for knowledge purpose

1. Presenter:
Kalpana Bhandari
M.optom(2nd batch)
Tilganga institute of ophthalmology
Moderator:
Dr. Malita Amatya

2.  Blepharitis
 Ectropion
 Entropion
 Ptosis
 Disorder of lacrimal drainage system

3. BLEPHARITIS

4.  Blepharitis is the subacute or chronic inflammation of the eyelid.
Aetiology:
 Age: mostly in children.
 Usually bilateral.
 Irritation: from cosmetics, dusts smoke.
 Uncorrected refractive error.
 Seborrhea (dandruff) of the scalp.
 Chronic conjuctivitis.
 Parasitic infection.
- Blepharitis acarica – due to Demodex folliculorum,
-Phthiriasis palpebrarum
-Crab louse
-Head louse (Very rare)

6.  Blepharitis
 Anterior
▪ Squamous/
▪ Seborrhoeic
▪ Ulcerative
 Posterior
▪ Meibomitis

7. Blepharitis
Anterior
Squamous/
seborrhoeic
Ulcerative
Posterior
Meibomitis
Parasitic

8.  Anterior blepharitis affects the area surrounding the
bases of the eyelashes and may be
ulcerative(staphylococcal) or seborrhoeic.

9. Etiology.
 It is usually associated with seborrhoea of scalp
(dandruff). In it, glands of Zeis secrete abnormal
excessive neutral lipids which are split by
Corynebacterium acne into irritating free fatty acids.
Symptoms:
 Patients usually complain of deposition of whitish
material at the lid margin associated with mild
discomfort, irritation, occasional watering and a
history of falling of eyelashes.

10. Signs:
 Accumulation of white dandruff-like scales are
seen on the lid margin, among the lashes.
 On removing these scales underlying surface is
found to be hyperaemic (no ulcers).
 The lashes fall out easily but are usually replaced
quickly without distortion.
 In long-standing cases lid margin is thickened
and the sharp posterior border tends to be
rounded leading to epiphora.

11. Treatment:
 General measures include improvement of health and
balanced diet.
 Local measures include removal of scales from the lid margin
with the help of lukewarm solution of 3% soda bicarbonate
or baby shampoo and frequent application of combined
antibiotic and steroid eye ointment at the lid margin.

12. Etiology:
 It is a chronic staphylococcal infection of the lid margin
usually caused by coagulase positive strains.
 The disorder usually starts in childhood and may continue
throughout life.
 Chronic conjunctivitis and dacryocystitis may act as
predisposing factors.
Symptoms:
 These include chronic irritation, itching, mild lacrimation,
gluing of cilia, and photophobia.
 The symptoms are characteristically worse in the morning.

13. Signs:
 Yellow crusts are seen at the root of cilia which glue
them together.
 Small ulcers, which bleed easily, are seen on removing
the crusts.
 In between the crusts, the anterior lid margin may show
dilated blood vessels (rosettes).

14. Complications and sequelae:
 These are seen in longstanding (non-treated) cases and
include chronic conjunctivitis, madarosis, trichiasis, poliosis ,
tylosis and eversion of the punctum leading to epiphora.
 Associated tear film instability and dry eye syndrome are
common.
 Atopic keratoconjunctivitis may be present in patients
with atopic dermatitis.
 Eczema of the skin and ectropion may develop due to
prolonged watering.
 Recurrent styes is a very common complication.

15. Treatment:
 It should be treated promptly to avoid complication and sequelae.
 Crusts should be removed after softening and hot compresses with
solution of 3% soda bicarbonate.
 Antibiotic ointment should be applied at the lid margin,
immediately after removal of crusts, at least twice daily.
 Antibiotic eyedrops should be instilled 3-4 times in a day.
 Avoid rubbing of the eyes or fingering of the lids.
 Oral antibiotics such as erythromycin or tetracyclines may be
useful.
 Oral anti-inflammatory drugs like ibuprofen help in
reducing the inflammation.

17.  Blepharitis acrica refers to a chronic blepharitis associated with
Demodex folliculorum infection and Phthiriasis palpebram to
that due to crab-louse, very rarely to the head-louse.
 In addition to features of chronic blepharitis, it is characterized
by presence of nits at the lid margin and at roots of eyelashes.
Treatment:
 consists of mechanical removal of the nits with forceps
followed by rubbing of antibiotic ointment on lid margins, and
delousing of the patient, other family members, clothing and
bedding.

