1. Presentation
• lacrimal gland
• dr .mohamed Hasan
• dr.anas abdiwali ali

2. Lacrimal
system
• the lacrimal system of each eye consists of....
secretory system –which secrets the tear
-main lacrimal gland
-accessory lacrimal gland
2.excretory system –which drains the tears
-lacrimal puncta
-lacrimal canaliculi
-lacrimal sac
-nasolacrimal duct

3. Lacrimal
gland
• 1.main lacrimal gland
• it is an exocrine gland approximately the size and shape
of an almond
• anteriorly the lateral horn of levator aponeurosis indents
the gland and divides it into upper orbital and lower
palpebral lobe
• about 10-12 ducts drain the secretion of lacrimal gland
and open into upper fornix of the conjunctive . it is
composed of secretory epithelial cells
• the ocular surface irritation activates tear production
from the lacrimal gland
• blood supply –lacrimal artery
• venouns drainge –returns into superior ophthalmic vein
• lymphatic drainage-retuns to the preauricualar lymph
nodes

4. LACRIMAL
GLAND

5. CONT...
• nerve supply .sensory –lacrimal narve
branch of ophthalmic division of the
trigeminal nerve .
• .sympathetic vasomotor fibers originate
from superior cervical ganglion
• .parasympathetic secretomoter fibers from
facial nerve via pterygopalatine ganglion

6. 2.accessory
lacrimal
gland
• these are very small gland of same epithelial
structure as lacrimal gland
• GLANDS OF KRAUSE .these are located
within the stroma of conjunctive in the
upper and lower fornix
• GLANDS OF WOLFERING.these are located
near the upper border of the superior tarsal
plate and along the lower border of the
inferior tarsal

7. • EXCRETORY
SYSTEM
• LACRIMAL PUNCTI-THESE ARE TOO SMALL ROUNDED OPENINGS -0.3MM
DIAMETER
• ON UPPER AND LOWER LID MARGINS ABOUTE 6MM TEMPORAL TO THE
INNER CANTHUS .EACH PUNCTUM IS SITUSTED ON A SMALL ELEVATION
CALLED PAPILLA
• LACRIMAL CANALICULI--THE SUPERIOR AND INFERIOR CANALICULIE JOIN
THE PUNCTA TO THE LACRIMAL SAC.EACH CANALICULUS HAS TOW PART
VERTICAL*1-2MM*AND HORIZONTAL*6-8MM*
• THE TWO CANALICULI MAY OPEN SEPARATELY OR MAY JOIN TO FORM
COMMON CANALICULI*ON AVERGE 2MM*WHICH OPENS INTO THE OUTER
WALL OF THE LACRIMAL SAC.
• LACRIMAL SAC –THE LACRIMAL SAC LIES WITHIN A BONY FOSSA THAT IS
BORDERED BY ANTERIOR AND POSTERIOR LACRIMAL CRESTS,LOCATED IN
THE ANTERIOR PART OF THE MEDIAL ORBITAL WALL.THE LACRIMAL FOSSA IS
FORMED BY LACRIMAL BONE AND FRONTAL PROCESS OF MAXILLA LIES
POSTERIOR THE MEDIAL CANTHAL TENDON .THA LACRIAMAL SAC IS
ABOUT 12-15MM IN LENGTH AND 5.6MM IN BREADTH.

8. CONT...
• LACRIMAL PUNCTI-THESE ARE TOO SMALL ROUNDED OPENINGS -0.3MM
DIAMETER
• ON UPPER AND LOWER LID MARGINS ABOUTE 6MM TEMPORAL TO THE
INNER CANTHUS .EACH PUNCTUM IS SITUSTED ON A SMALL ELEVATION
CALLED PAPILLA
• LACRIMAL CANALICULI--THE SUPERIOR AND INFERIOR CANALICULIE JOIN
THE PUNCTA TO THE LACRIMAL SAC.EACH CANALICULUS HAS TOW PART
VERTICAL*1-2MM*AND HORIZONTAL*6-8MM*
• THE TWO CANALICULI MAY OPEN SEPARATELY OR MAY JOIN TO FORM
COMMON CANALICULI*ON AVERGE 2MM*WHICH OPENS INTO THE OUTER
WALL OF THE LACRIMAL SAC.
• LACRIMAL SAC –THE LACRIMAL SAC LIES WITHIN A BONY FOSSA THAT IS
BORDERED BY ANTERIOR AND POSTERIOR LACRIMAL CRESTS,LOCATED IN
THE ANTERIOR PART OF THE MEDIAL ORBITAL WALL.THE LACRIMAL FOSSA IS
FORMED BY LACRIMAL BONE AND FRONTAL PROCESS OF MAXILLA LIES
POSTERIOR THE MEDIAL CANTHAL TENDON .THA LACRIAMAL SAC IS
ABOUT 12-15MM IN LENGTH AND 5.6MM IN BREADTH.

