Ophthalmology

Diseases of lids & Lacrimal Apparatus

1. Ophthalmology By Dr. Laraib Jameel Rph Follow me on slideshare.net https://www.slideshare.net/

2. Symblepharon Definition:   A symblepharon is an adhesion between the eyelid and the eyeball. It can involve just one lid or both. This adhesion of Sub-epithelial (beneath) scarring can lead to other lid complications such as aberrant (deviated) lash growth and entropion .

3. Symblepharon

4. Anatomically   symblepharon  is a partial or complete adhesion of the palpebral conjunctiva of the eyelid to the bulbar conjunctiva of the eyeball . ANATOMY: The conjunctival tissue starts from the limbus and ends in the lid margin. According to the anatomic location, the conjunctiva can be subdivided into the bulbar and palpebral portions, palpebral conjunctiva: The part of the conjunctiva, a clear membrane, that coats the inside of the eyelids . The palpebral conjunctiva is as opposed to the ocular (or bulbar)  conjunctiva. bulbar conjunctiva : bulbar  conjunctiva, the part of the conjunctiva  that covers the outer surface of the eye. Synonym: pseudopterygium / cicatricial pterygium

5. Causes/etiology : Any conjunctival infections complicated with conjunctival scaring may cause symblepharon ; such as chlamydial conjunctivitis, vernal, atopic, bacterial conjunctivitis and epidemic keratoconjunctivitis . Vernal ( pertaining to spring) conjunctivitis Vernal conjunctivitis is long-term (chronic) swelling (inflammation) of the outer lining of the eyes. It is due to an allergic reaction. Causes Vernal conjunctivitis often occurs in people with a strong family history of allergies . These may include allergic rhinitis , asthma, and eczema . It is most common in young males, and most often occurs during the spring and summer . Chlamydial conjunctivitis : Chlamydial conjunctivitis (bacteria- chlamydia trachomatis) is a sexually transmitted disease and occurs most commonly in sexually active young adults. Women are more susceptible than men. The disease is usually transmitted through hand-to-eye spread of infected genital secretions . The incubation period is one to two weeks.

6. Bacterial conjunctivitis : Bacterial conjunctivitis is a common type of pink eye , The most common types of bacteria that causes bacterial conjunctivitis includes Staphylococcus aureus , Haemophilus influenzae , Streptococcus pneumonia and Pseudomonas aeruginosa . Bacterial conjunctivitis usually produces a thick eye discharge or pus and can affect one or both eyes. Atopic conjunctivitis: Allergic conjunctivitis is an acute, intermittent, or chronic  conjunctival  inflammation usually caused by airborne allergens. Symptoms include itching, lacrimation, discharge, and  conjunctival  hyperemia. Diagnosis is clinical. T reatment is with topical antihistamines and mast cell stabilizers . ATOPY- a hereditary disorder, marked by tendency to develop immediate hypersensitivity reaction) conjunctiva is transparent and the underlying sclera is white, these dilated vessels can easily be seen.  Conjunctival hyperemia can occur when the blood flow through the  conjunctival  vessels increases due to vasodilation.

7. Atopic Keratoconjunctivitis (AKC) Atopic keratoconjunctivitis (AKC) is the result of a condition called " atopy ". Atopy is a genetic condition where your immune system produces higher than normal antibodies in response to a given allergen.   Although AKC is a perennial (year round) disease, your symptoms may worsen in the winter . With AKC, the conjunctiva lining the eyelids is usually red and swollen. The lower eyelid generally is affected more than the upper eyelid. Causes AKC is a genetic condition. Risk Factors A family history of multiple allergies

8. Causes of Symblepharon Symblepharon can develop as a complication of several diseases that include: 1- Severe  dry eye syndrome Dry eye syndrome is caused by a chronic lack of sufficient lubrication and moisture on the surface of the eye . Consequences of dry eyes range from subtle but constant eye i rritation to significant i nflammation and even scarring of the front surface of the eye . And this scarring can lead to symblepharon . 2- Stevens-Johnson syndrome: is a rare, serious disorder of your skin and mucous membranes .  Often, it begins with flu-like symptoms, followed by a painful red or purplish rash that spreads and blisters. Cause: Stevens-Johnson syndrome is a rare and unpredictable reaction . A reaction to medication may start while you're using it or up to two weeks after you've stopped using it . Drugs that can cause Stevens-Johnson syndrome include: Anti-gout medications, such as allopurinol Medications to treat seizures and mental illness (anticonvulsants and antipsychotics ) Medications to fight infection, such as penicillin The rash caused by Stevens-Johnson syndrome can lead to inflammation in your eyes . In mild cases, this may cause irritation and dry eyes. In severe cases, it can lead to extensive tissue damage and scarring 

