This presentation discusses

1. Evaluation of nasolacrimal system
Balasubramanian Thiagarajan
Autor: 17.09.12

2. Why should we bother?
● Otolaryngologists perform endoscopic
dacryocystorhinostomy more and more
● Helps in deciding whether the patient will benefit
from this procedure
● Operating surgeon should clinically examine
patients before surgery
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3. History
● Anatomy of
nasolacrimal pathway –
Hamurabi 2200 BC
● Endo-DCR first
described by Caldwell
1893
● External DCR – Toti in
1904
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4. Epiphora (Downpour)
● Excessive lacrimation
● Defective drainage
● Lacrimal pump failure
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5. Classification of Epiphora
● Congenital causes
● Acquired causes
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6. Congenital
● 1% of infants
● Self limiting disorder
● Massaging of the sac helps
● Probing beneficial
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7. Acquired
● Primary acquired nasolacrimal duct obstruction
● Dacryocystolithiasis
● Orbital / lacrimal trauma
● Canalicular lacerations
● Actinomyces within canaliculi
● Canalicular lesions following herpes / antiviral
therapy (+ h/o keratoconjunctivitis)
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8. Anatomical obstruction
● Pathologies involving sac
● Canalicular stenosis / blockage
● Obstruction to nasolacrimal duct
● Formation of diverticula
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9. Types of obstruction
● Intrinsic – caused by internal derangements of the
mucosal lining of lacrimal apparatus
● Extrinsic – Caused by extraneous deforming lesions
which can deform the drainage channel as is the
case in tumors.
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10. Epiphora (Physiologic)
● No anatomical changes in the lacrimal pathway
● Lacrimal pump mechanism is at fault
● Eye lid malpositions, eversion of punctum, poor
orbicularis oculi muscle tone
● Bell's palsy
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11. Epiphora Grading (Sahlin)
Grade Degree of epiphora
0 No epiphora
1 Epiphora only outdoors and during
windy times
2 Outdoor epiphora No indoor
epiphora
3 Outdoor and indoor epiphora
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12. Anatomy of lacrimal system
● Nasolacrimal duct is
18mm long
● Junction between
common canaliculus
and sac is guarded by
Rosenmuller valve
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13. Sites of lacrimal system block
● Suprasaccal
● Saccal
● Subsaccal
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14. Suprasaccal obstruction
● Obstruction is proximal
to sac
● Upper canaliculus
● Lower canaliculus
● Common canaliculus
● Herpes infection,
trauma, irradiation
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15. Saccal obstruction
● Obstruction at the level
of sac
● Tumor
● Diverticula
● Trauma
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16. Subsaccal obstruction
Incomplete Compete
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17. Functional obstruction
● Lacrimal system is patent to syringing still there is
epiphora
● Obstruction is to be used only for anatomical
obstruction
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18. Causes of excessive tearing
● Hypersecretion
● Epiphora
● Combination of both
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19. Diagnostic evaluation
● Quantification of tear production
● Assessment of nasolacrimal system patency
● Differentiating epiphora from lacrimation
● Defining the pathological process
● Differentiating anatomical from functional
obstruction
● Attempting to locate the site of obstruction
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20. Classification of tests to evaluate
lacrimal system pathway
● Anatomical tests
● Functional tests
● Secretory tests
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21. Anatomical tests
● These tests helps in localization of obstruction
● Palpation of sac
● Syringing / irrigation
● Diagnostic probing
● Dacryocystography
● Nasal exam
● CT/MRI
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22. Functional tests
● To access functioning of lacrimal apparatus under
physiologic conditions
● Performed only when there is no evidence of
obstruction in anatomical tests
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23. Functional tests (contd)
● Flourescein dye disappearance test
● Scintigraphy
● Jones dye test I
● Sacharin test
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24. Tests for lacrimal secretions
● These tests are performed to access secretory
functions of lacrimal apparatus
● Schrimers test
● Bengal Rose test
● Tear-film break up
● Tear lysozyme
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25. Causes of excess lacrimation
● Supranuclear causes – Psychogenic / emotions
● Stimulation of V nerve
● Infranuclear causes
● Lacrimal gland stimulation
● Other causes – Bright lights / sneezing
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26. Stimulation of V nerve
● Reflex tearing
● Lid causes – Blepharitis / trichiasis
● Conjunctival diseases
● Corneal diseases
● Neuralgia
● Ocular inflammation
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27. Infranuclear causes
● Facial palsy
● Aberrant innervation
● Crocodile tears
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28. Epiphora causes
● Functional insufficiency – incorrect lid closure, lid
malposition, punctal eversion, punctal medialization
● Anatomical obstruction
● Combination of functional insufficiency and
anatomical obstruction
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29. Combined epiphora
● Facial nerve palsy – corneal irritation and pump
defects
● Lower lid ectropion – conjunctival irritation and
pump defects
● Thyroid diseases – corneal irritation and defective
canalicular function
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30. History taking
● Provides vital clues to the presence of canalicular
disorders
● H/o present /past opthalmological problems
● Nasal symptoms
● Previous surgeries
● Unilateral tearing – obstruction
● Bilateral tearing - Physiological`
