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nasolacrimal system examination

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nasolacrimal system examination

  1. 1. Evaluation of nasolacrimal system Balasubramanian ThiagarajanAutor: 17.09.12
  2. 2. Why should we bother? ● Otolaryngologists perform endoscopic dacryocystorhinostomy more and more ● Helps in deciding whether the patient will benefit from this procedure ● Operating surgeon should clinically examine patients before surgeryAutor: 17.09.12
  3. 3. History ● Anatomy of nasolacrimal pathway – Hamurabi 2200 BC ● Endo-DCR first described by Caldwell 1893 ● External DCR – Toti in 1904Autor: 17.09.12
  4. 4. Epiphora (Downpour) ● Excessive lacrimation ● Defective drainage ● Lacrimal pump failureAutor: 17.09.12
  5. 5. Classification of Epiphora ● Congenital causes ● Acquired causesAutor: 17.09.12
  6. 6. Congenital ● 1% of infants ● Self limiting disorder ● Massaging of the sac helps ● Probing beneficialAutor: 17.09.12
  7. 7. Acquired ● Primary acquired nasolacrimal duct obstruction ● Dacryocystolithiasis ● Orbital / lacrimal trauma ● Canalicular lacerations ● Actinomyces within canaliculi ● Canalicular lesions following herpes / antiviral therapy (+ h/o keratoconjunctivitis)Autor: 17.09.12
  8. 8. Anatomical obstruction ● Pathologies involving sac ● Canalicular stenosis / blockage ● Obstruction to nasolacrimal duct ● Formation of diverticulaAutor: 17.09.12
  9. 9. Types of obstruction ● Intrinsic – caused by internal derangements of the mucosal lining of lacrimal apparatus ● Extrinsic – Caused by extraneous deforming lesions which can deform the drainage channel as is the case in tumors.Autor: 17.09.12
  10. 10. Epiphora (Physiologic) ● No anatomical changes in the lacrimal pathway ● Lacrimal pump mechanism is at fault ● Eye lid malpositions, eversion of punctum, poor orbicularis oculi muscle tone ● Bells palsyAutor: 17.09.12
  11. 11. Epiphora Grading (Sahlin) Grade Degree of epiphora0 No epiphora1 Epiphora only outdoors and during windy times2 Outdoor epiphora No indoor epiphora3 Outdoor and indoor epiphoraAutor: 17.09.12
  12. 12. Anatomy of lacrimal system ● Nasolacrimal duct is 18mm long ● Junction between common canaliculus and sac is guarded by Rosenmuller valveAutor: 17.09.12
  13. 13. Sites of lacrimal system block ● Suprasaccal ● Saccal ● SubsaccalAutor: 17.09.12
  14. 14. Suprasaccal obstruction ● Obstruction is proximal to sac ● Upper canaliculus ● Lower canaliculus ● Common canaliculus ● Herpes infection, trauma, irradiationAutor: 17.09.12
  15. 15. Saccal obstruction ● Obstruction at the level of sac ● Tumor ● Diverticula ● TraumaAutor: 17.09.12
  16. 16. Subsaccal obstruction Incomplete CompeteAutor: 17.09.12
  17. 17. Functional obstruction ● Lacrimal system is patent to syringing still there is epiphora ● Obstruction is to be used only for anatomical obstructionAutor: 17.09.12
  18. 18. Causes of excessive tearing ● Hypersecretion ● Epiphora ● Combination of bothAutor: 17.09.12
  19. 19. Diagnostic evaluation ● Quantification of tear production ● Assessment of nasolacrimal system patency ● Differentiating epiphora from lacrimation ● Defining the pathological process ● Differentiating anatomical from functional obstruction ● Attempting to locate the site of obstructionAutor: 17.09.12
  20. 20. Classification of tests to evaluate lacrimal system pathway ● Anatomical tests ● Functional tests ● Secretory testsAutor: 17.09.12
  21. 21. Anatomical tests ● These tests helps in localization of obstruction ● Palpation of sac ● Syringing / irrigation ● Diagnostic probing ● Dacryocystography ● Nasal exam ● CT/MRIAutor: 17.09.12
