The document discusses the anatomy, histology, nerve supply, and functions of the lacrimal gland and drainage system. It describes the secretory and drainage components, including the lacrimal gland, puncta, canaliculi, lacrimal sac, and nasolacrimal duct. Symptoms and causes of various lacrimal diseases are outlined, along with examination and testing methods. Specific conditions like dacryoadenitis, epiphora, dry eye, and dacryocystitis are also reviewed.

1. Dr. Mohd Najmussadiq khan
M S (Ophth)
diSSO (ESASO)
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2. The lacrimal gland and lacrimal
drainage system
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4. Anatomy and histology
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5.  secretory system : a- Lacrimal gland
b- accessory Lacrimal glands.
 collecting[ drainage ] system: a- puncti (2).
b- conalculi (2).
c- Lacrimal sac (1).
d- nasolacrimal duct(1)
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6.  Lacrimal gland is a tear secreting gland located in the
anterior superior temporal (lateral ) portion of the
orbit .Lymphatics drain into preauricular lymph node
Lacrimal gland is formed of 2 parts:-
 orbital part is normally not felt .
 palpebral part is seen if person looks down and with
elevating upper lid.
 The secretory fibers to the lacrimal gland are derived
from the greater petrosal nerve (of the facial nerve) by
way of the nerve of the pterygoid canal.
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7.  A lacrimal canaliculis is present in each lid. The two
canaliculi open into the lacrimal sac, which is
continuous with the nasolacrimal duct.
 The sac, lodged in a fossa at the medial margin of the
orbit, is partly covered by the medial palpebral
ligament .
 The nasolacrimal duct extends from the lacrimal sac to
the inferior meatus of the nasal cavity.
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8. nerve supply of Lacrimal gland
1- sensory --trigeminal nerve .
2- parasympathetic --facial nerve
3- sympathetic--cervical sympathetic
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9. Tears
 Tears is a mixture of secretions from Lacrimal , accessory ,
Lacrimal gland , Meibomian gland , goblet cells .Tear form
a thin layer which covers corneal and conjunctival
epithelium ( preocular tear film ).
 Circulation of tears-produced by lacrimal and accessory
lacrimal glands then along the surface of the eye ball to
lower fornix.About 70% drained through lower punctum
and 30% through upper punctum.in the end from lacrimal
sac into the inferior metus of the nose by lacrimal pump
and gravity(by contraction of orbicularis oculi,specially its
Horner fibres around the sac).
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10. Composition of tears
 water(98.2%),proteins(0.6%),
 albumin , globulins (IgA , IgE ,IgG), lysozyme ,
betalysin , glucose , urea ,(K Na Cl ) in higher than
plasma concentration .
 pH about 7.35 but alkaline in spring catarrh
 osmotic pressure 1.4% of saline(blood 0.9% of saline)
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11. Tear distribution
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12. pre corneal tear film & functions
 outer lipid layer secreted by meibomian,zeis,moll
glands.It decreases evaporation and lubricates the eye
lids
 middle aqueous layer secreted by lacrimal and
accessory lacrimal glands.It has antibacterial
activity,wash away debris,supplies oxygen to corneal
epithelium
 inner mucin layer secreted by conjunctival goblet
cells,gland of manz and crypts of henle.It converts
hydrophobic corneal epithelium to hydrophilic
surface.
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13. Symptom of Lacrimal diseases
 Excess tearing (epiphora , lacremation ).
 Swelling painful or painless .
 Deficiency of tears lead to dry eye ---- keratinization
( keratitis sicca)of cornea and conjunctiva --- loss of
vision
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14. Acute dacroadenitis
 a rare catarrhal inflammation of Lacrimal gland .
 Cause associated with systemic diseases like mumps ,
measles , influenza , infectious mononucleosis and in
adult gonorrhea .Sometimes secondary to
inflammation from adjacent area.
 Clinically
 pain and discomfort in upper outer portion of the orbit .
 Swelling and redness of Lacrimal gland.
 S shape curve of lid margin.
 Ptosis of upper lid and eyeball downward + nasally
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15. Dacryoadenitis
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16. Dacryoadenitis
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17. Treatment
 Systemic and topical antibiotics
 Systemic analgesics with antacids
 hot compresses 3-4 times / day
 surgery Incision and Drainage (I & D).
 Its self limiting but treatment is to prevent spread
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18. Chronic dacroadenitis
 a proliferative inflammation of Lacrimal gland .
 Cause usually associated with granulomatus diseases
as sarcoidosis , T.B , post-traumatic granuloma
 clinically painless , enlargement of Lacrimal gland .
