The disorders of the lacrimal system are well explained.

1. DISORDERS OF THE
LACRIMAL SYSTEM
Professor Eki Oghre
Department of Optometry,
University of Benin, Benin City

2. The lacrimal apparatus
• Consist of the lacrimal glands, accessory lacrimal glands,
the puncta, the canaliculi, the lacrimal sac and the
nasolacrimal duct.
• It is a mucous membrane lined tract continuous with the
conjunctival and nasal mucosa
• Enables production, spreading, distribution, elimination of
tears across the ocular surfaces

3. • The lacrimal gland are located in the in the superior
temporal portion of the orbit, and are responsible for
aqueous tear secretion.
• The tears flow out of the gland and through the
secondary ducts to the superior fornix.
• They lubricate the conjunctiva and cornea surfaces and
are drained by the puncta into the superior and interior
canaliculi,
• This empties into the lacrimal sac and then into the
nasolacrimal duct.

5. Problems of the nasolacrimal drainage system
• Lacrimal gland inflammation
• Lacrimal gland tumours
• Lacrimal sac tumours
• Drainage obstruction
• These will often result either in
• tearing (excess tears)
• dry eye (insufficent tears).
Lacrimation which occurs without other symptoms in
often as a result of a disorder of the lacrimal drainage
system.

6. Dacryoadenitis
Inflammation of the lacrimal gland,
• Relatively rare,
• More in females between ages 30-40years,
• Frequently associated with viral infections.
• Can be unilateral or bilateral, acute or chronic.
• Often seen in children along with other viral infections
such as Mumps, Measles, Influenza, Herpes Zoster, etc

7. Symptoms of acute Dacryoadenitis
• unilateral severe pain
• redness,
• pressure in the superior temporal region of the orbit with 2-3hours
onset
• tenderness on palpation, especially in the superior temporal aspect
of the upper eyelid.
• there may be oedema, producing an S shaped lid,
• there may be purulent discharge, conjunctival injection
• there may be salivary gland involvement.
• Acute dacryocyadenitis is commonly caused by bacteria or viruses,
eg mumps
• In the acute form, Lymphadenopathy. There may be restriction of
ocular motility

8. Chronic Dacryoadenitis
• It may also occur bilaterally as a painless enlargement of
the lacrimal gland.
• There may be minimal ocular signs, mild ptosis
• The inflammation may lead to decreased function, from
mild to severe dry eye.
• Systemic involvement may include fever, malaise, and
upper respiratory tract infection.
• Chronic Dacryoadenitis usually due to non-infectious
inflammatory disorders, eg. Saccoidosis, Thyroid eye
disease, etc.
• .

9. management
• Treat the underlying systemic cause if any,
• Treatment varies with aetiology
• If Viral (most common), - Self limiting, so supportive
treatment eg, warm compress, Oral NSAIDs
• if purulent discharge is present, it is likely bacterial, so
give oral antibiotics four times daily . Eg Amoxicillin or
Cephalexin
• It may involve degeneration of the lacrimal gland, leading
to chronic dry eye

10. Lacrimal sac obstruction
• They can be
• Congenital
• Incomplete opening of the nasolacrimal duct
• Acquired
• Infections
• Stenosis of puncta
• Canaliculutis
• Lacrimal sac tumours (rare)

11. Dacryocystitis
• Infection or an inflammation of the lacrimal sac,
• usually secondary to an obstruction in the system.
• May be chronic or acute,
• congenital or acquired. The acquired is by far more common and
often seen in people over 40years.
• The congenital form is found in infants.
• Symptoms of acquired Dacryocystitis;-
• focal pain
• redness and
• swelling over the nasal aspect of the lower lid.
• the pain may extend to the nose, checks and teeth on the affected
side.
• There may be tearing and discharge.

12. • Examination reveals
• erythematous swelling over the lacrimal sac
• purulent discharge may be expressed from the
punctum if pressure is applied.
• In severe cases there may be headaches and
fever. There may be a secondary conjunctivitis
and untreated cases may lead to preseptal
cellulitis.

13. aetiology of dacryocystitis
• The primary aetiology of dacryocystitis is an obstruction of
the nasolacrimal apparatus, leading to secondary
infection.
• Most cases in older people result from
• chronic degeneration of the mucosa,
• stenosis of duct, stagnation of tears and bacterial overgrowth.
• Commonly isolated organisms are
• staphylococcus aureus and
• streptococcus,
• gram negative organisms include p. aeruginosa. H. Influezae and
fusobacterium

14. Infantile dacayocytitis
• This is less common and results from a delay in the
opening of the valve of hasner which allows nasolacrimal
drainage into the nose.
• Here there is difuse enlargement of the lacrimal sac and
epiphora
• Usually no pain

15. Management for acquired
• Rule out canalicalitis
• Because it is a deep tissue infection systemic antibiotics
are indicated alongside topical antibiotics
• augumentin or cephalexin 500mg p.o. qid,
• 0.5% moxifloxacin or 1% Azithramycin for topical use
• For acute cases warm compress 4 times daily
• Oral analgesics
• For febrile patients,
• hospitalization and iv antibiotics should be recommended
• On resolution of symptoms dilation and irrigation of nasolacrimal
duct

16. • For Children
• Warm compress
• Gentel massage
NEVER IRRIGATE OR DILATE ACUTE CASES OR CHILDREN
• Continue gentle message over the duct 4x daily for up to
3months.
• Antibiotic treatment should be continued for 10 to 14days.
• If the condition is worsening, MCS should be done and
medication adjusted appropriately for chronic cases.
Vigorous message should be done on first presentation,
then dilation and irrigation at a later date.

