DISORDERS OF THE LACRIMAL SYSTEM

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DISORDERS OF THE LACRIMAL SYSTEM

  1. 1. DISORDERS OF THE LACRIMAL SYSTEM Dr Russell J Watkins
  2. 2. Lacrimal System Disorders <ul><li>Tear film disorders (all phases) </li></ul><ul><ul><li>The dry eye </li></ul></ul><ul><ul><li>The wet eye </li></ul></ul><ul><li>Drainage obstruction </li></ul><ul><li>Lacrimal gland inflammation </li></ul><ul><li>Lacrimal gland tumours </li></ul><ul><li>Lacrimal sac tumours </li></ul>
  3. 3. Keratoconjunctivitis Sicca <ul><li>Aqueous phase deficiency </li></ul><ul><li>Symptoms </li></ul><ul><ul><li>Redness </li></ul></ul><ul><ul><li>Burning sensation </li></ul></ul><ul><ul><li>Gritty sensation </li></ul></ul><ul><ul><li>“ Stiff lids” - difficulty with initial opening </li></ul></ul><ul><ul><li>2° epiphora in some cases </li></ul></ul>
  4. 4. Keratoconjunctivitis Sicca <ul><li>Signs </li></ul><ul><ul><li> Tear meniscus </li></ul></ul><ul><ul><li>TF debris;  TBUT </li></ul></ul><ul><ul><li>Corneal epithelial filaments </li></ul></ul><ul><ul><li>SPE; frank ulceration </li></ul></ul><ul><ul><li>Vital staining with rose Bengal 1% </li></ul></ul><ul><ul><li>Abnormal Schirmer’s test (type I & type 2) </li></ul></ul>
  5. 5. Keratoconjunctivitis Sicca <ul><li>Other investigations </li></ul><ul><ul><li>Reduced lysozyme activity in Sjögren’s syndrome </li></ul></ul><ul><ul><li> Tear osmolarity (normal = ~300mosmol/l; Aqueous deficiency = ~340mosmol/l) </li></ul></ul>
  6. 7. Keratoconjunctivitis Sicca <ul><li>Causes of aqueous deficiency </li></ul><ul><ul><li>Idiopathic/age related </li></ul></ul><ul><ul><li>1° & 2° Sjögren’s syndrome </li></ul></ul><ul><ul><li>Inflammatory or infiltrative lesions e.g. Lymphoma, TB, sarcoidosis </li></ul></ul><ul><ul><li>Congenital/iatrogenic absence of lacrimal gland </li></ul></ul><ul><ul><li>CN V defect (sensory arc) </li></ul></ul><ul><ul><li>CN VII defect (motor arc; anticholinergics) </li></ul></ul><ul><ul><li>ADRs (antihistamines;  -blockers; phenothiazines; OCP) </li></ul></ul>
  7. 11. Mucin Deficiency <ul><li>Signs </li></ul><ul><ul><li> TBUT </li></ul></ul><ul><ul><li>Bitot’s spots: interpalpebral conjunctival foamy patches associated with severe  vitamin A & xerophthalmia </li></ul></ul><ul><li>Causes </li></ul><ul><ul><li>Vitamin A deficiency </li></ul></ul><ul><ul><li>Cicatrising disease (loss of conjunctival goblet cells): trachoma, SJS, cicatricial pemphigoid, chemical burns </li></ul></ul>
  8. 13. Oily Layer Abnormalities <ul><li>Meibomianitis, MGD </li></ul><ul><li>Blepharitis, often staphylococcal & compounding aqueous deficiency </li></ul>
  9. 16. Management of Dry Eyes <ul><li>Artificial tears - if used very frequently, consider preservative free preparations </li></ul><ul><li>Lid toilet and compresses with occasional use of topical antibiotics </li></ul><ul><li>Mucolytics for filamentary keratitis </li></ul><ul><li>Vitamin A supplements in xerophthalmia (topically is experimental) </li></ul><ul><li>Punctal plugs - optometric role? </li></ul><ul><li>Stop exacerbating medication </li></ul><ul><li>Surgery to lid deformities/punctal occlusion </li></ul>
