibiotics and anti-inflammatory drugs IV antibiotics in orbital cellulitis I ncision and drainage if lacrimal abscess is not responding to treatment. But may end up in lacrimal fistula which requires more demanding surgery later on.

20. Chronic dacryocystitis Stage of chronic cattrahal dacryocystitis Stage of mucocele Stage of chronic suppurative dacryocystitis Stage of chronic fibrotic sac

21. Treatment of chronic dacryocystitis Type of surgery depends on the site of obstruction in the lacrimal outflow tract . Site of obstruction Surgery Lacrimal sac or Nasolacrimal duct DCR Common canaliculi Canaliculo cystorhinostomy Canaliculi or punctum Conjunctivo canaliculocysto rhinostomy

22. Naso Lacrimal Duct causes Congenital- non canalization partial canalization imperforate membranous valves most common one is imperforate valve of hasner Acquired- Trauma Inflammation- dacryocystitis Tumors surrounding bony diseases

23. Congenital Nasolacrimal Duct Obstruction most common cause of epiphora or watering in children because of failure of canalization of the nasolacrimal duct which normally occurs by 8 months of gestation Obstruction can be membranous occlusion (most common- imperforate valve of hasner) or bony occlusion Though congenital nasolacrimal duct obstruction at birth is very common, symptoms of watering are seen only in about 5% of cases

24. Congenital dacryocystitis Inflammation of lacrimal sac as a result of congenital nasolacrimal obstruction seen in children is called as congenital dacryocystitis infection of the secretions of the lacrimal sac Staphylococcus aureus, Haemophilus influenzae, Pneumococci and beta hemolytic Streptococci are the commonest causative organisms for congenital dacryocystitis Congenital dacryocystitis usually presents as chronic dacryocystitis. Epiphora starts from second week as tears production from eyes starts only in second week, followed by mucoid or mucopurulent discharge * dacryocystocoele / amniocoele /encysted mucocoele .

25. Management Age of child Procedure < 2 months Lacrimal sac massage and antibiotic eye drops 2-6 months Lacrimal sac massage and antibiotic eye drops and Lacrimal syringing 6-18 months Probing 18 months to 4 years Silicone tube intubation and Balloon catheter dilatation >4 years DCR

26. Lacrimal massaging Lacrimal sac massaging acts by increasing the hydrostatic pressure within the lacrimal sac and opens up membranous lacrimal obstruction Start at the medial canthal tendon and gently massage downwards along the lateral nasal margin

27. Surgical treatment Dilatation and probing Probing is done between 6 months to 1 year of age has got success rate of upto 95%. Probing after 18 months of age is associated with high failure rate. Technique: video

28. Clinical evaluation of a watering eye External examination- to rule out other causes of reflex lacrimation like abnormalities of the eyelids as in ectropion, punctal ectropion or eversion, lagophthalmos, Lacrimal pump weakness because of laxity of the eyelids, weakness of orbicularis oculi Punctal abnormalities like atresia of punctum, punctal ectropion Presence of swelling in the lacrimal sac indicating nasolacrimal duct obstruction

29. Regurgitation test done by applying pressure over the lacrimal sac area with either thumb or index finger and observing the puncta. In cases with nasolacrimal duct obstruction like chronic dacryocystitis the contents of the sac regurgitate through the punctum

30. Fluorescein dye disappearance test Fluorescein dye is instilled into conjunctival sac and tear meniscus is observed for disappearance of dye Normally no dye is seen in conjunctival sac after 5 minutes Prolonged retention of the dye and a high marginal tear strip for more than 5 minutes indicates epiphora

31. Lacrimal syringing test Done under topical anesthesia by injecting normal saline into the lacrimal sac from lower or upper punctum with a lacrimal cannula (26G) fixed to syringe filled with saline I nterpreted as follows Saline is passing freely into throat as seen by swallowing reflex and appreciation of salt taste by patient- normal patent lacrimal passage. Fast regurgitation of clear fluid from same punctum- obstruction in same canaliculi. Fast regurgitation of clear fluid from opposite punctum- obstruction at common canaliculi. Slow regurgitation of mucoid/mucopurulent fluid from same and opposite punctum- obstruction in lacrimal sac or nasolacrimal duct. Partial regurgitation of saline from punctum and partial saline going into throat- partial obstruction in the lacrimal passage.

32. Jones dye test The primary test -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. The results are interpreted as follows: Positive : fluorescein recovered from the nose indicates patency of the drainage system Negative : no dye recovered from the nose indicates a partial obstruction (site unknown) or failure of the lacrimal pump mechanism. In this situation the secondary dye test is performed immediately .