17. Canaliculitis
• Inflammation/infection of the canaliculi
• uncommon chronic unilateral condition that occurs exclusively in
adults.
• It more often affects the upper canaliculi and may be caused by
fungi, bacteria or viruses.
• Signs and Symptoms
• Epiphora
• focal swelling at the medical canthus.
• often associated with a pouting puntum (the punctum in red, swollen and
turned outwards like a pair of pouting lips)
• history of previous therapy with topical antibiotics to no avail,
• complains of a chronic recalcitrant red eye
• Discharge and or concretions may be expressed from the punctum with
digital manipulations.
• formation of dacryolithis which are small stores or concretions.
• Other signs are erythema and swelling of lids and adnexa, a secondary
conjunctivitis.

18. Management:
• Management of canaliculitis is two fold,
• physical removal of associated foreign matter
• vigorous antimicrobial therapy.
Small dacryoliths and other debris may be expressed through the
punctum with direct manipulation using a cotton-tipped applicator.
Larger or numerous stones often require surgical canaliculotomy.
• Institute antimicrobial therapy only after alleviating the
blockage.

19. DRY EYE
• Dry eye disease (DED)—also called keratoconjunctivitis
sicca, dysfunctional tear syndrome1
• A multifactorial disorder of the tear film and ocular surface
that results in eye discomfort, visual disturbance, and tear
film instability with potential damage to the ocular surface.
It is accompanied by increased osmolarity of the tear film
and inflammation of the ocular surface.
• It can be classified into two aetiological categories.
• Decrease tears production or aqueous tear deficiency Dry eye
(keratoconjunctivitis sicca) and
• Increase tear evaporation dry eye or evaporative Dry eye

20. Decrease tears production dry eye
(keratoconjunctivitis sica):
• Decrease tear production results from
• damages the tears glands or its secretory ducts i.e.
autoimmune disease, medication, systemic
inflammatory diseases etc., resulting in ocular surface
disease.
• Aqueous-deficient dry eye is classified as either
• Sjögren
• Primary
• secondary
• Non-Sjögren.

21. • Primary Sjögren syndrome - is an autoimmune disorder in
which the lacrimal and salivary glands are infiltrated by
activated T-cells, resulting in symptoms of dry eye and dry
mouth.
• Secondary Sjögren syndrome is associated with other
autoimmune diseases such as rheumatoid arthritis or
systemic lupus erythematosus.
• Non-Sjögren aqueous-deficient DED results from lacrimal
gland insufficiency of various other aetiologies i.e. age-
related, congenital alacrima, lacrimal duct obstruction,
lacrimal gland denervation, reflex hyposecretion, Vit A
deficiency, etc.

22. Evaporative DED
• various causes, including
• meibomian gland disease (most common cause)
• eyelid aperture disorders
• lid/globe incongruity, blink disorders,
• ocular surface disorders
• Meibomian gland dysfunction (MGD; also called posterior
blepharitis), is the most common cause of meibomian
gland obstruction.
• Many dry eye cases involve overlap of the two major
aetiologies

23. Signs and Symptoms
• dryness,
• gritiness and foreign body sensation,
• burning,
• redness
• eye fatigue,
• vision may blur or fluctuate, worse in the evenings,
• eyes may seem sensitive to temperature, wind,
• paradoxically tearing may be one of the symptoms.
• Fluorescent staining will show punctate dots over the exposed
cornea and conjunctival surfaces.
• In severe cases abnormal mucous strands may be seen
attached to the corneal surface (filamentary keratitis) causing
pain due to tugging of the filaments during blink.

24. Risk factors
• • Older age and female sex :
• •Environmental conditions.
• • Occupational factors.
• • A diet low in omega-3 fatty acids or low vitamin A intake
• • Hormonal status.
• • Systemic medications i.e.anticholinergics eg, antihistamines,
antispasmodics, tricyclic antidepressants,
diphenoxylate/atropine), beta-blockers, diuretics, systemic
isotretinoin, amiodarone, interferon and postmenopausal
hormone replacement therapy
• • Topical ophthalmic medications. Freq use of preserved drops
• • Contact lens wear.
• Refractive surgery
• • Parkinson’s disease..
• Diabetes mellitus,

25. Diagnoses of dry eye involves
• History and symptoms
• Tear production tests i.e. Schirmer’s test
• Tear stability tests i.e. Tear break up time
• Ocular surface stain with fluorescent or lissamine
green
• Tear osmolality

26. • Management
• Treat underlying conditions ie. Blepheritis
• This involves supplementation of tears with ocular
lubricants
• Artificial tear drops
• Lubricant ointments
• Topical cyclosporine
• Provide a humid environment around the eyes with shielded
spectacles
• In severe cases, punctual occlusion may be done with punctual
plugs
• For more permanent occlusion, surgery may be required
• Other i.e. autologous serum. NSAIDs, SAIDs