Eye lid Disorders,Ptosis , Ectropion , Entropion , Lid Swelling

1. EYE LID
06/10/2020
DR M SAQUIB
Vice Principal , G.S.Medical College & Hospital
MBBS,MS , FSCEH DELHI,FHVDESAI PUNE,
EX REGISTRARA JNMCH,AMU
CONSULTANT OPHTHALMOLOGIST
HOD D/O OPHTHALMOLOGY
G.S .MEDICAL COLLEGE
Founder sec: MEDICS India ,
Mail-dms2k5@gmail.com , 9634123800

2. Anatomy
2

3. Structure
▸ Skin
▸ Subcutaneous Areolar Tissue
▸ Layer Of Striated Muscle
▸ Submuscular Areolar Tissue
▸ Fibrous Layer
▸ Layer Of Non Striated Muscles
▸ Conjunctiva
3

4. Glands of Eye lid
▸ Meibomian Gland
▸ Gland of Zeis
▸ Gland of Moll
▸ Accessory Lacrimal Gland of
Wolfring & Krause
4

5. Blood Supply
▸ Arteries
▸ Vein
▸ Lymphatics
5

6. Nerve Supply
▸ Motor : Facial - Orbicularis
▸ Oculomotor – LPS Muscles
▸ Sympathetic – Muller’s Muscles
▸ Sensory :
▸ Trigeminal ----( UL) Lacrimal , Supraorbital ,
Supratrochlear
▸ Lower Lid - Infraorbital , Infra trochlear
6

7. 7

8. Anomalies & Diseases
▸ Congenital Anomalies
▸ Eyelids Oedema
▸ Inflammatory Disorder of Eye lids
▸ Eye lash disorder
▸ Anomalies in Position of Eye Lids – Entropion, Ectropion
▸ Tumours of Eye Lids -
8

9. 9

10. 10

11. Congenital Anomalies
▸ Ptosis
▸ Coloboma
▸ Epicanthus
▸ Distichiasis
▸ Cryptophthalmos
▸ Microblephron
▸ Epiblephron
▸ Euryblephron
11

12. Congenital Ptosis
▸ A droopy eyelid, also called ptosis occurs when the muscle that
elevates the eyelid (the levator palpebrae superioris muscle) is
weak from various reasons.
▸ Congenital weakness of LPS due to maldevelopment .
12

13. 13

14. Clinical Features:
▸ Drooping of Eye Lid – U/L , B/L
▸ Lid Crease –Diminished or Absent
▸ Lid Lag on Downgaze – Ptotis lid level
higher than other in downgaze
▸ LPS- Function –Poor, Fair ,Good
14

15. The Droopy Eyelid May Cause:
▸ Astigmatism- If the pressure on the front of the eye causes distortion and
refractive error it may need close observation, treatment with glasses or even
surgery.
▸ A chin up position- If the ptosis is severe enough it may cause the child to
adopt a chin up position in order to be able to see beneath the droopy eyelids
and use the eyes together. Contraction of the frontalis muscle (in the forehead)
to further elevate the upper eyelid is a very common compensatory
mechanism. This is also an indication for surgical correction.
▸ Amblyopia (abnormal visual development)- This results from astigmatism (a
misshaping of the cornea) or other refractive errors (refractive amblyopia).
(Stimulus deprivation amblyopia).
15

16. Associated Features with Congenital Ptosis
▸ Simple Congenital Ptosis
▸ Congenital Ptosis with Superior Rectus Muscle
weakness – Double elevator palsy
▸ Blephrophimosis Syndrome
▸ Congenital Synkinetic Ptosis : Ptotic lid retraction
with Jaw movement
16

17. 17

18. ACQUIRED PTOSIS
▸ NEUROGENIC PTOSIS
▸ MYOGENIC PTOSIS
▸ APONEUROTIC PTOSIS
▸ MECHANICAL PTOSIS
18

19. NEUROGENIC PTOSIS
▸ Third Nerve Palsy
▸ Ophthalmoplegic Migraine
▸ Multiple Sclerosis
▸ Horner’s Syndrome :
▸ Oculosympathetic Paresis
▸ Mild Ptosis (Muller Muscle Paralysis )
▸ Miosis ( Dilator Pupillae paralysis )
▸ Reduced Iplsilateral sweating
▸ Enophthalmos
19

