Puyalasa

(dacryocystitis)
Dr. Preeti Patel
 Pooyalasa
• पक्वः शोफः सन्धिजः संस्रवेद्यः सान्द्रं पूयं पूति पूयालसः सः |४|
• Puyalasa is a swelling which occurs in the inner
angle (inner canthus) of the eye or kaneenika
sandhi (meeting place of upper and lower eyelids
on the inner side of the eye). This swelling
gradually undergoes suppuration followed by
discharge of thick, viscous and foul smelling pus.
• This condition can be compared to –
– Acute Dacryocystitis
– Chronic Dacryocystitis
– Lacrimal Abscess
 Chikitsa
• Snehana- swedana(Upanaha)
• Siravyadha
• Vrana shopha vata
• Anjana :
– kasisa + saindhava + aadraka + madhu
– above drugs + loha bhasma + tamra bhasma
 Lacrimal apparatus
• Main lacrimal gland
• Acessary lacrimal glands
• Lacrimal passage include:
– Puncta
– Canaliculi
– Lacrimal sac
– Nasolacrimal duct
 Main lacrimal gland
• 2 parts
– Upper orbital part
– Lower palpebral part.
 Orbital part
– size and shape of a small almond
– situated in the fossa for lacrimal gland at the
outer part of the orbital plate of frontal bone.
– two surfaces — superior and inferior.
• The superior surface is convex and lies in contact
with the bone.
• The inferior surface is concave and lies on the
levator palpebrae superioris muscle
 Palpebral part
• Small and consists of only one or two lobules.
• It is situated upon the course of the ducts of
orbital part from which it is separated by LPS
muscle.
• Posteriorly, it is continuous with the orbital part.
 Ducts of lacrimal gland
• 10-12 ducts pass downward from the main gland
to open in the lateral part of superior fornix.
• One or two ducts also open in the lateral part of
inferior fornix.
 Accessory lacrimal glands
• Glands of Krause. lying beneath the palpebral
conjunctiva between fornix and the edge of
tarsus.
– These are about 42 in the upper fornix and 6-
8 in the lower fornix.
• 2. Glands of Wolfring. These are present near
the upper border of the superior tarsal plate and
along the lower border of inferior tarsus.
• Blood supply.
– Main lacrimal gland is supplied by lacrimal
artery which is a branch of ophthalmic artery.
• Nerve supply
– Sensory supply comes from lacrimal nerve, a
branch of the ophthalmic division of the fifth
nerve.
– Sympathetic supply comes from the carotid
plexus of the cervical sympathetic chain.
– Secretomotor fibres are derived from the
superior salivary nucleus.
 Lacrimal passages
• Lacrimal puncta
– These are two small, rounded or oval openings on
upper and lower lids
• Lacrimal canaliculi
– These join the puncta to the lacrimal sac.
– Each canaliculus has two parts: vertical(1-2 mm)
and horizontal (6-8 mm) which lie at right angle to
each other.
 Lacrimal sac
– It lies in the lacrimal fossa located in the anterior
part of medial orbital wall.
– The lacrimal fossa is formed by lacrimal bone and
frontal process of maxilla.
– It has got three parts: fundus (portion above the
opening of canaliculi), body (middle part) and the
neck (lower small part which is narrow and
continuous with the nasolacrimal duct).
 Nasolacrimal duct (NLD)
– It extends from neck of the lacrimal sac to inferior
meatus of the nose.
– It is about 15-18 mm long and lies in a bony canal
formed by the maxilla and the inferior turbinate.
– valve of Hasner, which is present at the lower end
of the duct and prevents reflux from the nose.
 Dacryocystitis
• Inflammation of the lacrimal sac.
– Congenital
– Adult
 Congenital
• It is an inflammation of the lacrimal sac occurring
in newborn infants; and thus also known as
dacryocystitis neonatorum.
• Etiology
– blockage in the nasolacrimal duct
– Presence of epithelial debris,
– membranous occlusion at its upper end near
lacrimal sac,
– complete noncanalisation and rarely bony
occlusion.
 CLINICAL FEATURES
• Epiphora usually developing after seven days of
birth. It is followed by copious mucopurulent
discharge from the eyes.
• Regurgitation test is usually positive, i.e., when
pressure is applied over the lacrimal sac area,
purulent discharge regurgitates from the lower
punctum.
• Swelling on the sac area may appear
eventually.
 Differential diagnosis
– ophthalmia neonatorum and
– Congenital glaucoma.
• Complications
– recurrent conjunctivitis,
– acute on chronic dacryocystitis,
– lacrimal abscess and fistulae formation.
 TREATMENT
• Massage over the lacrimal sac area
• Topical antibiotics
• Lacrimal syringing (irrigation) with normal saline
and antibiotic solution.
• 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.
• 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.