18.  May lead to cylindrical dandruff-like scaling around the base
of eyelashes, though this is not always present.
 The mites can be demonstrated under ×16 slit lamp
magnification by first manually clearing around the base of
an eyelash then with fine forceps gently rotating the lash or
moving it from side to side for 5–10 seconds.
Fig: migrating demodex mite in 2 seconds.

19.  Leads to tear film instability and inferior punctate keratitis.
 Commonly presents in 2 ways:
1)Meibomian Seborrhoea: Oil droplets seen at the Meibomian
gland openings which can be expressed out like foam.
2)Meibomanitis: Diffuse rounded posterior lid margin &
thickening around Meibomian glands opening.
Lid massage expresses out an inspissated, toothpaste-like
material.
Cyst formation due to duct blockage may also be seen.

21.  Expression of the glands by repeated vertical lid massage, followed by
rubbing of antibiotic-steroid ointment at the lid margin.
 Antibiotic eyedrops should be instilled 3-4 times. Systemic
tetracyclines for 6-12 weeks remain the mainstay of treatment of
posterior blepharitis.
 Unresponsive meibomitis can be treated with topical ophthalmic
antibiotic/steroid ointments (e.g., tobramycin 0.3% /dexamethasone
0.1% b.i.d. to t.i.d.).Also consider an oral agent such as doxycycline 100
mg p.o. daily for 1 to 2 weeks; slowly taper to one-fourth full dose and
maintain for 3 to 6 months. Oral azithromycin 500 mg/day × 3 days for 3
cycles with 7-day intervals may also be used.
NOTE: Tetracycline derivatives such as doxycycline should not be used in pregnant
women, nursing mothers, or children ≤8 years. Erythromycin 200 mg p.o. b.i.d. is an
alternative in these cases.

22.  If little improvement has been made, consider LipiFlow,
pulsed light laser therapy, microblepharoexfoliation, and
probing of meibomian glands.

25. ECTROPION

26.  It is an outward turning of the
eyelid margin .
 This more frequently affects
the lower eyelid.
 Upper eyelid ectropion is
uncommon.

27.  Classified in 5 types
1)Congenital
2) Involutional (age related)
3) Paralytic
4) Cicatricial
5) Mechanical
 Involutional ectropion is more common and
Congenital ectropion is very rare.

28.  Cicatricial ectropion is caused by scarring
or contracture of the skin and underlying
tissues, which pulls the eyelid away from
the globe.
 Depending on the cause, both lids may be
involved and the defect may be local (e.g.
trauma) or general (e.g. burns, dermatitis,
ichthyosis).
 Paralytic ectropion is caused by ipsilateral
facial nerve palsy and is associated with
retraction of the upper and lower lids and
brow ptosis.

29. Mechanical ectropion:
 Mechanical tumour at or near the lid margin.
 Lid swelling due to inflammation from infection or
allergy.
 Genetic disorders: Rarely ectropion is present at
birth (congenital) and is usually associated with
genetic disorders, such as Down syndrome.

30.  Epiphora :- excessive tearing.
 Excessive dryness.
 Foreign body sensation.
 Irritation.
 Burning.
 Redness.
 Chronic conjunctivitis.
 Keratinization.
 Corneal exposure.

31.  Inferior lid margin not in contact with globe: Region involved may be
punctal, medial, lateral, or tarsal (complete).
 Involutional ectropion typically begins medially; central lid margin and
lateral lid may become involved later.
 Keratinisation of exposed tarsal conjunctiva.
 Lower punctum not in contact with tear meniscus: if punctum is
spontaneously visible at slit lamp, ectropion is present.
 Conjunctival hyperaemia, Exposure keratopathy, Epiphora.
 If lower lid can be pulled >6mm from globe, it is lax positive test indicates
canthal tendon laxity.
 In Snap-back test with finger if lid slow to return to normal position it
indicates poor orbicularis tone.

32. Lid margin is out rolled and depending on out rolling
ectropion can be classified as :
 Grade I –only punctum is everted.
 Grade II –lid margin is everted and palpebral
conjunctiva is visible.
 Grade III –fornix is also visible.

33.  Horizontal lid laxity:-can be demonstrated by
pulling the central part of the lid 8 mm or more from
the globe, with a failure to snap back to its normal
position on release without the patient first blinking.
Classified:-
 MILD – takes some time
 MODERATE – goes back slowly without blink
 SEVERE – does not go back even after a blink

34. FIG: Lid laxity

35.  Demonstrated by pulling the
lower lid laterally and observing
the position of the inferior
punctum.
 If the lid is normal the punctum
should not be displaced more than
1–2 mm
 Mild :- punctum reaches the
limbus.
 Severe :- may reach the pupil.