20. 20

21. Acquired Myogenic Ptosis
▸ Acquired disorder of the LPS / Myoneural junction .
▸ Myasthenia Gravis
▸ Dystrophia Myotonica
▸ Ocular Myopathy
▸ Oculopharyngeal Muscular Dystrophy
▸ LPS Trauma
▸ Muscle thyrotoxicosis
21

22. Aponeurosis Ptosis
▸ Defect in LPS Aponeurosis.
▸ LPS muscle is normal
▸ Involutional Ptosis
▸ Postoperative Ptosis (Cataract,RD)
▸ Blephrochalasis weakness of aponeurosis
▸ Traumatic Dehiscence or Disintertion
▸ Characteristic features of this type of Ptosis are that patients have a
good levator function with a high lid crease, affected eyelid appears
lower on down gaze and a thin upper eyelid with redundant skin.
22

23. Mechanical Ptosis
▸ Lid Tumours
▸ Multiple Chalazion
▸ Lid Oedema
▸ Cicatricial Ptosis (Pemphigoid,Trauma )
23

24. History
▸ Age ‘Family History
▸ Trauma
▸ Surgery
▸ Systemic disorder
▸ A history of dry eyes, intermittent epiphora, or
chronic conjunctivitis can indicate a dry eye
disorder .
24

25. Exclude Pseudoptosis
▸ Microphthalmos
▸ Pthisis Bulbi
▸ Enophthalmos
▸ Prosthesis
▸ Brow Ptosis
▸ Dermatochalasis
▸ Hypotropia
▸ Contralateral – Eye lid Retraction
▸ High Myopia
▸ Proptosis
25

26. Clinical History
▸ Age
▸ Progression
▸ Diurnal variation
▸ Change with Jaw Movement
▸ History of Trauma
▸ History of Previous Ocular Surgery
▸ History of Muscle Fatigue
26

27. Clinical Examination▸ Vision
▸ Pupil Reaction
▸ Head Posture
▸ Frontalis Overaction /Brow Fold/Level
▸ Lid Crease
▸ MRD –
▸ Palpebral Fissure ( Height & Width)
▸ LPS Function –
▸ Vertical Palpebral Height
▸ Lid Lag on Downgaze
▸ Marcus Gunn Jaw Winking Phenomenon
▸ Bell’s Phenomenon
▸ Extraocular Movement
▸ Corneal Sensation
▸ Tear Film Evaluation
▸ Old Photograph27

28. ▸ Measure amount of Ptosis – Mild/Moderate /Severe
– 2/3/4 mm
▸ Marginal Reflex distance – MRD- Normal – 4-5 mm
▸
▸ LPS Function – Normal- 15 mm
▸ Good- 8mm ,fair- 5-7 mm ,Poor -4mm less
28

29. 29

30. 30

31. Specific Investigation
▸ Tensilon test – I . V Endrophonium ,cause
improvement in Ptosis ( myasthenia)
▸ Phenylephrine Test – Horner’s syndrome
Neurological investigation –MRI
Photographic Records
31

32. Treatment of Congenital Ptosis
▸ Severe Ptosis – Urgent to prevent Amblyopia
▸ Mild –Moderate – Till anatomical structure form
▸ 1.TARS-OCONJUCTIVAL –MULLERECTOMY
▸ 2. LEVATOR RESECTION –
▸ 3.FRONTALIS SLING OPEARTION
▸
32

33. 33

34. Farsanella –Servat Operation
▸ Upper Lid eversion
▸ Upper Tarsal Border –
▸ Muller Muscle
▸ Conjuctiva
34

35. 35
Farsanella –Servat Operation

36. LEVATOR RESECTION
▸ Moderate –Severe grade Ptosis
▸ Contraindicated in severe Ptosis with Poor LPS
▸ Moderate Ptosis
▸ LPS Function -Good –16-17 mm – Minimal
Fair -18-22 mm- Moderate
Poor – 23-24 mm- Maximum
Severe Ptosis – LPS -18-22- LPS Resection – 23-24
mm36

