RAMJI PANDEY

1. LACRIMAL APPARATUS SYSTEM
EXAMINATION
BY:- Ramji pandey

2.  The lacrimal apparatus comprises the structures concerned
with formation of tears the main lacrimal gland and
accessory lacrimal glands and its transport
 Components of lacrimal apparatus
• Lacrimal gland
• Lacrimal puncta
• Lacrimal cannaliculi
• Lacrimal sac
• Naso lacrimal duct

3. LACRIMAL GLAND
• It is situated in the fossa for lacrimal gland,formed by the
orbital part of frontal bone,in the anterolateral part of orbit.The
gland is divided in its anterior aspect by the lateral horn of
aponeurosis of the levator muscle into two parts:
1. Superior Orbital
2. Inferior Palpebral,which are continuous with each other
posteriorly

4. PARTS OF THE LACRIMAL
GLAND
• The larger Orbital part is in a depression, the lacrimal fossa,
in the frontal bone;
• The smaller Palpebral part is inferior to levator palpebrae
superioris ,in the superolateral part of the eyelid

5. ORBITAL PART OF
LACRIMAL GLAND
• It is large about the size and shape of a
small almond. It has:
 Two Surfaces: Superior & Inferior
 Two Borders: Anterior & Posterior
 Two Extremities: Medial & Lateral

6. • Superior surface
 Convex
 Lies in contact with the periorbita lining the part of the frontal
bone forming the fossa for lacrimal gland
 Attached to periorbita by fine trabeculae.
• Inferior surface
 Concave
 Lies on the levator palpebrae superioris muscle and the
lateral horn of the levator aponeurosis.

7. • Anterior border
 Sharp
 Within and parallel to the orbital margin,upto the zygomatico-
frontal suture
 Lies in contact with the septum orbitale.
• Posterior border
 Round
 Continuous with the palpebral part of the gland
 Lies in contact with orbital pad of fat.

8. • Lateral extremity
 Rests on the lateral rectus muscle.
• Medial extremity
 Related to levator palpebrae superioris muscle.
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9. PALPEBRAL PART OF
LACRIMAL GLAND
• One-third the size of orbital part
• Consists of only 2-3 lobules.
• Situated upon the course of the ducts of orbital part from
which it is separated by the levator palpebrae superioris
muscle,which is related to it superiorly.

10. • Inferiorly the gland lies in relation to the superior fornix.
• Gland is compressed from above downwards and can be seen
through the conjunctiva when the lid is everted.
• Posteriorly it is continuous with the orbital part.
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11. • Lacrimal gland is drained by a series of 8-12 small ducts.
• Ducts open into the lateral part of the superior conjunctival
fornix.1-2 ducts also open into the lateral part of the inferior
fornix.
• Since all the ducts pass through the palpebral part of the
gland, therefore excision of the palpebral part alone amounts
to excision of the entire gland as far as secretory function of
the gland is concerned.
• The secretions from the gland is spread over the surface of the
eye by the action of the lids.

12. ACCESSORY LACRIMAL
GLANDS
• Same structure as main lacrimal gland
• Very small in size
Glands of Krause:
 Upper lid-40-42
 Lower lid-6-8
• Deeply situated in the conjunctiva near the fornix on lateral side
• Glands of Wolfring:
 Few in number
 Situated near the upper border of the tarsal plate
• Rudimentary accessory lacrimal glands:
 Present in the caruncle,plica semilunaris and infraorbital region.