  22. 22. Functional tests ● To access functioning of lacrimal apparatus under physiologic conditions ● Performed only when there is no evidence of obstruction in anatomical testsAutor: 17.09.12
  23. 23. Functional tests (contd) ● Flourescein dye disappearance test ● Scintigraphy ● Jones dye test I ● Sacharin testAutor: 17.09.12
  24. 24. Tests for lacrimal secretions ● These tests are performed to access secretory functions of lacrimal apparatus ● Schrimers test ● Bengal Rose test ● Tear-film break up ● Tear lysozymeAutor: 17.09.12
  25. 25. Causes of excess lacrimation ● Supranuclear causes – Psychogenic / emotions ● Stimulation of V nerve ● Infranuclear causes ● Lacrimal gland stimulation ● Other causes – Bright lights / sneezingAutor: 17.09.12
  26. 26. Stimulation of V nerve ● Reflex tearing ● Lid causes – Blepharitis / trichiasis ● Conjunctival diseases ● Corneal diseases ● Neuralgia ● Ocular inflammationAutor: 17.09.12
  27. 27. Infranuclear causes ● Facial palsy ● Aberrant innervation ● Crocodile tearsAutor: 17.09.12
  28. 28. Epiphora causes ● Functional insufficiency – incorrect lid closure, lid malposition, punctal eversion, punctal medialization ● Anatomical obstruction ● Combination of functional insufficiency and anatomical obstructionAutor: 17.09.12
  29. 29. Combined epiphora ● Facial nerve palsy – corneal irritation and pump defects ● Lower lid ectropion – conjunctival irritation and pump defects ● Thyroid diseases – corneal irritation and defective canalicular functionAutor: 17.09.12
  30. 30. History taking ● Provides vital clues to the presence of canalicular disorders ● H/o present /past opthalmological problems ● Nasal symptoms ● Previous surgeries ● Unilateral tearing – obstruction ● Bilateral tearing - Physiological`Autor: 17.09.12
  31. 31. Inspection & palpation ● Eye lids ● Medial canthus ● Palpation of sacAutor: 17.09.12
  32. 32. Eye lid examination ● Lower lid laxity ● Ectropion ● Punctal eversion ● Trichiasis ● BlepharitisAutor: 17.09.12
  33. 33. Snap back test ● Test for lower lid laxity ● Lower lid is pulled down and away from the orbit ● On release the lid resumes normal position ● Time taken for the lid to get back to normal postion is noted ● Longer the duration more lax is the lower lid ● Graded over a scale of 0-4Autor: 17.09.12
  34. 34. Lid examination (contd) ● Medial canthal laxity ● Lateral canthal laxity ● Orbicularis oculi muscle tone checkAutor: 17.09.12
  35. 35. Examination of medial canthus Neoplasm Sac enlargementAutor: 17.09.12
  36. 36. Sac palpation ● Normal sac not palpable ● Sac is palpable below the medial canthus ● Reflux of tears / pent up secretions ● Pain / tenderness – acute dacryocystitisAutor: 17.09.12
  37. 37. Dye excretion test ● Drainage function of entire lacrimal apparatus can be tested ● Fluorescein dye is used for this purpose ● This test is more physiological ● This test does not differentiate anatomical from physiological causes of nasolacrimal obstructionAutor: 17.09.12
  38. 38. Fluorescein dye test ● 1% fluorescein is instilled into the conjunctiva ● Conjunctiva is not anaesthetized ● After 5 mins thickness of fluorescein of the tear meniscus is measured using cobalt blue filter ● This test can be safely performed in infants & childrenAutor: 17.09.12
  39. 39. Fluorescein dye test (contd) ● Presence of residual fluorescein gives no information regarding localisation of block ● Presence of residual fluorescein is an indication for probing and syringing ● When performing this test in children they should be held in vertical postionAutor: 17.09.12
