Diseases of Lacrimal apparatus

Anatomy:

Main Lacrimal gland: [serous acinus glands like salivary]

1. ORBITAL part:
   • superior surface is in contact with outer orbital plate of frontal bone.
   • inferior surface is separated from Palpebral part by levator palpebrae superioris.
2. PALPEBRAL part: smaller part continous posteriorly with the larger Orbital part.
3. Ducts of lacrimal gland [10-12] pass downwards to open in lateral part of superior fornix [1or2 in inferior fornix]

Nerve supply:

1. Sensory: trigeminal-ophth-lacrimal.N
2. Sympathetic: cervical carotid plexus.
3. Secretomotor [parasympathetic]: superior salivary nucleus.

Accessory Lacrimal gland:

1. KRAUSE -beneath superior[42] & inferior[6-8] palpebral conjunctiva.
2. WOLFRING -extremes of superior&inferior tarsus.

LACRIMAL PASSAGES:

1. Puncta: opening on papilla of each lid near inner canthus, dipping into lacus lacrimalis [tear collection]
2. Canaliculi: from each puncta a short vertical part right angles with long horz part to converge to open into lacrimal sac.
3. Lacrimal sac: [fundus, body, neck] in lacrimal fossa of medial orbital wall [lacrimal bone, maxilla frontal process]
4. Nasolacrimal duct: [15-18mm] laterally down&backwards in the bony canal formed by maxilla & inferior turbinate, upper part is narrowest; one of its important valve is HASNER which prevents reflux from lower nose.

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Tear film

apart from washing away debris/noxious irritants & providing oxygen to cornea, has 3 layers:

1. outer lipid layer- Meibomian, Zeis, Moll secretion; air-tear interface that lubricates [facilitating movts] eyelids, retains shape & retards evaporation of tears.
2. bulky Aqueous layer- Lacrimal glands’ antibacterial [lysozyme,betalysin,lactoferrin] alkaline/saltish[solutes] watery secretion.
3. thin inner Mucus layer- conjunctival mucin secretory glands’ [goblet, henle, manz] secretion which by its hydrophilic nature keeps cornea & conjunctiva moist.

Tears are continously secreted by lacrimal glands. Basal secretion from accessory glands; Reflex secretion due to sensations[dry epithelium,broken tears] from cornea&conj from Main lacrimal glands; Hyperlacrimation due to irritants.

Elimination of tears by downward&medial flow towards lacus lacrimalis is due to:

1. orbicularis pump mechanism due to its insertion on lacrimal sac creates a negative syphoning pressure due to fundus distension & lower part compression.
2. orbicularis relaxation refills lower part from the fundus.
3. Hence, despite patency, atonia of lacrimal sac causes EPIPHORA.

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DRY EYE: deficiency / abnormality of tear film.

Etiology:

KCS [&darr water]	congenital alacrimia paralytic hyposecretion Sjorgen, RileyDay syndromes
&darr mucin	xerophthalmia [&darr vitA] conjunctival scarring – StevensJohnson, trachoma, pemphigoid, chemicals, radiation.
&darr lipids [rare]	congenital anhydrotic ectodermal dysplasia meibomian abscence – chronic meibomitis, chr blepharitis
&darr blinking	Bell’s plasy, nocturnal lagophthalmos, pterygium, ectropion, exposure keratitis, dellen, symblepharon
Corneal epeithelial abnormality affects tear film stability.

CFs:

• sandy sensation, itch, sore
• unresponsive to eyedrops
• particulate matter, stringy mucus
• lustreless
  • conjunctiva – xerosis, bitot spots, absent marginal tear strip.
  • cornea – punctate epithelial erosions & filaments

TEAR FILM tests:

Break up time	fluorescein is introduced & examined under cobalt blue slit-lamp while the patient is asked to keep blinking	corneal dry spot appearance normal=15-35sec, in unstable tear film <10sec
Schirmer 1	whatman41 filter paper in lower fornix & patient is asked to look up for 5min	[>15mm normal] in severe KCS <5mm.
Rosebengal staining		A pattern = confluent [severe KCS] B pattern = extensive staining [moderate KCS] C pattern = fine punctate stains in interpalpebral area [mild KCS]

Rx:

• artificial tears – cellulose, polyvinyl alcohol.
• &darr evaporation – cool temp, high humidity, glasses, bandage contact lens
• &darr drainage – punctal occlusion with collagen implants, cyanacrylate tissue adherent, electrocautrztn, argon laser, surgery
• &darr viscosity – mucolytic acetylcysteine
• retinoids, NSAIDs, steroids

Sjogren’s syndrome

autoimmune multi-sysytem chronic inflm [focal infiltrate + destruction of lacrimal gland = KCS]

• primary +xerostomia
• secondary +Rharthritis

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Watering eye:

Etiology:

1. Hyperlacrimation -
   1. Primary – direct stimulation, early Lgland tumor/cyst, parasympathomimetics
   2. Reflex – irritation to sensory br of trigeminal.N
      • eyelids – meibomitis, stye, entropion
      • conjunctivitis
      • corneal abrasion, ulcer, keratitis
      • scleritis, episcleritis
      • uveitis
      • acute glaucomas
      • end, pan ophthalmitis
      • orbital cellulitis
   3. Central – emotional, hysterical, voluntary
2. Epiphora -
   1. atonia causing lacrimal pump failure [weak orbicularis]
   2. mechanical obstruction to lacrimal passages
      • punctal obstruction – senile lax eversion, chr conj/blepharitis, ectropion, congenital abscence, foreign body/cicatrial closure, prolonged Rx with idoxuridine pilocarpine causes stenosis.
      • canalicular obstruction – foreign body, strictures from inflm[actinomyces] / trauma.
      • lacrimal sac – congenital folds, traumatic strictures, tumor, stones, atonia, dacryocystitis, TB, syphilis.
      • NLD obstruction – congenital non-canalization, imperforated valves, inflm/traumatic strictures, tumor, bone disease.