36.  Characterized by a rounded
appearance of the lateral
canthus and the ability to pull
the lower lid medially more
than 2 mm.
 Normally, the displacement
should only be 0-2 mm.

37.  Proper history:- time, duration, h/o trauma, h/o
surgery of eye.
 Check severity of ectropion.
 External examination.
 Slit lamp examination:- for lid, conjunctiva, cornea,
pupil.
 Test for ectropion:- eyelid snap test, medial canthus
laxity test, lateral canthal laxity test.
 OCT cornea.

38. Non- surgical treatment : to protect the cornea,
 Advise that lid rubbing may increase lid laxity.
 Lubrication with higher viscosity tear substitutes during the day.
 Taping shut of the lids during sleep, are usually adequate in mild
cases.
 soft bandage contact lenses.
 Scleral lenses.
 Botulinum toxin injection into the levator to induce temporary ptosis.
 Temporary tarsorrhaphy.
Surgical treatment:
 Removal of the cause If possible in mechanical ectropion.
 A variety of surgical procedures (choice determined by nature,
position and degree of ectropion) e.g. lateral tarsal strip, with or
without transconjunctival retractor plication, or wedge resection.
 Tarsorrhaphy sometimes is necessary.

40. ENTROPION

41.  Entropion is a condition in
which eyelid, usually the
lower one, is turned inward
so that eyelashes rub
against eyeball, causing
discomfort.

42.  Involutional
 Cicatricial
 Spastic
 Congenital

43.  Foreign body sensation
 Photophobia
 Irritation
 Pain
 Lacrimation

44.  Lid margin is inturned inward.
 Depending on degree of in turning, divided into
three grades.
 Grade 1 only posterior lid border is inrolled.
 Grade 2 inturning of intermarginal strip.
 Grade 3 whole lid margin including anterior border
inturned.

45.  Recurrent corneal abrasions.
 Superficial corneal opacities.
 Corneal vascularisation.
 Non healing corneal ulcer.

46.  Age related entropion.
 Affects mainly the lower eye lid.
Pathogenesis:
Age related degeneration of elastic fibrous tissue within
the eyelid results in following :
 Horizontal lid laxity caused by stretching of canthal
tendons and tarsal plate.
 Vertical lid instability caused by disinsertion of lower
eyelid retractors.
 Overriding of the pretarsal by the preseptal orbicularis.

47. Pathogenesis:
 It is caused by severe scarring of the palpebral
conjunctiva which pulls the upper or lower lid
margin towards the globe.

49.  Spasm of orbicularis muscle in presence of degeneration of
palpebral connective tissue separating orbicularis muscle
fibres.
 Degeneration of aponeurosis of orbicularis muscle tends to
approximate lid margins and turns them inwards on
contraction.
 Horizontal lid laxity.
CAUSES:
 Ocular irritations causing inflammation and trauma Chronic
conjunctivitis Keratitis
 Tight bandage post operatively
 Blepharophimosis

50.  Rare condition due to the
dysgenesis of lower eyelid
retractors or
developmental
abnormality of tarsal plate.
 Associated with
microophthalmos.

51.  Extra horizontal row of skin across lid margin.
 When fold of skin is pulled down lashes turn out but
lid remains in apposition to the globe.

52. Congenital entropion
• rare
• Inturning of entire lower eyelid and
lashes
• Absence of lower lid crease
• When skin is pulled down lid also pulls
away from globe
• Does not resolve spontaneously
Epiblepharon
• Common
• Extra horizontal row of skin across lid
margin
• Presence of lowerlid crease
• Skin remains in apposition with the
globe
• Resolve spontaneously

53. MEDICAL
 Lubricants
 Taping
 Soft bandage contact lenses
 Adhesive tape-pulling the skin outward with
strip of adhesive tape.
 Injection of botulinum toxin.

54. Surgery
Transverse
everting sutures
Weis procedure Jones procedure
Bicks procedure
with rees
modification

55. PTOSIS

56.  Blepharoptosis is derived from the greek word
blepharon=eyelid and ptosis= falling. So, blepharoptosis
means drooping of upper eyelid.
 Blepharoptosis often abbreviated as ptosis.
 Normally upper eyelid covers 1/6th of cornea i.e. 2mm
 Therefore in ptosis it covers more than 2mm.

