Lecture on Epiphora, Dacryocystitis For 4th Year MBBS Undergraduate Students By Prof. Dr. Hussain Ahmad Khaqan

1. Epiphora, Dacryocystitis
Prof. Dr. Hussain Ahmad Khaqan
 MD
 FRCS(Glasgow)
 FCPS(Ophth.)
 FCPS(Vitreo Retina)
 MHPE (KMU)
 CICO(UK)
 CMT(UOL)
 Fellowship in Medical Retina (LMU, Munich)
 Fellowship in Vitreo Retinal Surgery (LMU, Munich)
 Consultant Ophthalmologist & Retinal Surgeon
Professor of Ophthalmology
Lahore General Hospital, Lahore
Ameer Ud Din Medical College, Lahore
Post Graduate Medical Institute, Lahore
Shaukat Khanum Memorial Cancer Hospital & Research Centre ,Lahore

2. EPIPHORA

3. INTRODUCTION
• The tear disposal system of the eye that consists of
the punctum, canaliculi, lacrimal sac and
nasolacrimal duct. The eyelids also form a
physiological lacrimal pump.
• Tearing (a watery eye) may be caused by
hypersecretion of tears or decreased elimination,
called epiphora.

4. CAUSES CONTINUE….
• Increased tear production
– Basal increase
• Increased parasympathetic drive: from pro-secretory drugs (e.g. pilocarpine)
or autonomic disturbance.
– Reflex increase
• Local irritants, e.g. Foreign body, trichiasis.
• Chronic ocular disease, e.g. blepharitis, Keratoconjunctivitis sicca
• Systemic disease, e.g. Thyroid eye disease
• Lacrimal pump failure
– Lid tone
• Lid laxity: common involutional change in the elderly.
• Orbicularis weakness: associated with facial nerve palsy.
– Lid position
• Ectropion: most commonly an involutional change in the elderly but may also
be cicatricial, mechanical, or congenital.

5. • Decreased drainage
– Punctal obstruction
• Congenital: punctal atresia.
• Acquired: punctal stenosis is most commonly idiopathic but may
arise secondary to punctal eversion, post-HSV (herpes simplex
virus) infection, or any scarring process (e.g. post-irradiation,
trachoma, and cicatricial conjunctivitis).
– Canalicular obstruction
• Acquired: canalicular fibrosis is most commonly idiopathic but may
arise secondary to HSV ( herpes simplex virus) infection, chronic
canaliculitis (usually Actinomycosis), chronic dacrocystitis,
cicatricial conjunctivitis, Fluorouracil (5-FU)-administration.
CAUSES CONTINUE….

6. – Nasolacrimal duct obstruction
• Congenital: delayed canalization.
• Acquired: stenosis is most commonly idiopathic but
may arise secondary to trauma (nasal/orbital fracture),
post-irradiation, Granulomatosis with polyangiitis
(GPA), tumours (e.g. nasopharyngeal carcinoma) and
other nasal pathology (chronic inflammation/polyps).
CAUSES

7. WORK UP CONTINUE…
• A history of topical medication such as echothiophate iodide
(Phospholine Iodide), epinephrine (adrenaline), or pilocarpine
drops is important, because they may produce lacrimal
obstruction. Chemotherapy such as 5 fluorouracil (5-FU) and
radiotherapy can cause obstruction in the canaliculi.
Photodynamic therapy also has been associated with
canalicular stenosis.
• Dye retention test: the tear meniscus can be seen elevated
with fluorescein 2% instilled into the conjunctival fornix when
there is delayed outflow.

8. • Lacrimal Syringing
• Jones Fluorescein Dye Test: Jones I and II dye tests
• Endoscopic Jones test
• Radiological investigations such as lacrimal scintigraphy
(nuclear imaging) and dacryocystography
WORK UP CONTINUE…

9. WORK UP
Figure: Lacrimal scintigraphy Figure: Dacryocystography

10. TREATMENT
• Correction of congenital obstruction is typically achieved with
a simple probing procedure.
• For acquired obstructions, a dacryocystorhinostomy (DCR) is
usually required for permanent resolution.

