This document discusses the evaluation of the nasolacrimal system. It covers the history and anatomy of the system, classification of epiphora, diagnostic tests used to evaluate the system including anatomical tests like syringing and probing, functional tests like dye disappearance tests, and secretory tests like Schirmer's test. The document also discusses differentiating anatomical obstruction from functional/physiological causes of excessive tearing and localization of blockages in the system.

1. Evaluation of nasolacrimal system
Balasubramanian Thiagarajan
Autor: 17.09.12

2. Why should we bother?
● Otolaryngologists perform endoscopic
dacryocystorhinostomy more and more
● Helps in deciding whether the patient will benefit
from this procedure
● Operating surgeon should clinically examine
patients before surgery
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3. History
● Anatomy of
nasolacrimal pathway –
Hamurabi 2200 BC
● Endo-DCR first
described by Caldwell
1893
● External DCR – Toti in
1904
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4. Epiphora (Downpour)
● Excessive lacrimation
● Defective drainage
● Lacrimal pump failure
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5. Classification of Epiphora
● Congenital causes
● Acquired causes
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6. Congenital
● 1% of infants
● Self limiting disorder
● Massaging of the sac helps
● Probing beneficial
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7. Acquired
● Primary acquired nasolacrimal duct obstruction
● Dacryocystolithiasis
● Orbital / lacrimal trauma
● Canalicular lacerations
● Actinomyces within canaliculi
● Canalicular lesions following herpes / antiviral
therapy (+ h/o keratoconjunctivitis)
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8. Anatomical obstruction
● Pathologies involving sac
● Canalicular stenosis / blockage
● Obstruction to nasolacrimal duct
● Formation of diverticula
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9. Types of obstruction
● Intrinsic – caused by internal derangements of the
mucosal lining of lacrimal apparatus
● Extrinsic – Caused by extraneous deforming lesions
which can deform the drainage channel as is the
case in tumors.
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10. Epiphora (Physiologic)
● No anatomical changes in the lacrimal pathway
● Lacrimal pump mechanism is at fault
● Eye lid malpositions, eversion of punctum, poor
orbicularis oculi muscle tone
● Bell's palsy
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11. Epiphora Grading (Sahlin)
Grade Degree of epiphora
0 No epiphora
1 Epiphora only outdoors and during
windy times
2 Outdoor epiphora No indoor
epiphora
3 Outdoor and indoor epiphora
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12. Anatomy of lacrimal system
● Nasolacrimal duct is
18mm long
● Junction between
common canaliculus
and sac is guarded by
Rosenmuller valve
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13. Sites of lacrimal system block
● Suprasaccal
● Saccal
● Subsaccal
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14. Suprasaccal obstruction
● Obstruction is proximal
to sac
● Upper canaliculus
● Lower canaliculus
● Common canaliculus
● Herpes infection,
trauma, irradiation
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15. Saccal obstruction
● Obstruction at the level
of sac
● Tumor
● Diverticula
● Trauma
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16. Subsaccal obstruction
Incomplete Compete
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17. Functional obstruction
● Lacrimal system is patent to syringing still there is
epiphora
● Obstruction is to be used only for anatomical
obstruction
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18. Causes of excessive tearing
● Hypersecretion
● Epiphora
● Combination of both
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19. Diagnostic evaluation
● Quantification of tear production
● Assessment of nasolacrimal system patency
● Differentiating epiphora from lacrimation
● Defining the pathological process
● Differentiating anatomical from functional
obstruction
● Attempting to locate the site of obstruction
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20. Classification of tests to evaluate
lacrimal system pathway
● Anatomical tests
● Functional tests
● Secretory tests
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21. Anatomical tests
● These tests helps in localization of obstruction
● Palpation of sac
● Syringing / irrigation
● Diagnostic probing
● Dacryocystography
● Nasal exam
● CT/MRI
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22. Functional tests
● To access functioning of lacrimal apparatus under
physiologic conditions
● Performed only when there is no evidence of
obstruction in anatomical tests
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23. Functional tests (contd)
● Flourescein dye disappearance test
● Scintigraphy
● Jones dye test I
● Sacharin test
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24. Tests for lacrimal secretions
● These tests are performed to access secretory
functions of lacrimal apparatus
● Schrimers test
● Bengal Rose test
● Tear-film break up
● Tear lysozyme
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25. Causes of excess lacrimation
● Supranuclear causes – Psychogenic / emotions
● Stimulation of V nerve
● Infranuclear causes
● Lacrimal gland stimulation
● Other causes – Bright lights / sneezing
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26. Stimulation of V nerve
● Reflex tearing
● Lid causes – Blepharitis / trichiasis
● Conjunctival diseases
● Corneal diseases
● Neuralgia
● Ocular inflammation
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27. Infranuclear causes
● Facial palsy
● Aberrant innervation
● Crocodile tears
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28. Epiphora causes
● Functional insufficiency – incorrect lid closure, lid
malposition, punctal eversion, punctal medialization
● Anatomical obstruction
● Combination of functional insufficiency and
anatomical obstruction
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29. Combined epiphora
● Facial nerve palsy – corneal irritation and pump
defects
● Lower lid ectropion – conjunctival irritation and
pump defects