13. LACRIMAL DRAINAGE SYSTEM
• Comprises of :
1. The Puncta :
Small, round to oval orifices of 0.2 mm in diameter.
 Situated on the summit of an elevation, the Papilla
Lacrimalis that lies near the medial end of eyelid margins at
the junction of its ciliated & non-ciliated parts.
 The puncta being avascular is paler than its
surrounding structures.
 The puncta are surrounded by a ring of dense
fibrous tissue which keeps them patent.
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14. 2. The Canaliculi:
 Hollow tubes of 0.5 mm in diameter
connecting the puncta to the Lacrimal sac.
 It has :
i) Vertical Part - 2mm in length
ii) Horizontal part - 8-10 mm in length
 Upper canaliculi is slightly shorter than the
lower.
 There is a dilatation at the junction of these 2
parts- called AMPULLA.
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15.  The canaliculi unite at an angle of 25 degrees to form
common canaliculus (0.5mm).
 The common canaliculus is directed an angle of 45 degrees
with the sac before entering it.
 This acute entry into the Lacrimal Sac creates a potential
mucosal flap or valve across the opening, The Valve of
Rosenmuller.
 The point of entry of common canaliculus into the Lacrimal
sac is called the Lacrimal sinus of Maier.
 The canaliculi are lined by stratified squamous
epithelium.

16. 3. THE LACRIMAL SAC:
Dimensions : 12-15 mm in length
4-6 mm anteroposteriorly
2-3 mm wide
Situation : Lies in the lacrimal fossa formed by the lacrimal
bone & frontal process of maxilla in the anterior part of the
medial wall of the orbit which is continuous below with the
Nasolacrimal duct.

17. 4.NASOLACRIMAL DUCT:
Continuation of Lacrimal sac. It is divided
into 2 parts :
a) An Interosseous Part : 12.5 mm
b) An Intermeatal Part : 5.5 mm
The opening of Nasolacrimal duct has a
mucosal fold , the Valve of Hasner, which
prevents air from entering the lacrimal sac
on sudden blowing the nose.

18. • CLINICAL EVALUATION OF A
CASE OF ‘WATERING EYE’
Slit – Lamp Examination :
It is done for the evidence of following conditions:
Punctum : Patency, size,position,discharge, obstruction by
an eyelash, large caruncle, Pouting Punctum , Centurion
Syndrome
Ectropion
Lesions of eyelid margins as papillomas, molluscum
contagiosum,chalazia,nevi, carcinoma
Signs of Blepharitis , Dry eye syndrome .
Conjunctival lesions as Pinguecula ,Pterygium,
Follicles , Papillae, allergic conjunctivitis.
Corneal Irregularities, Dystrophies
Volume of tear lake 18