9. Steven- johnson syndrome

10. 3- Ocular cicatricial pemphigoid : It is autoimmune disease. Cicatrical =caused by a scar pemphigoid = autoimmune blistering skin disease, ocular= eye This is a subclass of mucous membrane pemphigoid affecting predominantly the conjunctiva. OCP is a Type II hypersensitivity response with antibodies binding at the basement membrane zone , leading to the activation of complement and recruitment of inflammatory cells. The release of cytokines causes fibroblast (play role in healing) activation with consequent progression to scarring . Type2– antibody binding with membrane—activation of complement—recruitment of inflammatory cells– release cytokines—causes fibroblast(healing process)--- scar formation .

11. Ocular cicatricial pemphigoid

12. 4- Chemical injury /   corneal chemical burn: Acid tends to cause less severe injury than alkali. Acid denatures and precipitates proteins, which form a barrier to further penetration. Alkali denatures but does not precipitate proteins, and also saponifies fats (disrupts lipid membranes), causing deeper penetration into ocular tissues.

13. Symptoms:   Symptoms may be dependent upon the etiology . For most patients, the common symptoms include: Redness Tearing Burning sensation Foreign body sensation Photophobia Lid heaviness Blepharo -spasm Diplopia  is the simultaneous perception of two images of a single object that may be displaced horizontally, vertically, diagonally (i.e., both vertically and horizontally), or rotationally in relation to each other . Entropion  is a medical condition in which the eyelid (usually the lower lid) folds inward. It is very uncomfortable, as the eyelashes continuously rub against the cornea causing irritation. and inadequate lid closure.

14. Treatment: Copious (vast) irrigation checking pH level,  Debridement (any necrotic  conjunctiva and particulate matter ), frequent lubrication , topical antibiotic and  Cycloplegic drugs ( Cycloplegic  drugs are generally muscarinic receptor blockers . These include atropine, cyclopentolate , homatropine , scopolamine and tropicamide . They are indicated for use in  cycloplegic  refraction (to paralyze the ciliary muscle in order to determine the true refractive error of the eye) Ciliary muscle: enable the lens to change shape for focusing

15. Symblepharon lysis Symblepharon lysis is performed with a glass rod . Mild to severe based on degree of corneal damage and ischemia(an inadequate blood supply to an organ or part of the body): Grade I: corneal epithelial damage, no ischemia Grade II: iris details visible, ischemia < 1/3 of limbus Grade III: total corneal epithelial loss, iris obscured Grade IV: opaque cornea, ischemia > 1/2 of limbus

16. Schematic illustration and clinical photographs showing the 3 strategies for fornix reconstruction. In mild symblepharon (A), after symblepharon lysis , AM (black) is used to cover the denuded sclera up to the recessed conjunctiva (green) with fibrin glue (B) or sutures. In moderate symblepharon (C), anchoring suture (red) is used to secure the recessed conjunctival edge (green) to the skin with a bolster (red circle); one double-armed 4-0 silk suture is used per quadrant (D). In severe symblepharon (E), additional OMG (orange) is used to cover the tarsal plate and secured with fibrin glue (F) and sutures. 

17. Management: may require oculoplastics procedure to release the symblepharon Oculoplastics , or  oculoplastic  surgery, includes a wide variety of surgical procedures that deal with the orbit (eye socket), eyelids, tear ducts, and the face. It also deals with the reconstruction of the eye and associated structures Prevention: Minimize the cause definitely you will able to stay away the disease, such as Chemical burns Trauma Disease (conjunctivitis)

18. Herpes Zoster Definition: Herpes zoster is infection that results when varicella-zoster virus reactivates from its latent ( hidden) state in a posterior spinal ganglion ( a structure containing a number of nerve cell bodies). Synonym: Shingles, Zoster Shingles , also known as  zoster  or  herpes zoster , is a  viral disease  characterized by a  painful skin rash with blisters in a localized area

