simplified slide to learn easily about acquired anomalies of lacrimal system.

1. Bipin Bista
Resident
Ophthalmology
NMCTH

2.  h/o : tearing –
epiphora or
lacrimation.
 Constant vs
intermittent
 Period of remission vs
no remission.
 Unilateral vs bilateral.
 h/o lacrimal sac
inflammation
 Subjective ocular
discomfort
 Use of topical
medications
 h/o probing during
childhood
 Prior infections
 Sinus surgeries/mid-
facial trauma
 Clear tear vs
discharge.

3.  Pseudoepiphora
evaluation – tear
meniscus, TBUT.
 Corneal & conjunctival
epithelium evaluation :
staining, Inferior 1/3rd of
cornea is devitalised –
more severe malfunction
with epithelial loss.
 Schirmer’s test
 Corneal irritation
 Lacrimal outflow
evaluation

4.  Eyelid evaluation
 Facial nerve dysfunction
 Carancular hypertrophy & conjunctival
chalosis or frank prolapse.
 ROPAS
 Routine nasal examination

5.  This diagnostic test was first outlined by Lester
Jones.
 Dye disappearance test followed by Jones I & II

6.  Useful for assessing the
presence or absence of
adequate lacrimal
outflow, in unilateral
cases.
 Fluorescein is instilled
in fornices, then observe
tear film – persistent of
significant dye –
lacrimal drainage
dysfunction.
 Hard to rule out :
allergy, dacryolith or
intranasal obstruction.

7.  Investigate whether lacrimal outflow is under
normal condition.
 Instill fluorescein into conjunctival fornices &
recoring it in Inferior meatus by passing a
cotton-tipped wire applicator into the region of
ostium of NLD at 2 & 5 minutes.

8.  In this part cannula is placed in the sac & the
system is irrigated.
 If no fluorescein is passed meaning upper (
canalicular ) abnormality.
 If fluorescein passed meaning lower lacrimal (
sac/duct abnormality.

9.  Most frequently performed test after DDT.
 Done to determine the level of occlusion.
 Difficulty in irrigating, if refluxes from upper
canaliculi, complete blockage.
 Patent : passed freely.

10.  Direct visualization of lacrimal passage.
 Helpful in evaluating lacrimal anatomy.

11. CONTRAST
DACROCYSTOGRAPHY DACROSCINTIGRAPHY
 Knowing the LDS
anatomy by dye
injection into LS
followed by
computerised digital
substraction.
 Physiological
evaluation
 Performs by flowing
radionucleotide drops
to flow as tear using
scintigram.

12.  Results in epiphora
 May be too small (
occlusion & stenosis) or
too big ( iatrogenic).
 May be malpositioned
or occluded by adjacent
structures.
 Punctal stenosis –
treated by dilatation,
punctoplasty or
stenting.
 Regular monitoring
requires as stenting may
cause ‘cheese wiring’.

13.  May be common, upper or lower.
 Diagnostic : canalicular probing.
 SOFT STOP vs HARD STOP.
 Total Functional Occlusion : weakness of
lacrimal pump or inability of tears to pass
through even minimal obstruction . Usually it
is a physiological condition and can be
overcomed by irrigation by creating abnormal
hydrostatic pressure.

15. 1. Lacrimal plug
2. Medication
3. Infection
4. Inflammatory diseases
5. Trauma
6. Neoplasm

16.  Punctal & canalicular
 For dry-eye.
 Diagnosed by :
canalicular probing,
high frequency USG
 Surgical excision of
canaliculi & re-
anastomosis.

17. 2. Medication : systemic chemotherapeutic
agents – 5-fluorouracil, docetaxel, idoxuridine.
3. Infection : HSV, Vaccinia virus.
4. Inflammatory disease : pemphigoid, SJS, graft
vs host disease.
5. Trauma : permanent damage if not managed
at time.
6. If present in medial canthal area, complete
excision along with puncta & canaliculi.

18.  Canalicular stenting : 1st line management.
 Reconstruction : successful if only few mm is
involved. If its proximal then occluded canaliculi is
resected and cut ends of canaliculi is anastomosed.
If occlusion is distal at common canaliculi, then
stenting is required to prevent contracture & for
epithelisation.
 Canaliculodacryocystorhinostomy : If total
obstruction.
 Conjunctivodacryocystorhinostomy : when there’s
severe occlusion. Inferior half of caruncle –
osteotomy—middle meatus.

