Evaluation of Epiphora

3/28/2010
EVALUATION OF EPIPHORA
BY
ELSADEK MAALY
WATERING OF THE EYE
 Lacrimal disorders functionally classified

as::
as
tear excretion
tear secretion
tear quality
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Before rushing into specific tests,

meticulous history & clinical
evaluation of the eye should be
performed
History
Age
Onset and Duration
Unilateral or Bilateral
Intermittent or Constant
Pain,
Pain Discharge,
Discharge or Swelling
Trauma, Operations, or Medication
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Clinical Evaluation
Inspection
 The eyelids : malpositions, entropion, ectropion,
or lid laxity
 Lid closure Dynamics
 The puncta : malpositions, stenosis, agenesis,

atresia or accessory puncta.
puncta.
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Clinical Evaluation
 Slit--lamp : F.B,
Slit F B ulcers,
ulcers or recurrent
erosions.
 The marginal tear strip of both eyes

should be examined.
examined
 Swelling, Inflammation & Fistula below

Medial Palpebral Ligament.
Clinical Evaluation
Palpation
Regurgitation test
Mucocele
Dacryolith
Tumor
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Clinical Evaluation
Nasal Examination
Anatomic Abnormalities
Hypertrophied turbinates
Nasal polyps
Deviated septum
Atrophic rhinitis
Tests of lacrimal drainage

Fluorescein dye disappearance test
Instillation of fluorescein drops 2% into the

conjunctiva of both eyes then examine after 5
minutes .
 Normally, very little or no dye present

 significant residual dye or prolonged retention is
an indication of inadequate drainage of the dye.
dye.
 The amount estimated on 0 to 4 + scale

scale..
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Fluorescein dye disappearance

test
Package
Flor.dye disappearance.wmv
Jones dye testing

Primary dye test:
test:
 Differentiates partial obstruction from hypersecretion
of tears
tears..
 Fluorescein 2% drops instilled into the conjunctiva
conjunctiva..
After about 5 minutes, cotton tipped applicator
inserted under the inferior turbinate.
turbinate.
 Positive:: Detection of fluorescein from the
Positive
nose means patency of the system
system..
 Negative:: No dye detected, means either a partial or
Negative
absolute obstruction or failure of the lacrimal pump.
pump.
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Jones dye testing
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Secondary Jones dye test:

test:
 Conjunctiva & drainage system is

irrigated with saline.
saline.
 Positive:: Recovery of dye stained saline
Positive
from the nose meaning a partial
obstruction of the NLD.
NLD.
 Negative:: Recovery of unstained saline
Negative
through the nose means partial
obstruction of the upper drainage system
or a defective lacrimal pump mechanism
mechanism..
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Probing & Irrigation
 After punctal dilatation,

dilatation lacrimal probe introduced in
the either punctum & canaliculus
 If the probe touches the medial orbital wall, this

means Hard StopStop..
 At this point, if saline is injected into the canaliculus,
andd fluid
fl id passes to
t the
th nose then
th watering
t i isi due
d to t
hypersecretion..
hypersecretion
 Fluid returns from the other punctum there is
nasolacrimal duct obstruction
obstruction..
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Probing
LACRIMAL_DUCT_PROBING_70.MPG
Package
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Soft Stop Hard Stop
 Soft stop is a spongy feeling due to canalicular

obstruction
 The level of obstruction assessed by measuring

the length of the probe
probe..
 Irrigation will not distend the sac

sac..
 In canalicular obstruction reflux from the same

canaliculus..
canaliculus
 Reflux through the other canaliculus means

obstruction of the common canaliculus
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Imaging Techniques
Conventional X-
X-ray:
Useful in post-
post-traumatic cases.
Contrast Dacryocystography
(DCG)
 Technique
T
Technique:
h i : Plastic
Pl ti catheters
th t are placed
l d
into one canaliculus in both eyes, 1ml
lipidol is simultaneously injected through
both catheters and Water's view
radiographs are taken, 5 minutes later,
an erect oblique film is taken
taken..
 Results:: The site of obstruction is
Results
usually evident.
evident. Diverticula, filling
defects due to stones and strictures can
be diagnosed
diagnosed..
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13
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Lacrimal scintillography
 Scintillography is used to assess the

lacrimal drainage system under
physiological conditions.
conditions.
 Technique:: Tchnetium
Technique Tchnetium--99 is delivered
by a micropipette to the inferior
conjunctival sac.
sac. The tracer is imaged
using a gamma camera
camera..
Lacrimal scintillography
Rt
10
15
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Computed Tomography (C.T)

C.T useful in detecting the anatomical
abnormalities,, particularly
p y its relation to
adjacent bone, nasal and sinus structures.
structures.
C.T Dacryocystography
C.T.DCG entails a contrast injection of the
lacrimal system and simultaneous C.T.
scanning of the facial structures
Diagnostic UltraSonography
 A & B Mode Ultra Ultra--Sonography provides

non--invasive method to evaluate the
non
drainage system & to detect patency of
surgical fistula after DCR
DCR..
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UBM
Long. Section Normal Canaliculus cross section
Lacrimal Endoscopy
 1.0 mm diameter rigid endoscope or

fibroptic flexible endoscopes was inserted
through the puncti and canaliculi to
inspect the lining mucosa of lacrimal
system,
t it contents
its t t andd investigating
i ti ti DCR
fistulae..
fistulae
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Lacrimal Endoscopy
endoscopy.wmv
endoscopy_mpeg1_no_titoli_chunk_1.mpg
Nasal Endoscopy
endoscopy.wmv
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Nasal endoscopy
 Pre--operative nasal examination

Pre
 Nasolacrimal duct intubation
 Endoscopic DCR
 Post-operative evaluation of lacrimal

Post-
fistula
THANK YOU
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3/28/2010

WATERING OF THE EYE

 Lacrimal disorders functionally classified

Before rushing into specific tests,

 Lid closure Dynamics

 The puncta : malpositions, stenosis, agenesis,

 The marginal tear strip of both eyes

 Swelling, Inflammation & Fistula below

Tests of lacrimal drainage

Instillation of fluorescein drops 2% into the

 Normally, very little or no dye present

 The amount estimated on 0 to 4 + scale

Fluorescein dye disappearance

Jones dye testing

Jones dye testing

Secondary Jones dye test:

 Conjunctiva & drainage system is

Probing & Irrigation

 After punctal dilatation,

 If the probe touches the medial orbital wall, this

Soft Stop Hard Stop

 Soft stop is a spongy feeling due to canalicular

 The level of obstruction assessed by measuring

 Irrigation will not distend the sac

 In canalicular obstruction reflux from the same

 Reflux through the other canaliculus means

 Scintillography is used to assess the

Computed Tomography (C.T)

 A & B Mode Ultra Ultra--Sonography provides

Long. Section Normal Canaliculus cross section

 1.0 mm diameter rigid endoscope or

 Pre--operative nasal examination

 Nasolacrimal duct intubation

 Post-operative evaluation of lacrimal

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