19. ROPLAS TEST :
Regurgitation On Pressure Over Lacrimal Apparatus
System.
Also called as Palpation of Lacrimal Sac.
Punctal reflex of mucopurulent material indicates
mucocele with a patent canalicular system, but with
an obstruction at or distal to the lower end of
Lacrimal Sac. In acute dacryocystitis palpation &
compression are painful & should be avoided.
Rarely it reveals the presence of a stone or tumor.
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20.  Fluorescein Dye Disappearance test :
 It is a semiquantitaive test of delayed or obstructed
tearflow.
 It is of particular importance for evaluation of
congenital dacryostenosis in infants & toddlers
where lacrimal irrigation is impossible without
anaesthesia or deep sedation.
 1 drop of 2% fluorescein is instilled into the
unanaesthesised conjunctival sac of both the eyes.
 The volume of tear lake is then noted preferably
under cobalt blue light.
 The patient is instructed not to wipe the eyes & tear
lakes are examined 5 mins. later & relative volume is
determined.
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21. Persistance of significant dye & especially asymmetric
clearance of the dye from the tear meniscus over a
5 minutes period indicates a relative obstruction
of the side retaining the dye.
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22. • Diagnostic Probing :
It provides information regarding the site of obstruction.
It is performed only after obstruction is demonstrated by other
tests
After topical anaesthesia of conjunctival sac,the canaliculi are
also irrigated by anaesthetics
A probe of appropriate size is inserted into the punctum,
turned medially & advanced untill it encounters the lacrimal
bone.
The probe is then withdrawn a few mm and rotated
inferiorly & slightly posterolaterally untill the proximal
part of NLD is felt.
The probe is then passed untill it strikes the floor of
the nose in the inferior meatus.
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23. If in between any obstruction is felt, the site of
obstruction is noted by grasping the probe with a
forceps at its entrance before withdrawing.
Obstruction can be felt as a “ Soft stop” in case of
canalicular stenosis or as a “ Hard stop” as the probe
hits the bone at the medial wall of lacrimal sac.
Obstruction
< 8mm- canalicular obstruction
8-10mm-common canalicular obstruction
>10 mm- distal part i.e. sac & NLD
Probing in children :
It should be done through upper canaliculus.
Upto 1 yr of age , the distance from punctum to
NLD is 12mm & to the floor of nose is 20mm.
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24. • Syringing :
Principle : It provides information regarding the patency of
canalicular system.
Procedure :
• 1-2 drops of topical anaesthesia is instilled into the
conjunctival sac.
• The punctum is dilated gently by advancing the Nettleship
dilator, first vertically for about 2mm & then horizontally with
a twisting movement.
• Simultaneously lateral traction is applied to the eyelid.
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25. • With the eyelid stretched, dilator is withdrawn & the Lacrimal
cannula attached with syringe filled normal saline is advanced
horizontally through punctum canaliculus.
• No resistance should be felt in its entire path.
• Irrigation is then done & the patient is asked to respond if fluid
passes into the oropharynx or nose.
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26. • Inference :
If there is resistance to irrigation: obstruction is partial.
Regurgitation of fluid from same punctum indicates
that there is a canalicular block.
Regurgitation of fluid from upper punctum indicates
blockage at the level of common canalicular duct,
lacrimal sac or nasolacrimal duct.
Immediate regurgitation of clear fluid usually suggests
a common canalicular obstruction.
Relatively delayed regurgitation of fluid mixed with
mucous or pus usually indicates NLD blockage. 26

27. • JONES DYE TESTING :
It is rarely needed.
Indication : Patients with suspected partial
obstruction of drainage system. It is of
no value in context with total obstruction
These are the Dye tests for functional epiphora
where the lacrimal drainage system is found to be
patent on syringing.
Types : These are of 2 types :
a) Jones test I
b) Jones test II
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28. • Jones test 1 :
It investigates the Lacrimal outflow under normal
physiological conditions.
It is also called as Primary test.
It differentiates the partial obstruction of lacrimal
passage from primary hypersecretion of tears Procedure :
First a drop of 2 % fluorescein is
instilled into the conjunctival sac.
After about 5 minutes a cotton tipped
bud moistened in a local anaesthetic
is inserted under the inferior turbinate
at the nasolacrimal duct opening.
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29. • Inference :
• i)Positive test : If fluorescein is recovered from the
nose ( presence of dye in cotton )
it indicates patency of drainage
system.Watering is due to primary
hypersecretion & no further tests
are necessary.
ii ) Negative test : No dye recovered from nose
indicates a partial obstruction (site unknown )
or failure of lacrimal pump mechanism.
 In this case Jones Test II is performed immediately.

