Lacrimal System

Lacrimal System
Normal Anatomy
Secretory System
Drainage System
Lacrimal Drainage System
Phisiology
Abnormalities of the Lacrimal

Secretory and Drainage Systems
Developmental Abnormalities
Lacrimal Secretory System
Congenital abnormalities : hypoplasia and agenesis
of the lacrimal gland, Lacrimal gland prolapse,
lacrimal gland fistula.
Lacrimal drainage system :
(1) errors in the genesis of the proximal system
(multiple puncta or lacrimalcutaneous fistula) or (2)
incomplete patency, either at the eyelid (eg, punctal
or canalicular hypoplasia or aplasia) or intranasally
(eg, nasolacrimal duct [NLD] obstruction).
In symptomatic patients, direct

surgical excision of the epitheliumlined fistulous tract with direct suture
closure is indicated.
In patients with underlying NLDO
and chronic dacryocystitis, silicone
intubation or dacryocystorhinostomy
may also be required.
Aplasia and hypoplasia

Punctal hypoplasia or stenosis is encountered more
frequently than true aplasia.
Management of punctal stenosis, membranes, and aplasia
is discussed in the section addressing lacrimal drainage
obstruction.
Nasolacrimal duct obstruction
In most cases, congenital NLDO is due to failure of the duct
to fully canalize; however, associations with more severe
abnormalities have been described.
Treatment of lacrimal drainage obstruction differs according
to the cause and location of the obstruction. Obstruction
may involve the puncta, canaliculi, lacrimal sac, or NLD.
Congenital Lacrimal Drainage

Obstruction
a history of tearing, mucopurulent
discharge, or both beginning shortly
after birth.
In rare cases, visible distension of the
lacrimal sac is present, suggesting a
congenital dacryocystocele.
Distinction should be made among the following:

constant tearing with minimal mucopurulence,
suggesting blockage of the upper system
(puncta, canaliculi, and common canaliculus)
caused by punctal or canalicular dysgenesis
constant tearing with frequent mucopurulence
and matting of the eyelashes, suggesting
complete obstruction of the NLD
intermittent tearing with mucopurulence,
suggesting intermittent obstruction of the NLD
Office examination
inspection of the eyelid margins for patent puncta and
evaluation for extrinsic causes of reflex hypersecretion,
such as ocular surface irritation, infectious
conjunctivitis, epiblepharon, trichiasis, and congenital
glaucoma.
inspection of the medial canthal region to uncover a
distended lacrimal sac (below the tendon),
inflammation, or congenital defects such as an
encephalocele (above the tendon).
single most important maneuver is application of digital
pressure over the tear sac. If mucoid reflux
is present, complete obstruction at the level of the NLD
becomes the working diagnosis.
Trauma
Canaliculus
Most traumatic injuries to the canaliculi occur in
one of 2 ways: by direct laceration, such as from a
stab wound, or by traction, which occurs when
sudden lateral displacement of the eyelid tears the
medial canthal tendon and associated canaliculus.
Repair of injured canaliculi should be performed
as soon as possible, preferably within 48 hours of
injury.
The first step of the repair is locating the severed
ends of the canalicular system.
Irrigation using air, fluorescein, or yellow

viscoelastic material through an intact
adjacent canaliculus may be helpful.
The probe is introduced through the
opposite, uninvolved punctum; passed
through the common canaliculus; and
finally passed through the medial cut end.
Lacrimal intubation also facilitates the softtissue reconstruction of the medial canthal
tendon and eyelid margin.
A type of silicone monocanalicular stent without the

metallic probe is inserted into the punctum and
threaded directly into the lacerated canaliculus to
bridge the laceration but does not extend into the nose.
Stents are usually left in place for 2 months or longer.
However, cheese-wiring, ocular irritation, infection,
local inflammation, or pyogenic granuloma formation
may necessitate early removal.
Bicanalicular stents are usually cut at the medial
canthus and retrieved from the nose.
Monocanalicular stents are simply pulled through the
punctum.
Lacrimal Sac and Nasolacrimal Duct