11. DACRYOCYSTITIS

12. DEFINITION
• Dacryocystitis is acute, subacute, or chronic
inflammation of the lacrimal drainage system. It may
be localized in the sac, extend to include a
pericystitis, or progress to anterior orbital cellulitis. It
very rarely causes posterior orbital cellulitis with
proptosis and muscle limitation.

13. SYMPTOMS
• Pain at the side of the nose
• Redness
• Tearing
• Discharge
• Fever

14. SIGNS
• Erythematous, tender, tense swelling over the nasal
aspect of the lower eyelid and extending around the
periorbital area nasally.
• A mucoid or purulent discharge can be expressed
from the punctum when pressure is applied over the
lacrimal sac.

15. Figure 1: Left eye acute dacryocystitis.
Figure 2: Expression of mucopurulent
discharge

16. CAUSES
• Almost always related to nasolacrimal duct
obstruction.
• Uncommon causes include diverticula of the lacrimal
sac, dacryoliths, nasal or sinus surgery, trauma, and
rarely a lacrimal sac tumor.
• Gram-positive bacteria are the most common
pathogens; however, gram-negative and atypical
organisms are seen more commonly in diabetics,
immunocompromised, and nursing home patients.

17. DIFFERENTIAL DIAGNOSIS
• Facial cellulitis involving the medial canthus
• Dacryocystocele
• Acute ethmoid sinusitis
• Frontal sinus mucocele/mucopyocele

18. WORK UP
• Transcutaneous aspiration of sac contents for culture
and gram staining
• Computed tomography (CT) scan of the orbits and
paranasal sinuses

19. TREATMENT Continue..
CONGENITAL NASOLACRIMAL OBSTRUCTION
• More than 90% of patients with congenital nasolacrimal obstruction
undergo spontaneous resolution by age 1 year.
• Persistent swelling at the medial canthus may represent a widened
nasolacrimal duct and dilated inferior meatus cyst that requires
endoscopic marsupialization
• Probing under general anesthesia
• Fluorescein-tinted irrigation saline is introduced to see whether it passes
into the inferior meatus, or metal-to-metal contact may be obtained by
inserting a probe in the nose.
• Endoscopic monitoring of syringe and probing is recommended for second
procedures
• Silastic tubes should be placed for at least 3 months (preferably 6 months)
• Dacryocystorhinostomy (DCR)

20. TREATMENT
ACQUIRED NASOLACRIMAL OBSTRUCTION
• After an attack of dacryocystitis, symptoms may resolve spontaneously.
• Medical: Systemic antibiotics in the following regimen:
 Children older than 5 years and <40 kg:
• Afebrile, systemically well, mild case and reliable parent:
Amoxicillin/clavulanate: 25 to 45 mg/kg/day p.o. in two divided doses for
children, maximum daily dose of 90 mg/kg/day.
• Alternative treatment: Cefpodoxime: 10 mg/kg/day p.o. in two divided
doses for children, maximum daily dose of 400 mg.
• Febrile, acutely ill, moderate-to-severe case or unreliable parent:
Hospitalize and treat with cefuroxime, 50 to 100 mg/kg/day intravenously
(i.v.) in three divided doses in consultation with infectious disease
specialist.

21. Adults:
• Afebrile, systemically well, mild case and reliable
patient: Cephalexin 500 mg p.o. q6h.
• Alternative treatment: Amoxicillin/clavulanate
500/125 mg t.i.d. or 875/125 mg p.o.b.i.d.
• Febrile, acutely ill, or unreliable: Hospitalize and treat
with cefazolin 1 g i.v. q8h. The antibiotic regimen is
adjusted according to the clinical response and the
culture /sensitivity results. The i.v. antibiotics can be
changed to comparable p.o. antibiotics depending on
the rate of improvement, but systemic antibiotic
therapy should be continued for at least a full 10 to 14
day course
TREATMENT