LCRIMAL APPARATUS SYSTEM

DR M SAQUIB , G S MEDICAL COLLEGE, DACRYOCYSTITIS , DCR , OPHTHALMOLOGY

1. LACRIMAL System 18/09/2020 DR M SAQUIB Vice Principal , G.S.Medical College & Hospital MBBS,MS , FSCEH DELHI,FHVDESAI PUNE, EX REGISTRARA JNMCH,AMU CONSULTANT OPHTHALMOLOGIST HOD D/O OPHTHALMOLOGY G.S .MEDICAL COLLEGE Founder sec: MEDICS India , Mail- [email protected] , 9634123800

2. NASOLACRIMAL APPARATUS 1.Secretory system 2.Excretory system 2

3. SECRETORY SYSTEM Lacrimal gland Accessory Glands - Gland of Krause - Gland of Wolfring 3

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5. SECRETORY SYSTEM- Development Lacrimal gland- multiple solid ectodermal buds- anterior supero -lateral orbit- 6-8 weeks age of gestation Buds branch and canalize- ducts and alveoli Do not function fully- 6 weeks after birth Newborn infants- do not produce tear- crying Congenital NLDO seen following defective canalization of the Caudal End . 50% of the Newborns will have obstruction of the distal end ( Valve of Hasner ) 5

6. SECRETORY SYSTEM Lacrimal gland- Exocrine gland, almond size, situated at lacrimal gland fossa - Superior temporal orbit in frontal bone. LPS divides gland into orbital & palpebral lobe anteriorly . Ducts from orbital lobe passes thru palpepral lobe- empty into upper conj fornix temporally. Biopsy is avoided from Palpebral Lobe 6

7. Accessory Glands - Gland of Krause - Gland of Wolfring 7

8. ACCESSORY GLANDS Gland of Krause- Accessory exocrine gland present deep in superior fornix Gland of Wolfring -situated near superior border of tarsal plate. Previously- Main lacrimal gland- reflex secretion - Accessory glands- basal secretion Recent evidence- All tearing –Reflex- single unit 8

9. TEAR FILM 1. Lipid layer- secreted by Meibomian glands Increase surface tension of tear film & decreases its rate of evaporation 2. Aqueous layer- secreted by main lacrimal glands & gland of Krause & Wolfring . Provides oxygen to cornea & antibacterial function. 3. Mucinous layer- secreted by goblets cells of conjunctiva-allows even distribution of tear film over ocular surface 9

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12. EXCRETORY SYSTEM The lacrimal drainage system includes the - Upper & lower puncta - Lacrimal canaliculi - Upper canaliculi - Common canaliculi - Lower canaliculi - Lacrimal Sac - Nasolacrimal duct 12

13. Development : 5 weeks age of gestation The lacrimal drainage system- ectodermal cord- b/w the lateral nasal process and the maxillary process. Cord canalize- form NLD caudally and lacrimal sac and canaliculi cranially Caudally NLD extends intranasally - exiting -inferior meatus Canalization- complete around birth NLD Obstruction- 50% of infants at time of birth 13

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15. EXCRETORY SYSTEM Lacrimal puncta - 0.3 mm in diameter located medially on upper & lower lid margin, 6 mm & 6.5 mm from inner canthus respectively- directed posteriorly towards tear lake vertical canaliculus ( ampulla )- 2 mm-turns 90 deg horizontal canaliculus - 8 mm opens into sac by common canaliculus (90%) Common canaliculus - Mucosal fold- Valve of Rosenmuller - 1 way valve prevents tear reflux from lacrimal sac back into the canaliculi 15

16. EXCRETORY SYSTEM Lacrimal sac- lies b/w ant & post head MCT in lacrimal fossa bordered by anterior & posterior lacrimal crest Size of sac 12-15x5 mm when distended, Fundus - part of sac above common canaliculus Body of sac Medial wall- lacrimal fossa - lacrimal bone posteriorly & frontal process of maxilla anteriorly Medial to lacrimal fossa - Middle meatus of nose 16

17. EXCRETORY - Nasolacrimal duct - 12- 18 mm in length - Travels thru bony nasolacrimal canal- directed Inferiorly, Laterally And Posteriorly -opens thru an ostium into inferior nasal meatus ,lateral & below inferior turbinate - ostium - covered by partial mucosal fold ( Valve of Hasner ) 17

18. DACRYOCYSTITIS Infection of Lacrimal sac- b,coz of stasis of fluid(tears & mucus secretions) due to NLD blockage 18

19. CLASSIFICATION Congenital Acquired - Acute - Chronic 19

20. EPIDEMIOLOGY Age: most common in patients older than 40 years- with a peak at 60-70 years. Sex: MC in females- NLD more angulated & narrow Race: Rare in blacks-the nasolacrimal ostium into the nose is large. Also the NLD is shorter and straighter in blacks 20