30. Jones Test II:
Also called Irrigation or secondary test
It is a non-physiological test.
Principle :It identifies the probable site of partial
obstruction, on the basis of whether the
fluorescein dye instilled for primary/Jones
test 1 entered the Lacrimal sac
Procedure :Topical anaesthetic is instilled & any
residual fluorescein is washed out
instilled during Jones test 1.The drainage
system is then irrigated with saline with
the cotton bud under inferior turbinate.
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31. • Inference :
a)Positive test : Fluorescein stained saline
recovered from the nose indicates
that fluorescein entered the lacrimal sac,
thus confirming functional patency of
upper lacrimal passages ( punctum,
canaliculi ). Partial obstruction of
Naso-lacrimal duct is inferred.
b)Negative test : Unstained saline recovered from the nose
indicates that fluorescein did not enter
the lacrimal sac. This implies partial
obstruction of puncta, canaliculi, common
canaliculi or defective lacrimal pump
mechanism.
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32. • Ancillary Radiological Investigations :
Radiological tests help in confirming the site of
obstruction or stenosis in case of blocked syringing,
confirm a functional cause of epiphora & delineate the
anatomical as well as the pathological process
pertaining to the problem.
a ) Dacryocystography:
DCG involves injection of radio-opaque dye into the canaliculi
& taking magnified images.
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33. • Indications of DCG :
 To confirm the site of obstruction,especially prior to
lacrimal surgery.
 To aid diagnosis of diverticula, fistulae & filling
defects caused by stones & tumours.
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34. • Technique :
The inferior puncta are dilated with a Nettleship
punctum dilator.
Plastic catheters are inserted into canaliculi on both sides after
instillation of anaesthesia.
Contrast medium, usually 1-2ml Lipiodol,0.5-2ml of water
soluble iodinated contrast medium is injected simultaneously
on both the sides & postero-anterior radiographs are taken.
10 mins later an erect oblique film is taken to
assess the effect of gravity on tear drainage
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35. • Interpretation :
Failure of dye to reach the nose indicates an
anatomical obstruction, the site of which is usually
evident .
A normal DCG in the presence of epiphora indicates
either lacrimal obstruction or lacrimal pump failure,
especially if contrast is retained on the late film.
IN DCG both the sides are usually interpreted
simultaneously.

36. B)Nuclear Lacrimal Dacryoscintigraphy :
It is a sophisticated test which assesses tear drainage under
more physiological condition than a DCG.
The disadvantage as compared to DCG is that it
fails to show finer anatomical details.
Apart from being a non-invasive procedure,radiation exposure
to lens is minimal compared to DCG.
It is more sensitive in assessing incomplete blocks.

37. • Technique :
a) Radionuclide technitium 99 is delivered by a
micropipette to the lateral conjunctival sac as a 10 micro litre
drop.The tears are thus labelled with this gamma-emitting
radioactive substance.
b) The tracer is imaged by a gamma camera focussed
on the inner canthus & a sequence of images is
recorded over 20 minutes.

38. c ) Computerised Tomography :
 Its role comes when anatomical or pathological
abnormalities are suspected as the underlying
cause
of epiphora.
E.g. Cranio-facial injury, congenital deformities,
Lacrimal sac neoplasia.
 The paranasal sinuses especially the maxillary
sinuses are imaged for any abnormalities that might
be affecting the NLD.
 Preoperative assessment of cribriform plate to
avoid
possible cerebrospinal leak at the time of injury.

39. • Newer Modalities :
a) Chemiluminiscene test : Cyalume, a
chemiluminiscent material is injected with a
sialography catheter to demonstrate the patency of
outflow passeges.
b) Dacryoscopy : Dacryoscope, a mini rigid endoscope
allows the direct visualisation of the interior &
lining of lacrimal passages.
c) Standardised echography :Gross anatomical
structural defects can be evaluated.
d)Thermography : It is used in conjunction with
routine lacrimal irrigation to visualise the tear
ducts in normal subjects and in patients with
obstructive epiphora.