  40. 40. Dye test grading ● 0=No fluorescein in the conjunctival sac ● 1=Thin flurescing marginal tear drop persists ● 2=More fluorescein persists somewhere between 1 and 3 grades ● 3=Wide brightly fluorescein tear strip ● Grades 0 and 1 are considered normalAutor: 17.09.12
  41. 41. False negative dye test 1. Large lacrimal sac 2. Mucocele 3. Distal nasolacrimal duct blockAutor: 17.09.12
  42. 42. Break up time test ● Performed by placing a drop of fluorescein in the outer canthus of the eye ● Its transport can be observed from lateral to medial ● Holes in the tear film can also be observed ● Normal breakup time is 15-30 secs ● Breakup time of less than 10 secs indicate epiphoraAutor: 17.09.12
  43. 43. Jones dye test ● Distinguishes between functional and anatomical obstruction ● Topical xylocaine application ● Flurescein dye instilled ● Negative result indicates functional / anatomical block ● Useless in totalAutor: 17.09.12 obstruction
  44. 44. Saccharin test ● Similar to fluorescein dye test ● Physiological ● Saccharin is placed in conjunctiva ● Saccharine taste appears within 3.5 mins ● Pt should have normal taste sensationAutor: 17.09.12
  45. 45. Probing & syringing ● Invasive test ● Provides information regarding site of obstruction ● Useless in functional obstruction ● This is not a physiological test ● This test should be interpreted with fluorescein dye test and clinical examinationAutor: 17.09.12
  46. 46. Syringing (contd) ● Topical xylocaine applied ● Punctum dilator applied to dilate punctum ● Tip of irrigator placed in the inferior canaliculus. It is directed first vertically and then horizontally. Eyelid is stretched ● Tip is advanced 3-7 mm into canaliculus and saline is injected ● Irrigation should not be forcedAutor: 17.09.12
  47. 47. Syringing (Interpretation) ● Regurgitation through opposite punctum – obstruction in the common canaliculus or more distal structures ● Regurgitation via the same punctum indicates punctal obstruction ● Drainage via nose does not rule out physiological obstructionAutor: 17.09.12
  48. 48. Diagnostic probing Hard stop Soft stopAutor: 17.09.12
  49. 49. Irrigation / probing interpretationAutor: 17.09.12
  50. 50. Radiological evaluation ● Dacryocystography ● Nuclear lacrimal scintigraphy ● CT ● MRIAutor: 17.09.12
  51. 51. Dacryocystography ● Anatomical investigation ● Creates interior image of the entire lacrimal system ● Radio opaque water soluble dye is injected into the canaliculus ● Magnified images are created ● Digital subtraction is usedAutor: 17.09.12
  52. 52. Radiologic criteria of lacrimal pathology ● Regurgitation of radio-opaque fluid into the conjunctival sac ● Absence of fluid in the nose ● Fluctuation of lumen of lacrimal system ● Irregularity in contrast ● Deformation involving lacrimal sacAutor: 17.09.12
  53. 53. Nuclear lacrimal scintigraphy ● Non invasive physiological test ● Utilizes radiotracer technitium-99M pertechnitate. ● Images can be captured using epiphora ● Drop of technetium-99m instilled into conjunctiva ● Recording is made using gamma camera ● 20 mins is the recording timeAutor: 17.09.12
  54. 54. CT/MRI Helpful in identifying adjacent areas and other mass lesionsAutor: 17.09.12
  55. 55. Secretory tests ● Schimers test ● Rose bengal testAutor: 17.09.12
  56. 56. schirmers test ● 35x5 mm paper ● 5 mins duration ● 10-30 mm wetness normal ● Above 30mm epiphora ● 10mm drynessAutor: 17.09.12
  57. 57. ThankyouAutor: 17.09.12

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