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ANATOMY

When the eye blinks, the lid pushes the tears across the eye into the drains (puncta) at the inner corner. The drains
empty into channels (canaliculi) that connect the eye with the nose. The channels drain into a tear sac (lacrimal sac)
that lies beside the nose. The sac narrows into the tear duct (lacrimal duct), which drains through the nasal bone into
the nostril.
Puncta
Puncta are openings 0.3 mm in diameter located on the medial aspect of the upper and lower eyelid margins. Each
punctum sits on top of an elevated mound known as the papilla lacrimalis. The puncta are relatively avascular in
comparison with the surrounding tissue, giving them a pale appearance, which is accentuated with lateral traction of
the lid. This pallor can be helpful in localizing a stenosed punctum.
Puncta are directed posteriorly against the globe; therefore, they are not usually visible unless the eyelid is everted.
Punctal ectropion may lead to inadequate tear drainage and resulting epiphora. The inferior punctum is approximately
0.5 mm lateral to the superior punctum, with distances to the medial canthus of 6.5 mm and 6.0 mm, respectively.
Tears within the medial canthal area enter the puncta to pass into the canaliculi.
Canaliculi
Canaliculi have an initial vertical segment, measuring 2 mm, followed by an 8-mm horizontal segment (see the image
below). The angle between the vertical and horizontal segments is approximately 90 degrees, and the canaliculi
dilate at the junction to form the ampulla. In most individuals, the horizontal portion of the canaliculi converges to form
the common canaliculus. Canaliculi pierce the lacrimal fascia before entering the lacrimal sac. At its entrance to the
lacrimal sac, the common canaliculus may dilate slightly, forming the sinus of Maier.

Canaliculi are lined by nonkeratinized, stratified squamous epithelium and are surrounded by elastic tissue, which
permits dilation to 2 or 3 times the normal diameter. The oblique entrance of the common canaliculus into the lacrimal
sac forms the valve of Rosenmller, which prevents retrograde reflux of fluid from the sac into the canaliculi.
However, the posterior angulation of the upper and lower canaliculi followed by anterior angulation of the common
canaliculus may also block reflux at the canaliculus-sac junction. An incompetent valve of Rosenmller is observed
clinically as air escaping from the lacrimal puncta when the individual blows his or her nose.
Lacrimal Sac
The lacrimal sac sits within the lacrimal fossa, which is bound anteriorly by the frontal process of the maxillary bone
(anterior lacrimal crest) and posteriorly by the lacrimal bone (posterior lacrimal crest). (See the image below.)
Differing proportions of lacrimal bone and maxillary bone make up the lacrimal fossa; the position of the vertically
oriented suture between them is variable.
The thickness of the lacrimal bone varies; however, one study found an average thickness of 0.1 mm. Because the
lacrimal bone is generally thinner than the maxillary bone, during dacryocystorhinostomy a perforation of the lacrimal
bone can be made, followed by extension of the osteotomy to include the maxillary bone. The lacrimal bone can be
localized intranasally by its position, which is anterior to the uncinate process of the ethmoid bone.
The lacrimal sac is lined by a double-layered epithelium (superficial is columnar, and deep is flatter). It can be divided
into a fundus superiorly and a body inferiorly. The fundus extends 3-5 mm above the superior portion of the medial
canthal tendon, and the body extends approximately 10 mm below the fundus to the osseous opening of the
nasolacrimal canal.
At the posterior lacrimal crest, the orbital periosteum splits to envelop the lacrimal sac as a covering known as the
lacrimal fascia. This periosteum then continues inferiorly to enclose the nasolacrimal duct. The lacrimal fascia is
surrounded by fibers of the orbicularis oculi muscle; the superficial head of the muscle travels around the front of the
sac to attach to the anterior lacrimal crest, and the deep head of the muscle travels behind the sac to attach to the
posterior lacrimal crest. Between the lacrimal fascia and the lacrimal sac lies a venous plexus. The orbital septum
attaches to the medial orbital wall at the posterior lacrimal crest, so the lacrimal sac is a preseptal structure.
Nasolacrimal Duct
The nasolacrimal duct consists of a 12-mm superior intraosseous portion and a 5-mm inferior membranous portion.
The bony nasolacrimal canal is approximately 1 mm in diameter; the intraosseous part travels posterolaterally
through the nasolacrimal canal within the maxillary bone, while the membranous part runs within the nasal mucosa,
eventually opening into the inferior meatus under the inferior nasal turbinate.
The double layer of epithelium similar to that observed in the lacrimal sac lines the nasolacrimal duct. The venous
plexus surrounding the lacrimal sac continues inferiorly to surround the nasolacrimal duct, eventually connecting to
the vascular tissue of the inferior turbinate.
Although multiple valves have been named throughout the nasolacrimal duct, most have been inconsistently
anatomically identified. The valve of Hasner, at the opening of the nasolacrimal duct within the nasal cavity, has been
found to be imperforate in up to 70% of newborns. Spontaneous opening of an imperforate valve of Hasner usually
occurs within 6-12 months.
PHYSIOLOGY
Tears are the fluid secreted by the eyes to nourish it by maintaining a balance of the ingredients of the eyes and
moisture content of the eye. Precorneal (tear) film is spread across the eye and it has three layers namely, lipid layer,
aqueous layer and mucous layer. Lipid layer (secretes lipid) acts as an hydrophobic barrier and prevents the overflow
of tears. Aqueous layer (contains water and tear proteins) acts as a physiological barrier and controls infection to the
eyes. Mucous layer (secrete mucin) acts as a hydrophilic layer. In a day, 0.75-1.1 grams of tears is secreted which
decreases with age.

