LACRIMAL SYSTEM

By : Fajri Mohammed MD,

Ophthalmology R1

Moderator : Dr. sinbona Geleta MD,

Ophthalmologist)

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Outline
• Introduction
• Embryology
• Congenital anomalies
• Gross anatomy
• Clinical comments & Evaluations

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Introduction
The lacrimal apparatus has two components
The secretory system
• Main lacrimal gland
• Accessory lacrimal glands
The  excretory system
• Puncta
• Canaliculi
• Lacrimal sac
• Nasolacrimal duct

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Embryology

The lacrimal gland

• Develops at 6-week embryonic stage from multiple solid
ectodermal buds in the anterior super lateral conjunctival
fornix

Early buds (first 2 months) --- orbital lobe

Secondary buds (appear later) --- palpebral lobe

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• The lacrimal artery enters the gland in (7.5-week) stage
• at 9–11-weeks levator aponeurosis differentiates, separate the orbital and
palpebral lobes of the lacrimal gland.
• At 12 -13 week stage glandular acini will develop and canalization of the
glandular tissue started to form ducts .

• The lacrimal glands are small and do not function fully until
approximately 6 weeks after birth
• This explains why newborn infants do not produce tears when crying

• Full development of the gland does not occur until 3 to 4 years postnatally.
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 Excretory Apparatus
• begins its development at an earlier stage by the time embryo is 7-mm.
• depression termed the naso-optic fissure develops, bordered superiorly by the lateral nasal
process and inferiorly by the maxillary process.
• The naso- optic fissure or groove gradually shallows as the structures bordering it grow and
coalesce.
• Before it is completely obliterated, however, a solid strand of surface epithelium thickens along
the floor extending from the orbit to the nose.
• The thickened cord of epithelium becomes buried to form a rod connected to the
surface epithelium at only the orbital and nasal ends.
• This separation from the surface typically occurs at 43 days of embryologic age.

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• The superior end of the rod enlarges to form the lacrimal sac, and gives off two
columns of cells that grow into the eyelid margins to become the canaliculi .
• Canalization of this nasolacrimal ectodermal rod begins at the fourth month or
the 32- to 36-mm stage of development, proceeding first in the lacrimal sac, the
canaliculi, and lastly in the nasolacrimal duct .
• The central cells of the rod degenerate by necrobiosis, forming a lumen
closed at the superior end by conjunctival and canalicular epithelium and closed
at the inferior end by nasal and nasolacrimal epithelium .

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• The superior membrane at the puncta is usually completely canalized
when the eyelids separate at 7 months of gestation, and therefore is
normally patent by birth.
• In contrast, the inferior membrane (Valve of Hasner) frequently persists in
newborns, resulting in congenital nasolacrimal obstruction.

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.

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 Congenital anomalies of lachrymal system

Lacrimal gland anomalies:

• Lacrimal gland prolapse
Associated with craniosynostosis syndromes
• Ectopic lacrimal gland tissue -- within the orbit
• Lacrimal gland fistula
Aberrant ductule open to the skin of eyelid overlying the gland
Usually accompanied by adjacent cluster of eyelashes
Can mimic epiphora

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Cont.…

Lacrimal Drainage System

Duplication
• In rare cases, multiple puncta and
additional canaliculi develop

• There is extra opening on the eyelid

margin, it may be asymptomatic and
requires no treatment.

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 Con…

congenital lacrimal–cutaneous fistula

• has been used to describe uncommon fistulas that
exit through the skin, typically infra nasal to the
medial canthus.
• These anlage ducts or fistulas from an otherwise
normal canalicular system or lacrimal sac are
sometimes asymptomatic, or they may be
associated with tears that appear on the skin.

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 Cont.…
Congenital Nasolacrimal Duct Obstruction
• usually caused by a membrane blocking the valve of Hasner at the nasal end
of the NLD.
• Many newborns are born with imperforate NLDs, but most obstructions open
spontaneously within the first few months of life.
• at 3–4 weeks of age, clinically evident only in 2%–6% of full-term infants.
• Of these, one-third have bilateral involvement.