19. Shingles

20. Location: Although shingles can occur anywhere on your body , it most often appears as a single stripe of blisters that wraps around either the left or the right side of your body or face (eye). Most cases of shingles clear up within two to three weeks. Shingles rarely occurs more than once in the same person

21. Causes: Shingles is caused by the varicella-zoster virus , the same virus that causes chickenpox. Anyone who's had chickenpox may develop shingles . After you recover from chickenpox , the virus can enter your nervous system and lie dormant (inactive) for years. Eventually, it may reactivate and travel along nerve pathways to your skin — producing shingles. Note: But , not everyone who's had chickenpox will develop shingles .

22. The reason for shingles is unclear . But it may be due to lowered immunity to infections as you grow older . Shingles is more common in older adults and in people who have weakened immune systems . Mostly shingles occur after 50 years of age. Virus which causes the disease: Chickenpox and herpes zoster are caused by the varicella-zoster virus (human herpesvirus type 3 ) a double-stranded DNA virus related to the herpes simplex virus chickenpox is the acute invasive phase of the virus, and herpes zoster (shingles) represents reactivation of the latent phase .

23. Are you contagious ?

24. Ans : A person with shingles can pass the varicella-zoster virus to anyone who isn't immune to chickenpox . This usually occurs through direct contact with the open sores of the shingles rash . Once infected, the person will develop chickenpox, however, not shingles.

25. Risk factors: Anyone who has ever had chickenpox can develop shingles. Factors that may increase your risk of developing shingles include : Being older than 50.  Shingles is most common in people older than 50. The risk increases with age. Some experts estimate that half the people age 80 and older will have shingles. Having certain diseases.   Diseases that weaken your immune system , such as HIV/AIDS and cancer, can increase your risk of shingles. Undergoing cancer treatments.  Radiation or chemotherapy can lower your resistance to diseases and may trigger shingles . Taking certain medications.   Drugs designed to prevent rejection of transplanted organs can increase your risk of shingles (these are immunosuppressant drugs) as can prolonged use of steroids , such as prednisone . (prolong use of steroids can increase high blood sugar, thinning bones(osteoporosis), clouding of lens in one/both eyes, increase risk of infections.

26. Symptoms: Localized burning, tingling, itching, prickling pain that starts days to weeks before the rash appears. A widespread rash Rash in the eye Fluid-filled blisters that scab within 7 to 10 days and resolve within 2 to 4 weeks Sensitivity to touch or light The rash may be accompanied by fever, fatigue, or headache. The rash will not cross the mid-line of your body . Pain is usually the first symptom of shingles. For some, it can be intense. Depending on the location of the pain, it can sometimes be mistaken for a symptom of problems affecting the heart, lungs or kidneys. Some people experience shingles pain without ever developing the rash.

27. Transmission of disease: The varicella zoster virus can spread through direct contact with herpes zoster lesions which have not yet crusted over or via the airborne route over distances of greater than 3 feet.

28. Diagnosis: Most cases of shingles can be diagnosed with a physical examination of rashes and blisters . Your doctor will also ask questions about your medical history . (if you had chickenpox as a child, you might recall the itchy, spotted  rash that popped up on your face and body .) In rare instances, your doctor may need to test a sample of your skin or the fluid from your blisters. This involves using a sterile swab to collect a sample of tissue or fluid . Samples are then sent to a medical laboratory to confirm the presence of the virus . Blood test: The most popular test detects VZV-specific  IgM  antibody in blood; this appears only during chickenpox or shingles and not while the virus is dormant

29. Treatment Type Purpose Drug frequency Method anti-viral medications, including acyclovir, valacyclovir , and famciclovir to reduce pain and speed recovery 2 to 5 times daily, as prescribed by your doctor oral anti-inflammation drugs, including   ibuprofen to ease pain and swelling every 6 to 8 hours oral narcotic medications or analgesics to reduce pain likely to be prescribed once or twice daily oral anticonvulsants or tricyclic antidepressants to treat prolonged pain once or twice daily oral antihistamines, such as diphenhydramine ( Benadryl ) to treat itching every 8 hours oral numbing creams, gels, or patches, such as  lidocaine to reduce pain can be applied as needed topical