37. ▸ Conjuctival - Double
Evert Upper Eyelid
▸ Skin Approach Incision
along Lid Crease
37

38. Frontalis Sling ( Brow suspension)
▸ Severe Ptosis with NO levator
Function
▸ Material Used – Fascia Lata ,Silicon
rod
38

39. ▸ Crawford method
▸ Fox Pentagon
39

40. Treatment of Acquired Ptosis
▸ Treat Underlying cause
▸ Conservative treatment – Neurogenic Ptosis – 6
Month
▸ Surgery – Levator resection
40

41. Treatment of Acquired Ptosis
▸ LPS Dehiscence – Levator Advancement
▸ Neurological Ptosis with Bell’s – Conservative –
Crutch Glasses
41

42. Anomalies in the Position of Eye lid
Margin & Lashes
▸ Entropion – Congenital
▸ Involutional
▸ Cicatrial
▸ Spastic
▸ Mechanical
▸ Ectropion - Congenital
▸ Senile
▸ Paralytic
▸ Cicatrial
▸ Mechanical42

43. 43

44. A. Normal Lid Position
B. Spastic Entropion
C. Cicatricial Entropion
D. Senile Ectropion
44

45. Congenital Ectropion
▸ Vertical insufficiency of the anterior Lamella of the
Eye lid
▸ Associated with – Blephrophimosis Syndrome
Down Syndrome , Ichthyosis , Eublephron .
Treatment – Full Thickness Skin graft to lengthen the
anterior lamella
45

46. Congenital Entropion
▸ Congenital Inversion of Eye lid
▸ Developmental Factor associated – Lower Lid
Retractor Dysgenesis,Tarsus kink ,Relative
shortening of Posterior lamella
46

47. Senile (Involutional ) Entropion
▸ Very common
▸ Only lower lid
▸ Factors: Attenuation and disinternation of Eye lid
retractors
▸ Tissue atrophy with Horizontal laxity of the Eye lid
▸ Overriding of Pre tarsal fiber of orbicularis by
Preseptal Fibres of Orbicularis
47

48. 48

49. 49

50. Clinical Features -
▸ Foreign Body sensation
▸ Irritaion
▸ Lacrimation
▸ Photophobia
▸ Scarring of Palpebral Conjuctiva
▸ Recurrent corneal abrasion
▸ Superficial corneal Opacity
50

51. ▸ Snapback Test : Horizontal laxity detected by
poor eye lid tone ,
▸ Distraction Test – Ability to pull Eye lid more
than 6 mm from the Globe
▸ Grading of Entropion –
▸ Grade 1 –Posterior Lid Border is inrolled
▸ Grade 2- Inturing up to intermarginal strip
▸ Grade 3 –Whole lid margin inturned
51

52. Treatment
Reattachment of Lid Retractors
Shortening of Horizontal width of the Tarsal
plate
Forming cicatrix between pretarsal and preseptal
part of Orbicularis
52

53. Surgical Correction of Cicatrial
Entropion
▸ Mild Entropion -Anterior lamellar Resection
▸ Moderate Entropion with Atrophic Tarsus – Tarsal
Wedge Resection
▸ Mild to Moderate Cicatrial Entropion –
▸ Transposition of Tarsoconjuctival Wedge ) – Tarsus
Fracture and Eversion of Distal Tarsal
▸ Posterior Lamellar Graft
53

54. Surgical Technique for Senile
Entropion
1.- Very Old Patient – Temporary Transverse Everting
Sutures
▸ 2.Little Horizintal Laxity – Long Term – Wies Procedure
–Transverse Lid Split and Everting Sutures
▸ 3.Severe /Recurrence case- Plication of Lower Lid
Retractor – Jones Procedure
▸ 4.Severe Horizontal Lid Laxity – Quickert Procedure
54

55. 55

56. 56

57. 57

58. 58

59. Cicatrial Entropion
▸ Cicatrical contraction of Palpebral Conjuctiva
▸ Relative shortening of the inner tarsoconjuctival
lamina of the lid
▸ Inversion of Lid Margin
▸ Causes :
▸ Trachoma
▸ Trauma
▸ Chemical Burn
▸ Steven Jhonson Syndrome
▸ Cicatrical pemphigoid
59