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 Cont…

Dacryocystocele
• It occurs when mucus (secreted by lacrimal sac goblet cells) is trapped in the
tear sac because of a functional block above the sac (valve of Rosenmüller)
and obstruction at the distal end (valve of Hasner) of the NLD.
• it may be present at birth or may develop within 1 to 4 weeks after birth.

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 Gross Anatomy
Secretory system
Main Lacrimal Gland: Located in the superotemporal aspect of the orbit
in fossa for lacrimal gland formed by orbital plate of frontal bone in
anterolateral part of the roof of orbit .
• It may extend inferiorly to the lateral canthal tendon
• Surrounded by fibrous tissue with attachment to periorbita of the fossa and
zygomatic bone

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• Divided into two in the anterior aspect --- by a lateral horn of levator
aponeurosis
Orbital lobe --- larger, oval shaped 20mm long, 12mm wide, & 5mm
thick
Palpebral lobe --- smaller (1/3), 2-3 lobules

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 Cont.…
Orbital lobe of lacrimal gland

• It is large about the size and shape of small almond

• Represents approximately 65% to 75% of the gland

• Measures 20 mm long, 5 mm thick and 12 mm wide.

• It has two borders ( anterior and posterior) ,two surface (superior and
inferior) and two extremities (medial and lateral).
Cont….
superior Surfaces
• convex
• suspended from the periorbita of the lacrimal gland fossa by fine trabeculae.
 Inferior surface
• concave
• rests on levator p superiors muscle and lateral horn of its aponeurosis

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Cont…
Anterior border
• Sharp and seems within and parallel to orbital margin, up to the
zygomaticofrontal suture
• Covered by orbital septum and a portion of the temporal aspect of
the central pre aponeurotic fat pad.
Posterior border
• Round, continuous with the palpebral part and lies In contact with
the orbital fat pad

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Cont…
Lateral extremity
• smooth, convex, rests on the lateral rectus muscle

Medial extremity
• related to levator palp superioris muscle

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 Cont….
Palpebral lobe of lacrimal gland
• It represents approximately 25% to 35% of the gland
Superiorly
• the levator aponeurosis
Anteriorly
• It extends beyond the orbital margin to lie in the lateral portion of the
superior fornix.
• Can be seen through conjunctiva when eyelid is everted.

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Ducts of lacrimal gland
• Has 8-12 secretory ducts
• 0.66 mm wide & 2.3 mm long
• Pass posterior to aponeurosis and through Muller muscle
• Empty into lateral part of superior fornix, about 4-5mm above
superior margin of upper tarsus
• 1-2 open in lateral part of inferior fornix, near lateral canthus

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• 2-5 of them originate from orbital lobe & 6-8 from palpebral lobe
• Ducts from orbital portion run through and join ducts of palpebral
lobe
• Damage to palpebral portion impairs function
• Biopsy shouldn’t be performed on the palpebral lobe or temporal conj fornix

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Structure of lacrimal gland
• It is a branched tubulo-alveolar ( serous acinus) gland.
• Histology is similar to salivary gland and accessory
lacrimal glands
• Microscopically it consists of
• Glandular tissue
• Stroma
• Septa
• Lined by a capsule as the outermost limit

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• Glandular tissue
• Consists of acini and ducts arranged in lobes & lobules separated from each
other by intervening fibrovascular septa.

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• Acini
• Lined by aSingle layer of pyramidal cells mounted on basement
membrane.
• this cell are surrounded by layer of flattened myoepithelial cells
• Pyramidal cells are of the serous type with
• Eosinophilic granules & round nucleus situated towards base
• Myoepithelial cells– secret the tear, expelled by the contraction
of myofibrils.

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• The secretion of the acinar unit is drained by connecting channels
which to began with are intra lobular, then these becames extra
lobular and lastly open into the ducts .