30. Complications: The pain and rash occur near an eye. If left untreated, this infection can lead to permanent eye damage . The affected area becomes secondarily infected with bacteria. Nerve problems such as brain swelling, facial paralysis, hearing problems, and problems with balance

31. Preventions: There are several  shingles vaccines  that reduce the risk of developing shingles or developing severe shingles if the disease occurs. The Centers for Disease Control and Prevention (CDC) recommend that people over 60 years old are vaccinated with the shingles vaccine at least once. The varicella-zoster shot, known as Zostavax , or VZV, is approved by the Food and Drug Administration (FDA) for those over 50 years old. There are vaccines  that reduce the risk of developing chickenpox.

32. Lacrimal Apparatus The  lacrimal apparatus is the physiological system & a set of connected anatomical structures located within the orbit that are responsible for the production and drainage of tears . The lacrimal apparatus include the following structures: lacrimal gland lacrimal canaliculi lacrimal sac nasolacrimal duct.

33. Lacrimal gland This gland is about the size of an almond, and sits within the lacrimal fossa, located in the superior and outer edge of the orbital roof. The gland is divided into two sections anatomically . These are the small palpebral portion that lies closer to the eye, and the orbital portion that forms around four ducts. These ducts then combine with the 6 ducts of the palpebral portion, and are secreted onto the surface of the eye. Composition: The lacrimal gland is composed of cells that produce proteins and electrolytes, and cause water to follow by osmosis .

34. Lacrimal canaliculi /canals These are small channels that lie in each eyelid , and commence at the  puncta   lacrimalia ; small openings where the tears are drained from the surface of the eye . These canaliculi are divided into the superior duct and the  inferior duct that drain into the lacrimal sac . They are lined with stratified squamous epithelium . The lacrimal canaliculi convey the tears to the lacrimal sac

35. Lacrimal sac This is the upper dilated end of the nasolacrimal duct . Function: It connects to the  lacrimal canaliculi , which function to drain the tears from the eyes surface to the nasal cavity via the nasolacrimal duct. The cells that line these canaliculi are stratified columnar epithelium, with goblet cells .

36. nasolacrimal duct : which is the final part of the lacrimal apparatus  and Location: opens into the nasal cavity. If there is excess of tears, it drains via the nasolacrimal duct into the nasal cavity, thus causing what is called a runny nose . The cells that line this duct are stratified columnar epithelium.

37. Innervation: The   innervation of the lacrimal apparatus involves both the a  sympathetic supply through the carotid plexus of nerves around the internal carotid artery, and   parasympathetically  from the  lacrimal nucleus of the facial nerve . (7 th cranial neve ) Vasculature The main arterial supply to the lacrimal gland is from the  lacrimal artery , which is derived from the ophthalmic artery – a branch of the internal carotid artery. Venous drainage is via the   superior ophthalmic vein , and ultimately empties into the cavernous sinus. Lymphatic drainage is to the  superficial parotid lymph nodes . They empty into the superior deep cervical nodes.

38. The function of the lacrimal apparatus 1-   is to produce tears , 2- channel them to the surface of the eye where they maintain moisture, 3- flush debris and waste material from the ocular surface . Tear: Tears have an integral role in the functioning of the eye . They protect the eye from infection , lubricate the movements of the eye and eyelid, and also ensure the presence of a thin transparent layer on the surface of the conjunctiva . There are three types of tears .   Basal tears  are normally present and maintain lubrication and a general functioning of the eye. There are  reflex tears   that are generated due to irritation of the eye from dirt of debris. The third type is  psychic tears/crying , which are formed under emotional control.

39. Dry Eyes Definition: Dry eye is a condition in which a person doesn't have enough quality tears to lubricate and nourish the eye, or if you produce poor-quality tears . After a long day of staring at your computer screen , your eyes are shot . You may feel your vision to get blurry or have a burning sensation in your eyes. Perhaps in the course of your normal routine you experience a sharp pain in your eye or have excessive watering. These are all symptoms of the dry eyes syndrome People with dry eyes either do not produce enough tears or their tears are of a poor quality

