3. EPIPHORA
• Epiphora is defined as the sign of overflow of tears,
and may be caused by the following:
• Hypersecretion secondary to ocular inflammation or
surface disease.
• Defective drainage due to compromise of the
lacrimal drainage system.
• It may be caused by:
• Malposition of the lacrimal puncta (e.g. secondary to
ectropion).
4. • Obstruction along the lacrimal drainage system, from
the puncta to the nasolacrimal duct.
• Lacrimal pump failure, which may occur secondarily
to lower lid laxity or weakness of the orbicularis
muscle (e.g. facial nerve palsy).
5. EVALUATION
• External examination
• The puncta and eyelids are best examined on the
slit-lamp for evidence of the following conditions:
– Punctal stenosis
– Ectropion causing malposition of the punctum
– Punctal obstruction by an eyelash
– A large caruncle displacing the punctum away from the
globe
6. • A pouting punctum is typical of canaliculitis
• Centurion syndrome is characterized by anterior
malposition of the medial part of the lid
• The lacrimal sac:
• This should be palpated
• Punctal reflux of mucopurulent material on lacrimal
compression .
• In acute dacryocystitis palpation is severely painful
and compression should be avoided.
7. • Fluorescein disappearance test
• The marginal tear strip of both eyes should be
examined on the slit-lamp prior to any manipulation
of the eyelids or instillation of topical medication.
• Many patients with watering do not have obvious
overflow of tears onto the face but merely show a
high marginal tear strip on the affected side.
• Normally, little or no dye remains after 5 minutes.
• Prolonged retention is indicative of inadequate
lacrimal drainage and can be graded from 1-4.
8.
9. • Probing and irrigation:
• Probing and irrigation are performed only after
ascertaining punctal patency
– Local anaesthetic is instilled into the conjunctival sac
– The lower punctum is dilated
– A gently curved, blunt-tipped 26-gauge lacrimal cannula on
a 2 mL saline-filled syringe is inserted into the lower
punctum.
– If irrigation confirms lacrimal obstruction an attempt can
be made to pass the tip of the cannula into the lacrimal sac
10. • Acquired obstruction
• Primary punctal stenosis
• Primary stenosis occurs in the absence of punctal
eversion.
– Associated with chronic blepharitis
– Idiopathic primary stenosis
– Herpes simplex and herpes zoster lid infection
– Following irradiation of malignant lid tumours
– Cicatrizing conjunctivitis and trachoma
– Systemic cytotoxic drugs such as 5-fluorouracil and docetaxel
11. • Secondary punctal stenosis
• Is caused by punctal eversion
• Treatment
– Ziegler cautery
– Medial conjunctivoplasty
– Lower lid tightening
12. • Canalicular obstruction
• causes
– Congenital
– trauma,
– herpes simplex infection,
– drugs and irradiation.
– Chronic dacryocystitis can cause a thin membrane to form
at the common canaliculus.
13. • Treatment depends on the site and the severity of
obstruction
• Partial obstruction of the common or individual
canaliculi
• Total individual canalicular obstruction, with 6–
8 mm of patent normal canaliculus between the
punctum and the obstruction, is treated by
anastomosis of the patent part of the canaliculus into
the lacrimal sac (canaliculodacryocystorhinostomy –
CDCR)
14. NASOLACRIMAL DUCT OBSTRUCTION
• Causes
• Idiopathic stenosis is by far the most common
• Naso-orbital trauma and previous nasal and sinus
surgery
• Infiltration by nasopharyngeal tumours.
• Treatment is with DCR; other techniques include
intubation, stent insertion and balloon dilatation.
15. CONGENITAL OBSTRUCTION: (NASOLACRIMAL
DUCT OBSTRUCTION)
• It is better termed delayed canalization since it often
resolves spontaneously.
• The lower end of the nasolacrimal duct ;at the valve
of Hasner is the last portion of the lacrimal drainage
system to canalize
• Complete patency usually occurring soon after birth.
• Epiphora affects approximately 20% of neonates, but
spontaneous resolution occurs in 96% of cases within
the first 12 months.
16. Congenital nasolacrimal duct obstruction
• Caused by delayed canalization near valve of Hasner
• On pressure reflux of purulent material from punctum
Infrequently acute dacryocystitis
Epiphora and matting
18. • Clinical features:
• Epiphora and matting of lashes may be constant or
intermittent, occurring particularly when the child
has a cold or upper respiratory tract infection.
• Gentle pressure over the lacrimal sac causes reflux of
purulent material from the puncta
• Acute dacryocystitis is uncommon.
19. • Treatment
– Massage, ten strokes four times daily of the
lacrimal sac
– Probing, not before the age of 12 months
– Dacryocystorhinostomy (DCR) between 3 and 4
years of age
• Topical antibiotics to manage infection
20. Treatment of congenital nasolacrimal
duct obstruction
• Massage of nasolacrimal duct and antibiotic drops 4 times daily
• Improvement by age 12 months in 95% of cases
• If no improvement - probe at 12-18 months
• Results - 90% cure by first probing and 6% by second
21. Dacryocystitis
• Infection of the lacrimal sac is usually
secondary to obstruction of the nasolacrimal
duct.
• It may be acute or chronic
• Treatment is with dacryocystorhinostomy