60. Principle-
Lengthening of the posterior lid
lamina
Tarsal Plate Rotation
▸ Mild to Moderate Entropion – with Thick Tarsus-
Wedge Resection of Tarsus
▸ Severe Entropion / Entropion without Thick
Tarsus – Tarsal Fracture
60

61. Mechanical Entropion
▸ Due to lack of Support
▸ Pthisis Bulbi
▸ Enophthalmos
▸ After Enucleation or Evisceration
61

62. Ectropion
▸ Outward turning of the Eye lid margin.
Clinical Feature –
▸ Epiphora
▸ Irritation ,Discomfort ,
▸ Mild Photophobia
62

63. Senile( Involutional ) Ectropion
▸ Most common type of Ectropion
▸ Causes-
▸ Horizontal Laxity of Eyelid
▸ Medial Canthal Tendon laxity
▸ Lateral Canthal tendon laxity
▸ Disintertion of lower lid Retractors
63

64. Cicatrial Ectropion
▸ Due to scarring of lid skin
▸ Can involve both lids
Causes-
▸ Thermal burn
▸ Chemical burn
▸ Laceration, Ulcer
64

65. ▸ The skin, orbicularis muscle, and orbital septum are
normally flexible enough that spontaneous movement of the
eyelids can occur.
▸ Anterior lamella (skin and muscle) and posterior lamella
(tarsus and conjunctiva). Scarring of the anterior
lamella can cause a cicatricial ectropion .
▸ Lengthening of the shortened lamella by adding a full-
thickness skin graft is the treatment for cicatricial
ectropion.
▸ Scarring of the posterior lamella also causes a cicatricial
entropion.
65

66. Mechanical Ectropion
▸ Proptosis
▸ Chemosis
▸ Tumour
66

67. Paralytic Ectropion
▸ Facial Nerve Palsy
▸ Lower Lid
▸ Causes-
▸ Facial Nerve Palsy
▸ Bell’s Palsy
▸ Head Injury
▸ Infection of middle Ear
▸ Operation of Parotid Gland
67

68. Signs
▸ Out rolling of Lid Margin – Grading
▸ Grade I - Puntum is everted
▸ Grade II -Lid Margin is everted ,Palpebral Conjuctiva is visible
▸ Grade III -Fornix is also visible .
68

69. If the ectropion is not cicatricial and not paralytic, it must be
involutional.
Involutional ectropion occurs in older patients with eyelid
laxity . The eyelid laxity can be demonstrated by the eyelid
distraction test and the eyelid snap test
▸ Involutional Ectropion – Positive snap Test –
Horizontal lid laxity ,lid can be easily pulled
away from the globe but fails to snape back to
the normal position on release .
▸ Medial Canthal Tendon laxity
▸ Lateral canthal tendon Laxity69

70. 70

71. 71
The eyelid distraction test is
performed by manually pulling
the eyelid away from the eyeball.
The lower lid should not move
more than 6 mm off the eyeball.

72. The Eyelid Distraction
Test
The eyelid distraction
test is performed by
manually pulling the
eyelid away from the
eyeball. The lower lid
should not move more
than 6 mm off the
eyeball.
72

73. Congenital Ectropion
▸ Mild Ectropion : No Treatment
▸ Moderate –Severe : Horizontal lid Tightening
,Full thickness skin graft , Vertical lengthen
anterior lamella.
73

74. Paralytic Ectropion
▸ Spontaneous resolved 6 month
▸ Temprarory measures: Topical Lubricant
▸ Taping temporal side of eye lid
▸ Suture tarsorrhaphy
▸ Permanent :
▸ Horizontal lid tightening
▸ Palpebral sling Operation
74

75. Cicatrial Ectropion
▸ V-Y OPERATION
▸ Z- PLASTY
▸ Excision of scar tissue and full thickness skin
grafting -
75

76. Mild Degree Ectropion
76

77. 77

78. Involutional Ectropion
Age Related
Medial Conjuctivoplasty : Mild cases of ectropion involving punctal area
.Excising a spindle –shaped piece of conjuctiva and subconjuctival
tissue
Horizontal Lid Shortening – Full thickness pentagonal excision in
moderate ectropion .
Lateral Tarsal Strip Procedure – Generalised ectropion with horizontal
lid laxity
Byron Smith’s modified Kuhnt- Szymanowski78