57. Mild ptosis
• 2mm of drop
Moderate ptosis
• 3mm of drop
Severe ptosis
• 4 mm or more drop

58. Ptosis
Congenital
Simple
congenital
With
abnormal
moveme
nts
With lid
abnorm
alities
Acquire
d
Myogenic Neurogenic Aponeurotic Mechanical
Pseudoptosis

59.  It is associated with congenital weakness
(maldevelopment) of the levator palpebral superioris (LPS)
muscle.
1.Simple congenital ptosis :
Not associated with any other anomaly and ptosis occurs
due to weakness of superior rectus muscle.
2.Blepharophimosis syndrome:
 Which comprises congenital ptosis, blepharophimosis,
telecanthus and epicanthus inversus .

3.Congenital synkinetic ptosis :
 (Marcus Gunn jaw winking phenomenon).
 Its the condition of misdirection 3rd nerve , retraction of
the upper lid with various ocular movements.

60. 1. Neurogenic
 Third nerve palsy
 Horner syndrome
 Myasthenia gravis
 Marcus Gunn jaw-winking syndrome (ptotic eyelid
elevates with jaw movement)
 multiple sclerosis
2.Myogenic
 Myasthenia gravis
 Ocular myopathies
 Simple congenital
 Blepharophimosis syndrome

61. 3.Mechanical ptosis:
Due to excessive weight on the upper lid.
 Retained contact lens in upper fornix; upper
eyelid or forniceal inflammation (chalazion,
giant papillary conjunctivitis, posttraumatic or
postsurgical
edema) or neoplasm.
4.Aponeurotic ptosis:
Senile,Trauma to levator muscle, post surgeries.

63.  Pseudoptosis is the appearance of ptosis in the absence of
levator abnormality.
 Its common causes are:
 Microphthalmos,
 Anophthalmos,
 Enophthalmos,
 Phthisis bulbi,
 Double elevator palsy,
 Blepharospasm,
 Contralateral proptosis,

64. Ptosis
 Age of onset
 Duration
 One/both eye
 Diurnal variability
Associated history :
 Diplopia
 Fatigability
 Muscle weakness
Vision

65. Association with
 Jaw movements
 Abnormal ocular movements
 Abnormal head posture
History of
 Trauma or previous surgery
 Poisoning
 Use of steroid drops
 Any reaction with anesthesia
 Bleeding tendency
Previous photographs may prove to be of great help.
Is there a family history of ptosis or of other muscle weakness?

66.  Head posture
 Periocular fullness (puffy eyes, swelling around eye)
 Frontalis overaction
 Scar mark
 Lid skin laxity
 Telecanthus, epicanthus inversus.

67. Ocular Motility:
 Importance in myogenic ptosis, to rule out 3rd
nerve palsy.
 Presence of strabismus, especially vertical
strabismus has to be corrected prior to the
correction of the ptosis.
Visual acuity:
 Best-corrected visual acuity should be assessed to
record any amblyopia if present, especially in cases
of congenital ptosis.

68. Refraction:
 Cycloplegic refraction is indicated in all
children with ptosis since it is known that a
significant number have anisometropia,
primarily due to astigmatism on the ptotic
side.
 Any significant refractive error should be
corrected.

69. Margin reflex distance1
(MRD 1):
 After shining the
torchlight in the patient
eye, the distance
between the corneal
light reflex to the
centre of the upper lid
margin is measured.
 Normal value is 4-
4.5mm.

70. Margin reflex distance 2 (MRD 2):
 the distance of corneal light reflex to the
centre of the lower eyelid margin in primary
gaze.
 Normal value is 5- 5.5mm
Margin reflex distance 3(MRD 3):
 the distance between the corneal light reflex
and the centre of upper eyelid margin in
extreme upgaze.

71. Palpebral fissure height (PFH):
 PFH=MRD1 + MRD2.
 Central palpebral fissure height is measured
in primary gaze and compared with the
normal eye in unilateral ptosis.
 Normal palpebral fissure height is 8-11mm.

72.  It is an important anatomical landmark,
which give clue to levator action.
 It is measured with patient looking down,
distance from the central eyelid margin to
the most prominent lid crease.
 Normal value in Men is 5-7mm, women 8-
10mm.
 Crease is absent in congenital ptosis and is
higher in aponeurotic ptosis.

73.  An absent lid crease is often accompanied by poor
levator function.
 If a lid crease is present, but higher than normal and
if there is a deeper upper lid sulcus on that side
these should be noted as signs of levator
disinsertion.

74.  It gives the degree of loss of
Levator action.
 It is measured as the distance
between the center of upper
lid margin to 6o’clock limbus in
extreme upgaze.
 Normally it is 9mm.

