M Notes on lacrimal investigations

1. Investigations of lacrimal system
presenter
Dr / Moustafa

4. What is epiphora ??
 It is a condition in which we have a normal lacrimal secretion
with abnormal excretion .
What is lacrimation ??
 It is a condition in which we have over lacrimal secretion
with normal excretion .
What is dry eye ??
 It is a multifactorial disease of tears affecting external ocular
surface.
( DRY EYE WORKSHOP 2007 )

6. What are the causes of lacrimation ?
1 •Psychic
2 •Reflex
3 •Autoimmune

7. What are the causes of epiphora?

9. obstruction of drainage
epiphora
Failure of lacrimal pump
Lid abnormalities

10. 1.Eyelid abnormalities
ECTROPION ( Rolling out of lid margin )

11. failure of lacrimal pump
1.Facial nerve palsy .
2.Lid laxity.

12. Obstruction of lacrimal drainage
Punctum ( stenosis , obstruction , eversion )
Canaliculi ( obstruction , decanalization , infection )
Lacrimal sac ( tumor , trauma , infection )
NLD ( inflammation , radiotherapy , chemotherapy )
Hasner valve ( DNS , nasal polyps )

13. What are the clinical investigations to diagnose Epiphora ?
1. Probing & irrigation test .
2. Jone dye tests
3. Regurge test

14. Probing & irrigation test

15. • What is the lacrimal probe ?
It is a straight metal wire with blunt rounded ends and
flattened central part.
• What about the sizes ??
It is of different sizes from ( 0 – 8 )
• What is the uses of lacrimal probes ?
1) Probing & irrigation test
2) DCR

16. Probing
Soft stop
Hard stop

24. • What are jones tests ??
They are tests using to examine NLDO .
There is 2 types ( JDT1 , JDT2 )
JDT1 :
How to perform it ??
1) Instill fluorescein drops into the eye .
2) Put dry cotton piece in the nostril.
3) Wait 5 – 10 minutes
Results /
a) Cotton piece will be stained= +ve test = patent lacrimal
drainage
b)Cotton piece still dry = -ve test = do JDT2

25. HOW to do JDT2 ??
Proper Wash and clean the eye by normal saline .
Inject normal saline in lower punctum
Results :
a) If cotton piece is stained= patent canaliculi = NLDO
b)If cotton piece is colorless = obstruction of canaliculi .

28. • What are the DD of –ve Regurge test ??
1. Normal person
2. Acute dacryocystitis = obstruction Of canaliculi by edema
3. Chronic dacryocystitis = mucocele = obstruction of
canaliculi by fibrosis

29. What are radiological examinations for
epiphora ??
1. X- ray .
2. Dacryocystography (inject dye into canaliculi and take x-ray
3. Nuclear lacrimal scintigraphy

30. What is Contrast Dacryocystography ?
It is injection of radio-opaque dye (1- 2 ml of lipidol) into the
canaliculi & taking magnified images .
The test is usually performed on both sides .
The view plans will be ( PA – Lateral – Oblique )
what is indications of Dacryocystography ?
1) To detect site of obstruction
2) To diagnose diverticula, fistulae & filling-defect masses
what is contraindications of Dacryocystography ?
1) Sensitivity to the contrast .
2) Local sepsis at the punctum .
3) Pregnancy .

33.  What is Nuclear lacrimal scintigraphy ( DSG ) ?
Def.
 It is an advanced nuclear medicine technique test used to asses
the tear drainage ( qualitative asses )
 Technique :
The image is taken by gamma camera focused on inner
canthus .
The sequence of images is recorded over 20 minutes
 What is advantage over Dacryocystography ?
It asses the functional problems of tears even if no obstruction.
 What is disadvantage of ( DSG ) ?
Cant localized the site of anatomical obstruction .

34. Dry eye

37. What is classification of dry eye ??
1) mild = symptoms with no signs
2) Moderate = symptoms with reversible signs
3) Severe = irreversible
How to diagnose / investigate dry eye ??
1) Tear film break up time test ( mucin )
2) Rose Bengal stain test ( mucin )
3) Lissamine green dye test. ( mucin )
4) Schirmer test ( 1 & 2 ) ( aqueous )
5) Osmolality of tear film ( > 310 = diagnostic )
6) Impression cytology

38. Tear film break up time test :
idea /
 Check stability of tear film
How ?
 Instill fluorescein
 Ask pt. to blink several times to spread the dye
 Ask pt. Open your eyes ( don’t blink )
 Normal = fluorescein will cover all the cornea
 Dry spot appear > 10 sec. = normal
 Dry spot appear 5 – 10 sec. = mild – moderate dry eye
 Dry spot appear < 5 sec. = severe dry eye

40. Rose Bengal test :
 idea /
 Check stability of tear film
 How ?
 Instill rose Bengal stain
 Ask pt. to blink several times to spread the dye
 Normal = it will not stain the eye
 If stained = ++ mucous secretion why ??
Because rose Bengal stain is sticky to mucous only ..

42. Lissamine green dye test :
 idea /
Check stability of tear film
How ?
Same as well as ( rose Bengal )
Advantages /
Less eye irritations than rose Bengal .

44. SCHIRMER TEST
 idea /
 Check amount of aqueous in tear film
 How ?
 Use test filter paper ( 5 mm * 35 mm ) = ( Whatmann paper )
 Knick 5 mm at one end of the paper .
 Put the paper in the lower fornix
 Don’t touch the cornea why ???
 It will activate tear reflex
 Wait 5 minutes = normal is > 15 mm .

45. What is DD ( ) Schirmer 1 & 2 ?
Schirmer 1 /
without topical anesthesia
It measure total secretion ( basic + reflex )
Normal = 15 mm / 5 min.
Schirmer 2 /
with topical anesthesia
It measure only basic secretion .
Normal = 5 mm / 5 min

46. What are the precautions in Schirmer tests ?
( DO & DON’T RULE )
DO DON’T
ROOM Dim light No fan , no AC nearby
PT . Upright setting position Don’t blink more
DOCTOR Wait a will after topical
anesthesia till reactive
hyperemia subsided .
Don’t touch the cornea
when you put the filter
paper

47. Schirmer’s test

49. References
Ocular physiology by ( Simon Schlocky )
OST Oxford ( Louise A. Bye)
American academy series of ophthalmology
Eye overview ( my.clevelandclinic.com )
Duane anatomy
Medweb.com