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Lacrimal System

Important topics in this chapter:

 Causes of watering
 Work up of patient with watering
 DCR surgery (From Essential Ophthalmic Surgery)
- Idea
- Anaesthesia
- Technique
- Complications esp. bleeding during DCR/ watering after DCR
 Indication of canalicular DCR (CDCR) and conjunctival DCR (CJDC)

Causes of watering

Cause of watering in a child:

 Lacrimation (hypersecretion):
o lid entropion/trihisasis/FB under lid
o conj conjitis including ON
o cornea defect/abrasion/keratitis
o raised IOP buphthalmos
 Epiphora
o upper system drainage  atresia
o lacrimal sac  dacrocystits

A Sallam, FRCS/FRCOphth Final Exam Course 2013-2014 1

Work up of patients with epiphora History: Age: congenital NLDO or acquired Bilaterality:  bilaterality is more with reflex hypersecretion  unilateral epiphora Course:  intermittent reflex lacrimation  intermittent obstruction (swollen inferior turbinate)  continuous & by cold and wind epiphora Discharge:  watery  bloody tumour  mucopurulent discharge – minimal  upper system obstruction  mucopurulent discharge – frequent  NLD obstruction  concretions at corner at morning dry eye Etiological cause:  obstructive lesions: Nasal symptoms/ midfacial fracture/ herpetic eye dis  functional causes: VII paralysis (surgery on parotid or middle ear)  drugs: .Slit Lamp examination: A Sallam.Lids: Eye lids: Inspect for : ectroion & punctal eversion trichiasis Medial inflammation: canaliculitis 2.dry eye: anticholinergics/ pills . systemic: 5 FU/ Irrad // topical antivirals Examination: I.Laxity snap test / verical distraction test / canthal tendon laxity 4. FRCS/FRCOphth Final Exam Course 2013-2014 2 .canalicular obst.External: 1.lacrimation: pilocarpine .Lagopthalmos 3.Lacrimal sac area:  Inspect swellings/ fistula  Palpate tenderness // mass: mucocoele/ stone / tumour  Compress +ve regurge: complete NLDO (work up is complete except for nasal examination) II.

1.5 mm  High in epihora  Low + presence of concretions  Dry eye 2.Due to: Cannula touches medial wall of the lacrimal sac & the lacrimal bone . an attempt is made to touch the medial wall of the lacrimal sac and lacrimal bone. graded from 1. .  This test parallels Dye test I if patient does not wipe his eye  In practice.FLOROUSCEINE (marginal tear strip/ BUT/ DDT) 1.Lacrimal cannula on a 3-ml saline filled syringe is put into lower canaliculus after lateral stretching of lid .Puncti: malposition/ stenosis/ obstruction/ Pouting 2.Tear Break up time (BUT): if > 10 sec Dry eye 3.Saline reaches the nose:  No complete obs  consider.  NO further tests are needed (schedule for DCR) Soft stop: A Sallam. Hard stop: .Indicates: lacrimal sac has been entered  exculdes complete obstruction of the canalicular system. partial obstruction/ functional obs/ hypersecretion  DYE test may be indicated b.Lacrimal drainage system irrigation : .Failure of saline to reach the nose & lacrimal sac distension or mucoid reflux through the canalicular system:  complete NLDO. FRCS/FRCOphth Final Exam Course 2013-2014 3 . this is a very important test. .4.Nasal exanination: (Speculum or endoscopy)  Nasal septum position for significant deviation/ polyp/ mucosa IV.LA into the conjunctival sac .Cannula can come either to a hard stop or a soft stop.Dye disappearance test (DDT):  little or no dye remains in the conjunctival sac after 5 min if system is patent & functioning  In epihora: prolonged dye retention. III.As the cannula is inserted deeper.Then: place one finger over the lacrimal sac area and irrigate 2 possibilities: a.Marginal tear strip:  N height: 0.