The lacrimal sac and NLD may be injured by direct
laceration or by fracture of surrounding bones.
Injuries of the lacrimal sac or NLD may also occur
during rhinoplasty or endoscopic sinus surgery when
the physiologic maxillary sinus ostium is being
enlarged anteriorly.
Early treatment of the lacrimal sac and NLD is
appropriate and consists of fracture reduction, softtissue repair, and silicone intubation of the entire
lacrimal drainage system.
Late treatment of persistent epiphora may require
DCR.
INFECTION
Dacryoadenitis
Acute inflammation of the lacrimal gland and most often
seen
in inflammatory disease and occasionally is the consequence of
malignancy, such as lymphoproliferative disease.
unusual, and gross purulence and abscess formation are
uncommon.
with the emergence of community-acquired methicillin-resistant
Staphylococcus aureus (MRSA), this condition is seen more
frequently.
Most cases are the result of bacterial infection, which may develop
secondary to an adjacent infection, after trauma, or
hematogenously
Many nonsuppurative cases are treated empirically, without
isolation of the alleged pathogen; coverage for MRSA infection
should be considered.
Canaliculitis
The most common pathogen is a filamentous
gram-positive rod, Actinomyces israelii.
The patient presents with persistent weeping and
discharge, sometimes accompanied by a follicular
conjunctivitis centered in the medial canthus.
The punctum is often erythematous and dilated,
or pouting.
A cotton-tipped applicator can be used to apply
pressure to the canaliculus (milking).
The expression of purulent discharge confirms
the diagnosis
Management
Culture of the discharge may be useful in
identifying the cause of the infection.
Conservative management consists of warm
compresses, digital massage, and topical and
sometimes oral antibiotic therapy.
Curettage through the punctum is sometimes
successful at removing multiple stones.
In some cases a canaliculotomy is required to
completely remove all particulate matter
Dacryocystitis
Inflammation of the lacrimal sac (acute dacryocystitis)
has various causes.
in most cases the common factor is complete NLDO,
which prevents normal drainage from the lacrimal sac
into the nose.
Chronic tear retention and stasis lead to secondary
infection.
Clinical findings : edema and erythema with distension of
the lacrimal sac. The degree of discomfort ranges from
none to severe pain.
Complications : dacryocystocele formation, chronic
conjunctivitis, and spread to adjacent structures (orbital
or facial cellulitis).
Treatment of acute Dacryocystitis
Irrigation or probing of the canalicular system

should be avoided until the infection subsides.
In most cases, irrigation is not needed to
establish the diagnosis, and it is extremely
painful for patients with active infection.
Diagnostic or therapeutic probing of the NLD is
not indicated in adults with acute
dacryocystitis.
Topical antibiotics are of limited value. They do
not reach the site of the infection because of
stasis within the lacrimal drainage system.
Oral antibiotics are effective for 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 may be performed if a pyocele or
mucocele is localized and approaching the skin.
Smears and cultures of the aspirate may inform the selection of
systemic antibiotic therapy.
A localized abscess involving the lacrimal sac and adjacent soft
tissues may require incision and drainage. This treatment should
be reserved for cases that do not respond to more conservative
measures or for patients in severe discomfort.
A chronically draining epithelialized fistula that communicates
with the lacrimal sac can form (rare).
Dacryocystitis indicating total NLDO requires a DCR in most
cases because of inevitable persistent epiphora and recurrence.
Chronic dacryocystitis
a smoldering low-grade infection, may develop
in some individuals.
It usually results in distension of the lacrimal sac.
Massage may reflux mucoid material through the
canalicular system onto the surface of the eye.
If a tumor is not suspected, no further diagnostic
evaluation is indicated to confirm the diagnosis
of total NLDO.
Chronic dacryocystitis is treated before elective
intraocular surgery
Neoplasm
Lacrimal Gland
Neoplasms of the lacrimal gland are
discussed in Chapter 5.
Lacrimal Drainage System

Neoplastic causes of acquired obstruction of the lacrimal drainage
system may be classified into the following groups:
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 basal and squamous cell carcinoma of
the eyelid skin; others include adenoid cystic carcinoma, infantile
[capillary] hemangioma, inverted papilloma, epidermoid
carcinoma, osteoma, and lymphoma)
tumors metastatic to the nasolacrimal region
Histologically, 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.
Primary lacrimal sac tumors are rare and may present clinically as a
mass located above the medial canthal tendon.
associated with epiphora or chronic dacryocystitis.
Dacryocystitis associated with tumor may differ from simple NLDO
in that the irrigation fluid may pass into the nose. Also, blood may
reflux from the punctum on irrigation, and more ominously, some
patients report spontaneous bleeding.
Tumors that invade the skin may produce ulceration with
telangiectasia over the lacrimal sac.
Metastasis to regional lymph nodes may also occur.
Dacryocystography is useful for outlining uneven, mottled densities
in the dilated lacrimal sac.
CT or MRI is far superior in identifying neoplasms and determining
disease extent.
CT also has the advantage of clearly revealing bone erosion.
Treatment
Treatment of benign lacrimal sac tumors commonly requires a
dacryocystectomy.
Malignant tumors may require a dacryocystectomy combined
with a lateral rhinotomy and medial maxillectomy sometimes
performed in concert with 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 for treatment of lymphomatous lesions, as
an adjuvant after removal of malignant lesions, or as a
palliative measure for unresectable lesions.
The recurrence rate for invasive squamous and transitional
cell carcinoma of the lacrimal sac is approximately 50%, with
50% of these cases being fatal.

Lacrimal System

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Lacrimal System

Lacrimal Drainage System

Abnormalities of the Lacrimal

In symptomatic patients, direct

Aplasia and hypoplasia

Congenital Lacrimal Drainage

Distinction should be made among the following:

Irrigation using air, fluorescein, or yellow

A type of silicone monocanalicular stent without the

Lacrimal Sac and Nasolacrimal Duct

Treatment of acute Dacryocystitis

Irrigation or probing of the canalicular system

Oral antibiotics are effective for most infections.

Lacrimal Drainage System

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