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Epiphora

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epiphora watering hyper lacrimation

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Epiphora

  1. 1. EPIPHORA EVALUATION SIVA TEJA CHALLA
  2. 2. • Epiphora implies overflowing of tears due to impairment lacrimal drainage. • due to a disruption in the balance between tear production and tear loss.
  3. 3. CAUSES
  4. 4. • Anatomical  complete or partial punctal canalicular or NLD obstruction • Functional  Lacrimal pump failure due to Anatomical deformity (Laxity, orbicularis weakness)
  5. 5. Eyelids • Horizontal laxity and floppy lids • Lower lid entropion with orb.oculi overriding • Lower lid ectropion with ineffective orb.oculi • Loss of skin / orbicularis
  6. 6. Punctal Causes Congenital agenesis/imperforate Acquired : • OcclusioN • Infection/radiation • Systemic: phemphigoid,SJS,Burns • Tumors Mal position • Medial displacement • Medial ectropion
  7. 7. Canalicular • Congenital absence/fistula • Acquired Intrinsic • Canaliculitis • Trauma/ Post radiation Trauma/ Post radiation • Tumours Extrinsic • Compression by adjacent tumours
  8. 8. Lacrimal Sac Abnormality o Sac inflammation o Perilacrimal fibrosis o Dacryolith o Sac tumors (rare in pediatric age group) o Adnexal tumors pressing on lacrimal sac or drainage pathway
  9. 9. NASOLACRIMAL DUCT OCCLUSION Congenital: • NLD obstruction • Delayed opening of Hasner’s valve, • Cranio facial anomalies • Agenesis. Acquired: • Primary obstruction • Secondary obstruction: tumour, trauma NASAL CONDITIONS o Severe Deviated Nasal Septum or Turbinate Hypertrophy
  10. 10. Excessive tears production Reflex lacrimation in response to various factors Trichiatic cilia severe entropion, raised IOP  allergic conjunctivitis, corneal exposure,  drug irritation  environmental irritants like pollution
  11. 11. OTHERS • Ocular surface disorders like chronic KCS, conjunctivochalasis, cicatricial ocular surface pemphigoid, symblephron. • Neurogenic hypersecretory disorders like compressive irritation of parasympathetic lacrimal fibres, Aberrant regeneration of facial nerve following trauma. • Facial palsy
  12. 12. CLINICAL EVALUATION OF A PATIENT WITH EPIPHORA
  13. 13. • Careful history • External examination • Slit lamp biomicroscopy • Syringing and probing • Imaging
  14. 14. HISTORY • constant versus intermittent tearing • periods of remission versus no remission • unilateral or bilateral condition • subjective ocular surface discomfort • history of allergies • use of topical medications • history of probing during childhood • prior ocular surface infections • prior sinus disease or surgery, midfacial trauma, or nasal fracture • previous episodes of lacrimal sac inflammation • clear tears versus tears with discharge or blood
  15. 15. EXTERNAL EXAMINATION The eyelids : malpositions, entropion, ectropion,or lid laxity The puncta : malpositions, stenosis, agenesis,atresia or accessory puncta.
  16. 16. SLIT LAMP BIOMICROSCOPY: • abnormalities of eyelids, • position of punctas,size and patency,discharge, • size of caruncle, • eyelid laxity, blinking mechanism, • marginal tear strip, • Tearfilm debris, • papillae or follicles • pinguecula,pterygium, conjunctival chelosis. • Ocular cicatricial pemphigoid.
  17. 17. Nasal Examination • Anatomic Abnormalities • Hypertrophied turbinates • Nasal polyps • Deviated septum • Atrophic rhinitis
  18. 18. DIAGNOSTIC TESTS
  19. 19. Anatomical tests These tests helps in localization of obstruction ● Syringing / irrigation ● Diagnostic probing ● Dacryocystography ● CT/MRI
  20. 20. Functional tests ● To access functioning of lacrimal apparatus under physiologic conditions ● Performed only when there is no evidence of obstruction in anatomical tests  Flourescein dye disappearance test  Scintigraphy  Jones dye test I
  21. 21. DYE DISAPPERANCE TEST • heavily relied upon in children, in whom lacrimal irrigation is impossible without deep sedation • Instillation of fluorescein drops 2% into the conjunctiva of both eyes then examine after 5 minutes . • Normally, very little or no dye present • significant residual dye or prolonged retention is an indication of inadequate drainage of the dye
  22. 22. Fluorescein dye disappearance test
  23. 23. 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 normal