  10. 17. Epiphora <ul><li>Causes </li></ul><ul><ul><li>Exclude eye disease </li></ul></ul><ul><ul><ul><li>Allergic/infective/irritative conjunctivitis </li></ul></ul></ul><ul><ul><ul><li>Trichiasis, distichiasis </li></ul></ul></ul><ul><ul><ul><li>Corneal disease </li></ul></ul></ul><ul><ul><li>Dry eye with compensatory hypersecretion </li></ul></ul><ul><ul><li>Lacrimal pump failure (e.g. CN VII palsy) </li></ul></ul><ul><ul><li>Lid-globe incongruity such as ectropion </li></ul></ul><ul><ul><li>Lacrimal drainage system obstruction </li></ul></ul><ul><ul><li>Hypersecretion </li></ul></ul>
  11. 18. Epiphora <ul><li>Assessment of the patient with epiphora </li></ul><ul><ul><li>Exclude dry eye </li></ul></ul><ul><ul><li>Check punctal position & patency </li></ul></ul><ul><ul><li>Apply lacrimal sac pressure looking for reflux (mucocele) </li></ul></ul><ul><ul><li>Test lacrimal drainage patency </li></ul></ul>
  12. 19. Epiphora <ul><li>Specific tests of patency </li></ul><ul><ul><li>Fluorescein disappearance test </li></ul></ul><ul><ul><li>Jones’ test - staining of nasal swab after instillation of fluorescein into fornix </li></ul></ul><ul><ul><li>Syringing & probing - diagnostic & therapeutic (optometric role?) </li></ul></ul><ul><ul><li>Ophthalmologists may also perform CT & MRI scans, radionucleotide scans </li></ul></ul>
  13. 20. Lacrimal Drainage System Obstruction <ul><li>Causes: </li></ul><ul><ul><li>Congenital </li></ul></ul><ul><ul><ul><li>Absence/atresia of the canaliculi &/or puncta </li></ul></ul></ul><ul><ul><ul><li>Incomplete opening of the nasolacrimal duct </li></ul></ul></ul><ul><ul><ul><li>Associated with craniofacial anomalies </li></ul></ul></ul><ul><ul><li>Senile: punctal stenosis or associated with chronic infection </li></ul></ul><ul><ul><li>Ectropion or conjunctival cicatrisation </li></ul></ul>
  14. 21. Lacrimal Drainage System Obstruction <ul><li>Causes (continued) </li></ul><ul><ul><li>Trauma (physical or radiation) </li></ul></ul><ul><ul><li>Inflammation (sarcoid, Wegener’s) </li></ul></ul><ul><ul><li>Drug induced (pilocarpine, idoxuridine, adrenaline et al) </li></ul></ul><ul><ul><li>Infection </li></ul></ul><ul><ul><ul><li>Acute or chronic dacryocystitis </li></ul></ul></ul><ul><ul><ul><li>Canaliculitis (HSV, VZV, actinomyces israelii) </li></ul></ul></ul><ul><ul><ul><li>Sinusitis </li></ul></ul></ul>
  15. 22. Lacrimal Drainage System Obstruction <ul><li>Causes (continued) </li></ul><ul><ul><li>Lacrimal sac tumours </li></ul></ul><ul><ul><ul><li>1° (e.g. papillomata, SCC) </li></ul></ul></ul><ul><ul><ul><li>2° (e.g. BCC, lymphomata, sinus tumours) </li></ul></ul></ul>