40. Cause: Dry eyes are caused by a lack of adequate tears. tears are a complex mixture of water, fatty oils and mucus. This mixture helps make the surface of eyes smooth and clear, and it helps protect your eyes from infection. For some people, the cause of dry eyes is decreased tear production . For others it's increased tear evaporation and third is an imbalance in the makeup of your tears. 1- Decreased tear production Dry eyes can occur when you're unable to produce enough tears . The medical term for this condition is keratoconjunctivitis sicca . Common causes of decreased tear production include: Aging Tear gland damage from inflammation or radiation Certain medical conditions, including diabetes, rheumatoid arthritis, Sjogren's syndrome, and vitamin A deficiency Certain medications, including antihistamines, decongestants, hormone replacement therapy, antidepressants, and drugs for high blood pressure, acne, birth control and Parkinson's disease

41. In Sjögren’s Syndrome , the glands in your eyes and mouth that typically produce mucus and moisture no longer produce effectively . Rheumatoid arthritis (RA) is a chronic autoimmune disease that causes pain, swelling, stiffness, and loss of function in the joints . The ends of your bones are covered by elastic tissue called cartilage, which supports and helps protect the joints during movements. A tissue known as synovium or synovial membrane lies next to the cartilage. The synovium produces synovial fluid, a substance that acts as a lubricant and provides nourishment to the cartilage. In people with RA, the autoimmune process causes the synovium in certain joints to become inflamed. The tissue swells and becomes painful with every movement of the affected joints. diabetic patients complain of typical dry eye symptoms, such as burning and/or foreign body sensation due to retinopathy Vitamin   A helps form and maintain healthy teeth, skeletal and soft tissue, mucus membranes, and skin. It is also known as retinol because it produces the pigments in the retina of the eye.  Vitamin  A promotes good eyesight, especially in low light

42. 2- Increased tear evaporation Common causes of increased tear evaporation include: Wind, smoke or dry air Blinking less often , which tends to occur when you're concentrating, for example, while reading, driving or working at a computer Eyelid problems , such as out-turning of the lids ( ectropion ) and in-turning of the lids ( entropion ) 3- Imbalance in tear composition The tear film has three basic layers: oil, water and mucus . Problems with any of these layers can cause dry eyes. For example, the oil film produced by small glands on the edge of your eyelids ( meibomian glands) might become clogged . Blocked meibomian glands are more common in people with inflammation along the edge of their eyelids ( blepharitis ), rosacea or other skin disorders.

43. There are two main types of dry eye. Aqueous tear-deficient dry eye is when the tear glands are unable to produce enough of the fluid component of tears to clean the surface of the eye properly. This type of dry eye is also sometimes called "painful blindness dry eye." It is caused by damage to the tear gland by factors , such as aging, pollution, or side effects from some medicines. The other main type of dry eye is known as "evaporative dry eye." This type is caused by inflammation of another set of glands located in the eyelids, the meibomian glands . The inflammation prevents these glands from producing enough of an oil that helps stop tears from evaporating too quickly.

44. Symptoms: These are some of the symptoms and causes of dry eye syndrome, which can damage the surface of the eyes and impair vision if not treated immediately:  A painful or itchy feeling in your eyes . ​ Stringy mucus in or around your eyes . ​ Sensitivity to light. Redness of the eye. Feeling like something is stuck in your eyes. Difficulty in applying contact lenses. Problem while driving in the night. Excessively watery eyes . ​ Blurred vision.

45. Risk factors Factors that make it more likely that you'll experience dry eyes include: AGE: Being older than 50. Tear production tends to diminish as you get older. Dry eyes are more common in people over 50. GENDER: Being a woman. A lack of tears is more common in women, especially if they experience hormonal changes (prolactin & adrenocorticotropic hormone- stress level) due to pregnancy, using birth control pills or menopause. DIET: Eating a diet that is low in vitamin A , which is found in liver, carrots and broccoli, or low in omega-3 fatty acids , which are found in fish, walnuts and vegetable oils Environmental conditions.   Exposure to smoke, wind and dry climates can increase tear evaporation resulting in dry eye symptoms . Failure to blink regularly, such as when staring at a computer screen for long periods of time, can also contribute to drying of the eyes. OTHER FACTORS: Wearing contact lenses

46. Diagnosis: comprehensive eye examination: Dry eyes can be diagnosed through a comprehensive eye examination. This eye exam that includes a complete history  to determine the patient's symptoms and to note any general health problems, medications or environmental factors that may be contributing to the dry eye problem . External examination of the eye, including lid structure and blink dynamics . Evaluation of the eyelids and cornea using bright light and magnification Other procedures are: Measuring the volume of your tears.  Your doctor may measure your tear production using the Schirmer test . In this test, blotting strips of paper are placed under your lower eyelids. After five minutes your doctor measures the amount of strip soaked by your tears. Determining the quality of your tears.  Other tests use s pecial dyes in eyedrops to determine the surface condition of your eyes . Your doctor looks for staining patterns on the corneas and measures how long it takes before your tears evaporate.