21. EPIDEMIOLOGY Facial features: Individuals with brachycephalic heads- the NLD is longer, narrower. patients with a flat nose and narrow face- narrow osseous nasolacrimal canal. MC on left side than on the right side - the nasolacrimal duct and lacrimal fossa formed a greater angle on the right side than on the left side. 21

22. ETIOLOGY PrimaryAcquired Nasolacrimal Duct Obstruction(PANDO) : Idiopathic Involutional stenosis -older persons- due to compression of NLD lumen b.coz of fibrous obstruction by chronic inflammation 22

23. ETIOLOGY Secondary: 1. Dacryolith 2.Sinus disease- Ethmoid sinusitis 3.Trauma- Naso orbital #- involve NLD - Surgical- Endoscopic sinus surgery - Rhinoplasty 4. Granulomatous diseases: - Sarcoidosis - Wegner granulomatosis 23

24. PATHOGENESIS There are two main factors resulting in vicious cycle- 1. Stasis of sac contents due to NLD blockage 2. Infection may- ascend from nose - descend from conjunctiva Both aerobic and anaerobic bacteria- Mainly gram positive & gram negative. 24

25. ACUTE DACRYOCYSTITIS Acute dacryocystitis is characterized by the sudden onset of - severe pain - redness & - oedema in the medial canthal region - Epiphora 25

26. ACUTE DACRYOCYSTITIS SIGNS 1. A Tender & Hyperemic Palpable Mass Is Noted Inferior To The Medial Canthal Tendon- Non Reducible 2 . Purulent Discharge Is Noted From The Puncta . 3.Lacimal Abscess- Rupture- Lacrimal Fistula Through The Skin. 4 . Conjunctival Injection And Preseptal Cellulitis 26

27. ACUTE DACRYOCYSTITIS 27

28. COMPLICATIONS Orbital Cellulitis - bact overgrowth which rupture thru lacrimal sac wall into surrounding orbital soft tissue. Cavenous sinus thrombosis Blindness Osteomyelitis of lacrimal bone 28

29. MANAGMENT Syringing/Probing- CONTRAINDICATED - extremely painful- cellulitis Oral Broad Spectrum Antibiotics- Amoxicillin ( 250-500 mg) Cloxacillin (250-500 mg) TDS Anti inflammatory/ Analgesics drugs Hot compress Parentral antibiotics- severe cases- orbital cellulitis 29

30. MANAGMENT Aspiration of lacrimal sac- If lacrimal abcess is localised & approaching the skin. Incision & drainage- in severe cases not responding to conservative mgt abscess involving lacrimal sac & adjacent soft tissue- vertical incision is given- wound is packed- open- healing by secondary intention- lacrimal fistula formation 30

31. MANAGMENT DACRYOCYSTORHINOSTOMY(DCR) - Definitive treatment after resolution of acute inflammation 31

32. CHRONIC DACRYOCYSTITIS Chronic Suppurative Inflammation Of Lacrimal Sac Usually Resulting From Obstruction Of NL 32

33. SYMPTOMS Epiphora with or without mucopurulent discharge Swelling over sac area- present or absent Matting of eyelashes 4. Recurrent conjunctivitis 33

34. Sign Swelling in lacrimal sac area (below MCT) which is reducible- regurgitation test + ve Fullness in medial canthal area with no obvious swelling Enlarging mucocele - due to chronic low grade infection of sac-Increased glandular secretions into the sac. Pooling of tears at medial canthus . Chronic discharging fistula of sac 34

35. MUCOCELE 35

36. SEQULAE Atonic sac Lacrimal abscess Lacrimal fistula Following I.O. injury Hypopyon corneal ulcer Panophthalmitis 36

37. DIFFERENTIAL DIAGNOSIS Dermoid Cyst Cavernous haemangioma Neurofibromas Lacrimal sac tumours Above lesions are not reducible NLD may be blocked on syringing but DCG is diagnostic. 37

38. MANAGMENT EVALUATION TREATMENT Dacryocystorhinostomy (DCR)- External DCR Endonasal DCR Laser DCR- Transcanalicular or Endonasal External DCR with silicone intubation Conjunctivo DCR 38

39. EXTERNAL DCR Standard gold treatment, success rate >90% Indications: Chronic dacryocystitis with NLD blockage Mucocele of lacrimal sac Congenital dacryocystitis -failed conservative managment 39

40. EXTERNAL DCR It is a lacrimal drainage surgery in which a fistula is created b/w the lacrimal sac & middle meatus of the nasal cavity in order to bypass a obstruction in NLD 40

41. EXTERNAL DCR 41

42. EXTERNAL DCR Contraindications : 1.Age less than 3 years 2.Acute dacryocystitis 3.Tumour of sac 4.Atrophic Rhinitis Disadvantage - Scar mark 42

43. ENDONASAL DCR Done with the help of a nasal endoscope. Indication : Blockage at NLD Advantage : 1.No Cutaneous Scar 2. Short Operative Time 3. Minimum disruption of adjacent structures. Disadvantage : Low success rate (80%-85%) 43