  16. 23. Lacrimal Drainage System Obstruction <ul><li>Treatment depends on site of obstruction & falls into the ophthalmologists realm </li></ul><ul><ul><li>Puncta may be dilated (± snips) </li></ul></ul><ul><ul><li>Lid malposition correction </li></ul></ul><ul><ul><li>Recanalisation operations </li></ul></ul><ul><ul><li>Treat infectious causes (e.g. canaliculitis, dacryocystitis) </li></ul></ul><ul><ul><li>Recurrent dacryocystitis requires DCR </li></ul></ul><ul><ul><li>Probing atretic nasolacrimal ducts, DCR = mainstay of treatment of NLD obstruction </li></ul></ul>
  17. 25. Lacrimal Gland Inflammation <ul><li>Viral dacroadenitis e.g mumps, glandular fever </li></ul><ul><li>Acute bacterial dacryoadenitis often 2° to conjunctivitis </li></ul><ul><li>Chronic bacterial e.g. TB, syphilis </li></ul><ul><li>Inflammatory conditions e.g. Sjögren’s, sarcoidosis, Wegener’s </li></ul><ul><li>Reactive lymphoid hyperplasia, lymphoma </li></ul>
  18. 28. Lacrimal Gland Tumours <ul><li>50% are inflammations & lymphoid proliferations </li></ul><ul><li>Pleomorphic adenoma (benign mixed cell tumour) </li></ul><ul><ul><li>Epithelial origin </li></ul></ul><ul><ul><li>20-60 yrs </li></ul></ul><ul><ul><li>Painless, usually with long history (>1yr) </li></ul></ul><ul><ul><li>Palpable hard nodular mass </li></ul></ul><ul><ul><li>Non-axial proptosis;  ROEM; astigmatism </li></ul></ul><ul><ul><li>Surgical removal en bloc rather than biopsy </li></ul></ul><ul><ul><li>Good prognosis if completely removed </li></ul></ul>
  19. 29. Lacrimal Gland Tumours <ul><li>Carcinoma </li></ul><ul><ul><li>Epithelial origin </li></ul></ul><ul><ul><li>Painful, usually short history </li></ul></ul><ul><ul><li>Causes local bony erosion </li></ul></ul><ul><ul><li>Usually biopsied after trial of antibiotics </li></ul></ul><ul><ul><li>If biopsy +ve, requires radical local resection with RT </li></ul></ul><ul><ul><li>Poor prognosis </li></ul></ul>
  20. 30. Lacrimal Sac Tumours <ul><li>Features </li></ul><ul><ul><li>Rare </li></ul></ul><ul><ul><li>Painless swelling </li></ul></ul><ul><ul><li>Punctal reflux of pus & blood </li></ul></ul><ul><ul><li>Can be SCC, adenocarcinoma </li></ul></ul>
  21. 32. DISORDERS OF THE SCLERA & EPISCLERA Dr Russell J Watkins
  22. 33. Episcleritis <ul><li>Inflammation of episclera & overlying conjunctiva, occasionally associated with systemic disease (HZO, RA) </li></ul><ul><li>Nodular or diffuse </li></ul><ul><li>Benign & self-limiting </li></ul><ul><li>More common in young adults, M=F </li></ul><ul><li>Mild ache, tenderness, burning </li></ul><ul><li>Blanches with phenylephrine </li></ul>
  23. 34. Episcleritis <ul><li>Treatment </li></ul><ul><ul><li>None (self-limiting) </li></ul></ul><ul><ul><li>Topical corticosteroids </li></ul></ul><ul><ul><li>Systemic/topical NSAIDs </li></ul></ul>
  24. 35. Scleritis <ul><li>Less common but more serious than episcleritis </li></ul><ul><li>Can be very painful; occasionally painless </li></ul><ul><li>Pain can be worse at night </li></ul><ul><li>Older age group; F>M </li></ul>