Results: .  Dye testing is of NO value in cases of total obstruction. Secondary (irrigation) test: A Sallam.Due to: spongy feeling as the cannula presses the common canaliculus and the lateral wall against the medial wall of the orbit.Reflux through lower canaliculus or inability to irrigate  complete canalicular obstruction b. .Dye tests: Indication:  Dye tests are ONLY indicated in patients with suspected partial obstruction of the drainage system (irrigation: hard stop and saline reaches nose).Indicates: an obstruction in the canalicular system: the cannula has been prevented from entering the lacrimal sac by.After 5 minutes. .determines and measures the site of canlicular obstruction . . . cotton-tipped bud moistened in LA is inserted under the inferior turbinate at NLD opening.2 possibilities: a.Probing of the NLD is ONLY done in children VI. FRCS/FRCOphth Final Exam Course 2013-2014 4 .reflux through upper canaliculus  complete common canalicular obstruction V.Negative: no dye recovered from the nose Indicates: partial obst (site unknown)or pump failure In this situation Secondary dye test is performed. .Positive: fluorescein recovered from the nose Indicates: patency of the drainage system.Probing of the Lacrimal drainage system : .LA into the conjunctival sac . The Cause of excessive watering: primary hypersecretion NO further tests are necessary. Technique: .A small probe (000) .  These tests are tedious to perform/ limited clinical use Primary dye test: Differentiates: partial obst of lacrimal passages from primary hypersecretion of tears.Fluorescein into the conjunctival sac.

FRCS/FRCOphth Final Exam Course 2013-2014 5 . Identifies: probable site of partial obstruction.residual fluorescein is washed out. lower or common) or defective lacrimal pump n VII. .Positive: fluorescein-stained saline recovered from nose indicates partial NLDO .drainage system is then irrigated using clear saline Results: .Negative: unstained saline recovered from the nose indicates partial obstruction of upper drainage system (canaliculi: upper. Technique: . when suspecting tumours orbital CT A Sallam.Contrast dacryocystography & lacrimal scintillography  Both are sophisticated tests & are usually NOT done.  Tumors and stones are confirmed at time of surgery  In practice.LA into the conjunctival sac and any .

How to benefit from this anatomical fact?? Start the osteotomy posterior and widen it on the expense of the ethmoidals. mucocele  Poor cosmetic scar Best cosmesis: linear/ perpendicular to tissues/ does not extend above MCT Osteotomy related complications: CSF leak: Complicates: A fissure fracture of the cribriform bone Due to improper technique during osteotomy. Presentation: postoperative CSF rhinorrhea with watery/salty discharge & double ring sign TTT:  Conservative: Bed rest with head up /No nose blowing Abio Neurosurgeon opinion Incorrect Osteotomy location:  Drainage of the lacrimal sac into the ethmoidal air cells . DCR Intraoperative complications: Anesthetic complications with LA:  inadequate duration: xylocaine + marcaine/adrenaline  Inadequate depth: add anterior ethmoidal block to avoid pain during osteotomy  retrobulbar hge… Skin incision:  Bleeding: avoid angular vessels at 8mm ( incision at 5 or at 10mm from medial canthus)  Injury to lacrimal sac esp with cases of. FRCS/FRCOphth Final Exam Course 2013-2014 6 . twisting the bone before fracturing it.Eethmoidal air cells extends in 90% of persons under part of the lacrimal fossa & in 40% under the whole fossa ethmoidal cells mucosa : thin/gray/friable Vs nasal mucoperiosteum: thick/red/not friable . Finally change plane of dissection antromedially to open ostuim to nasal mucosa Injury to the nasal mucoperiosteum: Solution: try extending osteotomy and undermine more mucosal flap  If failed suture lacrimal sac flap to periosteum at the osteotomy edge DCR Intraoperative hge Importance : uncontrolled intraoperative hge is the most dreadful complication A Sallam. This torque movement may cause a fissure fracture radiating from the twisted bone.

