Lacrimal System

Lacrimal Apparatus
 Main Lacrimal Gland
Orbital part – size of almond, situated in fossa at outer part of
orbital plate of frontal bone
Palpebral part – small consists of one or two lbules situated in
the course ducts from orbital part , separated by LPS muscle
Ducts – 10-12 open into lateral part of upper fornix
 Accessory Lacrimal Glands
Krause Microscopic glands located beneath palpebral
conjunctiva between fornix and edge of tarsus
Glands of Wolfring –sitauted along upper border of sup tarsal
plate and lower border of lower tarsus
Lacrimal Gland

 Blood supply Lacrimal artery

 Nerve supply – Sensory- Lacrimal Nerve
 Sympathetic – Carotid plexus
 Secretomotor – Superior Salivary nucleus- Greater petrosal
nerve- Pterygopalatine ganglion – zygomatic Nerve –
Lacrimal nerve – Lacrimal gland
Lacrimal Passage

 Lacrimal Puncta
 Lacrimal canaliculi
 Lacrimal Sac
 Nasolacrimal Duct- At lower end Valve of Hasner
Tear film - Structure
 Mucinous layer 0.2 micron thick made up of mucin secreted by
Globlet cells and glands of manz
Converts hydrophobic corneal surface into hydrophilic one
 Aqueous Layer 7.0 micron thick Formed by tear secreted
by main and accessory lacrimal gland
Contains anti bacterial substances like lysozyme,
beta lysin, lactoferin IgA, IgG, IgM,
 Lipid Layer - outermost and thinnest of tear film
Forms air tear interface
Formed secretions of Meibomian , Zeis and Moll Glands
Prevents overflow of tears, retards evaporation, lubricates
the eyelids as it moves over the globe
Functions of Tear Film

 Keeps cornea and conjunctiva moist,

 Maintains corneal surface optically uniform
 Washes away debris, prevents infection
 Facilitates movements of lids over the globe
Dry Eye causes
Aqueous Deficiency(Keratoconjunctivitis Sicca)
 Sjogren’s Syndrome
 Age related hypo secretion
 Alacrima,
 Infiltration of Lacrimal Gland - Sarcoidosis
 Fibrosis following radiation
 Surgical Removal-
 Obstruction lacrimal gland duct- Trachoma, Chemical
Burns, pemphigoid stevens Johnson syndrome
 Chronic use of drugs
Evaporative Causes dry eye
1. Intrinsic Cause
 Meibomian Oil Deficiency
 Disorders of lid aperture
 Low blink rate

2. Extrinsic cause
 Vitamin A deficiency
 Tropical drug preservatives
 Contact lens wear
 Occular surface disease eg.Allergy
DRY EYE

 SCHIMER TEST :
a. Schimer test 1:
b. Schimer test 2
Schirmer Test
Schirmer Test -I
 evaluate aqueous-deficient dry eye
 performed without anesthesia
 reflex & basal tear secretion
 <10 mm is considered diagnostic of
aqueous tear deficiency
 less than 5 mm is diagnostic of severe
aqueous tear deficiency
 Schirmer Test –II
 Performed with anesthesia measures basal secretion
TEAR FLIM BREAK UP TEST
 Interval between complete blink and appearance of
first randomly distributed dry spot on cornea
 Normal value is 10 sec.
 <10 sec indicate an abnormal or unstable tear film.

Rose Bengal Staining

 Useful in detecting mild KCS
 Stains devitalized epithelium
 Staining in interpalpebral area
 Dacryoadenitis
 Inflammation of the lacrimal gland
 Etiology:
Infectious- Viral (EBV, mumps,adenovirus,varicella
zoster), Bacterial
Autoimmune disorders
Dacryoadenitis
Symptoms:
 Pain in the superolateral orbit
 Droopy upper eyelid or difficulty opening
the affected eye
 Redness of the eye
Dacryoadenitis
SIGNS:
 Tenderness, edema, erythema or induration overlying the
superolateral orbit
 Lid ptosis
 Conjunctival injection with or without chemosis
 Regional lymphadenopathy
 Proptosis, limitation of ocular motility
DACRYOADENITIS INVESTIGATIONS:
 A contrast-enhanced CT scan of the orbits will typically demonstrate
enlargement of the affected lacrimal gland with enhancement
DACRYOADENITIS -TREATMENT

 Observation and symptomatic treatment for viral dacryoadenitis.