40. Dacryocystitis
• Inflammation of the lacrimal sac.
• It may occur in two forms:
Congenital dacryocystitis
Adult dacryocystitis
1)Acute
2)Chronic
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41. Congenital Dacryocystitis
• Inflammation of the lacrimal sac occurring in newborn infants;
and thus also known as dacryocystitis neonatorum.
• Clinical Picture:
1.Epiphora, usually developing after seven days of birth. It
is followed by copious mucopurulent discharge from the
eyes.
2.Regurgitation test is usually positive, i.e., when pressure
is applied over the lacrimal sac area, purulent discharge
regurgitates from the lower punctum.
3.Swelling on the sac area may appear eventually.
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42. • Complications:If not treated in time it may be complicated by
recurrent conjunctivitis, acute on chronic dacryocystitis,
lacrimal abscess and fistulae formation.
• Treatment: Depends upon the age at which the
child is brought
1. Massage over the lacrimal sac area and topical antibiotics
constitute the treatment of congenital NLD block, up to 6-8
weeks of age.
1. Lacrimal syringing (irrigation) with normal saline and
antibiotic solution. It should be added to the conservative
treatment if the condition is not cured up to the age of 2
months
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43. 3. Probing of NLD with Bowman's probe. It should be
performed, in case the condition is not cured by the age of 3-4
months. Some surgeons prefer to wait till the age of 6 months.
4. Intubations with silicone tube may be performed if repeated
probings are failure. The silicone tube should be kept in the NLD
for about six months.
5. Dacryocystorhinostomy (DCR) operations: When the child is
brought very late or repeated probing is a failure, then
conservative treatment by massaging, topical antibiotics and
intermittent lacrimal syringing should be continued till the age of
4 years. After this, DCR operation should be performed.
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44. Chronic Dacryocystitis
• More common than the acute dacryocystitis
• Clinical Picture:
1. Stage of chronic catarrhal dacryocystitis
2. Stage of lacrimal mucocoele
3. Stage of chronic suppurative dacryocystitis
4. Stage of chronic fibrotic sac
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45. • Complications:
• Chronic intractable conjunctivitis, acute on chronic
dacryocystitis.
• Ectropion of lower lid, maceration and eczema of lower lid
skin due to prolonged watering.
• Simple corneal abrasions may become infected leading to
hypopyon ulcer.
• If an intraocular surgery is performed in the presence of
dacryocystitis, there is high risk of developing
endophthalmitis. Because of this, syringing of lacrimal sac is
always done before attempting any intraocular surgery.
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46. • Treatment:
1. Conservative treatment by repeated lacrimal syringing.
2. Dacryocystorhinostomy (DCR)- It should be the operation of
choice as it re-establishes the lacrimal drainage.
3. Dacryocystectomy (DCT)- It should be performed only when
DCR is contraindicated.
Indications of DCT:
a)Too young(<4 yrs) or too old(>60 yrs)
b)Markedly shrunken or fibrosed sac
c)TB,syphilis,leprosy or mycotic infections of sac
d)Tumours of the sac
e)Gross nasal diseases Atrophic Rhinitis
4. Conjunctivodacryocystorhinostomy (CDCR)-
Performed in presence of blocked canaliculi
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47. Acute Dacryocystitis
• Acute dacryocystitis is an acute suppurative inflammation of
the lacrimal sac, characterised by presence of a painful
swelling in the region of sac.
• Clinical Picture:
1. Stage of cellulitis
2. Stage of lacrimal abscess
3. Stage of fistula formation
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48. • Complications:
1. Acute conjunctivitis,
2. Corneal abraision which may be converted to corneal
ulceration,
3. Lid abscess,
4. Osteomyelitis of lacrimal bone,
5. Orbital cellulitis,
6. Facial cellulitis and acute ethmoiditis.
7. Rarely cavernous sinus thrombosis and very rarely
generalized septicaemia may also develop.
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49. • Treatment:
During cellulitis stage:It consists of systemic and
topical antibiotics to control infection; and systemic
anti- inflammatory analgesic drugs and hot
fomentation to relieve pain and swelling.
During stage of lacrimal abscess: In addition to the
above treatment when pus starts pointing on the
skin, it should be drained with a small incision. The
pus should be gently squeezed out, the dressing
done with betadine soaked roll gauze.
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50. • Later on depending upon condition of the lacrimal sac either
DCT or DCR operation should be carried out, otherwise
recurrence will occur.
Treatment of external lacrimal fistula: After
controlling the acute infection with systemic
antibiotics, fistulectomy along with DCT or DCR
operation should be performed
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