79. 79

80. Generalized Ectropion With Associated
Horizontal Lid Laxity
80

81. 81

82. 82

83. Blephrophimosis Syndrome
83

84. Euryblephron
84

85. 85

86. 86

87. Lid Oedema
▸ Inflammatory
▸ Solid Oedema
▸ Passive Oedema
87

88. 88

89. 89

90. Inflammatory Disorder of Eye lids
▸ Blephritis – Anterior , Posterior ( Meibomitis)
▸ External Hordeolum
90

91. 91

92. 92

93. 93

94. 94

95. 95

96. NASOLACRIMAL APPARATUS
1.Secretory system
2.Excretory system
96

97. SECRETORY SYSTEM
▸ Lacrimal gland
▸ Accessory Glands
- Gland of Krause
- Gland of Wolfring
97

98. 98

99. SECRETORY SYSTEM-Development
 Lacrimal gland- multiple solid ectodermal
buds- anterior supero-lateral orbit- 6-8 weeks
age of gestation
 Buds branch and canalize- ducts and alveoli
 Do not function fully- 6 weeks after birth
 Newborn infants- do not produce tear- crying
 Congenital NLDO seen following defective
canalization of the Caudal End .
 50% of the Newborns will have obstruction of
the distal end (Valve of Hasner )
99

100. SECRETORY SYSTEM
▸ Lacrimal gland- Exocrine gland, almond size,
situated at lacrimal gland fossa- Superior
temporal orbit in frontal bone.
▸ LPS divides gland into orbital & palpebral lobe
anteriorly.
▸ Ducts from orbital lobe passes thru palpepral
lobe- empty into upper conj fornix temporally.
▸ Biopsy is avoided from Palpebral Lobe
100

101. Accessory Glands
- Gland of Krause
- Gland of Wolfring
101

102. ACCESSORY GLANDS
▸ Gland of Krause- Accessory exocrine gland
present deep in superior fornix
▸ Gland of Wolfring -situated near superior
border of tarsal plate.
▸ Previously- Main lacrimal gland- reflex
secretion
- Accessory glands- basal secretion
Recent evidence- All tearing –Reflex- single unit
102

103. TEAR FILM
▸ 1.Lipid layer- secreted by Meibomian glands
Increase surface tension of tear film &
decreases its rate of evaporation
▸ 2. Aqueous layer- secreted by main lacrimal
glands & gland of Krause & Wolfring.
Provides oxygen to cornea & antibacterial
function.
▸ 3.Mucinous layer- secreted by goblets cells of
conjunctiva-allows even distribution of tear
film over ocular surface
103

104. 104

105. 105

106. EXCRETORY SYSTEM
▸ The lacrimal drainage system includes the
- Upper & lower puncta
- Lacrimal canaliculi
- Upper canaliculi
- Common canaliculi
- Lower canaliculi
- Lacrimal Sac
- Nasolacrimal duct
106

107.  Development : 5 weeks age of gestation
 The lacrimal drainage system- ectodermal cord-
b/w the lateral nasal process and the maxillary
process.
 Cord canalize- form NLD caudally and lacrimal sac
and canaliculi cranially
 Caudally NLD extends intranasally- exiting-inferior
meatus
 Canalization- complete around birth
 NLD Obstruction- 50% of infants at time of birth
107

108. 108

109. EXCRETORY SYSTEM
 Lacrimal puncta- 0.3 mm in diameter located medially on upper
& lower lid margin, 6 mm & 6.5 mm from inner canthus
respectively- directed posteriorly towards tear lake
 vertical canaliculus(ampulla)- 2 mm-turns 90 deg
 horizontal canaliculus- 8 mm opens into sac by common
canaliculus(90%)
 Common canaliculus- Mucosal fold- Valve of Rosenmuller- 1
way valve prevents tear reflux from lacrimal sac back into the
canaliculi
109