 Bacterial dacryoadenitis will require systemic broad spectrum
antibiotics and, when indicated, abscess drainage.
 Oral corticosteroids may be considered especially in idiopathic
dacryoadenitis
 Dacryocystitis

 Inflammation of the lacrimal sac is known as dacryocystitis.

Classification
 Congenital dacryocystitis
 Acute dacryocystitis
 Chronic dacryocystitis
 Chronic dacryocystitis

 It is more common.

 Result of chronic obstruction of the nasolacrimal duct

 The essential symptom is epiphora.

 There may be a swelling at the site of the sac (a mucocele)

Pathophysiology

 Dacryocystitis typically occurs secondary to obstruction of the

nasolacrimal duct.
 Obstruction of the nasolacrimal duct leads to stagnation of tears in a
pathologically closed lacrimal drainage system
 Stagnated tears providing a favorable environment for infectious
organisms.
 The lacrimal sac will then become inflamed leading to the
characteristic erythema and edema at the inferomedial portion of the
orbit.
Chronic Daryocystitis
• Females are at greater risk due to their narrower duct diameter as
compared to males
Aetiology
• Nasal septum deviation, Nasal Polyp, Atrophic rhinitis and turbinate
hypertrophy
• Damage to the nasolacrimal system due to trauma – Fracture maxilla
• Neoplasm , Granulomatous inflammation or fungal infection of
Lacrimal sac
 Regurgitation Test or ROPLAS test
 Sac Syringing
 Dacryocystography
 Macro dacryocystography
 Dacryo scintigraphy
TREATMENT:

 DCR – treatment of choice

 Stenting
 Balloon dacryoplasty
 SURGICAL INDICATIONS :

DCR
 Persistent congenital lacrimal duct obstructions
 Congenital lacrimal duct obstructions associated with mucocele, dacryocystitis and not
responsive to other treatments
 Primary acquired nasolacrimal duct obstructions
 Secondary acquired nasolacrimal duct obstructions.

DCT
 in patients with NLDO who are unfit for DCR(<4years or >70years)
 Preferable in cases of NLDO associated with dry eyes
 For granulomatous leisons and tumous of lacrimal sac
 ACUTE DACRYOCYSTITIS

 Acute suppurative inflammation of the lacrimal sac

 Most common -
Staphylococcus and Streptococcus species, followed
by Haemophilus influenza and Pseudomonas aeruginosa
Clinical features:

 Skin over the sac becomes red and swollen.

 The redness and swelling rapidly extend to the lower lid and upper
part of the cheek.
 Severe pain, and often slight fever.
 The abscess usually points below and to the outer side of the sac
TREATMENT:

 Conservative measures such as warm compresses

 For uncomplicated cases- oral antibiotics
 In complicated cases or patients who appear toxic - intravenously
antibiotics should be administered.
 Empiric antibiotics should include gram positive and gram negative
coverage.
 Abscess pointing under the skin - a small incision should be given, the
pus gently squeezed out
 Congenital dacryocystitis

 Due to incomplete canalization of the lacrimal system, most often

the valve of Hasner.

 Needs aggressive therapy as the infection can spread to become

an orbital cellulitis, leading further to even meningitis
Treatment:
 In the newborn, antibiotic drops and frequent expression of the contents
of the sac cure most infections.
 Hydrostatic pressure is applied by massaging downwards and medially
with a clean thumb behind the lacrimal crest
 If, however, 1 year elapses without marked improvement,
an anaesthetic should be given and probing of the nasolacrimal duct through
the upper canaliculus carried out

 A balloon dilatation of the duct or placement of a silicone tube may be used

as a secondary procedure.

 >4yrs : DCR