9. PHYSIOLOGY
TEARS SECRETED BY THE MAIN LACRIMAL GLANDS PASS
ACROSS OCULAR SURFACE.THE 10-20 OF THE TEARS
ARE ELIMINATED THROUGH EVAPORATION . THE
REMAINING 80-90% OF TEARS ARE ACTIVELY
PUMPED FROM THE TEAR LAC BY ACTION OF THE
ORBICULARIS MUSCLE THROUGH PUNCTI CANALICULI
LACRIMAL SAC NASOLACRIMAL DUCTI INTO THE NASAL
CAVITY

10. TEARS
• TEARS IS A SECRETION FROM THE LACRIMAL GLAND .
• THE SECRETION OF TEAR BEGINS 3-4 WEEKS AFTER
BIRTH
• THE TEAR SECRETION IS COMPOSED OF WATER ,SMALL
QUANTITIES OF SALTS,SUCH AS SODIUM CHLORIDE
,SUGAR ,UREA PROTEIN AND LYSOZYME ,A
BACTERICIDAL ENZYME.
• THE AVERAGE NORMAL SECRETION RATE IS 1-2
MICROLITER
• IT IS SLIGHTLY ALKALINE AND THE NORMAL PH OF
TEAR IS 7.5.

11. THREE LAYERS
OF TEAR FILM
• MUCUS LAYER.IT IS THE INNER MOST AND THINNEST LAYER
OF TEAR FILM .
• IT CONSISTS OF MUCIN SECRETED BY CONJUNCIVAL
GOBLET CELLS GLAND OF HENLE AND GLANDS OF MANZ .IT
CONVERTS THE HYDROPHOBIC CORNEAL SURFACE INTO
HYDROPHILIC.
• LIPID OR OILY LAYER .IS THE OUTER MOST LAYER OF TEAR
FILM WHICH CONSIST MAINLY CHOLESTEROL ESTERS AND
LIPID SECRETED BY MEIBOMAIN,ZEIS AND MOLL GLANDS
.IT PREVENTS OVERFLOW OF TEARS,RETARDS THEIR
EVAPORATION AND LUBRICATES THE EYELIDS
• AQUEOUS LAYER . IS THICKEST INTERMEDIATE LAYER
OF TEAR FILM WHICH CONSISTS OF TEARS SECRETED
BY THE LACRIMAL GLANDS

12. FUNCTIONS OF
TEAR FILM
• IT MAINTAINS THE HEALTH OF THE OCULAR SURFACE AND
TRANSPARENCY BY PROVIDING THE MOIST ENVIRONMENT
ESSENTIAL FOR THE CORNEAL AND CONJUCTIVAL EPITHELIAL
CELLS.
• IT MAINTAINS THE CLEAR VISION BY MAKING THE ANTERIOR
CORNEAL SURFACE SMOOTH AND REGULAR FOR REFRACTION .
• NUTRITIONAL ROLE. IT IS THE SOURCE OF NUTRITION AND
OXYGEN SUPPLY TO THE AVASCULAR CORNEA EPITHELIUM.
• ANTIMICROBIAL .IT HAS ANTIBACTERIAL ACTIVITY DUE TO
PROTEINS SUCH AS LYSOZYME AND LACTOFERIAL .
• SERVES AS A MEDIUM FOR THE REMOVAL OF DEBRIS AND
NOXIOUS IRRITANTS .
• LUBRICATES THE CORNEA EYELID INTERFACE

13. DISEASES OF
THE DRAINAGE
SYSTEM
• NASOLACRIMAL DUCT OBSTRUCTION
• CONGENITAL
• ACQUIRED
• DACROCYSTITIS
• ACUTE DACROCYSTITIS
• CHRONIC DACROCYSTITIS

