epiphora watering hyper lacrimation

1. EPIPHORA
EVALUATION
SIVA TEJA CHALLA

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. CAUSES

4. • Anatomical  complete or partial punctal
canalicular or NLD obstruction
• Functional  Lacrimal pump failure due to
Anatomical deformity (Laxity, orbicularis weakness)

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. Punctal Causes
Congenital agenesis/imperforate
Acquired :
• OcclusioN
• Infection/radiation
• Systemic: phemphigoid,SJS,Burns
• Tumors
Mal position
• Medial displacement
• Medial ectropion

7. Canalicular
• Congenital absence/fistula
• Acquired
Intrinsic
• Canaliculitis
• Trauma/ Post radiation Trauma/ Post radiation
• Tumours
Extrinsic
• Compression by adjacent tumours

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. 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. 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. 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. CLINICAL EVALUATION
OF A PATIENT WITH
EPIPHORA

13. • Careful history
• External examination
• Slit lamp biomicroscopy
• Syringing and probing
• Imaging

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. EXTERNAL EXAMINATION
The eyelids : malpositions, entropion, ectropion,or
lid laxity
The puncta : malpositions, stenosis, agenesis,atresia
or accessory puncta.

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. Nasal Examination
• Anatomic Abnormalities
• Hypertrophied turbinates
• Nasal polyps
• Deviated septum
• Atrophic rhinitis

18. DIAGNOSTIC TESTS

19. Anatomical tests
These tests helps in localization of
obstruction
● Syringing / irrigation
● Diagnostic probing
● Dacryocystography
● CT/MRI

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. 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. Fluorescein dye disappearance test

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. 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.

26. 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.

29. 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

30. • 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

32. 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

33. Complete canalicular obstruction. The cannula is advanced with difficulty,
and irrigation fluid refluxes from the same canaliculus

34. 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

35. 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.

36. Partial nasolacrimal duct obstruction. The cannula is easily placed, and
irrigation fluid passes into the nose as well as refluxing through the opposite
punctum.

37. Patent la crimal drainage system. The cannula is placed with ease, and
most of the irrigation fluid passes into the nose .

38. IMAGING TECHNIQUES

39. 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.

41. 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.

43. 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

44. 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.

45. Epiphora in children

46. 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

49. WATERING IN ADULTS

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