110. EXCRETORY SYSTEM
 Lacrimal sac- lies b/w ant & post head MCT
in lacrimal fossa bordered by anterior &
posterior lacrimal crest
 Size of sac 12-15x5 mm when distended,
 Fundus - part of sac above common
canaliculus
 Body of sac
 Medial wall- lacrimal fossa- lacrimal bone posteriorly
& frontal process of maxilla anteriorly
 Medial to lacrimal fossa- Middle meatus of nose
110

111. EXCRETORY -Nasolacrimal duct
▸ -12- 18 mm in length
- Travels thru bony nasolacrimal canal-
directed Inferiorly, Laterally And
Posteriorly
-opens thru an ostium into inferior nasal
meatus ,lateral & below inferior turbinate
- ostium- covered by partial mucosal fold
( Valve of Hasner)
111

112. DACRYOCYSTITIS
▸ Infection of Lacrimal sac- b,coz of stasis
of fluid(tears & mucus secretions) due to
NLD blockage
112

113. CLASSIFICATION
▸ Congenital
▸ Acquired
- Acute
- Chronic
113

114. EPIDEMIOLOGY
▸ Age: most common in patients older
than 40 years- with a peak at 60-70
years.
▸ Sex: MC in females- NLD more
angulated & narrow
▸ Race: Rare in blacks-the nasolacrimal
ostium into the nose is large. Also the
NLD is shorter and straighter in blacks
114

115. EPIDEMIOLOGY
▸ Facial features: Individuals with
brachycephalic heads- the NLD is
longer, narrower.
▸ patients with a flat nose and narrow
face- narrow osseous nasolacrimal canal.
▸ MC on left side than on the right side
- the nasolacrimal duct and lacrimal
fossa formed a greater angle on the right
side than on the left side.
115

116. ETIOLOGY
▸ PrimaryAcquired Nasolacrimal Duct
Obstruction(PANDO): Idiopathic
▸ Involutional stenosis-older persons- due
to compression of NLD lumen b.coz of
fibrous obstruction by chronic
inflammation
116

117. ETIOLOGY
▸ Secondary:
1. Dacryolith
2.Sinus disease- Ethmoid sinusitis
3.Trauma- Naso orbital #- involve NLD
- Surgical- Endoscopic sinus
surgery
- Rhinoplasty
4. Granulomatous diseases:
-Sarcoidosis
- Wegner granulomatosis
117

118. PATHOGENESIS
▸ There are two main factors resulting in
vicious cycle-
1. Stasis of sac contents due to NLD
blockage
2. Infection may- ascend from nose
- descend from
conjunctiva
Both aerobic and anaerobic bacteria-
Mainly gram positive & gram negative.
118

119. ACUTE DACRYOCYSTITIS
▸ Acute dacryocystitis is characterized by
the sudden onset of
- severe pain
- redness &
- oedema in the medial canthal region
- Epiphora
119

120. ACUTE DACRYOCYSTITIS
▸ SIGNS
1. A Tender & Hyperemic Palpable Mass
Is Noted Inferior To The Medial Canthal
Tendon- Non Reducible
2. Purulent Discharge Is Noted From The
Puncta.
3.Lacimal Abscess- Rupture- Lacrimal
Fistula Through The Skin.
4.Conjunctival Injection And Preseptal
Cellulitis
120

121. ACUTE DACRYOCYSTITIS
121

122. COMPLICATIONS
▸ Orbital Cellulitis- bact overgrowth
which rupture thru lacrimal sac wall into
surrounding orbital soft tissue.
▸ Cavenous sinus thrombosis
▸ Blindness
▸ Osteomyelitis of lacrimal bone
122

123. MANAGMENT
▸ Syringing/Probing-
CONTRAINDICATED- extremely
painful- cellulitis
▸ Oral Broad Spectrum Antibiotics-
Amoxicillin ( 250-500 mg) Cloxacillin
(250-500 mg) TDS
▸ Anti inflammatory/ Analgesics drugs
▸ Hot compress
▸ Parentral antibiotics- severe cases-
orbital cellulitis
123

124. MANAGMENT
▸ Aspiration of lacrimal sac- If lacrimal
abcess is localised & approaching the
skin.
▸ Incision & drainage- in severe cases not
responding to conservative mgt
▸ abscess involving lacrimal sac &
adjacent soft tissue- vertical incision is
given- wound is packed- open- healing
by secondary intention- lacrimal fistula
formation
124