33. 2. The secondary (irrigation) test- Topical anaesthetic is instilled and any residual fluorescein washed out. The drainage system is then irrigated with saline with a cotton bud under the inferior turbinate. Positive : fluorescein-stained saline recovered from the nose indicates that fluorescein entered the lacrimal sac, thus confirming functional patency of the upper lacrimal passages. Partial obstruction of the nasolacrimal duct is inferred. Negative : unstained saline recovered from the nose indicates that fluorescein did not enter the lacrimal sac. This implies partial obstruction of the upper lacrimal passages (puncta, canaliculi or common canaliculus) or a defective lacrimal pump.

34. Probe test A probe is passed into the lacrimal sac. Normally probe can be advanced till it touches the medial wall of lacrimal sac and lacrimal bone, which is felt as hard stop . If the probe stops proximal to common canaliculi because of obstruction in canaliculi, soft stop is felt as the probe is pressed against the soft tissue of common canaliculus, lateral wall of lacrimal sac, and medial wall of lacrimal sac before touching the lacrimal bone

35. Dacryocystography I nvolves the injection of radio-opaque contrast medium into the canaliculi followed by capture of magnified images . The test is usually performed on both sides simultaneously. Not to be performed in a patient with acute dacryocystitis . Technique The inferior puncta are dilated. Plastic catheters are inserted into the inferior canaliculi on either side; alternatively the upper puncta may be used. Contrast medium, usually 1–2 mL of Lipiodol, is simultaneously injected on both sides and postero-anterior radiographs are taken. Ten minutes later an erect oblique film is taken to assess the effect of gravity on tear drainage. Digital subtraction DCG provides a higher quality image capture than conventional

36. Dacryocystography (DCG). (A) Conventional DCG without subtraction shows normal filling on both sides; (B) normal left filling and obstruction at the junction of the right sac and nasolacrimal duct

37. Radionucleotide lacrimal scintillography Scintigraphy is a sophisticated test which assesses tear drainage under more physiological conditions than DCG more sensitive in assessing incomplete blocks also useful in assessing physiological obstruction beyond the sac. Technique Radionuclide technetium-99 is delivered by a micropipette to the lateral conjunctival sac as a 10 µl drop. The tears are thus labelled with this gamma-emitting radioactive substance . The tracer is imaged by a gamma camera focused on the inner canthus and a sequence of images is recorded over 45–60 minutes

38. nuclear lacrimal scintigraphy shows passage of tracer in the right lacrimal system but obstructed drainage in the left nasolacrimal duct

39. Obstruction site C/F Syringing Jones test Treatment Single canaliculus Pouting of punctum , soft stop (probing) Reg through same canaliculus Test 1- pos Astringent drops Both canaliculi Soft stop Reg through same canaliculus Test 1 and 2- neg CDCR- lester jones tube Common canaliculus Soft stop Immediate reg thro opp canaliculus Test 1 and 2- neg Canaliculo DCR Complete NLD Pr over sac regurgitation , Hard stop reg thro opp canaliculus after some time Test 1 and 2- neg DCR Partial NLD Pr over sac regurgitation , Hard stop reg thro opp canaliculus after some time+some fluid in nose Test 1- some fluoroscein in nose Pressure syringing with antibiotics Lacrimal pump failure No regurgitation patent Test 1- neg Test 2- pos Astringent drops

40. Acquired NLD obstruction treatment Conventional DCR Endoscopic DCR Endolaser DCR DCT- dacryocystectomy

41. Conventional DCR (video) The blood vessels in the middle nasal mucosa are constricted with ribbon gauze or cotton buds lightly wetted with 1 : 1000 adrenaline or cocaine 4–10% solution. A straight vertical incision is made 10 mm medial to the inner canthus, avoiding the angular vein The anterior lacrimal crest is exposed by blunt dissection and the superficial portion of the medial palpebral ligament divided. The periosteum is divided from the spine on the anterior lacrimal crest to the fundus of the sac and reflected forwards. The sac is reflected laterally from the lacrimal fossa The anterior lacrimal crest and the bone from the lacrimal fossa are removed A probe is introduced into the lacrimal sac through the lower canaliculus and the sac is incised in an ‘H-shaped’ manner to create two flaps. Membranous obstruction at the common canalicular opening or distal canalicular obstruction can be opened by excision or trephine of obstructing tissue (canaliculo-DCR). A vertical incision is made in the nasal mucosa to create anterior and posterior flaps The posterior flaps are sutured Silicone intubation may be performed. The anterior flaps are sutured The medial canthal tendon is resutured to the periosteum and the skin incision closed with interrupted sutures.

