Common OPD Cases:

Pterygium
Nasolacrimal Duct Obstruction
and Dacryocystitis

Alyssa Angela A. Trinidad

Post Graduate Intern
Manila Doctors Hospital
Pterygium
 Pterygium

• Pterygium comes from the Greek word

pterygos meaning wing.

• Pterygium is a triangular fibrovascular

growth that extends from the
conjunctiva toward the cornea.

• May occur nasally, temporally or both.

Nasal area (more common)
 Risk Factors

• Ultraviolet exposure (single most

significant risk factor)
• Exposure to irritants (dust, sand, wind)
• Inflammation
• Dry ocular surface
 Pathology

Pathologically pterygium is a degenerative

and hyperplastic condition of
conjunctiva.
The subconjunctival tissue undergoes
elastotic degeneration and proliferates
as vascularised granulation tissue
under the epithelium, which ultimately
encroaches the cornea.
The corneal epithelium, Bowman's layer
and superficial stroma are destroyed.
 Pathophysiology

UV light forms free Ultraviolet-B (UVB) Polymorphisms of the

radicals that induce induces expression of DNA break repair gene
damage in DNA, RNA, cytokines and growth Ku70 have been
and the extracelluar factors in pterygial associated with genetic
matrix of cells. epithelial cells. predisposition to pterygia
development.
 Symptoms

• May be asymptomatic
• Decreased vision
• Redness
• Irritation
• Diplopia
 Signs
• Wedge-shaped, translucent membrane
with apex extending onto cornea
• White to pink in color, depending on
vascularity
• Vascular straightening in the direction
of the advancing head of the
pterygium
• Stocker line: iron line on cornea at
leading edge of pterygium
• Regular or irregular astigmatism
• Degenerative changes such as cystic
changes
 Parts of a Pterygium

A fully developed pterygium consists of three parts:

• Head (apical part present on the cornea)
• Neck (limbal part)
• Body (scleral part) extending between limbus and the
canthus
 Types

Progressive pterygium
thick, fleshy and vascular with a few
infiltrates in the cornea, in front of
the head of the pterygium

Regressive pterygium
thin, atrophic, attenuated with very
little vascularity
Differentials
 Treatment

• Surgical excision is the only satisfactory treatment

(1) cosmetic reasons
(2) continued progression threatening to encroach onto the
pupillary area (once the pterygium has encroached pupillary area,
wait till it crosses on the other side)
(3) diplopia due to interference in ocular movements.
 Treatment

Surgical techniques include the following:   

• Simple excision (without transplantation, aka bare sclera) is associated with
a higher recurrence rate and hence it has been supplemented with
conjunctival transplantation.
• Adjuvant therapies including mitomycin C (MMC), 5-fluorouracil (5-FU),
ethanol, irradiation, and anti-angiogenic agents, among others, are used to
reduce recurrence rate, but there is insufficient evidence that one is
superior (Kaufman et al, 2013).
 Treatment

The ideal treatment recommended involves excision of pterygium with

conjunctival autograft (CAG) supplementation. Alternatively, if there is not
enough conjunctiva, then amniotic membrane transplant (AMT) may be
glued or sutured into place

Another approach is autoblood graft fixation, a technique also known as

suture- and glue-free autologous graft. This approach affixes the graft into
place with the patient’s own blood, eliminating the concern of disease
transmission.
 Post-op

• Patch/shield overnight
• Drops:  Steroid antibiotic combination 4 times a day for 1 month
 Complications of Pterygium Surgery

Intraoperative:
Buttonhole of the conjunctival autograft
Injury to extraocular muscles

Postoperative (immediate):
Graft slippage
Graft retraction
Donor site granuloma formation
 Complications of Pterygium Surgery

Long-term complications:

The most common complication is recurrence after removal.

The recurrence rate is as high as 50% within 4 months and 97% recurrence
rate within 12 months without autograft or amniotic membrane transplant
(Hirst LW, 2003).

The recurrence rate is higher with fleshy, nontranslucent pterygia and

increased postoperative inflammation. It is often dependent on the surgical
procedure.
Nasalacrimal Duct and
Dacryocystitis
 Dacryocystitis

Dacryocystitis is inflammation of the lacrimal sac which typically

occurs secondarily to obstruction within the nasolacrimal duct
and the resultant backup and stagnation of tears within the
lacrimal sac.

with the stagnated tears, it will then provide a favorable

environment for infectious organisms.
 Risk Factors

• Females are at greater risk due to their narrower duct diameter as

compared to males
• Older age leads to narrowing of the punctual openings, slowing tear
drainage
• Dacryoliths; often idiopathic, a collection of shed epithelial cells, lipids,
and amorphous debris within the nasolacrimal system 
• Nasal septum deviation, rhinitis and turbinate hypertrophy
• Damage to the nasolacrimal system due to trauma of the nasoethmoid
region or endoscopic/endonasal procedures
• Neoplasm within the nasolacrimal system
• Systemic disease such as Wegener’s granulomatosis, sarcoidosis, and
Systemic Lupus Erythematosus (SLE)
• Medications such as timolol, pilocarpine, idoxuridine, and trifluridine 
 Diagnostic Procedures

The diagnosis of dacryocystitis is generally made clinically based off of the

patient’s history and physical exam

In acute cases, a Crigler, or tear duct, massage can be performed to

express material for culture and gram stain.

In patients who appear to be acutely toxic or those who present with

visual changes, imaging and bloodwork should be considered .

In chronic cases, serologic testing can be performed if systemic conditions

are suspected.
 Diagnostic Procedures

Imaging is not typically needed for diagnosis unless

suspicion arises on history and physical (for
example, patient complains of hemolacria). CT
scans may be performed in cases of trauma.