Evaluation:

diffuse illumination under magnification	reflex hypersecretion causes, punctal obstruction, Lsac swelling
Regurgitation test [press over Lsac]	mucopurulent discharge thr punctum in chr dacryocystitis
Flourescein dye disappearance	retention of dye in conjsacs is due to obstruction to passages
Lacrimal syringing with N.saline into lower punctum under topical anaesthesia 4%xylocain	partial obstruction requires more pressure while syringing for free passage into nose reflux from the same lower punctum indicates lower canalicular obstruction if on repeating the syringing thr upper punctum also causes reflux from opposite lower punctum, then it indicates common canalicular obstruction reflux thr opposite upper punctum indicates NLD/ Lsac obstruction.
Jones dye [flourescein into conjsac, 5min & cotton bud at NLD end]	positive dye stain indicates primary hyperlacrimation negative unstaining indicates epiphora on syringing gives positive stain, then it indicates partial obstruction causing the retained dye in Lsac. still negative unstaining indicates pump failure.
Dacryocystography [Xrays after radioopaque dianosil.condray280 into Lsac]	obstruction extent, fistulae, diverticulae, stone, tumor
Non-invasive Scintillography with radioactive tracer [sulphur, technitium] to visualize passages with gamma camera

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Dacryocystitis: [Lsac inflm]

Congenital dacryocystitis:

etiology:	symptoms:	complications:
NLD obstruction [membranous(mostly at hasner), epithelial debris, non-canlization, bony occlusion] + infection [staph, strep, pneum]	mild chronic inflm epiphora after 7days copious mucopurulent discharge positive regurgitation test [swelling]	recurrent conjunctivitis chronic dacryocystitis abscess, fistulae

Rx:

1. age <8wks : antibiotic drops + massage[hydrostaticP] to open membranous occlusion
2. >2mos: irrigation &uarr HydraulicP
3. >4mos: bowmann’s probe, if unsuccessful silicone intubation of NLD for 6mos.
4. >4yrs: DCR surgery

Adult dacryocystitis:

Chronic [more common]	Acute
Etiology: chronic NLD obstruction &darr mild infection of conjunctiva, nose, sinuses.	acute exacerbation of chronic disesa or direct extension of infection from neighbouring structures
predisposers: 40-60 age, narrow NLD [females, heriditary], poor hygiene. stasis causes- narrow bony canal, partial canalization, mem folds foreign body, polyp, hypertrophied concha, tumor, DNS hyperlacrimation inflmmatory epithelial debris & mucus plugs stenosis from atrophic rhinitis organisms – staph, strep, pneum, pseudomonas, [granulomatous]
Stages:	Stages:
chronic catarrhal - mild inflm of Lsac [red inner canthus] NLD obstruction epiphora- regurgitation test shows clear fluid [few mucoid flakes]	cellulitis- red hot painful firm swelling epiphora constitutional – fever, malaise
mucocoele- swelling just below inner canthus epiphora – regurgitation test shows mucoid discharge [negative regurgitation test is seen in ENCYSTED mucocoele(large fluctuant swelling) due to obstruction of opening of canaliculi into Lsac. Rx: conjunctivocystorhinostomy.	Abscess- canalicular obstruction causes pus to burst Lsac's ant wall forming a fluctuant PERICYSTIC swelling which due to gravity&ligament opens below&out.
Pyocoele- red swelling, epiphora, conjunctivitis regurgitation test shows purulent discharge.	fistula discharging spontaneously.
chronic fibrotic sac- thickenned mucosa from repeated infection [dacryocystography shows a small sac with mucosal folds]
complications: chronic intractable conjunctivitis lower lid ectropion, skin maceration, eczaema corneal abrasions, hypoyon ulcer surgery on unresolved infection causes endophthalmitis, ∴ prior syringing is essentisl.	complications: conjunctivitis lid abscess corneal ulcer facial cellulitis, osteomyelitis, ethmoiditis cavernous sinus thrombosis septecaemia
Rx: recent cases require SYRINGING + topical antibiotics later DCR is essential [DCT indications: aga60, fibrotic Lsac, granulomatous infection, tumor, atrophic rhinitis	Rx: topical&systemic antibiotics for cellulitis abscess requires draining & later DCT/DCR end stage requires fistulectomy with DCT/DCR

DCR:

• general anaesthesia
• skin incision medial to canthus
• expose MPligament & antLcrest
• dissect Lsac
• expose thick oink nasal mucosa
• prepare lacrimal & nasal H-flaps
• suture nasal with lacrimal flaps.

DCT – Lsac is removed & infected NLD parts are curettaged.