14. AETIOLOGY
• IT IS A COMMON CONGENITAL LACRIMAL DRAINAGE
ANOMALY CAUSED BY NON-CANALIZATION OF THE
MEMBRANE AT THE LOWER END OF THE
NASOLACRIMAL DUCT.
• AT BIRTH THE LOWER END OF THE NASOLACRIMAL
DUCT IS FREGUENTY NON-CANALIZED AND BECOMES
PATENT SPONTANEOUSLY DURING THE FIRST FEW
WEEKS OF LIFE FAILURE OF THIS CAUSES EPIPHORA
AND SECONDARY INFECTION
• MALDEVELOPMENT OF PUNCTUM AND CANALICULI

15. CLINICAL
FEATURES
• IT OCCURS IN ABOUT 5% OF FULL TEAR NEW BORN
• IT MAY BE UNILATERAL OR BILATERAL THE BILATERAL
INVOLVEMENT IS MORE COMMON.
• SYMPTOMS BECOME MANIFESTED BY AGE OF 3 TO 4
WEEKS IN 80 TO 90% OF CASES.
• TYPICALLY THE SYMPTOMS ARE WATERY EYES AND STICKY
MUCOID OR MUCOPURULENT DISCHARGE THAT
ACCUMULATES ON THE EYELID MARGIN AND LASHES NEAR
THE MEDIAL CANTHUS.
• REGURGITATION TEST NAY BE POSITIVE –GENTLE PRESSURE
OVER THE LACRIMAL SAC CAUSES REFLUX OF FLUID OR
MUCOPURULENT MATERIAL FROM THE PUNCTA.

16. COMPLICATIONS
• MUCOCELE
• CONJUNCTIVITIS
• ACUTE DACRYOCYSTITIS
• CHRONIC DACRYOCYSTITIS
• FISTULA FORMATION

17. Right
eye Acute
dacryosy stitis
nasolacrimal
duct bloked

18. DIFFERENTIAL
DIAGNOSIS
• PUNCTAL ATRESIA
• CONJUNCTIVITIS E.G.CHLAMYDIA
• CONGENITAL GLAUCOMA-IT IS IMPORTANT TO
EXCLUDE CONGENITAL GLAUCOMA WITH WATERY EYE
• KERATITS AND UVEITIS

19. TREATMENT
• CONSERVATIVE
• SPONTANECOUS PATENCY –OCCURS IN 90% CASES
WITHIN 6 MONTHS,AND IN 95% CASES WITHIN
• 9 MONTHS THEREFORE ,PROBING MAY BE DELAYED
UNTIL THE AGE OF 6-9 MONTHS.
• MASSAGE OF THE LACRIMAL SAC-DIGITAL PRESSURE
APPLIED OVER THE SAC INCREASES THE HYDROSTATIC
PRESSURE AND THUS MAY RUPTURE THE
MEMBRANOUS OBSTRUCTION .TEN STROKES 4 TIMES
A DRY ARE APPLIED

20. Cont......
• ANTIBIOTICS
• TOPICAL ANTIBIOTIC DROPS ARE USED TO CONTROL
THE SECONDARY INFECTION TILL PATENCY OF THE
DUCT OCCURS.
• SYSTEMIC MAY BE REQUIRED WHEN THERE IS
COMPLICATION

21. SURGICAL
• IT IS INDICATED AFTER 4-6 MONTHS WHEN CONSERVATIVE TREATMENT
FAILS.
• PROBING-IT IS DONE UNDER GENERAL ANAESTHESIA.A PROBE IS PASSED
THROUGH THE PUNCTUM,CANALICULUS AND LACRIMAL SAC INTO THE
NASOLACRIMAL DUCT TO OVERCOME THE OBSTRUCTIVE MEMBRANE AT THE
LOWER END OF THE NASOLACRIMAL DUCT.
• SYRINGING-IRRIGATION. IT IS DONE TO CONFIRM THE OPENING AND
FUNCTIONING OF THE LACRIMAL DRAINAGE SYSTEM.THE RESULTS OF
PROBING ARE EXCELLENT AND 90% OF CHILDREN ARE CURED BY THE FIRST
PROBING AND FURTHER 6% BY SECOND PROBING .THE FAILURE IS USUALLY
DUE TO ABNORMAL ANATOMY.
• OTHER OPTIONS-ARE INDICATED WHEN REPEATED PROBING IS FAILURE.
• INTUBATION WITH SILASTIC TUBE
• BALLOON CATHETER DILATATION OF NASOLACRIMAL DUCT