125. MANAGMENT
▸ DACRYOCYSTORHINOSTOMY(D
CR)
- Definitive treatment after resolution of
acute
inflammation
125

126. CHRONIC DACRYOCYSTITIS
▸ Chronic Suppurative Inflammation Of
Lacrimal Sac Usually Resulting From
Obstruction Of NL
126

127. SYMPTOMS
1. Epiphora with or without mucopurulent
discharge
2. Swelling over sac area- present or
absent
3. Matting of eyelashes
4. Recurrent conjunctivitis
127

128. Sign
 Swelling in lacrimal sac area (below MCT)
which is reducible- regurgitation test +ve
 Fullness in medial canthal area with no
obvious swelling
 Enlarging mucocele- due to chronic low grade
infection of sac-Increased glandular secretions
into the sac.
 Pooling of tears at medial canthus.
 Chronic discharging fistula of sac
128

129. MUCOCELE
129

130. SEQULAE
▸ Atonic sac
▸ Lacrimal abscess
▸ Lacrimal fistula
 Following I.O. injury
▸ Hypopyon corneal ulcer
▸ Panophthalmitis
130

131. DIFFERENTIAL DIAGNOSIS
▸ Dermoid Cyst
▸ Cavernous haemangioma
▸ Neurofibromas
▸ Lacrimal sac tumours
Above lesions are not reducible
NLD may be blocked on syringing but
DCG is diagnostic.
131

132. MANAGMENT
▸ EVALUATION
▸ TREATMENT
 Dacryocystorhinostomy (DCR)-
External DCR
Endonasal DCR
Laser DCR- Transcanalicular or
Endonasal
External DCR with silicone
intubation
Conjunctivo DCR
132

133. EXTERNAL DCR
▸ Standard gold treatment, success rate
>90%
▸ Indications:
Chronic dacryocystitis with NLD
blockage
Mucocele of lacrimal sac
Congenital dacryocystitis-failed
conservative managment
133

134. EXTERNAL DCR
▸ It is a lacrimal drainage surgery in which
a fistula is created b/w the lacrimal sac
& middle meatus of the nasal cavity in
order to bypass a obstruction in NLD
134

135. EXTERNAL DCR
135

136. EXTERNAL DCR
▸ Contraindications:
1.Age less than 3 years
2.Acute dacryocystitis
3.Tumour of sac
4.Atrophic Rhinitis
▸ Disadvantage- Scar mark
136

137. ENDONASAL DCR
Done with the help of a nasal endoscope.
Indication : Blockage at NLD
Advantage :
1.No Cutaneous Scar
2. Short Operative Time
3. Minimum disruption of adjacent
structures.
Disadvantage : Low success rate (80%-
85%)
137

138. 138

139. LASER DCR
▸ Done through endonasal or canalicular
approach.
▸ Endonasal laser DCR :
- KTP ( Potassium-Titanyl-Phosphate
) Laser
- Ho:Yag ( Holium YAG ) Laser
▸ Transcanalicular laser DCR:
- 980 nm Diode Laser
139

140. EXTERNAL DCR WITH SILICONE
INTUBATION
▸ It is the procedure of DCR in which
there is insertion of a silicone stent. The
function of stent is to maintain patency
of fistula created.
Indications:
1. Failed DCR
2. Traumatic Dacryocystitis
3. Common canalicular blockage
4. Canalicular Blockage(<8mm)
140

141. EXTERNAL DCR WITH
SILICONE INTUBATION
141

142. DACRYOCYSTECTOMY
▸ Excision of lacrimal sac done
Indication
- Fibrosed contracted sac,
- Sac tumors
- Atrophic rhinitis
Disadvantage: Persistent epiphora
142

143. TEAR DRAINAGE
 Evaporation
- 10%-Young
- 20%-Old
 Most of the tears are actively pumped by orbicularis
 Tears flows- upper & lower marginal strips
 Enter –Upper & Lower canaliculi by capillarity &
suction
- 70% -Lower canaliculi
- 30%- Upper canaliculi
143