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31. Inspection & palpation
● Eye lids
● Medial canthus
● Palpation of sac
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32. Eye lid examination
● Lower lid laxity
● Ectropion
● Punctal eversion
● Trichiasis
● Blepharitis
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33. Snap back test
● Test for lower lid laxity
● Lower lid is pulled down and away from the orbit
● On release the lid resumes normal position
● Time taken for the lid to get back to normal postion
is noted
● Longer the duration more lax is the lower lid
● Graded over a scale of 0-4
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34. Lid examination (contd)
● Medial canthal laxity
● Lateral canthal laxity
● Orbicularis oculi muscle tone check
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35. Examination of medial canthus
Neoplasm Sac enlargement
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36. Sac palpation
● Normal sac not palpable
● Sac is palpable below
the medial canthus
● Reflux of tears / pent up
secretions
● Pain / tenderness –
acute dacryocystitis
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37. Dye excretion test
● Drainage function of entire lacrimal apparatus can
be tested
● Fluorescein dye is used for this purpose
● This test is more physiological
● This test does not differentiate anatomical from
physiological causes of nasolacrimal obstruction
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38. Fluorescein dye test
● 1% fluorescein is instilled into the conjunctiva
● Conjunctiva is not anaesthetized
● After 5 mins thickness of fluorescein of the tear
meniscus is measured using cobalt blue filter
● This test can be safely performed in infants &
children
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39. Fluorescein dye test (contd)
● Presence of residual fluorescein gives no
information regarding localisation of block
● Presence of residual fluorescein is an indication for
probing and syringing
● When performing this test in children they should be
held in vertical postion
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40. Dye test grading
● 0=No fluorescein in the conjunctival sac
● 1=Thin flurescing marginal tear drop persists
● 2=More fluorescein persists somewhere between 1
and 3 grades
● 3=Wide brightly fluorescein tear strip
● Grades 0 and 1 are considered normal
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41. False negative dye test
1. Large lacrimal sac
2. Mucocele
3. Distal nasolacrimal duct block
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42. Break up time test
● Performed by placing a drop of fluorescein in the
outer canthus of the eye
● Its transport can be observed from lateral to medial
● Holes in the tear film can also be observed
● Normal breakup time is 15-30 secs
● Breakup time of less than 10 secs indicate epiphora
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43. Jones dye test
● Distinguishes between
functional and
anatomical obstruction
● Topical xylocaine
application
● Flurescein dye instilled
● Negative result
indicates functional /
anatomical block
● Useless in total
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44. Saccharin test
● Similar to fluorescein dye test
● Physiological
● Saccharin is placed in conjunctiva
● Saccharine taste appears within 3.5 mins
● Pt should have normal taste sensation
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45. Probing & syringing
● Invasive test
● Provides information regarding site of obstruction
● Useless in functional obstruction
● This is not a physiological test
● This test should be interpreted with fluorescein dye
test and clinical examination
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46. Syringing (contd)
● Topical xylocaine applied
● Punctum dilator applied to dilate punctum
● Tip of irrigator placed in the inferior canaliculus. It
is directed first vertically and then horizontally.
Eyelid is stretched
● Tip is advanced 3-7 mm into canaliculus and saline
is injected
● Irrigation should not be forced
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47. Syringing (Interpretation)
● Regurgitation through opposite punctum –
obstruction in the common canaliculus or more
distal structures
● Regurgitation via the same punctum indicates
punctal obstruction
● Drainage via nose does not rule out physiological
obstruction
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48. Diagnostic probing
Hard stop Soft stop
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49. Irrigation / probing interpretation
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50. Radiological evaluation
● Dacryocystography
● Nuclear lacrimal scintigraphy
● CT
● MRI
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51. Dacryocystography
● Anatomical investigation
● Creates interior image of the entire lacrimal system
● Radio opaque water soluble dye is injected into the
canaliculus
● Magnified images are created
● Digital subtraction is used
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52. Radiologic criteria of lacrimal
pathology
● Regurgitation of radio-opaque fluid into the
conjunctival sac
● Absence of fluid in the nose
● Fluctuation of lumen of lacrimal system
● Irregularity in contrast
● Deformation involving lacrimal sac
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53. Nuclear lacrimal scintigraphy
● Non invasive physiological test
● Utilizes radiotracer technitium-99M pertechnitate.
● Images can be captured using epiphora
● Drop of technetium-99m instilled into conjunctiva
● Recording is made using gamma camera
● 20 mins is the recording time
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54. CT/MRI
Helpful in identifying
adjacent areas and other
mass lesions
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55. Secretory tests
● Schimer's test
● Rose bengal test
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56. schirmer's test
● 35x5 mm paper
● 5 mins duration
● 10-30 mm wetness
normal
● Above 30mm epiphora
● 10mm dryness
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57. Thankyou
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