● Thyroid diseases – corneal irritation and defective
canalicular function
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30. History taking
● Provides vital clues to the presence of canalicular
disorders
● H/o present /past opthalmological problems
● Nasal symptoms
● Previous surgeries
● Unilateral tearing – obstruction
● Bilateral tearing - Physiological`
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31. Inspection & palpation
● Eye lids
● Medial canthus
● Palpation of sac
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32. Eye lid examination
● Lower lid laxity
● Ectropion
● Punctal eversion
● Trichiasis
● Blepharitis
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33. Snap back test
● Test for lower lid laxity
● Lower lid is pulled down and away from the orbit
● On release the lid resumes normal position
● Time taken for the lid to get back to normal postion
is noted
● Longer the duration more lax is the lower lid
● Graded over a scale of 0-4
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34. Lid examination (contd)
● Medial canthal laxity
● Lateral canthal laxity
● Orbicularis oculi muscle tone check
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35. Examination of medial canthus
Neoplasm Sac enlargement
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36. Sac palpation
● Normal sac not palpable
● Sac is palpable below
the medial canthus
● Reflux of tears / pent up
secretions
● Pain / tenderness –
acute dacryocystitis
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37. Dye excretion test
● Drainage function of entire lacrimal apparatus can
be tested
● Fluorescein dye is used for this purpose
● This test is more physiological
● This test does not differentiate anatomical from
physiological causes of nasolacrimal obstruction
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38. Fluorescein dye test
● 1% fluorescein is instilled into the conjunctiva
● Conjunctiva is not anaesthetized
● After 5 mins thickness of fluorescein of the tear
meniscus is measured using cobalt blue filter
● This test can be safely performed in infants &
children
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39. Fluorescein dye test (contd)
● Presence of residual fluorescein gives no
information regarding localisation of block
● Presence of residual fluorescein is an indication for
probing and syringing
● When performing this test in children they should be
held in vertical postion
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40. 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
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41. False negative dye test
1. Large lacrimal sac
2. Mucocele
3. Distal nasolacrimal duct block
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42. Break up time test
● Performed by placing a drop of fluorescein in the
outer canthus of the eye
● Its transport can be observed from lateral to medial
● Holes in the tear film can also be observed
● Normal breakup time is 15-30 secs
● Breakup time of less than 10 secs indicate epiphora
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43. Jones dye test
● Distinguishes between
functional and
anatomical obstruction
● Topical xylocaine
application
● Flurescein dye instilled
● Negative result
indicates functional /
anatomical block
● Useless in total
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44. Saccharin test
● Similar to fluorescein dye test
● Physiological
● Saccharin is placed in conjunctiva
● Saccharine taste appears within 3.5 mins
● Pt should have normal taste sensation
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45. Probing & syringing
● Invasive test
● Provides information regarding site of obstruction
● Useless in functional obstruction
● This is not a physiological test
● This test should be interpreted with fluorescein dye
test and clinical examination
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46. Syringing (contd)
● Topical xylocaine applied
● Punctum dilator applied to dilate punctum
● Tip of irrigator placed in the inferior canaliculus. It
is directed first vertically and then horizontally.
Eyelid is stretched
● Tip is advanced 3-7 mm into canaliculus and saline
is injected
● Irrigation should not be forced
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47. Syringing (Interpretation)
● Regurgitation through opposite punctum –
obstruction in the common canaliculus or more
distal structures
● Regurgitation via the same punctum indicates
punctal obstruction
● Drainage via nose does not rule out physiological
obstruction
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48. Diagnostic probing
Hard stop Soft stop
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49. Irrigation / probing interpretation
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50. Radiological evaluation
● Dacryocystography
● Nuclear lacrimal scintigraphy
● CT
● MRI
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51. Dacryocystography
● Anatomical investigation
● Creates interior image of the entire lacrimal system
● Radio opaque water soluble dye is injected into the
canaliculus
● Magnified images are created
● Digital subtraction is used
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52. Radiologic criteria of lacrimal
pathology
● Regurgitation of radio-opaque fluid into the
conjunctival sac
● Absence of fluid in the nose
● Fluctuation of lumen of lacrimal system
● Irregularity in contrast
● Deformation involving lacrimal sac
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53. Nuclear lacrimal scintigraphy
● Non invasive physiological test
● Utilizes radiotracer technitium-99M pertechnitate.
● Images can be captured using epiphora
● Drop of technetium-99m instilled into conjunctiva
● Recording is made using gamma camera
● 20 mins is the recording time
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54. CT/MRI
Helpful in identifying
adjacent areas and other
mass lesions
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55. Secretory tests
● Schimer's test
● Rose bengal test
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56. schirmer's test
● 35x5 mm paper
● 5 mins duration
● 10-30 mm wetness
normal
● Above 30mm epiphora
● 10mm dryness
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57. Thankyou
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