47. Treatment Tear glands and tear ducts For most people with occasional or mild dry eye symptoms , it's enough to regularly use over-the-counter eye drops (artificial tears). If your symptoms are persistent and more serious, you have other options. What you do depends on what's causing your dry eyes . Treating the underlying cause of dry eyes In some cases, treating an underlying health issue can help clear up the signs and symptoms of dry eyes. For instance, if a medication is causing your dry eyes, your doctor may recommend a different medication that doesn't cause that side effect.

48. Medications Prescription medications used to treat dry eyes include: Drugs to reduce eyelid inflammation.  Inflammation along the edge of your eyelids can keep oil glands from secreting oil into your tears. Your doctor may recommend antibiotics to reduce inflammation. Antibiotics for dry eyes are usually taken by mouth, though some are used as eyedrops or ointments. Eyedrops to control cornea inflammation.  Inflammation on the surface of your eyes (cornea) may be controlled with prescription eyedrops that contain the immune-suppressing medication cyclosporine ( Restasis ) or corticosteroids. Corticosteroids are not ideal for long-term use due to possible side effects . Eye inserts that work like artificial tears.  If you have moderate to severe dry eye symptoms and artificial tears don't help, another option may be a tiny eye insert that looks like a clear grain of rice. Once a day, you place the hydroxypropyl cellulose ( Lacrisert ) insert between your lower eyelid and your eyeball. The insert dissolves slowly, releasing a substance that's used in eyedrops to lubricate your eye.

49. Tear-stimulating drugs.  Drugs called cholinergics ( pilocarpine , cevimeline ) help increase tear production. These drugs are available as pills, gel or eyedrops . Possible side effects include sweating . Eyedrops made from your own blood.  These are called autologous blood serum drops. They may be an option if you have severe dry eye symptoms that don't respond to any other treatment. To make these eyedrops , a sample of your blood is processed to remove the red blood cells and then mixed with a salt solution . because they contain diluted concentrations of vitamins and growth factors that are important for corneal epithelial health Other procedures Other procedures that may be used to treat dry eyes include: Closing your tear ducts to reduce tear loss.  Your doctor may suggest this treatment to keep your tears from leaving your eye too quickly. This can be done by partially or completely closing your tear ducts, which normally serve to drain tears away. Tear ducts can be plugged with tiny silicone plugs ( punctal plugs). These are removable. Or tear ducts can be plugged with a procedure that uses heat. This is a more permanent solution called thermal cautery . (cautery- seal body tissues)

50. Punctal plugs

51. Using special contact lenses.   Some people with severe dry eyes may opt for special contact lenses that protect the surface of your eyes and trap moisture. These are called scleral lenses or bandage lenses. Unblocking oil glands.   Warm compresses or eye massages used daily can help clear up blocked oil glands . A thermal pulsation device is another way to unclog the oil glands , but it is unclear whether this method provides any advantage over warm compresses.

52. Self care / Preventions: You can take the following steps to reduce symptoms of dry eyes: Remember to blink regularly when reading or staring at a computer screen for long periods of time. Increase the humidity in the air at work and at home . Wear sunglasses outdoors , particularly those with wraparound frames, to reduce exposure to drying winds and the sun . Nutritional supplements containing essential fatty acids may help decrease dry eye symptoms in some people . Avoiding becoming dehydrated by drinking plenty of water (8 to 10 glasses) each day.

53. Epiphora Definition: is a condition in which there is an overflow of tears onto the face, often without a clear explanation . Synonym : Watering eye , tearing eye Epiphora can develop at any age, but it is more common in those aged under 12 months or over 60 years . It may affect one or both eyes .