144. PHYSIOLOGY OF TEAR DRAINAGE
144

145. PHYSIOLOGY OF TEAR DRAINAGE
 Mechanism( Rosengren-Doane) of tear drainage
- Blinking- contraction of Orbicularis oculi- ampulla is
compressed- horizontal canaliculi is shortened- puncta
move medially
- Simultaneously lacrimal sac expands- negative
pressure- sucking tears from canaliculi
- Eye opens-muscle relaxes-sac collapses-positive
pressure-forces the tears down the NLD into nose
- Puncta move laterally- canaliculi lenghtens-fill with
tears145

146. CONGENITAL NLD OBSTRUCTION(NLDO)
▸ Caused by membranous block of valve
of Hasner
▸ Present in 50% of new borns
▸ Opens spontaneously in 4-6 weeks
▸ Becomes clinically evident in 2-6% at 4-
6 weeks of age. 1/3rd is B/L
▸ 90% of these symptomatic cases resolve
in 1st year of life
146

147. Evaluation
 Congenital Tearing Evaluation-Straight forward
 H/o tearing and/or mucopurulent discharge shortly
after birth
 Constant tearing with minimal mucopurulence-
upper system block-punctal or canalicular stenosis/
dysgenesis
 Constant tearing with frequent mucopurulence-
complete obstruction of NLD
 Intermittent tearing with mucopurulence-
intermittent obstruction of NLD- impaction of
swollen inferior turbinate associated with URTI147

148. Evaluation
 Eyelid margin examination- puncta
open/absent
 Hypersecretion causes- rule out
- infectious conjunctivitis
- trichiasis
- congenital glaucoma
 Inspection of medial canthus
- cong dacryocystocele/mucocele
- inflammation of sac
- Cong encephalocele
148

149. SYMPTOMS
1. Epiphora- usually few weeks of birth,
commonly unilateral, may be bilateral.
(normally tears are secreted after 4-6
weeks after birth).
2. Mucopurulent discharge.
Infective discharge at birth always due to
conjunctivitis.
149

150. SIGNS
1. Epiphora
2. Discharge- mucopurulent
3. Regurgitation test positive- Gentle
pressure over the lacrimal sac causes
reflex of mucopurulent material from
puncta- complete obstruction at the level
of NLD
4. Rarely Acute dacryocystitis
150

151. Acute Dacyocystitis
151

152. CONSERVATIVE MANAGMENT
Crigler massage over lacrimal sac area-Bilateral/
unilateral massage.
10 strokes four times a day.
Place index finger at common canaliculus & massage
firmly downwards
Mechanism: Massage increases hydrostatic pressure
in the sac & helps to open membranous occlusion
Broad spectrum antibiotic drops- instilled after
massage if discharge is present
90% cure rate
152

153. CRIGLER MASSAGE TECHNIQUE
153

154. SURGICAL MANAGMENT
 Probing & Irrigation
 Done at 1 yr of age under GA
 Punctal dilatation is required
 Bowman’s probe is introduced first vertically then
horizontially towards medial canthus then rotate
superiorly- inferiorly, laterally & posteriorly.
 Visualize with nasal endoscope
 Syringing with saline mixed with fluorescein followed
by suction
 Repeat probing- 6 weeks if no improvement154

155. Irrigation Of Nasolacrimal System
155

156. Nasolacrimal Silicone Intubation
Indications
- Failed probing
- Older children with scarring or stenosis
- punctal stenosis or canalicular stenosis
Silicone stent having two lacrimal probes at both ends
passed through both canaliculi, common
canliculus, L. sac, NLD, pulled out through NLD
openings in inferior meatus where both ends are
tied with simple square knots
Removal of silicon tube after 3-6 months
156

157. Congenital Dacryocystocele/Mucocele
 Also k/a Amniontocele
 Collection of amniotic fluid or mucus in the
lacrimal sac- imperforate Hasner valve.
Presentation: Perinatal with a bluish cystic
swelling- at or below the medial canthal area
- accompanied epiphora
Sign: A tense lacrimal sac- mucus- secondarily
infected157

158.  Differential Diagnosis
Encephalocele- pulsatile swelling above
the medial canthal tendon
 Treatment
- Conservative initially
- If fails- probing should not be delayed
158

159. 159