  25. 36. Scleritis <ul><li>Systemic disease associated with scleritis </li></ul><ul><ul><li>HZO </li></ul></ul><ul><ul><li>RA </li></ul></ul><ul><ul><li>SLE </li></ul></ul><ul><ul><li>PAN </li></ul></ul><ul><ul><li>Wegener’s granulomatosis </li></ul></ul><ul><ul><li>Behçet’s syndrome </li></ul></ul><ul><ul><li>Ankylosing spondylitis </li></ul></ul><ul><ul><li>IBD et al </li></ul></ul>
  26. 37. Scleritis <ul><li>Classified as </li></ul><ul><ul><li>Anterior scleritis </li></ul></ul><ul><ul><li>Posterior scleritis </li></ul></ul><ul><li>Anterior scleritis further subclassified </li></ul><ul><ul><li>Diffuse non-necrotizing </li></ul></ul><ul><ul><li>Nodular non-necrotizing </li></ul></ul><ul><ul><li>Necrotizing, without inflammation </li></ul></ul><ul><ul><li>Necrotizing with inflammation </li></ul></ul>
  27. 38. Anterior Scleritis <ul><li>Diffuse non-necrotizing </li></ul><ul><ul><li>Segmented or widespread inflammation </li></ul></ul><ul><ul><li>Oedema </li></ul></ul><ul><ul><li>Treat with oral NSAIDs e.g. flurbiprofen </li></ul></ul><ul><li>Nodular non-necrotizing </li></ul><ul><ul><li>Focal inflammation & oedema </li></ul></ul><ul><ul><li>Nodule is immobile </li></ul></ul><ul><ul><li>Treat with oral NSAIDs e.g. indomethacin </li></ul></ul>
  28. 39. Anterior Scleritis <ul><li>Necrotizing, without inflammation </li></ul><ul><ul><li>Scleromalacia perforans </li></ul></ul><ul><ul><li>Seen in RA </li></ul></ul><ul><ul><li>Painless scleral thinning with marked ischaemia </li></ul></ul><ul><ul><li>Perforation rare </li></ul></ul><ul><ul><li>Treatment is difficult </li></ul></ul>
  29. 40. Anterior Scleritis <ul><li>Necrotizing, with inflammation </li></ul><ul><ul><li>Progressive, painful </li></ul></ul><ul><ul><li>Injected ++ </li></ul></ul><ul><ul><li>Scleral ischaemia & non-perfusion </li></ul></ul><ul><ul><li>Focal or diffuse </li></ul></ul><ul><ul><li>Associated anterior uveitis </li></ul></ul><ul><ul><li>Scleral thinning </li></ul></ul>
  30. 41. Anterior Scleritis <ul><li>Necrotizing, with inflammation (cont.) </li></ul><ul><ul><li>25% 5-yr mortality from associated disease </li></ul></ul><ul><ul><li>Severe complications e.G. Peripheral corneal melt, cataract, glaucoma </li></ul></ul><ul><ul><li>Treat with high dose systemic steroids ±immunosuppressants </li></ul></ul>
  31. 42. Posterior Scleritis <ul><li>Features </li></ul><ul><ul><li>Diffuse or focal thickened inflamed posterior sclera ±pain </li></ul></ul><ul><ul><li>Anterior segment may be unaffected </li></ul></ul><ul><ul><li>Easily missed </li></ul></ul><ul><ul><li>Exudative RD; choroidal folds </li></ul></ul><ul><ul><li>Posterior vitritis; disc & macular oedema </li></ul></ul><ul><ul><li>Uveal effusion syndrome </li></ul></ul><ul><ul><li>Proptosis </li></ul></ul><ul><ul><li>Ocular myositis with ophthalmoplegia </li></ul></ul><ul><ul><li>Usually no associated systemic disorder </li></ul></ul>
  32. 43. Posterior Scleritis <ul><li>Investigations </li></ul><ul><ul><li>CT scan or USS(B) </li></ul></ul><ul><li>Treatment </li></ul><ul><ul><li>High dose systemic steroids ±immunosuppression </li></ul></ul>

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