54. Causes The two main causes of watering eyes are blocked tear ducts and excessive production of tears. 1- Blocked tear ducts Some people are born with underdeveloped tear ducts . Newborns often have watery eyes that clear up within a few weeks, as the ducts develop. The most common cause of watering eyes among adults and older children is blocked ducts or ducts that are too narrow . Narrowed tear ducts usually become so as a result of swelling , or inflammation . If the tear ducts are narrowed or blocked, the tears will not be able to drain away and will build up in the tear sac . Stagnant tears in the tear sac increase the risk of infection , and the eye will produce a sticky liquid, making the problem worse . Infection can also lead to inflammation on the side of the nose, next to the eye .

55. 2- Over-production of tears Irritated eyes may produce more tears than normal as the body tries to rinse the irritant away. The following irritants can cause the over-production of tears: some chemicals, such as fumes, and even onions infective conjunctivitis allergic conjunctivitis an injury to the eye, such as a scratch or a bit of grit (tiny pebble or piece of dirt) trichiasis , where eyelashes grow inward ectropion , when the lower eyelid turns outward Some people have tears with a high fat, or lipid, content . This may interfere with the even spread of liquid across the eye , leaving dry patches which become sore, irritated and cause the eye to produce more tears .

56. Other causes There are many causes of watering eyes. The following conditions among others can also lead to an overflow of tears: an infection of the cornea corneal ulcer, an open sore that forms on the eye styes or chalazions , lumps that can grow on the edge of the eyelid allergies , including  hay fever

57. Symptoms: Epiphora can cause your eyes to water slightly, or excessively with a constant stream of tears . You may also experience other symptoms in your eyes, such as: redness enlarged, visible blood vessels soreness eyelid swelling blurred vision light sensitivity

58. Diagnosis: Diagnosis of epiphora is clinical by history presentation and observation of the lids.   Fluorescein dye can be used to examine for punctal reflux by pressing on the canaliculi in which the clinician should note resistance of reflux as it irrigates through the punctum into the nose . Staining method : A piece of blotting paper containing the dye is touched to the surface of your eye. You are asked to blink. Blinking spreads the dye and coats the tear film covering the surface of the cornea. The tear film contains water, oil, and mucus to protect and lubricate the eye. The health care provider then shines a blue light at your eye. Any problems on the surface of the cornea will be stained by the dye and appear green under the blue light.

59. Treatment Treatment depends on how severe the problem is and the cause . D ifferent causes of watering eyes have specific treatment options: Irritation : If the watering eye is caused by infective conjunctivitis, the doctor may prefer to wait for a week or so to see if the problem resolves itself without  antibiotics . Trichiasis : An inward-growing eyelash, or some foreign object that lodged in the eye, the doctor will remove it . Ectropion : The eyelid turns outwards - the patient may need to undergo surgery in which the tendon that holds the outer eyelid in place is tightened . Blocked tear ducts : Surgery can create a new channel from the tear sac to the inside of the nose. This allows the tears to bypass the blocked part of the tear duct. This surgical procedure is called dacryocystorhinostomy (DCR ). If the drainage channels, or canaliculi , on the inside of the eye are narrowed b ut not entirely blocked, the doctor may use a probe to make them wider . When the canaliculi are completely blocked an operation may be required.

60. Dacryocystitis Definition: Dacryocystitis is an infection of the tear sacs or lacrimal sacs in the lower, inner corner of the eye that can cause pain, redness , and discomfort.

61. Dacryocystitis

62. The lacrimal glands underneath your upper eyelids produce tears , Tears act as pathway to keep your eyes hydrated, clean from dirt and free of bacteria .  These tears travel through small openings to the front of your eye. Every time you blink, the tears spread across your eyes. To make room for new tears, the fluid drains out of your eyes through small holes, called puncta , in the corners of your upper and lower eyelids. Then it drains through the nasolacrimal sac into the tear duct (lacrimal duct) and into the back of your nose.