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• Ducts
• Connecting channels of intralobular, interlobular and
excretory ducts
• Lined by two layers of epithelial cells:
• Inner thick cylindrical cells
• Outer layer of flattened cells
• Pseudo-stratified, non-keratinized epithelium
possessing microvilli

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• Stroma
• Formed of mesodermal tissue, which contains:
• CT , elastic tissue
• Lymphoid tissue , plasma cells
• Rich nerve terminals and blood vessels

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 Blood supply

Arterial supply:
• Lacrimal artery (main)
• Branch of transverse facial
aa
• Infraorbital aa (from
internal maxillary aa)

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Venous drainage:
• Lacrimal vein --->
ophthalmic vein

• Lymphatic drainage:
• Along conj. drainage --->
pre-auricular LNs

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 Nerve supply
• Sensory: Lacrimal nerve (from CN-V1
• Sympathetic nerve supply from carotid plexus

• efferent pathway(parasympathetic ) originating in the superior salivatory

nucleus of the pons, exit the brainstem with the facial nerve,CN VII
• Lacrimal fibers leave CN VII as the greater superficial petrosal nerve and
pass into the sphenopalatine ganglion

• Enter the lacrimal gland via the superior branch

of the zygomatic nerve, through an anastomosis
between the zygomatico temporal nerve and
the lacrimal nerve.

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 Accessory lacrimal glands
• They are cytologically identical to the main lacrimal gland and receive
similar innervation .
• These glands account for approximately 10% of the total lacrimal
secretory mass.

Glands of Krause
glands of wolfring
Rudmentary accessory lacrimal glands

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Glands of Krause
• Beneath palpebral conj. near to fornices
• 40-42 in upper & 6-8 in lower fornix
• There duct united to form a long duct
which open in to the fornix.
Wolfring glands --- present along:
• Upper border of superior tarsus (2-5)
• Lower border of inferior tarsus (2-3)

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Clinical comments
Lacrimal gland swelling

• Dacryoadenitis
• Tumours
• Dacryopes
• Mekuliczs syndrome

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Excretory System
• Some tear fluid is lost by evaporation and some by reabsorption through
conjunctival tissue, but approximately 75% passes through the nasolacrimal
drainage system.
• The nasolacrimal drainage system consists of
 the puncta,
 canaliculi,
 lacrimal sac, and
 nasolacrimal duct, which
empties into the nasal cavity

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Cont…

Punctum
• Round/oval openings on medial margin of each eyelids at
junction of lacrimal and ciliary portions of the eyelid margin
• Average diameter is 0.2-0.3mm

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Cont…
• Situated on slight tissue elevation called lacrimal papilla
• Surrounded by ring of dense fibrous tissue that keeps them patent.
• Slightly inverted, lying within the tear lake
• Upper , directed down ward and back ward and lower , directed
upward and backward.
• Distance from the medial canthus:
 6.5mm -- inferior punctum
 6mm -- superior punctum
They don’t overlap on eyelid closure

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 cont….
Canaliculi
• Diameter of 0.5mm --- can distend up to 2mm
• Two parts -- vertical (2mm) & horizontal (8mm)
• At the junction Slight dilatation called --- ampulla

• Each canaliculi piers lacrimal fascia separately then forms common

canaliculus which open in lacrimal sinus of maier Of sac as:
• Common canaliculus --- in >90% of patients
• Separately --- in 10%

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Cont….

• Tear reflux from lacr. sac is prevented by:

• Mucosal fold -- valve of Rosenmuller
• Common canaliculus bends at an acute angle behind medial
canthal tendon

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 Cont….
• Three histologic layers (from inside out)
• Epithelium -- lining the canaliculi is stratified squamous, non
keratinized type (6-12 layers)
• Corium rich elastic tissue which makes its wall so stretchable
• Orbicularis fibers --- which surround the corium are called pars
lacrimalis . This help to draw the the lid inward thus allows the
punctum to glide in the groove b/n plica semilunaris and eye ball

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Lacrimal sac
• It is found in Lacrimal fossa which is located along the anterior aspect of
the medial orbital wall .
• Lacrimal fossa is formed by lacrimal bone and frontal process of maxillary
bone. Its bounded by anterior and posterior lacrimal crest

• It is covered by the periorbita, which laterally splits at the posterior lacrimal

crest, sandwiching the lacrimal sac in between. and meet at anterior
lacrimal crest.

• between the lacrimal fascia and the lacrimal sac, a narrow space is present
that contains a fine venous plexus and alveolar tissue .

