Describe the anomaly of the lacrimal drainage system Abikoye O. P.

Ophthalmology Department (OOUTH) OUTLINE INTRODUCTION FUNCTIONAL ANATOMY OF THE LACRIMAL DRAINAGE SYSTEM PHYSIOLOGY OF TEAR DRAINAGE OVERVIEW OF THE ANOMALIES DISUSSIONS CONCLUSION INTRODUCTION The tear manufacturing and clearing system. Secretory System The lacrimal & accessory lacrimal gland Accessory Sytem (The Spreading and Pumping System) Excretory System BASIC SECRETORS 1.Accessory lacrimal glands of Krause: 40 in the upper conjunctival fornix and about 6 in the lower fornix: 2.Accessory lacrimal glands of Wolfring: usually 3 adjacent to the upper margin of the upper tarsus and one below the lower tarsus. 3.An occasional gland in the plica; in the caruncle an infraorbital gland may be found. Location: Subconjunctival tissue. Function: Exocrine glands which form the intermediate layer of the precorneal tear film. REFLEX SECRETORS The Lacrimal gland (DRAINAGE) ACCESSORY SYSTEM THE EYELIDS (Distributes/ spreads) THE LID MARGIN & THE TEAR LAKE (Retains and/or directs the tear film) THE BLINKING REFLEX (The pump) FUNCTIONAL ANATOMY OF THE DRAINAGE SYSTEM PUNCTUM AMPULLA CANNALICULI Vertical part Horizontal Part Common Cannaliculus(In 90% of patients, both join to form a single common duct which enters a small diverticulum of the sac, the lacrimal sinus of Maier. The entry point is just behind the middle of the lateral surface of the lacrimal sac, about 2.5mm from the apex.) LACRIMAL SAC NASOLACRIMAL DUCT Lacrimal Fascia The periorbita splits at the posterior lacrimal crest, encloses the sac and meet at the anterior lacrimal crest forming the lacrimal fascia. Relations:

Medially: above, the anterior ethmoidal sinuses and below, the middle meatus of the nose. Laterally: Skin, orbicularis fibres, lacrimal fascia, medial palpebral ligament and the angular vein. Posteriorly: Lacrimal fascia and muscle, septum orbitale and the check ligament of the medial rectus. INTERNAL STRUCTURE OF THE MEMBRANOUS CONDUIT FOR LACRIMAL ELIMINATION Valvelike folds are diagrammatically represented: 1, valve of Rosenmller 2, valve of Krause 3, spiral valve of Hyrtl 4, valve of Taillefer 5, valve of Hasner or plica lacrimalis Blood Supply 1.Superior 2.Inferior palpebral branches of the ophthalmic artery 3.Angular artery 4.Infraorbital artery 5.Nasal branch of the sphenopalatine artery

VENOUS DRAINAGE 1.Angular veins 2.Infraorbital veins 3.Nasal veins LYMPHATIC DRAINAGE 1.Submandibular 2.Deep cervical glands

NERVE SUPPLY 1.Infratrochlear 2.Anterior superior alveolar nerves DEVELOPMENT OF THE LACRIMAL PASSAGE A. 10MMSTAGE The lacrimal sac develops from a solid column of surface ectodermal cells which sinks into the furrow between the lateral nasal and maxillary prominences. B. 15MM STAGE It becomes free from the surface ectoderm and grows into the lids to form the canaliculi and into the nose to form the nasolacrimal duct. C. AT ABOUT THE THIRD MONTH canalization occurs by degeneration and shedding of the central cells, first in the region of the lacrimal sac. D. AT 6 MONTHS It reaches the nose and the puncta at 7 months. Embryology of lacrimal drainage system