63. Pathophysiology: Tear ducts act as pathways that carry away the tears that have washed away dirt on the surface of the eyes. As the used tears move away from the eye through the tear ducts, fresh tears come in. When there is a blockage in the tear sacs or tear ducts, this process gets disrupted, and used tears cannot travel away from the eye . Bacteria can then collect in the area. Dacryocystitis is most common in infants. However, adults over the age of 40 also have a higher risk of developing dacryocystitis . Causes: Causes of dacryocystitis in older children and adults include : Sinusitis: some times called rhinosinusitis   nasal abscess trauma to the region that causes a blockage ( injury to the nose or eye, such as a broken nose) tumors in the sinus , nasal passages bacteria that causes strep or staph infections

64. Types: : it can be either acute or chronic Acute dacryocystitis : Symptoms of acute dacryocystitis start suddenly and often include  fever and pus from the eye . Bacterial infections are usually the cause of acute dacryocystitis , More serious sequela of acute dacryocystitis is the extension into the orbit with formation of an abscess and development of orbital cellulitis . and  antibiotic treatment usually resolves the infection within a few days. chronic dacryocystitis : In cases of chronic dacryocystitis , the onset of symptoms may be more gradual . The symptoms are often less severe, and fever and pus may not be present . However, some people may experience long lasting pain or discomfort from the corner of the eye. Chronic dacryocystitis may be caused by an obstruction in the tear ducts . Treatment: In some severe cases of chronic dacryocystitis , surgery to widen the tear ducts may be needed to relieve symptoms

65. Symptoms: Symptoms of dacryocystitis vary in intensity from person to person and depend on the type. People with acute dacryocystitis often experience more severe symptoms than those with chronic dacryocystitis . Both acute or chronic dacryocystitis can cause the following symptoms: pus and thick discharge from the eye pain in the lower outside corner of the eyelid redness and swelling near the lower outside eyelid watery eye excess tears Fever People with chronic dacryocystitis are less likely to experience pain, redness, or swelling.

66. Diagnosis Diagnosing dacryocystitis is relatively simple. During an exam, a doctor may ask for a person's medical history and then access the eye for visible signs of dacryocystitis , such as swelling or redness . A doctor may press on the lacrimal sac to see if pus comes out. If it does, the doctor may collect a sample of the pus to test for bacteria. In some cases, a doctor may do a dye disappearance test . During this test, the doctor will place yellow dye in the corner of the eye. In a healthy eye, the yellow dye will disappear after a few minutes. If there is a blockage, the dye will linger in the eye for much longer. The dye disappearance test can also indicate whether the tear ducts are partially or entirely blocked. To check the level of blockage , a doctor will then swab inside the person's nose on the side with the suspected blockage. Sometimes , imaging test s like CT scans are done to help the doctor look for the cause of the blockage.

67. Treatment The main treatment for dacryocystitis is antibiotics . These drugs kill the bacteria that caused the infection. Usually you take antibiotics by mouth , but if you have a severe infection, you may get them through an IV . Your doctor might also prescribe antibiotic eye drops or ointment. To relieve pain and swelling from the infection, hold warm compresses to your eye a few times per day. After the infection clears, you may need a procedure called dacryocystorhinostomy (DCR). This surgery bypasses the blocked duct, usually by removing a nearby bone. It allows tears to drain directly from the lacrimal sac into the nose . Widening the duct prevents you from getting infections in the future .

68. Complications An acute infection can become chronic if you don’t treat it quickly enough . In babies with congenital dacryocystitis , the infection can spread into the eye socket. This can lead to life-threatening complications such as : Fistula formation Lacrimal sac abscess brain abscess, a collection of pus in the brain meningitis, or inflammation of the membranes around the brain and spinal cord sepsis, a body-wide inflammatory response caused by infection

69. Risk Factors: Dacryocystitis is most common in babies, who can be born with a blockage of the tear duct. This is called congenital dacryocystitis . Middle-aged women are more likely than men to have a blockage because their duct is naturally narrower . The condition becomes more common as you age. Other risk factors for dacryocystitis include: deviated septum, when your septum (the thin wall between your nostrils) is off-center, making one nostril smaller than the other inferior turbinate hypertrophy, or swelling of one of the bony structures in your nose that help filter and humidify the air you breathe

70. Preventions/Home care: If you or your child often gets tear duct infections , one way to prevent them is to drain the tear sac . Wash your hands , then hold a warm, wet washcloth over the tear sac. Carefully place your finger in the corner of your eye near your nose and apply pressure to the tear sac . Fluid or pus should release from the sac . Afterward, hold the warm compress to your eye again