75.  Marcus Gunn jaw-winking phenomenon is the most common
form of congenital synkinetic neurogenic ptosis.
 The unilaterally ptotic eyelid elevates with jaw movements
due to cross innervations between oculomotor nerve and
mandibular branch of trigeminal nerve.
 This synkinesis is best demonstrated by having the patient
move the jaw the opposite side.
 The internal pterygoid may be involved, but rarely.

76. Grading of marcus gunn phenomenon:
 Mild- maximum elevation of ptotic eyelid to non-ptotic position.
 Moderate- maximum elevation goes upto superior limbus .
 Severe- maximum elevation beyond the superior limbus with
scleral show.

77.  The eyes moves generally upwards and outwards on eyelid
closure. It is extremely important in assessing post-operative
corneal complications.
 Poor bells phenomenon invariably warrants under correction.
GRADING:
 good= >2/3rd of cornea disappears
 fair= 1/3 – 2/3rd of cornea disappears
 poor= <1/3rd of cornea disappears
VARIANT:
 Inverse- upward & inward
 Reverse- downward & outward
 Preverse- different directions

79.  It is a characteristic sign of myasthenia
gravis. May be seen when the patient
first looks down for a short period and
then look back to primary position.
 The upper eyelid elevates excessively
during this upward movement.
 This is interpreted as transient
improvement in lid strength after rest of
the levator in downgaze, followed by
droop in the primary position as the
levator fatigues.

80.  Excursion of upper eyelid from extreme downgaze to
extreme upgaze is a measure of LPS function, neglecting the
action of frontalis muscle (Berke’s method).
 Grading of levator function:
 >15mm= normal
 >8 mm= good
 5-7 mm= fair
 <4 mm= poor

81.  Used in children.
 Pt upper lid is everted in downgaze. On looking up,
the lid should return to normal position if levator
action is good.

82.  The function of muller’s muscle is
tested by applying drops of 2.5 or
10% phenylephrine to the eye on
the side of blepharoptosis.
 A rise in the MRD1 of 1.5 mm or
greater is considered a positive test.
This indicates that Muller's muscle is
viable. So, operation to resect
muller’s muscle and conjunctiva can
relieve blepharoptosis.

84.  An ice pack is applied to the affected upper eyelid for 5 minutes. A
positive test is the improvement of ptosis by > 2mm or more.
 This transient improvement in ptosis is due to the cold decreasing
the acetylcholinesterase break-down of acetylcholine at the
neuromuscular junction. More acetylcholine collects in the
junction and therefore increases the muscle contraction.

85.  HB reflex: central, eccentric, inward, outward.
 Lid crease: 10mm/8mm
 MRD: mild 2mm, moderate 3mm, severe 4mm.
 Levator palpebral superior action(LPSA): 15mm normal, 8-
12mm good, 5-11mm fair, <4mm poor.
 PFH: 8-10, 7-9mm
 Bell’s phenomenon: good poor.
 Ocular motility: full, restricted.
 MGJWP: +ve, -ve.
 Corneal sensitivity: good, fair.

86. • Treatment of ptosis varies according to the underlying
mechanism.
• Ptosis due to papillary conjunctivitis – resolve by medication
only.
• The surgical technique depends on the disease and its stage,
along with cosmetic concerns.
• Despite the surgical advances, however, in certain cases the
results of surgery may be poor, or considerable side effects
may occur.

87. • Crutch glasses
• Non-surgical option –involves adding an attachment
permanently to the frames
• Wires are fixed to top edges of glass
• Crutches can be fixed on nearly all types of eyeglasses but
work best on metal frames
The adjustable eye crutch:
• attached to one side of the
frame i.e nasal side
• Benefit: it easily adjust the
size
The Reinforced eye crutch
• Attached to both sides of
frame
• More durable
• Can slightly adjust upward
and downward
2 types:

88. • May be considered in difficult ptosis pathologies.
• Practitioner may manipulate the sagittal depth in
order to provide support for the upper eyelid.This
may be effective in many cases in order to achieve the
expected cosmetic result.
• As a high vault is required, such lenses are fitted with
significantly more corneal clearance than the normal
of 100–200 μm.
• Studies have shown that in such cases, oxygen
delivery to the cornea may be reduced, as the saline
which fills the lens bowl acts as a barrier to oxygen
transmissibility.

89. • Another modality utilized for complicated ptosis cases
is the “shelf” scleral lenses.
• In these lenses, a shelf is embedded on the front
surface, acting as support for the upper eyelid.
• Benefits of this modality include the use of regular
vault scleral lenses, and thus oxygen delivery through
saline is expected to be less hampered.
• Thought that the shelf may act as an obstacle, thus
preventing proper eyelid closure during blinking.