Limiting measures: Preoperative  Stop unnecessary use of NSAID for at least 1 week prior to surgery  If patients on anticoagulants: consult GP + adjust dose according to INR up to 2  Nasal pack with vasoconstrictors Intraoperative:  Head elevation (Reverse Trendenlenburg position)  Low BP  LA with adrenaline infiltration use even if under GA  Dissection in tissue planes  Place a sucker up the nose once the nasal mucosa is opened Management: First identify site of bleeding  good exposure + good illumination (head light) Angular vs Nutrient bone Anterior Nasal mucosa vs ethmoid air cells Onset During During During Opening nasal incision osteotomy osteotomy esp. FRCS/FRCOphth Final Exam Course 2013-2014 7 .000 conc. mucosa Retraction of if started wound posteriorly edges Control Easily Need more Significant hge Most difficult controllable time Solution Cautery Bone wax Mucosa Repack Suture ligation stripping EP injection in Gel foam pack mucosa using 1:200. Early postoperative complications: Hemorrhage: Primary/reactionary/secondary TTT: Usually mild epistaxis is not uncommon Mild : Reassure/ elevate head/ cold compressors If marked hge  ENT surgeon opinion + nasal pack after VC spray + Abio Pack is usually placed under vision using Lubricated guaze for 3 days or Nasal tampoon for 3 days or Absorbable gelfoam Infection: Incidence: Rare Importance: Infection may be the cause or the result of DCR failure A Sallam.

sac is eliminated as a closed space 4.Obstructive: anatomical or functional 1.e. Osteotomy related  Small in size  Adhesions between common canaliculus & osteotomy  Redundant flaps posterior or anterior 3.incision extending above MCT TTT: massage steroid cream steroid injection Z plasty Wound granuloma: TTT: massage steroid cream steroid injection Silicone tube related complications:  Cheese wiring of punctum/canaliculi  Tube prolapse into eye with ocular irritation  Silicone granuloma Watering after DCR Causes: I.Late postoperative complications: Cosmetically unsatisfactory scar: Avoidance: avoid curved incision/ incision at canthus/.Non ostructive:  missed diagnosis: hypersecretion / lid problem eg laxity. II. Canalicular related: A Sallam. FRCS/FRCOphth Final Exam Course 2013-2014 8 . Sac related  Failure to open the sac : lacrimal fascia is only opened  Sump $ : oイ Faulty opening of lacrimal sac with only a small & high opening oロ accumulation of mucus in the sac even though there is an opening in the nose oハ Presentation: Intermittent tearing + reflux of mucus e’ external pressure on the sac area oニ Confirm by: dacrocystography oホ Avoidance: sac should be widely opened from fundus to NLD → i. Nasal passage related :  Missed pathology: Deviated septum/ polyps  New pathology: Silicone granuloma 2.

with the edoscope ㄹ Probe & irrigate Management According to the site of pathology ㄱNasal causes: …. ㄱCanalicular: Intubate If failed DCR with retrograde caniluclostomy via damaged canaliculus i.e. Missed pathology: stricture or fibrosis New pathology: granuloma or surgical trauma Work up: Those pts should be worked up as if they are new cases of epiphora ㄱ Exclude dry eye/ lid problems ㄴ DDT ㄷ Nasal examination esp. create a second canalicular opening or CJDCR ㄱCommon canaliculus or osteotomy : Intranasal DCR + intubation or Redo-DCR or CDCR A Sallam. FRCS/FRCOphth Final Exam Course 2013-2014 9 .

Canalicular laceration Single canalicular laceration Acute injury: -2 school of thoughts: a.DCR with retrogrde canaliculostomy via damaged canaliculus. . FRCS/FRCOphth Final Exam Course 2013-2014 10 .patient may devlop a future problem with the othe canaliculus . Irrigation of the opposite canaliculus with milky corticosteroid suspension or diluted fluorescein .Identification of the cut ends:  The medial end of the canaliculus can usually be found  Lateral end: How to identify? 1.monocanalicular intubation is safe . Pig tail probe 5. posterior.Repair.torn canaliculus may be simply marsupilized and still functions . canliculus is enough . Characteristic shape and glistening epithelium of the canaliculus 4. inferior (7-0.epiphora may happen .Repair may jeopardise the integrity of the other canaliculus b. or 8-0 vicryl suture)  lid repair as needed Chronic epiphora: . Let tissue swelling to subside: postpone repair 36 hrs/ ice compresses 2.CDCR Bicanalicular laceration: Acute: Reapir with bicanalicular intubation Chronic: DCR with canalicular exploration or CJCR A Sallam. .Stenting the canaliculus: 3 months  monocanalicular and minimonocanlicular  bicanalicular stents (Crawford tubes) -Suturing the wound  Pericanalicular mattress sutures: anterior. a second canlicular opening or . if possible.No repair . Anatomical landmarks: canalicular position is near the posterior aspect of lid margin 3.