22. Cont....
• DACRYOCYSTORHINOSTOMY-DCR-.IT IS INDICATED
WHEN SYMPTOMS OF EPIPHORA PERSIST AFTER THE
FAILURE OF ABOVE PROCEDURES.IT MAY BE
NECESSARY TO PERFORM DCR OPERATION
PREFERABLY.AFTER 5 TO 6 YEARS OF EGE.

23. RIGHT EYE
AMNIOTOCELE

24. CONT.....
• AMNIOTOCELE –CONGENITAL DACRYOCELE-
• IT IS BLUISH –GRAY CYSTIC SWELLING OF THE
LACRIMAL SAC DUE TO THE COLLECTION OF AMNIOTIC
OR MUCOUS WITHIN THE LACRIMAL SAC AS A
CONSEGUENCE OF CONGENITAL NASOLACRIMAL DUCT
BLOCK AT THE LEVEL OF VALVE OF HASNER .WHICH IS
A FOLD OF MUCUS MEMBRANE AT THE LOWER END
OF NASOLACRIMAL DUCT

25. CONT....
• ACQUIRED NASOLACRIMAL DUCT OBSTRUCTION
• CAUSES
• INVOLUTION STENOSIS –IDIOPATHIC – IS PROBABLY
THE MOST COMMON CAUSE .FEMALES ARE AFFECTED
MORE THAN MALES .
• TRAUMA-NASAL AND ORBITAL FRACTURES INCLUDING
NASAL AND SINUS SURGERY
• INFLAMMATORY DISEASE SUCH AS SARCOIDOSIS AND
WAGNER GRANULOMATOSIS.
• INFILRATION BY NASOPHARYNGEAL TUMOURS
• DACRYOLITH OR CAST FORMATION WITHIN THE
LACRIMAL SAC

26. CONT..
• CLINICAL FEATURES
• EXCESSIVE TEARING
• MUCOID OR MUCOPURULENT DISCHARGE
• RECURRENT ATTACKS OF DACRYOCYSTITIS
• RECURRENT ATTACK OF CONJUNCTIVITIS

27. CONT....
• TREATMENT
• DACRYOCYSTORHINOSTOMY –DCR- OPERTION.IN
THIS PROCEDURE, APASSAGE IS CREATED BETWEEN
THE LACRIMAL SAC AND NASAL CAVITY THROUGH
BONY OSTIUM, WHICH DRAINS TEARS FROM
CANALICULI TO THE LATERAL WALL OF THE NOSE IT IS
90 TO 95% SUCCESSFUL

28. TYPES OF DCR
• EXTERNAL DCR IS PERFORMED THROUGH SKIN
APPROACH IT IS THE PREFERRED PROCEDURE WITH
SUCCESS RATE USUALLY ABOVE 90%
• ENDOLASER [TRANSNASAL LASER] DCR IS
PERFORMED THROUGH NASAL APPROACH .IN THIS
PROCEDURE OPENING IN THE LATERAL WALL OF THE
NOSE IS MADE BY LASER THROUGH NASAL CAVITY
WITHOUT GIVING AN INCISION TO THE SKIN . THE
SUCCESS RATE IS LESS THAN SKIN APPROACH,ABUT
THERE IS NO SKIN SCAR.

29. CONT..
• ACUTE DACRYOCYSTITIS –IT IS THE ACUTE
INFLAMMATION OF THE LACRIMAL SAC.
• AETIOLOGY
• IT MAY ARISE DE NOVO OR MORE COMMONLY AS A
SECONDARY INFECTION AFTER NASOLACRIMAL DUCT
OBSTRUCTION
• PYOGENIC ORGANISMS SUCH AS
STAPHYLOCOCCUS,STEPTOCOCCUS AND
PNEUMOCOCCUS ETC.INVADE THE LACRIMAL SAC

30. CONT....
• CLINICAL FEATURES
• SYMPTOMS
• PRESENTATION IS WITH SUB-ACUTE ONSET OF A
PAINFUL REDNESS AND SWELLING AT THE MEDIAL
CANTHUS ASSOCIATED WITH EPIPHORA.
• ON EXAMINATION
• SWELLING AT THE MEDIAL CANTHUS WHICH IS
REDDISH AND TENDER ON TOUCH
• REGURGITATION TEST IS DIFFICULT TO PERFORM
BECAUSE OF TENDERNESS
• ABSCESS FORMATION MAY OCCUR IN UNTREATED
CASES .