Tears have main functions on the eye:


1.
2.
3.
4.
5.

Wetting the corneal epithelium, thereby preventing it from being damaged due to dryness,
Creating a smooth optical surface on the front of the microscopically irregular corneal surface,
Acting as the main supplier of oxygen and other nutrients to the cornea,
Containing an enzyme called lysozyme, which destroys bacteria and prevents the growth of microcysts on
the cornea, and
Flushing harmful bacteria and other microbes away from the eye, into the lacrimal canals and then out
through the nose.

TEAR FILM
Tear film is the thin layer of tear fluid secreted continuously by the lacrimal glands. Tear film is important as the
relation between the air and tear film is responsible for two- thirds of the total refractory power of the eye. Tear film
covers an area of 1-3 square cm and has a thickness of 2.7-11micro m. Tear film break up time is used to check the
stability of the tear film in case of dry eye and other eye disorders. It is seen that lithium carbonate and sodium
valproate help in decreasing the time taken for tear film break up. Cortisol and dihydroepiandrosterone are some
stress biomarkers present in tear secretion. Thickness of the tear film is contributed mainly by the aqueous secretions
of the eye and it contributes nearly 60% of the total value. Tear film is smooth layer formed during blinking and finally
breaks up during evaporation. Thus the images become blurred with increase in time. Irregular tear films cause visual
problems.
The tear film resting on the corneal surface has three layers, from front to back:

lipid or oil layer,


lacrimal or aqueous layer, and
mucoid or mucin layer

The most external layer of the tear film is the lipid or oil layer. This layer prevents the lacrimal layer beneath it from
evaporating. It also prevents the tears from flowing over the edge of the lower eyelid (epiphora).
The lipid component of the tear film is produced by sebaceous glands known as Meibomian glands (located in the
tarsal plates along the eyelid margins) and the glands of Zeis (which open into the hair follicles of the eyelashes).
An enlargement of a Meibomian gland is known as a chalazion, while an infection of a Zeis gland is known as a
hordeolum or sty(e).
Beneath the lipid layer is located the lacrimal or aqueous layer of the tear film. This middle layer is the thickest of the
three tear layers, and it is formed primarily by the glands of Krause and Wolfring and secondarily by the lacrimal
gland, all of which are located in the eyelids. The lacrimal gland is the major producer of tears when one is crying or
due to foreign body irritation.
Lacrimal fluid, containing salts, proteins, and lysozyme, has several functions:
1.
2.
3.
4.

Taking the main nutrients (such as oxygen) to the cornea,


Carrying waste products away from the cornea,
Helping to prevent corneal infection, and
Maintaining the tonicity of the tear film.

If the eyes tears are isotonic, there will be no change in water volume in the cornea and vision will remain normal.
(Tears normally have a tonicity equal to .9% saline.) If the tears are hypotonic, water will flow into the cornea (such
as when crying or swimming in a pool) and it will swell, causing it to become more myopic. If the tears are
hypertonic, water will flow out of the cornea (such as when swimming in the ocean) and it will shrink, causing it to
become more hyperopic.
The epithelial surface of the cornea is naturally hydrophobic (water-repelling). Therefore, for a tear layer to be able
to remain on the corneal surface without rolling off, the hydrophilic (water-attracting) mucoid or mucin layer of the
tear film is laid down onto the surface of the cornea by goblet cells, which are present in the bulbar conjunctiva. In

turn, the lacrimal layer of the tear film, located above the mucoid layer, can defy gravity and remain on the front of the
eye.
TEAR PROTEINS
Tear proteins are secreted by the lacrimal glands and contains lactoferrins, antimicrobial molecules, lacrimal
secretory IgA etc. Lactoferrin (lactotransferrin) is a glycoprotein present majorly in neutrophils and secreted in small
concentrations by exocrine glands including lacrimal glands. Lactoferrin is a part of specific defence of the body in an
indirect way. Lactoferrin has antimicrobial activity and is a carier protein. Today almost 60 tear proteins are known
including the well known proteins like lacitin, proline rich proteins, lipocalin, lipophilin, etc. Lysozyme has antibacterial
activity. Lipocalin 1 (prealbumin) and lipophilin A are carrier proteins. Some other proteins include apolipoproteins H,
phospholipase A2, ribonuclease4, lipophilin C etc.. Tears also contain IgA, IgD, IgG, IgE.Secretory IgA acts as a
defence agent along with phagocytes and lisoymes present in the tear film. Hence they protect the eye from dust and
other infectious agents.