A. At 5.5 weeks' gestation, an ectodermal invagination forms between the lateral nasal process and maxillary process, which becomes pinched off from the surface. B. At 6 weeks' gestation, a solid cord of ectoderm is located between the primitive medial canthus and nose. C. At 12 weeks' gestation, proliferation of the cord occurs laterally toward the eyelid and inferiorly toward the inferior turbinate. The isolated cavities shown appear at 3 to 4 months. D. At 7 months, canalization is nearly complete, with only the puncta and valve of Hasner remaining imperforate. Structure Epithelium is composed of 2 layers superficial columnar and deeper flattened cells both reaching the basement membrane. It is non-ciliated and may contain some goblet cells and mucous glands. Substantia Propria: Consist of adenoid tissue overlying a fibroelastic tissue layer, having a rich vascular plexus which transforms it into a cavernous erectile tissue similar to that of the inferior turbinate. PHYSIOLOGY OF TEAR DRAINAGE EVAPORATION 10% of tear elimination in the young and 20% or more in the elderly. PUMP ACTION Most of the tear flow is actively pumped from the tear lake by the actions of the o rb icu lar is muscle. PUMP MECHANISM ROSENGREN-DOANE (contraction of the orbicularis ), The contraction is thought to produce positive pressure in the tear sac, forcing tears into the nose. As the eyelids open and move laterally, negative pressure is produced in the sac. This pressure is initially contained by opposition of the eyelids and therefore the puncta. When the eyelids are fully opened, the puncta pop open and the negative ressure draws tears into the canaliculi. OVERVIEW OF ANOMALIES CONGENITAL DEVELOPMENTAL ACQUIRED CONGENITAL LACRIMAL DRAINAGE ANOMALIES Pathogenesis: problems with embryogenesis of the drainage system. These are: DACRYOSTENOSIS ABSENCE OF VALVES (Absence of valve of Hasner, may lead to pneumatocele of the sac, reterograde air passage with nose blowing, if Rosenmuller valve is also absent, it is possible to blow air into the eye from the nose.) ANOMALIES OF THE SAC (lacrimal anlarge duct, lacrimal diverticulum) ANOMALIES OF THE PUNCTA (Congenital atresia, supernumerary or double puncta, congenital slitting of the puncta, lateral displacement of the puncta also occur in blepharophimosis syndrome). ANOMALIES OF THE CANNALICULI (Atresia or failure of canalization of the lacrimal

canaliculi may occur in junction with punctal atresia.) EPIDEMIOLOGY/MORBIDITY 2-4% of Neonates. Nasolacrimal Duct Obstruction 35% Punctal Agenesis 15% Congenital Fistulas 10% Craniofacial defects 5% Amniotocele Dacryocystitis (Acute mucocele or Pyocele) Tearing and Mattering No racial or sex differences CLINICALS HISTORY PRESENTATION Complaints usually come up in neonatal period with Tearing, matting of the lids, constant but may be recurrent in nature with or without (mucopurulent discharges) Some present with features attributable to dacryocystocele or dacryocystitis (not common in neonatal period) with swelling and inflamed skin over the lacrimal sac and purulent discharge. PREGNANCY BIRTH AND NEONATAL HISTORY These anomalies are sporadic. Possible influencing factors include: Genetic Prematurity Maternal Infection and or Drug use during pregnancy DEVELOPMENTAL HISTORY (HISTORY OF OTHER BIRTH DEFECTS) For few patients with serious CLD anomalies Ocular abnormalities (20% of patients) Systemic abnormalities (25% of patients) PAEDIATRIC REVIEW OF SYSTEMS Other possible complications of the defect or Comorbid conditions EXAMINATION Complete Ophthalmic Assessment starting the from visual acuity Ocular Examination (Eye lashes, conjuctival and Corneal appearance, diameter and clarity, telecanthus, ectropion, entropion and other lid margin anomalies) Most importantly, gentle digital pressure over the sac (reflux of mucoid secretion) Systemic Examination EVALUATION 1. Marginal tear strip 2. Dye Disappearance Test (Graded as Good, Fair or Bad) 3. Probing and irrigation (done only after ascertaining patency of the punctum). Check for distension of the sac, reflux through the upper cannaliculi or perception of the taste by the patient. A hard or soft stop, or a kink) 4. Jones Dye Test (Primary and Secondary) 5. Swabing of purulent dischage/secretions for laboratory srudies 6. Intubation dacryocystography 7. X-ray of the Sinuses 8. CT Scan/ MRI CONGENITAL NASOLACRIMAL DUCT OBSTRUCTION AETIOPATHOGENESIS Membranous blockage of the valve of Hasner covering the nasal end of the NLO May be present in roughly 50% of newborn infants.