31. Lacrimal sac abscess
left eye acute dacryostitis

32. CONT....
• COMPLICATION
• PRESEPTAL CELLULITIS.
• EXTERNAL FISTULA FORMATION

33. Dacryocystitis with fistula formation

34. CONT...
• TREATMENT
• CONSERVATIVE
• ANTIBIOTICS
• SYSTEMIC ANTIBIOTIC.TO CONTROL INFECTION
• TOPICAL EYE DROPS ARE ALSO USED
• ANALGESIC AND ANTI-INFLAMMATORY DRUGS TO
CONTROL THE PAIN AND INFLAMMATION
• HOT FOMENTATION GIVE SOOTHING EFFECT AND
ENHANCES THE RESOLUTION

35. CONT.......
• CHRONIC DACRYOCYSTITIS-IT IS CHRONIC
INFLAMMATION OF THE LACRIMAL SAC
• AETIOLOGY
• THE IMPAIRED OUTFLOW OF THE SAC LEADS TO THE
STASIS OF TEARS WHICH EVENTUALLY LEADS TO
SECONDARY INFECTION BY LOW VIRULENCE
ORGANISMS.

36. CONT..
• CLINICAL FEATURES
• IT IS MORE COMMON THAN THE ACUTE VARIETY
• IT PRESENTS WITH CONSTANT WATERING FROM THE EYE.
• IT MAY PRESENT WITH SWELLING IN THE MEDIAL CANTHAL AREA
AND WATERY EYE
• IN RARE CASES THERE MAY BE BILATERAL NASOLACRIMAL DUCT
OBSTRUCTION WITH BILATERAL LACRIMAL SAC SWELLING
• REGURGITATION TEST MAY BE POSITIVE WITH REFLUX OF WATERY
MUCOID OR MUCOPURULENT DISCHARGE FROM THE PUNCTI
• MUCOCELE FORMATION MAY OCCUR IF THE SAC BECOMES DILATED
AFTER BLOCKAGE OF COMMON CANALICULUS.
• IT MAY BE ASSOCIATED WITH CHRONIC UNILATERAL CONJUCTIVIS.

37. CONT....
• TREATMENT
• DACRYOCYSTORHINOSTOMY –DCR-
• EXTERNAL APPROACH –DCR-
• ENDOLASER-DCR-

38. CONT..........
• DISEASES OF THE LACRIMAL GLAND
• ACUTE DACRYOADENITIS
• CHRONIC DACRYOADENITIS
• KERATOCONJUNCTIVITIS SICCA-DRY EYE

39. Acute
dacryoadenitis
• Acute dacryoadenitis..it is an acute
inflammation of the lacrimal gland
• Aetiology
• It is usually caused by infection most
commonly by viral infection
• Viruses-epstein- bar virus cytomegalovirus
mumps and infectious mononucleosis
• Bacteria –staphylococcus,streptococcus and
gonococcus
• Fungi-histoplasma, blastomyces

40. Cont...
• Clinical features
• Pain and discomfort in the upper and outer
portion of the orbit and eyelid
• The eyelid becomes red and swollen with
typical s-shaped curve of its margin
• Painful proptosis with displacement of
eyeball downward and inward may occur
• Eversion of lid is painful and shows swollen
and reddish gland
• Pre-auricular lymph nodes may be enlarge
and tender

41. Cont..
• Differential diagnosis
• Eyelid abscess
• Hordeolum internum –suppurative infection
of meibomian gland
• Hordeolum externum [stye]
• Acute purulent conjunctivitis

42. Cont..
• Treatment
• Hot compresses may be applied several
times a day.
• Systemic analgesic
• Antibiotic –topical drops-systemic broad
spectrum antibiotics
• Incision and drainage when there is abscess
formation