42. Complications Intra operative Excessive uncontrollable bleeding  may require abandoning the operation and reattempting it at a later date. Damage to the medial rectus and superior oblique may cause  diplopia . Blindness  may occur from damage to the intraorbital vessels or optic nerve. Cerebrospinal fluid leak  due to penetration of the cribriform plate Injury to the orbital contents  from rongeurs or drill Injury to the canaliculi  from improper probing Shredding of the lateral nasal mucosa due to improper bone removal

43. Postoperative Complications Sump syndrome may occur if the rhinostoma is small and high up in the lacrimal sac. This causes tears and mucus to accumulate in the sac and discharge into the eye. Ocular-orbital lesions, especially from orbital fat exposure Persistent watering may indicate scarring of the rhinostoma and may require reoperation. Orbital hematoma Subcutaneous emphysema Cerebrospinal fluid leakage (leading to greater risk of infection, such as meningitis) Air regurgitation through puncta , especially when sneezing and when talking Dry eye Complete failure

44. Complications associated with silicon intubation as part of DCR Pyogenic granulomata may occur at the puncta or the site of rhinostomy if the tubing is left in too long. Retrograde migration and corneal irritation Soft tissue infection Retained silicon tube and DCR failure Adhesions, elongation, slitting or erosion of the puncta Nasal migration Traumatic injury to the nasal septum

45. Endoscopic DCR Technique: A slender light pipe is passed through the lacrimal puncta and canaliculi into the lacrimal sac and viewed from within the nasal cavity with an endoscope. The remainder of the procedure is performed via the nose . a The mucosa over the frontal process of the maxilla is stripped. b A part of the nasal process of the maxilla is removed. c The lacrimal bone is broken off piecemeal. d The lacrimal sac is opened. e Silicone tubes are passed through the upper and lower puncta, pulled out through the ostium and tied within the nose.

46. Advantages Endoscopic DCR External DCR No external scar More success rate (95%) Relatively bloodless surgery Easily performed by ophthalmologists Less chances of injury to ethmoidal vessels and cribriform plate Expensive equipment not required Less time consuming Does not require familiarity with endoscopic anatomy No post operative moorbidity

47. Disadvantages Endonasal DCR External DCR Less success rate (70-90%) Cutaneous scar Requires skilled rhinologist or ophthalmologist Relatively more bleeding during surgery Expensive equipment Potential injury to adjacent structures with unskilled hands Requires reasonable access to middle meatus and familiarity with endoscopic anatomy More operating time

48. Endolaser DCR Performed with a Holmium:YAG or KTP laser, this is a relatively rapid procedure which can be carried out under local anaesthesia . It is therefore particularly suitable for elderly patients. The success rate is only about 70% but because normal anatomy is not disrupted it does not prejudice subsequent surgical intervention in the cases that fail. Video

49. Other methods Balloon dacryocystoplasty Recanalisation with endodiahermy

50. Dacryocystectomy Indications Lacrimal causes Lacrimal sac tumours Atrophic lacrimal sac ( ch dacryocystitis in aged) TB lacrimal sac Dry eyes (severe) Other causes Atrophic rhinitis Chron’s disease Ocular phemphigoid SLE

51. Technique Anaesthesia - local/General Skin incision-curved incision along the anterior lacrimal crest Exposure of medial palpebral ligament ( MPL) and Anterior lacrimal crest. MPL cut with scissors and anterior lacrimal crest exposed Dissection of lacrimal sac. Removal of lacrimal sac. Curettage of bony NLD Closure . MPL is sutured to periosteum , orbicularis muscle is sutured with 6-0 vicryl and skin is closed with 6-0 silk sutures

52. Conjunctivo-canaliculo-dacryocystorhinostomy- L ester J ones T ube A DCR is performed as far as suturing the posterior flaps. The caruncle is partially excised. A stab incision is made with a Graefe knife from a point about 2 mm behind the inner canthus (under the former caruncle) in a medial direction, so that the tip of the knife emerges just behind the anterior flap of the lacrimal sac The track is enlarged sufficiently with dilators to allow the introduction of a Pyrex Lester Jones tube The incision is sutured as for a DCR Video

53. References Kanski and bowling clinical ophthalmology- 7 th edition Duanes ophthalmology Parson’s diseases of the eye Comprehensive ophthalmology by A.K.Khurana Ophthalmology clinicals by Dr.Dadapeer Ani sreedhar et al; canalicular tear repair; kerala journal of ophthalmology; 2011; 342-345

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