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Dimensions -12 mm in height, 4 to 6 mm in depth,
and 5-6 mm wide & (2mm wide in infants) 20mm
cube volume

Parts
• Fundus: above the opening of canaculi(3-5mm)
• Body: middle part (10-12mm)
• Neck: lower small & narrow part and Continues
with NLD

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• Relations of lacrimal sac
• Medially related to
• Anterior ethmoidal sinus -- upper part
• Middle meatus of nose -- lower par

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• Anterolaterally from deep to superficial
• Lacrimal fascia & few fibers of inferior oblique muscle which arise
from it.

• Lacrimal fibers of orbicularis muscle(Horner’s muscle)

• Medial palpebral ligament which covers only the upper part

• Palpebral fibers of orbicularis and skin is the most anterior relation of

sac
• Angular vein
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• Posteriorly: from anterior to posterior
• Lacrimal fascia
• Fibers of lacrimal part of orbicularis
• Orbital septum separates sac from orbital fat and
check ligament of medial rectus muscle.

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• Naso-lacrimal duct
• From neck of lacrimal sac to inferior meatus
• Opens at valve of Hasner --- about 2.5cm posterior to the naris
• About 18mm (12-24mm) long & 3mm wide
• Its upper end is the narrowest part
• Directed downward, slightly lateral & backward
• Represented by a line joining inner canthus to ala of nose

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• Consists of 2 parts
• Intraosseous part (12.5mm)
Lies in the bony naso-lacrimal canal
which is formed and bordered by:
Anterolaterally: maxilla
Posteromedially: lacrimal bone and
ascending process of inferior nasal
concha
• Intrameatal part (5.5mm)
Within the mucous membrane of the lateral
wall of nose
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• Histology of lacrimal sac & NLD
• Epithelium: two layers of cells
• Superficial layer
• Non-ciliated columnar cells with goblet cells
• Deep layer --- flattened cells
• Sub-epithelial tissue
• Contains lymphocytes which aggregate to form follicles in
pathological conditions

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• Fibro elastic tissue
• Continuous with that of the canaliculi
• Plexus of vessels
• Well developed around the NLD, forming an erectile tissue resembling in
structre with that on the inferior concha.
• Engorgement of these vessels will cause NLD obstruction& epiphora.

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 Blood supply of lacrimal passages

• Arterial supply:
• Palpebral arteries: superior and inferior
• Angular artery
• Infraorbital artery
• Nasal branches of sphenopalitine artery

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 Venous drainage:
• From above: Angular vein & Infraorbital
vein
• From below: Nasal vein

 Lymphatics:
• Submandibular & deep cervical LNs

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• Nerve supply to the lacrimal sac and NLD
• Sensory:
• Infra trochlear nerve
• Anterior superior alveolar nerves
• Have no direct motor supply

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Clinical comments

Canaliculitis
Punctal stenosis
Punctal eversion/medial ectropion

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 • Acute dacryocystitis
• Chronic dacryocystitis

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 Lacrimal gland epithelial cell types. The LG epithelium (a) is composed of three major cell types:
acinar (b), ductal (c), and myoepithelial (MECs) (d red) cells. Acinar cells synthesize and secrete
proteins, water, and electrolytes. Ductal cells modify the secretory fluid by secreting electrolytes
and water. Myoepithelial cells (MECs) produce basal membrane proteins and have contractile
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function
Lacrimal gland epithelial cell lineage(s). Illustration of the three main hypotheses in cell lineage
hierarchy in the LG. (a) Hypothesis I: slow cycling LG stem cell produce a common progenitor that
gives rise to all LG lineages, epithelial (acinar and ductal) and myoepithelial (MEC). Hypothesis II: The
LG has lineage-restricted stem/progenitor cells that give rise to specific cell types within each lineage.
(b) Hypothesis III: This hypothesis suggests that multipotent stem/progenitor cells exist in one of the
LG cell lineages. Based on reported plasticity of MECs, MEC lineage may likely contain multipotent
stem-like cells that can restore all epithelial lineages upon LG injury. Dashed arrows label unknown
connections
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