• Dacryocystorhinostomy (DCR) operations: When

the child is brought very late or repeated probing is a
failure.
 ADULT DACRYOCYSTITIS
• ACUTE
• CHRONIC
– CHRONIC IS MORE COMMON THEN
ACUTE DACRYOCYSTITIS.
 Predisposing factors
• Age: Between 40 and 60 years of age.
• More in females
• More common in lower socio economic group.
• Poor personal hygiene
• Anatomical factors, which retard drainage of
tears include:
– comparatively narrow bony canal, partial
canalization of membranous NLD and
excessive membranous folds in NLD.
• Foreign bodies in the sac may block opening of
NLD.
• Excessive lacrimation, primary or reflex, causes
stagnation of tears in the sac.
• Mild grade inflammation of lacrimal sac due to
associated recurrent conjunctivitis
• Obstruction of lower end of the NLD by nasal
diseases such as polyps, hypertrophied
inferiorconcha, marked degree of deviated nasal
septum,tumours and atrophic rhinitis causing
stenosis.
 Source of infection
• Conjunctiva
• Nasal cavity (retrograde spread),
• Paranasal sinuses.
 Causative organisms
•
– staphylococci,
– pneumococci,
– streptococci and
– Pseudomonas pyocyanea
 Clinical picture
• Stage of chronic catarrhal dacryocystitis
– mild inflammation of the lacrimal sac
– watering eye
– redness in the inner canthus
• On syringing the lacrimal sac, either clear fluid
or few fibrinous mucoid flakes regurgitate.
• Dacryocystography reveals block in NLD, a
normal-sized lacrimal sac with healthy
mucosa.
• Stage of lacrimal mucocoele
– distension of lacrimal sac
– constant epiphora
– swelling just below the inner canthus
• Milky or gelatinous mucoid fluid regurgitates
from the lower punctum on pressing the
swelling.
• Dacryocystography at this stage reveals a
distended sac with blockage
• Stage of chronic suppurative dacryocystitis
– Epiphora
– recurrent conjunctivitis and swelling at the inner
canthus
– erythema of the overlying skin.
• On regurgitation a frank purulent discharge
flows from the lower punctum.
• Stage of chronic fibrotic sac
– small fibrotic sac due to thickening of mucosa,
which is often associated with persistent epiphora
and discharge.
• Dacryocystography at this stage reveals a very
small sac with irregular folds in the mucosa.
 Complication
• Conjunctivitis
• Ectropion of lower lid
• maceration and eczema of lower lid skin due
to prolonged watering.
• corneal abrasions
• If an intraocular surgery is performed in the
presence of dacryocystitis, there is high risk
of developing endophthalmitis.
 Treatment
• repeated lacrimal syringing.
• Dacryocystorhinostomy (DCR). It should be
the operation of choice as it re-establishes the
lacrimal drainage.
• Dacryocystectomy (DCT). It should be
performed only when DCR is contraindicated.
• Conjunctivodacryocystorhinostomy (CDCR).
It is performed in the presence of blocked
canaliculi.
 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.
• 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 and
– Dental abscess or caries teeth in the upper jaw.
 Clinical picture
• Stage of cellulitis
– Painful swelling in the region of lacrimal sac
– epiphora and fever and malaise.
– The swelling is red, hot, firm and tender.
– Redness and oedema also spread to the lids
and cheek.
– When treated resolution may occur at this
stage. However, if untreated, self-resolution is
rare.
• Stage of lacrimal abscess
– occlusion of the canaliculi due to oedema
– The sac is filled with pus, distends and its
anterior wall ruptures forming a pericystic
swelling.
• Stage of fistula formation.
– discharges spontaneously,leaving an external fistula
below the medial palpebral ligament
 Complications
• Acute conjunctivitis,
• Corneal abraision 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 septicaemia may also
develop.