90. • Shelves with sharp edges might totally prevent
eyelid closure, thus possibly hampering proper
lubrication of the lens’ front surface, reducing
vision, and producing additional cosmetic concerns.
• Shelves with smooth edges may alleviate this
phenomenon.

92. Frontalis sling
Operation
Levator
advancement
Levator
resection
severe
moderate
Ptosis

93. DISORDER OF LACRIMAL
DRAINAGE SYSTEM

94. Introduction:
The lacrimal drainage
system consists of the
following structures:
 Puncta
 Canaliculi
 Lacrimal sac
 Nasolacrimal duct

95. Epiphora is the overflow of tears at the eyelid margin;
 There are two mechanisms:
 Hypersecretion secondary to anterior segment disease
such as dry eye (‘paradoxical watering’) or inflammation.
 Defective drainage this may be caused by:
 Malposition (e.g. ectropion) of the lacrimal puncta.
 Obstruction at any point along the drainage system, from
the punctal region to the valve of Hasner.
 Lacrimal pump failure, which may occur secondarily to
lower lid laxity or weakness of the orbicularis muscle (e.g.
facial nerve palsy).

96.  History
 External examination
 Fluorescein disappearance test
 Lacrimal irrigation
 Jones dye test
 Contrast dacryocystography
 Nuclear lacrimal scintigraphy
 CT and MRI
 Internal nasal examination

97. History:
 Enquiry should be made about ocular discomfort
and redness to aid in excluding hypersecretion.
 A complaint of the tears overflowing onto
the cheek is likely to indicate drainage failure
rather than hypersecretion.

98. The puncta and eyelids should be examined using a slit lamp.
 Visible mucopurulent discharge is more likely to occur with
nasolacrimal duct obstruction than a blockage more proximally.
 Punctal stenosis is extremely common, and has been reported as
present in up to about half of the general population.
 Ectropion, either localised to the punctal region.
 Punctal obstruction, usually partial, by a fold of redundant
conjunctiva (conjunctivochalasis).
 Occasionally an eyelash may lodge in the ampulla.
 The lacrimal sac should be palpated. Punctal reflux of mucopurulent
material on compression is indicative of a mucocele with a patent
canalicular system.

99.  The fluorescein
disappearance test is
performed by instilling
fluorescein 1 or 2% drops
into both conjunctival
fornices.
 Normally, little or no dye
remains after 5–10 minutes.
Prolonged retention is
indicative of inadequate
lacrimal drainage.

100.  Lacrimal irrigation should be performed only after ascertaining
punctal patency; if absent or severely stenosed, surgical
enlargement of the punctum may be needed before canalicular
and nasolacrimal duct patency can be confirmed.
 It is contraindicated in acute infection.
 If saline passes into the nose and throat, when it will be tasted by
the patient, a patent lacrimal system is present.

101.  Failure of saline to reach the throat is indicative of total
obstruction of the nasolacrimal duct. In this situation, the
lacrimal sac will distend slightly during irrigation and there
will be reflux, usually through both the upper and lower
puncta.
 The regurgitated material may be clear, mucoid or
mucopurulent, depending on the contents of the lacrimal
sac.

102.  A hard stop occurs if the cannula enters the lacrimal sac,
coming to a stop at the medial wall of the sac, through which
can be felt the rigid lacrimal bone.
 This excludes complete obstruction of the canalicular
system.
 A soft stop is experienced if the cannula stops at or proximal
to the junction of the common canaliculus and the lacrimal
sac.
 A spongy feeling is experienced as the cannula presses the
soft tissue of the common canaliculus and the lateral wall
against the medial wall of the sac and the lacrimal bone
behind it.

103. Fig: Hard stop Fig: Soft stop

104.  Dye testing is indicated only in patients with suspected
partial obstruction of the drainage system. Epiphora is
present, but there is no punctal abnormality and the patient
tastes saline in his/her throat on irrigation.
 The primary test differentiates partial obstruction of the
lacrimal passages and lacrimal pump failure from primary
hypersecretion of tears.
 A drop of 2% fluorescein is instilled into the conjunctival sac
of one eye only. After about 5 minutes, a cotton-tipped bud
moistened in local anaesthetic is inserted under the inferior
turbinate at the nasolacrimal duct opening.