  24. 24. JONES DYE TESTING Jones I test, or primary dye test: • Differentiates partial obstruction from hypersecretion of tears. • Fluorescein 2% drops instilled into the conjunctiva. • After about 5 minutes, cotton tipped applicator inserted under the inferior turbinate. • Positive: Detection of fluorescein from the nose means patency of the system. • Negative: No dye detected, means either a partial or absolute obstruction or failure of the lacrimal pump.
  25. 25. Jones II test, or secondary dye test: • the residual fluoresce in is flushed from the conjunctival sac following an negative jones 1 test. • clear saline is placed in to the inferior canaliculus using syringe/cannula • irrigant is retreived from nasal cavity • Positive: Recovery of dye stained saline from the nose meaning a partial obstruction of the NLD. • Negative: Recovery of unstained saline through the nose means total obstruction of the upper drainage system or a defective lacrimal pump mechanism.
  26. 26. Probing • After topical anaesthesia, curved lacrimal cannula on a saline filled syringe is gently inserted into lower punctum & advanced • Canula comes to either hard or soft stop
  27. 27. • Hard stop:it comes to stop at medial wall of sac through which rigid lacrimal bone is felt…this indicates obstruction of nasolacrimal duct • Soft stop:it comes to stop at junction of common canaliculus & lacrimal sac(lateral wall)…. it indicates common canalicular block
  28. 28. Lacrimal Sac Syringing • most frequently performed immediately after a DDT to determine the level of lacrimal drainage system occlusion • After instillation of topical anesthesia, the lower eyelid punctum is dilated • The irrigating cannula is placed in the canalicular system. • To prevent canalicular kinking and difficulty in advancing the irrigating cannula ,lateral traction of the lower eye lid • clear saline is injected and the results noted
  29. 29. Complete canalicular obstruction. The cannula is advanced with difficulty, and irrigation fluid refluxes from the same canaliculus
  30. 30. Complete common canalicular obstruction. A "soft stop" is encountered at the level of the lacrimal sac, and irrigated fluid ref luxes through the opposite punctum. Soft stop is a spongy feeling due to canalicular obstruction
  31. 31. Complete nasolacrimal duct obstruction. The cannula is easily advanced to the medial wall of the lacrimal sac, then a "hard stop" is felt, and irrigation fluid ref luxes through the opposite punctum. If the probe touches the medial orbital wall, this means Hard Stop.
  32. 32. Partial nasolacrimal duct obstruction. The cannula is easily placed, and irrigation fluid passes into the nose as well as refluxing through the opposite punctum.
  33. 33. Patent la crimal drainage system. The cannula is placed with ease, and most of the irrigation fluid passes into the nose .
  34. 34. IMAGING TECHNIQUES
  35. 35. Contrast Dacryocystography (DCG) • Technique: Plastic catheters are placed into one canaliculus in both eyes, 1ml lipidol is simultaneously injected through both catheters • Water's view radiographs are taken, 5 minutes later, an erect oblique film is taken. • Results: The site of obstruction is usually evident. Diverticula, filling defects due to stones and strictures can be diagnosed.
  36. 36. Lacrimal scintillography • Scintillography is used to assess the lacrimal drainage system under physiological conditions. • Technique: Tchnetium-99 is delivered by a micropipette to the inferior conjunctival sac. The tracer is imaged using a gamma camera.
  37. 37. CT/MRI ● Epiphora foll. Trauma with NLD obst. R/o orb. Rim/ max. # ● Infant with cystic mass at med. Can. Amniocele v/s meningocele ● Suspected malignancy
  38. 38. Lacrimal Endoscopy • 1.0 mm diameter rigid endoscope or fibroptic flexible endoscopes was inserted through the puncti and canaliculi to inspect the lining mucosa of lacrimal system, its contents and investigating DCR fistulae.
  39. 39. Epiphora in children
  40. 40. CAUSES Eye lid problems • Blepharitis • Distichiasis • Poor lid closure • entropion Surface abnormalities • Conjunctivitis • Corneal abrasioN • Foreign body • keratitis Lacrimal outflow abnormalities Punctal agenesis/stenosis  congenital dacryocele Canalicular obstruction  nasolacrimal duct obstruction
  41. 41. WATERING IN ADULTS
  42. 42. THANK YOU

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