 N.B sarcoidosis may not cause Lacrimal gland
enlargement .
 Mikulicz syndrome is chronic bilateral enlargement of
Lacrimal and salivary glands .It occur in leukemia and
lymphoma .
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19. Lacrimation (overproduction of
tears)
 Psychic stimulation .
 Parasympathetic stimulation like cholinergic drugs
and parasympathomimetic
 Lacrimal gland inflammation and tumor .
 Trigeminal irritation
a- lesion of lids , cornea , conjunctiva .
b- glaucoma .
 retinal stimulation by excess light
 facial nerve--misdirection regeneration after paralysis
& inflammation and tumor of sphenopalatine
ganglion .
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20. Epiphora (tearing due to defective
drainage system)
 abnormalities of puncta occlusion , absence ,
ectropion
 Lacrimal obstruction :-
 canalculi ---- inflammation .
 Lacrimal sac and duct ---- inflammation and
tumours .
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21. Punctal Ectropion & Punctal
Stenosis Due To Mild Eversion
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22. Dry eye( keratoconjunctivitis sicca
) KCS
conjunctival cicatrisation with loss of goblet cell and
accessory Lacrimal glands in
 trachoma , burns , erythema multiformi .
 Sjogren syndrome .
 paralysis of facial or trigeminal nerves.
 absence of Lacrimal gland.
 toxic e.g.. Atropine , debilitating diseases .
 injury to Lacrimal gland by surgery , burn , trauma.
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23. Clinical examination of Lacrimal
apparatus
 Lacrimal gland-orbital part is normally not felt &the
Palpebral part is seen when patient looks down and in with
elevation of upper lid .
Lacrimal drainage system :
Inspection :
 a-puncti – presence , shape , stenosed position ( seen on lid
eversion ).
 b-Swelling of Lacrimal sac area .
 c-Signs of inflammation .
palpation :
 tenderness over Lacrimal sac
swelling over Lacrimal sac if soft cystic ---- mucocele.
 if soft with positive regurgitation of pressure ---- chronic
dacrocystitis.
 If hard ---- tumor .
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24. Tests for measuring quantity of
tears
 In these tests we introduce filter paper strips ( width =
0.5 cm , length = 3.5 cm ) in the conjunctival sac then
measure the extent of wetting ( strips ).
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25.  Shimmer I tests :-Normally – 10-25 mm from point of
entry after 5 min.It is done without anaesthesia and
measures total secretion both basic and reflex
secretion(less than 4 mm dry eye)
 Basic secretion test :-Do schirmer I test with
anesthetizing cornea and conjunctiva normally 10-15 mm
after 5 min.If measures the function of accessory Lacrimal
glands(basic secretion only).
 Schirmer II test :-Do basic secretion test with ipsilateral
nasal irritation using cotton swab .This measure reflex and
basic secretion .If less the 15 mm in 2 min --- failure of
reflex secretion .
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26. Test for Lacrimal passages
a)Fluorescein tests--Procedure instillation of
fluorescein solution 2% in conjunctival sac if normally
disappear in 1min.
 If fluorescin is demonstrated in the nose or pharynx --
- Lacrimal passage are patent (JONES TEST I ).
 If fluorescin is not demonstrated in nose of pharynx
the residual fluorescin is irrigated with saline solution
--- if fluorescin reached nose of pharynx --- fluorescin
reached Lacrimal sac and obstruction is in
nasolacrimal duct (JONES TEST II ).
 IF FLUORESCEIN is not demonstrated in nose and
pharynx by irrigation ---- mostly block in canaliculi
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27.  b)Dacryocystography( D.C.G )AFTER INJECTING
radio-opaque substance in Lacrimal sac.
 c)Saccharine test :-Sodium saccharide 10% locally in
conj. Sac (patent lac. Passage –sweet taste ).
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28. Laboratory tests—
 Tear lysozyme assay—reduced in KCS
 Tear osmolality—normal upper limit is 311 mOsm/lit.