Dacryocystography or plain film dacrosystogram

(DCG) can be performed when anatomic
abnormalities are suspected.

Nasal endoscopy is useful to rule out hypertrophy

of the inferior turbinate, septal deviation and
inferior meatal narrowing.
 Diagnostic Procedures

The fluorescein dye disappearance test (DDT) is another option available

to evaluate for adequate lacrimal outflow, especially in patients unable
to undergo lacrimal irrigation.

In a DDT assay, sterile fluorescein dye if instilled into the conjunctival

fornices of each eye, and the tear firms are then examined under a slit
lamp.
 Congenital
Dacryocystitis
It is an inflammation of the lacrimal sac occurring in newborn infants; and
thus also known as dacryocystitis neonatorum

It follows stasis of secretions in the lacrimal sac due to congenital blockage

in the nasolacrimal duct.

Other causes of congenital NLD block are:

presence of epithelial debris, membranous occlusion at its upper end near
lacrimal sac, complete noncanalisation and rarely bony occlusion.
 Clinical Picture

Congenital dacryocystitis usually presents as a mild grade chronic

inflammation.

It is characterized by:
1. Epiphora, usually developing after seven days of birth.
It is followed by copious mucopurulent discharge from the eyes.
2. Regurgitation test is usually positive
3. Swelling on the sac area may appear eventually
 Complications

• Recurrent conjunctivitis
• Acute on chronic dacryocystitis
• Lacrimal abscess
• Fistulae formation
 Treatment

1. Massage over the lacrimal sac area and topical antibiotics constitute the
treatment of congenital NLD block, up to 6-8 weeks of age.

2. Lacrimal syringing (irrigation) with normal saline and antibiotic solution.

3. Probing of NLD with Bowman’s probe. It should be performed, in case the

condition is not cured by the age of 3-4 months.

4. Intubations with silicone tube may be performed if repeated probings are

failure. The silicone tube should be kept in the NLD for about six
months.
5. Dacryocystorhinostomy (DCR) operations
 Adult
Dacryocystitis

Adult dacryocystitis may occur in an acute or a chronic form.

Chronic dacryocystitis is more common than the acute dacryocystitis.

 Chronic
Dacryocystitis
 Etiology

Predisposing
Factors responsible for stasis Lacrimal Sac
factors
of tears in the lacrimal sac infection
• Age
• Sex
• Anatomical factors
• Race Causative organisms:
• Foreign bodies staphylococci,
• Heredity
• Excessive lacrimation pneumococci,
• Socio-economic
• Mild grade inflammation streptococci and
status
• Obstruction of lower end of Pseudomonas
• Poor personal pyocyanea.
the NLD
hygiene
 Clinical Picture

Clinical picture of chronic dacryocystitis may be divided into four stages:

1. Stage of chronic catarrhal dacryocystitis

2. Stage of lacrimal mucocoele
3. Stage of chronic suppurative dacryocystitis
4. Stage of chronic fibrotic sac.
 Complications
• Chronic intractable conjunctivitis, acute on chronic dacryocystitis.
• Ectropion of lower lid, maceration and eczema of lower lid
• Simple corneal abrasions may become infected leading to hypopyon
ulcer.

If an intraocular surgery is performed in the presence of dacryocystitis,

there is high risk of developing endophthalmitis.

Because of this, syringing of lacrimal sac is always done before

attempting any intraocular surgery.
 Treatment

1. Conservative treatment- lacrimal syringing

2. Dacryocystorhinostomy (DCR)- re-establishes lacrimal drainage
3. Dacryocystectomy (DCT)- only when DCR is contraindicated
4. Conjunctivodacryocystorhinostomy- done in the presence of blocked
canaliculi
 Acute
Dacryocystitis
 Acute
Dacryocystitis

Acute dacryocystitis is an acute suppurative

inflammation of the lacrimal sac, characterised by
presence of a painful swelling in the region of sac.
 Etiology

• As an acute exacerbation of chronic dacryocystitits

• As an acute peridacryocystitis due to direct involvement from the
neighbouring infected structures such as:
- paranasal sinuses, surrounding bones
- dental abscess or caries teeth in the upper jaw
 Clinical Picture

1. Stage of cellulitis.
Painful swelling in the region of lacrimal sac associated with
epiphora and constitutional symptoms such as fever and malaise.

2. Stage of lacrimal abscess.

Continued inflammation causes occlusion of the canaliculi due to
oedema.
The sac is filled with pus, distends and its anterior wall ruptures
forming a pericystic swelling.

3. Stage of fistula formation. When the lacrimal abscess is left

unattended, it discharges spontaneously, leaving an external
fistula below the medial palpebral ligament
 Complications

These include:
• Acute conjunctivitis
• Corneal abrasion which may be converted to corneal ulceration
• Lid abscess
• Osteomyelitis of lacrimal bone
• Orbital cellulitis
• Facial cellulitis and acute ethmoiditis
• Rarely cavernous sinus thrombosis and very rarely generalized
septicemia may also develop.
 Treatment

During cellulitis stage

• Systemic and topical antibiotics to control infection
• Systemic anti-inflammatory analgesic drugs
• Hot fomentation to relieve pain and swelling

During stage of lacrimal abscess

• Drainage with a small incision
• Gently squeeze pus out and place dressing with betadine soaked roll
gauze after

Treatment of external lacrimal fistula

• Fistulectomy along with DCT or DCR operation should be performed
Dacryocystorhinostomy
Dacryocystectomy
 Prognosis and Complications

Fortunately, the prognosis of dacryocystitis is generally positive, but

devastating complications are possible, so prompt referral to an
ophthalmologist is encouraged.

Possible complications include the formation of lacrimal fistulas, lacrimal

sac abscesses, meningitis, cavernous sinus thrombosis and vision loss.
Thank you for listening!