Disease of the lacrimal apparatus Dr. Md. Almas Hossain Associate Professor & Head Department of Ophthalmology Sylhet MAG Osmani Medical College.

1. Almas Eye Care
& Phaco Centre
Dr. Md. Almas Hossain
Associate Professor & Head
Department of Ophthalmology
Sylhet MAG Osmani Medical College.
Diseases Of The Lacrimal
Apparatus

2. Diseases Of The Lacrimal Gland
Dacryoadenitis
Definition
Inflammation of lacrimal gland. Usually developed as primary
inflammation of the gland or secondary to some local infection.
Clinical feature:
Inflammation of palpebral part, painful swelling in lateral part of
upper lid, typical S- shaped curve of lid.
Types:
Acute- Most common, unilateral & mostly viral Cause.
Chronic- Usually bilateral, due to non infectious inflammatory
disorders e.g- thyroid eye disease, orbital pseudotumour etc.

4. Treatment Of Acute Dacryoadenitis
Treatment varies by etiology as follows:
Viral (most common) -Usually self-limiting, supportive
measures e.g- warm compresses.
Oral nonsteroidal anti-inflammatories.
Bacterial - Initiate with broad-spectrum antibiotics e.g-
cephalosporins.

5. Treatment Of Chronic Dacryoadenitis
The treatment measures for Chronic Dacryoadenitis may include:
Treating the underlying conditions is important. The treatment
is usually given to control the degree of inflammation.
Steroid therapy for autoimmune disorders.
Treatment of symptoms: Analgesics for pain, antipyretics for
fever, etc.
Surgical excision and removal of any tumor, if it is the cause of
Dacryoadenitis.

6. Diseases Of The Lacrimal Gland cont.
Lacrimal Gland Tumors
Introduction
Lacrimal gland tumors are rare.
Representing only 5-18% of orbital space occupying
lesions.
Incidence- 1/million/year.
More prevalent in elderly.

7. Classification Of Lacrimal Tumor

8. Clinical Features Of Lacrimal Gland Tumor
Depends on types & nature of tumors.
A mass in the lacrimal gland area causing
inferonasal dystopia.
Peribulbar congestion.
Proptosis.
Periorbital oedema.
Ophthalmoplegia.

9. Investigations Of Lacrimal Gland Tumor
 CT scan :
• Globular lesion with irregular serrated edges.
• Often with contiguous erosion or invasion of bone.
• Calcification commonly seen.
 Biopsy & histopathology
 Neurological assessment (mandatory).
• Adenoid cystic carcinoma exhibits perineural spread and may
extend into the cavernous sinus.

10. Treatment Of Lacrimal Gland Tumor
Depends on types & nature of the tumors.
If benign & asymptomatic- Observation or excision
For malignant tumors
• Orbital exenteration
• Midfacial resection
Radiotherapy in combination to surgery
• May prolong life & reduce pain
• Adjuvant intra-arterial chemotherapy and/or brachytherapy
may also be considered.

11. Disease Of Lacrimal Puncta
Primary Punctal Stenosis.
Cause:
 Idiopathic primary stenosis (most common).
 Herpes simplex lid infection.
 Following irradiation of malignant lid tumors.
 Cicatrizing conjunctivitis & trachoma.
 Systemic cytotoxic drugs.
Punctal agenesis.

12. Treatment Of Lacrimal Punctal Stenosis
Punctum dilatation with Nettleship dilator.
If failed- then surgical procedure
One-snip procedure.
Two-snip procedure.
Laser punctoplasty with Argon laser.
Insertion of punctal plug.

13. Punctum Dilatation

14. Secondary Punctal Stenosis
This occurs secondary to punctal eversion .
Treatment- surgical procedure-
Ziglar cautery burns- Applied to the palpebral
conjunctiva, 5mm below the puncta.
Medial conjunctivoplasty.

15. Secondary Punctal Stenosis

16. Canaliculitis
Inflammation of the canaliculus.
May be acute or chronic & it is uncommon.
Frequently caused by actinomyces (Gm. +ve bacteria).
Presentation: Epiphora associate with chr. mucopurulent
conjunctivitis.
Sign:
• Oedema of the canaliculus.
Treatment:
• Systemic & Topical antibiotics.
• Canaliculotomy.

17. Congenital Anomalies Of Lacrimal Passage
Congenital nasolacrimal duct (NLD) obstruction.
Delayed canalization.
NLD obstruction occurs in 20% of newborns.
Can be bilateral.
Reflux of purulent material from punctum.

18. Cong. Nasolacrimal Duct (NLD) Obstruction cont.
 Better termed- delayed canalization of the NLD, as
it is resolved spontaneously.
 20% of the children manifest evidence of NLD in
the first year of life.
Sign:
• Epiphora & matting of lashes.
• Pressure of the lacrimal sac causes reflux of the
purulent discharge from the puncta.