Most obstructions open spontaneously with in 4-6 weeks PRESENTATION After birth such an obstruction becomes clinically evident in only 2%-6% of full-term infants at 3-4 weeks of age. Of these, one-third have bilateral involvement. Approximately 90% of all symptomatic congenital NLD obstructions resolve in the first year of life. CONGENITAL NASOLACRIMAL DUCT OBSTRUCTION MANAGEMENT Conservative (nonsurgical) and Surgical CONSERVATIVE options include Observation, Lacrimal sac massage, and Topical antibiotics. The long-term use of topical antibiotics may be needed to suppress chronic mucoid discharge with matting of the lashes. 1.PROBING AND IRRIGATION Diagnostic, theraputic, may be traumatic. Soft stop, kink, hard stop or patent. 2.Intubation With a silicone stent indicated (for children who have recurrent epiphora following nasolacrimal system probing or for older children when initial probing reveals Significant stenosis or scarring. Intubation is also useful for upper system abnormalities such as canalicular stenosis and agenesis of the puncta. Nasolacrimal intubation after failed probing has a reported success rate of greater than 70%. 3.Balloon dacryoplasty Balloon catheter dilation of the nasolacrimal. A collapsed balloon catheter is placed in a manner similar to probing and inflated inside the duct at multiple levels Indications (congenital nasolacrimal obstruction). now generally limited to complicated cases or to recurrence following standard probing techniques. 4.TURBINATE INFRACTURE Done when imparction of the NLD on the inferior meatus is suspected. This condition should be suspected in patients whose symptoms appear primarily related to upper respiratory tract infections, when swelling of the mucosa over the turbinate may cause intermittent obstruction of the inferior meatus. DACRYOCYSTORHINOSTOMY(DCR) Usually reserved for children who have persistent epiphora following intubation and balloon dacryoplasty and for patients with extensive developmental abnormalities of the nasolacrimal drainage system that prevent probing and intubation. DACRYOCYSTOCELE May result from congenital NLD obstruction Mucoceles may form within the lacrimal sac or within the nasal cavity. Distention of the nasal mucosa into the nasal cavity at the level of an occluded valve of Hasner may also occur. The intranasal portion often extends inferiorly under the inferior turbinate, where it can be observed during nasal examination.

 TREATMENT Prophylac tic topical antibiotics and massage. If there is no response in 1-2 weeks or if infection develops,

Probing of the lacrimal drainage system may be needed.

Excision or marsupialization of the prolapsed distended duct with nasal endoscopy is often necessary.

Urgent treatment may be needed if the condition is bilateral and causes airway obstruction. CONGENITAL LACRIMAL CUTANEOUS FISTULA With an otherwise normal canalicular system or lacrimal sac is occasionally encountered infranasal to the medial canthal area Frequently asymptomatic or associated with a minimal amount of tearing. Approximately one-third of patients have an underlying NLD obstruction +/- Chronic mucoid discharge from the affected nasolacrimal sac may be present. Direct surgical excision of the epithelium-lined fistulous tract with direct suture closure is indicated. In patients with underlying NLD obstruction and chronic dacryocystitis, silicone intubation of the NLD may also be required. ACQUIRED ANOMALIES Punctal Anomalies Canaliculi anomaly Obstruction (from various causes) Infections Neoplasms Trauma ACQUIRED PUNCTAL ANOMALIES Punctal Stenosis (too small) Dilated (or too big, usually iatrogenic), Malpositioned or Occluded by adjacent structures. Causes Inflammatory (Stevens- Johnson syndrome or pemphigoid), Infectious (herpetic), and Iatrogenic (deliberate occlusion in the treatment of dry-eye disease) punctal ectropion. Management Dilation, Punctoplasty, or stenting. Treatment of complete occlusion consists of surgical canalization and, in most cases, stenting. DILATEDPUNCTUM Also cause epiphora

Causes Iatrogenic injury. Aggressive punctoplasty Excision of adjacent neoplasms Treatment Stenting of the lacrimal drainage system. Stents should be removed if punctal deformation is detected. PUNCTAL MALPOSITIONING Displacement of the punctum from the normal position Causes Ectropion Entropion Conjuctivochalasis Hypertrophied caruncle Centurion Syndrome Tumour of adjacent structure Treatment Treat the underlying cause ACQUIRED CANALICULI ANOMALY CANALICULI OBSTRUCTION (Constriction or occlusion) Involutional Stenosis (f:m =2:1, edema & Inflammatory infilterates due to unidentifiable infection or autoimmune disorders) Iatrogenic (Therapeutic punctal plug for epiphora treatment which have migrated) Dacryolith (Cast formation within the lacrimal sac consisting of shed epithelial cells, lipids and morphous debris) Infection (canaliculitis, sinus disease) Inflammatory Disease (granulomatous diseases like sarcoidosis, Wegeners granulomatosis, pemphigoid, Steven Johnson) Trauma Neoplasm (Level of suspicion increased with presence of bloody punctal discharge or sac distension above the medial canthal tendon) Diagnosis Irrigation Management Intubation and or stenting Canaliculodacyocystorhinostomy (Common canaliculus obstruction) Dacryocystorhinostomy (TOC, for recurrent dacryocystitis, chronic mucoid reflux, painful distension of lacrimal sac) Conjuctivodacryocystorhinostomy (CDCR, complete bypass of the drainage system. With Jones tube) INFECTIONS CANALICULITIS DACRYOCYSTITIS CANALICULITIS Infection within the canaliculus Organisms (Filamentous G+ rod, actinomycetes) Presentation weeping eye, +/- Follicular conjuctivitis, punctal pouting, Treatment Culture and sensitivity, warm compresses, digital massage, topical antibiotics initially braod