105.  Positive: fluorescein recovered from the
nose indicates patency of the drainage
system. Watering is due to primary
hypersecretion and no further tests are
necessary.
 Negative: no dye recovered from the nose
indicates a partial obstruction (site
unknown) or failure of the lacrimal pump
mechanism. In this situation the secondary
dye test is performed immediately. Fig: a) primary b) secondary

106. The secondary (irrigation) test :
The drainage system is then irrigated with a cotton bud under
the inferior turbinate.
 Positive: fluorescein-stained saline recovered from the
nose indicates that fluorescein entered the lacrimal sac,
thus confirming functional patency of the upper lacrimal
passages.
 Negative: unstained saline recovered from the nose
indicates that fluorescein did not enter the lacrimal sac.
This implies upper lacrimal (punctal or canalicular)
dysfunction

107.  Dacryocystography (DCG) involves the injection of
radio-opaque contrast medium (ethiodized oil) into the canaliculi
followed by the capture of magnified images.
 Indications include confirmation of the precise site of lacrimal
drainage obstruction to guide surgery, and the diagnosis of
diverticuli, fistulae and filling defects (e.g. stones, tumours).
 It should not be performed in the presence of acute infection.
 A DCG is unnecessary if the site of obstruction is obvious (e.g.
regurgitating mucocoele).
 A normal dacryocystogram in the presence of subjective and
objective epiphora suggests failure of the lacrimal pump.

108. A)Conventional DCG without
subtraction shows normal filling on
both sides.
B) normal left filling and obstruction at the
junction of the right sac and nasolacrimal
duct.
Fig(C) digital subtraction DCG
showing similar findings to (B)

109.  Scintigraphy assesses tear drainage
under more physiological conditions
than DCG, by labelling the tears
with a radioactive substance and
tracking their progress.
 Although it does not provide the
same detailed anatomical
visualization as DCG, it may be used
to identify the location of a partial or
functional block, to confirm
functional obstruction or sometimes
to confirm the presence of normal
drainage such that surgery is not
indicated.
Fig: Nuclear lacrimal scintigraphy
showing passage of tracer via the
right lacrimal system but obstructed
drainage in the left nasolacrimal
duct.

110.  CT and MRI:
Computed tomography (CT) and magnetic resonance
imaging (MRI) are occasionally employed in the assessment
of lacrimal obstruction, for instance in the investigation of
paranasal sinus or suspected lacrimal sac pathology.
 Internal nasal examination:
Assessment of the nasal cavity, especially with endoscopy,
can be invaluable in the detection of obstructions such as
nasal polyps or a deviated septum.

111. Nasolacrimal duct obstruction:
 The lower end of the nasolacrimal duct, in the region of the valve of Hasner, is
the last portion of the lacrimal drainage system to canalize, with complete
patency most commonly occurring soon after birth. Epiphora affects at least
20% of neonates, but spontaneous resolution occurs in over 95% within the
first year .
Signs
 Epiphora and matting of eyelashes may be constant or intermittent, and may
be particularly noticeable when the child has an upper respiratory tract
infection.
 Gentle pressure over the lacrimal sac may cause mucopurulent reflux.
 Acute dacryocystitis is very rare.
 The fluorescein disappearance test is highly specific in this setting.

112. Differential diagnosis:
Includes other congenital causes of a watering eye, such as punctal atresia; it is
important to exclude congenital glaucoma, chronic conjunctivitis (e.g.
chlamydial), keratitis and uveitis.
Treatment:
 Massage of the lacrimal sac accompanied by cleaning the lids with warm water
and topical antibiotics.
 Probing: Passage of a fine wire via the canalicular system
and nasolacrimal duct to disrupt the obstructive membrane at the valve of
Hasner.
 If symptoms are mild–moderate, probing may be delayed until the age of
12–18 or even 24 months and is carried out under general anaesthesia.
 For more marked symptoms, early probing may be appropriate.

113.  A congenital dacryocoele (amniontocoele)
is a collection of amniotic fluid or mucus in
the lacrimal sac caused by an imperforate
Hasner valve. Presentation is perinatal with
a bluish cystic swelling at or below the
medial canthus accompanied by epiphora.
 Resolution is common with only
conservative treatment, but if this fails,
probing is usually adequate.

114.  Conjunctivochalasis
 Punctal stenosis
 Canalicular obstruction
 NLD obstruction
 dacryolithiasis

115.  Conjunctivochalasis is characterized by
one or more folds of redundant
conjunctiva prolapsing over the lower
eyelid margin.
 It is thought to be predominantly an
involutional process involving the loss of
conjunctival adhesion to underlying
tenon capsule and episclera .
 May be analogous to the conjunctival
abnormalities leading to superior limbic
keratoconjunctivitis.
Fig: Conjunctivochalasis.
Substantial exposed fold with
conjunctival and corneal rose
Bengal staining.