19.  Obstruction of tube with mucus & migration of
the tube.
 Forced inspiration. “MUST DO”
 Tube foreign body : Pyogenic granuloma
formation – Frosted, angled or modified Jones
tube.
 Porous polyethylene-coated tube.

20.  Usually diagnosed with irrigation.
 Etiology :
 Involutional stenosis
 Dacryolith
 Sinus disease
 Trauma
 Inflammatory disease
 Lacrimal plugs
 Radioactive iodine
 Neoplasm

21.  Most commonly female than in male.
Compression of NLD d/t inflammatory &
edematous condition. Management : DCR.

22.  Dacryolith : cast formation – consists of shed
epithelial cells, lipids & amorphous debris with
or without calcium deposition.
 Occassionally occur with Actinomycetes israelli
or Candida.
 Management : DCR without any difficulty.

23.  Often occurs with or in any instances which
may contribute to NL abnormality.
 H/o – Sinus surgery.

24.  Naso-orbital fracture.
 Early treatment with fracture reduction with
stenting of NLD.
 For late : DCR.

25.  Granulomatous dz
 Sarcoidosis
 WG
 Lethal midline granuloma

26.  Lacrimal plugs : similar to NLD Obstruction.
 Radioactive Iodine : Treatment for thyroid
disease : Closure of lacrimal apparatus.
 Neoplasm : bloody punctal discharge, swelling
above medial canthal tendon : suspicious
 h/o malignancy, sinus or NP
 CT/MRI
 Biopsy : while surgical intervention
 Benign : DCR, CDCR
 Malignancy : certainty of clear margins or
freedom from recurrence – DCR or CDCR .

27.  Intubation & stenting
 Dacrocystorhinostomy (DCR)

28.  Treatment of choice
 Creating an anastomosis between lacrimal sac
& nasal cavity through a bony ostium.
 Types : Internal(endoscopic) & external.
 Internal DCR : lack of visible scar, shorter
recovery period & shorter time .
 Success rate is more in external (90>70)%.
 GA .. LA (strong monitoring)
 Hemostasis

30.  Fibrosis & occlusion of osteotomy
 Common canalicular obstruction
 Inappropriate placement or size of bony ostium

31.  LACRIMAL GLAND (Dacroadenitis)
− Occurs in sterile condition & occurs in
consequence of malignancy.
− Extremely rare condition.
− Gross appearance & abscess formation is quite
uncommon.
− Emperical therapy

32.  Caused by variety of bacteria, viruses & mycotic
organisms.
 Most commonly caused by filamentous gram
positive rod :Actinomycetes israelli
 Complaints : persistent weeping, accompanied by
follicular conjunctivitis centered in conjunctiva.
 Punctum : erythematous
 Milking present.
 Warm compression, massage & topical antibiotics
 Canaliculotomy

34.  Inflammation of lacrimal sac
 Most commonly due to lacrimal
sac obstruction.
 Chronic tear retention & stasis :
secondary.
 C/F :edema & erythema with
distension of lacrimal sac below
medial canthal tendon.
 Complication : Dacryocystocele
formation, chronic conjunctivitis,
& spread to adjacent structure .

36.  Irrigation or probing
 Topical antibiotics : Limited value
 Oral antibioitics : gram positive are common ,
gram negative seen in diabetics &
immunocompromised.
 Parenteral Ab : severe cases.
 Aspiration of lacrimal sac : pyocele, mucocele
 I & D : Localised abscess . Packing- open
 Total obstruction : DCR surgery.

37.  Primary : papilloma, scc
 Primary tumors of tissue surrounding lacrimal
region : eyelid skin (basal & squamous cell),
adenoid cystic carcinoma, capillary
hemangioma, inverted papilloma, epidermoid
carcinoma,osteoma & lymphoma.
 Metastatic tumors

38.  Histologically, 45% are benign and 55 % are
malignant.
 Treatment : Dacrocystectomy (DCT)
 In case of malignancy : DCT with lateral
rhinostomy.
 Exenteration including bone removal in medial
canthal area.

39.  Hypoplasia &
agenesis
 Craniosynostosis
 Lacrimal gland
fistulas
 Duplication
 Congenital lacrimal
cutaneous fistula
 Naso-lacrimal duct
obstruction .