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45. LASER DCR Done through endonasal or canalicular approach. Endonasal laser DCR : - KTP ( Potassium- Titanyl -Phosphate ) Laser - Ho:Yag ( Holium YAG ) Laser Transcanalicular laser DCR: - 980 nm Diode Laser 45

46. EXTERNAL DCR WITH SILICONE INTUBATION It is the procedure of DCR in which there is insertion of a silicone stent. The function of stent is to maintain patency of fistula created. Indications: Failed DCR Traumatic Dacryocystitis Common canalicular blockage Canalicular Blockage(<8mm) 46

47. EXTERNAL DCR WITH SILICONE INTUBATION 47

48. DACRYOCYSTECTOMY Excision of lacrimal sac done Indication - Fibrosed contracted sac, - Sac tumors - Atrophic rhinitis Disadvantage : Persistent epiphora 48

49. TEAR DRAINAGE Evaporation - 10%-Young - 20%-Old Most of the tears are actively pumped by orbicularis Tears flows- upper & lower marginal strips Enter –Upper & Lower canaliculi by capillarity & suction - 70% -Lower canaliculi - 30%- Upper canaliculi 49

50. PHYSIOLOGY OF TEAR DRAINAGE 50

51. PHYSIOLOGY OF TEAR DRAINAGE Mechanism( Rosengren-Doane ) of tear drainage Blinking- contraction of Orbicularis oculi - ampulla is compressed- horizontal canaliculi is shortened- puncta move medially Simultaneously lacrimal sac expands- negative pressure- sucking tears from canaliculi Eye opens-muscle relaxes-sac collapses-positive pressure-forces the tears down the NLD into nose Puncta move laterally- canaliculi lenghtens -fill with tears 51

52. CONGENITAL NLD OBSTRUCTION (NLDO) Caused by membranous block of valve of Hasner Present in 50% of new borns Opens spontaneously in 4-6 weeks Becomes clinically evident in 2-6% at 4-6 weeks of age. 1/3 rd is B/L 90% of these symptomatic cases resolve in 1 st year of life 52

53. Evaluation Congenital Tearing Evaluation-Straight forward H/o tearing and/or mucopurulent discharge shortly after birth Constant tearing with minimal mucopurulence - upper system block- punctal or canalicular stenosis / dysgenesis Constant tearing with frequent mucopurulence - complete obstruction of NLD Intermittent tearing with mucopurulence - intermittent obstruction of NLD- impaction of swollen inferior turbinate associated with URTI 53

54. Evaluation Eyelid margin examination- puncta open/absent Hypersecretion causes- rule out - infectious conjunctivitis - trichiasis - congenital glaucoma Inspection of medial canthus - cong dacryocystocele / mucocele - inflammation of sac - Cong encephalocele 54

55. SYMPTOMS Epiphora - usually few weeks of birth, commonly unilateral, may be bilateral. (normally tears are secreted after 4-6 weeks after birth). Mucopurulent discharge. Infective discharge at birth always due to conjunctivitis. 55

56. SIGNS Epiphora Discharge- mucopurulent Regurgitation test positive- Gentle pressure over the lacrimal sac causes reflex of mucopurulent material from puncta - complete obstruction at the level of NLD Rarely Acute dacryocystitis 56

57. Acute Dacyocystitis 57

58. CONSERVATIVE MANAGMENT Crigler massage over lacrimal sac area-Bilateral/ unilateral massage. 10 strokes four times a day. Place index finger at common canaliculus & massage firmly downwards Mechanism : Massage increases hydrostatic pressure in the sac & helps to open membranous occlusion Broad spectrum antibiotic drops- instilled after massage if discharge is present 90% cure rate 58

59. CRIGLER MASSAGE TECHNIQUE 59

60. SURGICAL MANAGMENT Probing & Irrigation Done at 1 yr of age under GA Punctal dilatation is required Bowman’s probe is introduced first vertically then horizontially towards medial canthus then rotate superiorly- inferiorly, laterally & posteriorly . Visualize with nasal endoscope Syringing with saline mixed with fluorescein followed by suction Repeat probing- 6 weeks if no improvement 60

61. Irrigation Of Nasolacrimal System 61

62. Nasolacrimal Silicone Intubation Indications - Failed probing - Older children with scarring or stenosis - punctal stenosis or canalicular stenosis Silicone stent having two lacrimal probes at both ends passed through both canaliculi , common canliculus , L. sac, NLD, pulled out through NLD openings in inferior meatus where both ends are tied with simple square knots Removal of silicon tube after 3-6 months 62

63. Congenital Dacryocystocele / Mucocele Also k/a Amniontocele Collection of amniotic fluid or mucus in the lacrimal sac- imperforate Hasner valve. Presentation: Perinatal with a bluish cystic swelling- at or below the medial canthal area - accompanied epiphora Sign: A tense lacrimal sac- mucus- secondarily infected 63

64. Differential Diagnosis Encephalocel e - pulsatile swelling above the medial canthal tendon Treatment - Conservative initially - If fails- probing should not be delayed 64

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