116. Treatment of Conjunctivochalasis :
 Observation or lubricants alone may be appropriate
in mildcases.
 Topical steroids or other anti-inflammatories.
 Surgical options include securing the bulbar
conjunctiva to the sclera with absorbable sutures .

117.  Punctal stenosis is the narrowing or occlusion of the external
opening of the lacrimal canaliculus.
 Primary stenosis occurs in the absence of punctal eversion.
 The most common causes are chronic blepharitis and idiopathic
stenosis; others include herpes simplex and herpes zoster lid
infection, local radiotherapy, cicatrizing conjunctivitis, chronic
topical glaucoma treatment, systemic cytotoxic drugs such as 5-
fluorouracil, and rare systemic conditions such as porphyria
cutanea tarda.
 Treatment :
 Dilatation of the punctum
 Punctoplasty.

118.  Secondary stenosis occurs after punctal eversion
leads to chronic failure of tear entry.
 punctoplasty is usually performed in
conjunction with correction of the eversion.

119.  Causes include congenital, trauma, herpes simplex
infection, drugs and irradiation.
 Chronic dacryocystitis can cause a membrane to
form in the common canaliculus.
 Canalicular obstruction ican be of two types i.e. total
and partial obstruction.

120. Causes:
 Idiopathic stenosis – by far the most common.
 Naso-orbital trauma, including nasal and sinus surgery.
 Granulomatous disease such asWegener granulomatosis
and sarcoidosis.
 Infiltration by nasopharyngeal tumours.
Treatment:
 Conventional dacryocystorhinostomy (DCR).
 Endoscopic DCR
 Other procedures, often reserved for partial nasolacrimal
duct obstruction, include probing and intubation, stent
insertion and balloon dacryocystoplasty.

121.  Dacryoliths (lacrimal stones) may occur in any part of the lacrimal
system.They are more common in males.
 Tear stagnation secondary to inflammatory obstruction may
precipitate stone formation.
 Presentation is often in late adulthood; symptoms may include
intermittent epiphora, recurrent attacks of acute dacryocystitis
and lacrimal sac distension.
 The lacrimal sac is distended and relatively firm, but is not
inflamed and tender as in acute dacryocystitis.
 Mucus reflux on pressure may or may not be present.
 Treatment involves a DCR.

122.  Acute canaliculitis is usually due to herpes simplex infection
and self- limiting.
 Chronic canaliculitis is commonly caused by Actinomyces
israelii, anaerobic Gram-positive bacteria.
 Occasionally scarring and canalicular obstruction with
concretions may result.
 Unilateral epiphora associated with chronic mucopurulent
conjunctivitis, Pericanalicular redness, oedema and
mucopurulent discharge on pressure over the canaliculus .
 A ‘pouting’ punctum may be a diagnostic clue in mild cases.

123. Treatment:
 A topical antibiotic such as a
fluoroquinolone q.i.d for 10 days may
be tried initially but is rarely curative
unless combined with canaliculotomy (a
linear incision into the conjunctival side
of the canaliculus) and curettage of
concretions. Fig: Chronic canaliculitis

124.  Infection of the lacrimal sac is usually secondary to
obstruction of the nasolacrimal duct.
 It may be acute or chronic and is most
commonly staphylococcal or streptococcal.

125.  Presentation is with the
subacute onset of pain in
the medial canthal area,
associated with epiphora.
 A very tender, tense red
swelling develops at the
medial canthus ,commonly
progressing to abscess
there may be associated
preseptal cellulitis.
Fig: Acute dacryocystitis
Fig: lacrimal abscess and preseptal cellulitis

126. Treatment:
 Initial treatment involves the application of warm
compresses and oral antibiotics such as flucloxacillin or
co-amoxiclav; irrigation and probing should not be
performed.
 Incision and drainage may be considered if pus points and
an abscess is about to drain spontaneously. However, this
carries the risk of a persistent sac–skin fistula.
 Dacryocystorhinostomy is commonly required after the
acute infection has been controlled, and may reduce the
risk of recurrent infection.

127.  Presentation is with chronic epiphora, which may be associated with
a chronic or recurrent unilateral conjunctivitis.
 A mucocoele is usually evident as a painless swelling at the inner
canthus, but if an obvious swelling is absent pressure over the sac
commonly still results in mucopurulent canalicular reflux .
 Treatment is with a dacryocystorhinostomy.