spectrum Actinomycetes may form concretion (stones) and not accessible to the antibiotic agent, Canaliculotomy DACRYOCYSTITIS ACUTE inflammation of the lacrimal sac. common factor is complete NLD obstruction that prevents normal drainage from the lacrimal sac into the nose. Chronic tear retention and stasis lead to secondary infection. Organisms Gram-positive bacteria are the most common cause of acute dacryocystitis. However, the clinician should suspect gram-negative organisms in patients who are diabetic or Lml11unocomprornised orin those who have been exposed to atypical pathogens (eg, individuals residing in nursing homes). Clinical findings Edema and erythema with distension of the lacrimal sac below the medial canthal tendon The degree of discomfort ranges from none to severe pain. Complications include dacryocystocele formation, chronic conjunctivitis, and spread to adjacent structures (orbital or facial cellulitis). ACUTE DACRYOCYSTITIS Irrigation or probing of the canalicular system should be avoided until the infection subsides. Topical antibiotics are of limited value. They do not reach the site of the infection because of stasis within the lacri_mal drainage system. They also do not penetrate sufficientl y within the adjacent soft tissue. Oral antibiotics are effective in most infections. Parenteral antibiotics are necessary for the treatment of severe cases, especially if cellulitis or orbital extension is present. Aspiration of the lacrimal sac if a pyocele is present- mucocele is localized and approaching the skin. A localized abscess involving the la crimal sac and adjacent soft tissues requires incision and drainage. The incised abscess is packed open and allowed to heal by second intention. This reatment should be reserved for severe cases and those that do not respond to more conservative measures, because a chronically draining epithelialized fistula that communicates with the lacrimal sac can form. CHRONIC DACRYOCYSTITIS a smoldering low-grade infection. Usually results in distension of the lacrimal sac. Massage may reflux mucoid material through the canalicular system onto the surface of the eye. Diagnostic probing and irrigation should be confined to the upper system in adults, because probing of the NLD does not achieve permanent patency in adults. If a tumor is not suspected, no further diagnostic evaluation is indicated to confirm the diagnosis of a total NLD obstruction. Chronic dacryocystitis needs to be surgically resolved before elective intraocular surgery. NEOPLASM Primary lacrimal drainage system tumors (most commonly papilloma and squamous cell carcinoma) Primary tumors of tissues surrounding the lacrimal drainage system that secondarily invade or compromise lacrimal system structures (most commonly eyelid skin basal and squamous cell carcinoma; also included are adenoid cystic carcinoma, capillary hemangioma, inverted papil loma, epidermoid carcinoma, osteoma, and lymphoma) Tumors metastatic to the nasolacrimal region PRIMARY LACRIMAL DRAINAGE TUMOURS Approximately 45% of lacrimal sac tumors are benign and

55% are malignant. Squamous cell papillomas and carcinomas are the most common tumors of the sac. Treatment of benign lacrinlal sac tumors commonly requires a dacryocystectomy. Malignancies may require a dacryocystectomy combined with a lateral rhinotomy, performed by an otolaryngologist. Exenteration, including bone removal in the medial canthal area, is necessary if a malignant epithelial tumor has involved bone and the soft tissues of the orbit. Radiation is useful in treating lymphomatous lesions or as a palliative measure in extensive epithelial lesions. The recurrence rate for invasive squamous and transitional cell carcinoma of the lacrimal sac is approXimately 50%, with 50% of these being fatal. CANALICULAR LACERATION Trauma (Laceration around the medial canthus, multiple margnal lid lacerations, medial facial lacerations/ Iatrogenic) Assaults, falls, collissions, sharp trauma and RTA (MVA). Epidemiology Canaliculi involvement is most common of the partsof the drainage system with 50-75% involving the lower canalicli. MORBIDITY Abnormal appaerance of the medial canthus Tear drainage dysfunction CLINICALS Must elicit mechanism of injury from the history Associated ocular damage should be sought for Degree of contamiantion and Risk of retained FB Medicolegal importance. Examination Attention first to life threatening situation Open globe injuries also should be addressed before the ednexial injury Complete ocular examination Assess lid lacerations. Lacerations medial to the pupil should be considered to involve the canaliculi / punctum till proven otherwise. Orbital and facial fractures should examined. INVESTIGATIONS CONCLUSION THANK YOU