19. Treatment Of Cong. NLD Obstruction
Massage- Gentle massage over the lacrimal sac area- 10 stocks
should be applied 3 to 4 times a day.
Antibiotic (Moxifloxacin) eye drop- 1 drop 4 times a day.
Success rate- 90-95% in the first year of life.
If failed- probing of the lacrimal system under G/A within the
first 2 years of life.
Result- 90% of children are cured by the first probing.
If failed- after repeated probing- DCR operation at the age of
4-5 years.

20. Diseases Of The Lacrimal Sac
Dacryocystitis
 Inflammation of lacrimal sac.
 Often caused by obstruction of naso-lacrimal duct.
 Followed by bacterial infection.

21. Types Of Dacryocystitis
 Acquired
• Chronic.
• Acute on chronic.
 Congenital

22. Causes Of Dacryocystitis
Narrowness or chronic inflammation of sac.
Nasal polyps.
Following primary conjunctivitis.
Infection spreading from nasopharynx.
Organisms responsible : Pneumococcus, streptococcus,
staphylococcus, mycobacterium, etc.

23. Chronic Dacryocystitis
Risk Factors:
 Postmenopausal women – spontaneous or following lacrimal
sac infection.
 Infants – due to failure of NLD to open into inferior meatus.
Signs Symptoms:
 Watering.
 Mucopurulent discharge.
 Regurgitation of pus through puncta on pressure over the sac
area.
Sac patency test (SPT): Blocked.

24. Chronic Dacryocystitis

25. Complications Of Chronic Dacryocystitis
• Chronic intractable conjunctivitis.
• Lacrimal abscess.
• Orbital cellulitis.
• Osteomyelitis.
• Ectropion of lower lid.
• Eczema of lower lid skin.
• Corneal abrasion- Corneal ulcer.
• Operative complications – endophthalmitis.

26. Acute Dacryocystitis
Acute Dacryocystitis is an acute suppurative inflammation
of the lacrimal sac.
Characterized by the presence of painful swelling in the
lacrimal sac area.

27. Etiology Of Acute Dacryocystitis
It may be developed in two ways.
As an acute exacerbation of chronic dacryocystitis.
As an acute peridacryocystitis due to direct involvement from
the neighboring infected structures such as paranasal sinuses,
surrounding bones, dental abscess or caries teeth in the upper
jaw.
More common between 40-60 years.
Female are more sufferer.
Causative organisms- streptococcus, pneumococcus,
staphylococcus.

28. Presentation Of Acute Dacryocystitis
It can be divided into 3 stages
Stage of cellulitis- painful, red, firm & tender swelling.
Stage of lacrimal abscess- sac is filled with pus &
distended.
Stage of fistula formation- when the lacrimal abscess is
left unattended it discharges spontaneously leaving an
external fistula.

29. Complications Of Acute Dacryocystitis
• Acute conjunctivitis.
• Lid abscess.
• Osteomyelitis of lacrimal bone.
• Orbital cellulitis.
• Facial cellulitis and acute ethmoiditis.
• Corneal abrasion which may be converted to corneal
ulceration.

30. Treatment Of Acute Dacryocystitis
Systemic broad-spectrum antibiotics- e.g- Cephalosporin for
7 days.
Anti inflammatory drugs.
 Antibiotic eye drops.
 Hot compression.
 If abscess- drainage of the abscess.
After controlling the acute infection (after 3 weeks)- DCR
operation.
 If fistula- fistulectomy.

31. Investigations For DCR
• Blood CP.
• FBS/RBS.
• BT, CT.
• ECG.
• X-ray of PNS.
• G/A fitness if necessary.

32. Treatment Of Chronic Dacryocystitis
 Conservative treatment – repeated lacrimal syringing.
 Balloon catheter dilation.
 Dacryocystorhinostomy (DCR) with or without
intubation under L/A or G/A.
 Dacryocystectomy (DCT) – only when DCR is
contraindicated (suspected lacrimal sac neoplasm,
diverticulae, stones etc).

33. Types Of DCR Operation
External/Conventional DCR under L/A or G/A (Success rate-
almost 95%).
Endoscopic DCR- performed within the nasal cavity under
L/A or G/A (Success rate- about 85%).
Endolaser DCR- performed with a holmium YAG laser
under L/A (Success rate- 70%).
Lester Jones tube- when absence of canicular function
or lacrimal pump failure.
Balloon dacryocystoplasty- in partial NLD obstruction.

34. Prognosis Of DCR Surgery
 Prognosis after proper DCR surgery is
excellent.
 Success rate up to 90-95%.
 If failed re-DCR with intubation.

35. Mucocele Of The Lacrimal Sac
A swelling of the lacrimal sac that is due to
distension of the cavity with accumulated mucus
secretion.
As a result of infection, allergy, trauma & tumor.
Clinical features- Epiphora, eyelid or periorbital
swelling, proptosis but rarely pain unless there is an
infection.
Management- removal of the mucocele.