 Flrescein dilution test
 Tear mucin measurement
 Goblet cell count of the conjunctiva—maximum
inferonasally(8-15/sq mm)
 Conjunctival impression cytology
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29. Treatment for dry eye—
 Preservation of the existing tears—decrease room
temperature,humidifier,lid taping,tarsorrhaphy,punctual
occlusion(temporary or permanent)
 Supplementation of tears—(e.d.,ointment,ocuserts)
methyl cellulose,
polyvinyl alcohol,
sodiumhyaluronate
 tears stimulation by bromhexine and eledosin
 soft bandage contact lens
 parotid duct transplantation
 corneal transplantation & keratoprosthesis
 treatment of associated prolems
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30. Dacrocystitis
 acute or chronic inflammation of sac after obstruction of
nasolacrimal duct –
aetiology
 infants(congenital type)
 person over 40 years but more in post menopausal women .
 more common on left side
 low socio-economic condition
 nasolacrimal duct block,chronic inflammation of the sac
 DNS,hypertrophy of inferior turbinate,nasal polyp
 After primary conjunctivitis & nasopharynx infection
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31. Cause :-
 Pneumococcus(commonest)
 Staphylococci
 Streptococci
 Mycobacterium
 Chlamydia
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32. Acute dacrocystitis
 it is suppurative inflammation of Lacrimal sac with
cellulitis of overlying tissue .
Clinically :-
 red painful swelling of inner cantus and painful
swelling of tissue overlying Lacrimal sac with enlarged
sub mandibular lymph nodes.
 Fever & malaise may be present.
 Some times abscess may form leading to lacrimal
fistula.
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35. Treatment
 hot compresses 3-4 times/day
 broad spectrum systemic and topical antibiotics
 systemic analgesics with antacids
 if lacrimal abscess then incision and drainage .
 when every thing normal then DCR or DCT operation
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36. Chronic dacrocystitis
 in post menopausal women due to atresia of NLD or
weakness of orbicularis
 obstruction of Lacrimal sac either spontaneously
of after injury of nasal disease.
 in long standing cases thinning of the lacrimal sac
leading to mucocele/hydrops of the lacrimal sac
 Cause :- pneumococci
 Clinically :-1- epiphora. 2- pus regurgitation through
puncta .
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37. Chronic Dacryocystitis
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38. Complications of chronic
dacryocystitis
 chronic conjunctivitis/recurrent acute conjunctivitis
 acute on chronic dacryocystitis
 due to acute dacryocystitis there may be lacrimal
abscess, fistula, orbital/facial cellulitis, cavernous sinus
thrombosis, lacrimal osteomyelitis
 hypopyon corneal ulcer due to pneumococcal infection
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39. TREATMENT :-
 Probing ( not preferred )
 dacryocystorhinostomy(DCR)—the best treatment
 dacryocystectomy(DCT)—if less than 4 or more than
70 years of age, shrunken/fibrotic sac, tumour of sac,
atrophic rhinitis
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40. Chronic congenital dacrocystitis
 failure of nasolacrimal duct to open into interior
meatus(normally at 3rd week).There is constant epiphora and
regurgitation of pus.
Treatment--
 In first 6 month just use sulfacetamide/gentamycin eye drops
with daily hydrostatic massage 4 times/day of Lacrimal sac to
drain pus .( many case show opening of NLD duct ) .
 If the duct is not open upto 9 months: do Lacrimal probing
which is introducing a probe (sterile steel rod with blunt tip ) to
open the obstruction under general anesthesia
 In case of failure Lacrimal probing : surgery
dacrocystorhinostomy (D.C.R ) after 4 years.
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41. Technique Of Dilating The Inferior
Punctum (Punctal Dilatation)
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42. Probing Of The Nasolacrimal Duct
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43. Congenital Nasolacrimal Duct
Obstruction
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44. Dacrocystorhinostomy (DCR)
 an operation to make a connection between Lacrimal
sac and nasal mucosa through an opening in the
Lacrimal bone to by pass the nasolacrimal duct
obstruction.
 it is indicated in chronic dacrocystitis with permanent
nasolacrimal duct obstruction without nasal
contraindication (e.g atrophic rhinitis)
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45. Dacryocysistorhinostomy(DCR)
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47. Dacrocystectomy(DCT)
 surgical removal of Lacrimal sac
 indication in chronic dacrocystitis with destruction of
Lacrimal sac
 if there is contraindication for D.C.R
 old patient who required intraocular surgery
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48. Canaliculitis
 Uncommon chronic inflammation of canaliculi ( lower
canaliculus is more affected ).
 Cause :- actinomyces , Candida .
 Clinically :- red eye with slight discharge .
 Treatment :- surgery
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49. Canaliculitis
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50. Regurgitation of pus in a case of
canaliculitis
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51. Tumours of lacrimal sac
extremely rare but life threatening condition.they are
 Squamous cell carcinoma
 Transitional cell carcinoma
 Adeno carcinoma
The triad of malignancy is
 A mass below the medial palpebral ligament
 A chronic dacryocystitis that irrigates freely
 Regurgitation of bloody muco-pus
Treatment -by complete excision of the sac followed by
irradiation.
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52. Punctal Surgery
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