Diseases of lids & Lacrimal Apparatus

1. Ophthalmology
By
Dr. Laraib Jameel Rph
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2. Symblepharon
• Definition: A symblepharon is an adhesion
between the eyelid and the eyeball.
• It can involve just one lid or both.
• This adhesion of
Sub-epithelial
(beneath) scarring
can lead to other lid
complications such
as aberrant (deviated)
lash growth and entropion.

3. Symblepharon

4. • Anatomically symblepharon is a partial or complete adhesion of
the palpebral conjunctiva of the eyelid to the bulbar conjunctiva of
the eyeball.
• ANATOMY: The conjunctival tissue starts from the limbus and ends
in the lid margin. According to the anatomic location, the
conjunctiva can be subdivided into the bulbar and palpebral
portions,
• palpebral conjunctiva: The part of the conjunctiva, a clear
membrane, that coats the inside of the eyelids. The palpebral
conjunctiva is as opposed to the ocular (or bulbar) conjunctiva.
• bulbar conjunctiva: bulbar conjunctiva, the part of
the conjunctiva that covers the outer surface of the eye.
• Synonym: pseudopterygium / cicatricial pterygium

6. • Causes/etiology :
• Any conjunctival infections complicated with conjunctival scaring may cause
symblepharon; such as chlamydial conjunctivitis, vernal, atopic, bacterial
conjunctivitis and epidemic keratoconjunctivitis.
• Vernal (pertaining to spring) conjunctivitis
• Vernal conjunctivitis is long-term (chronic) swelling (inflammation) of the outer
lining of the eyes. It is due to an allergic reaction.
• Causes
• Vernal conjunctivitis often occurs in people with a strong family history of allergies.
These may include allergic rhinitis, asthma, and eczema. It is most common in
young males, and most often occurs during the spring and summer.
• Chlamydial conjunctivitis : Chlamydial conjunctivitis (bacteria- chlamydia
trachomatis) is a sexually transmitted disease and occurs most commonly in
sexually active young adults. Women are more susceptible than men. The disease
is usually transmitted through hand-to-eye spread of infected genital secretions.
The incubation period is one to two weeks.

7. • Bacterial conjunctivitis : Bacterial conjunctivitis is a common type of pink
eye, The most common types of bacteria that causes bacterial
conjunctivitis includes Staphylococcus aureus, Haemophilus influenzae,
Streptococcus pneumonia and Pseudomonas aeruginosa.
• Bacterial conjunctivitis usually produces a thick eye discharge or pus and
can affect one or both eyes.
• Atopic conjunctivitis: Allergic conjunctivitis is an acute, intermittent, or
chronic conjunctival inflammation usually caused by airborne allergens.
• Symptoms include itching, lacrimation, discharge,
and conjunctival hyperemia. Diagnosis is clinical. Treatment is with topical
antihistamines and mast cell stabilizers.
• ATOPY- a hereditary disorder, marked by tendency to develop immediate
hypersensitivity reaction)
• conjunctiva is transparent and the underlying sclera is white, these dilated
vessels can easily be seen. Conjunctival hyperemia can occur when the
blood flow through the conjunctival vessels increases due to vasodilation.

8. • Atopic Keratoconjunctivitis (AKC)
• Atopic keratoconjunctivitis (AKC) is the result of a condition called
"atopy". Atopy is a genetic condition where your immune system
produces higher than normal antibodies in response to a given
allergen. Although AKC is a perennial (year round) disease, your
symptoms may worsen in the winter.
• With AKC, the conjunctiva lining the eyelids is usually red and
swollen. The lower eyelid generally is affected more than the
upper eyelid.
• Causes
• AKC is a genetic condition.
• Risk Factors
• A family history of multiple allergies

9. Causes of Symblepharon
• Symblepharon can develop as a complication of several diseases that include:
• 1- Severe dry eye syndrome
• Dry eye syndrome is caused by a chronic lack of sufficient lubrication and moisture on the surface
of the eye.
• Consequences of dry eyes range from subtle but constant eye irritation to significant inflammation
and even scarring of the front surface of the eye. And this scarring can lead to symblepharon.
• 2- Stevens-Johnson syndrome:
• is a rare, serious disorder of your skin and mucous membranes. Often, it begins with flu-like
symptoms, followed by a painful red or purplish rash that spreads and blisters.
• Cause: Stevens-Johnson syndrome is a rare and unpredictable reaction. A reaction to medication
may start while you're using it or up to two weeks after you've stopped using it.
• Drugs that can cause Stevens-Johnson syndrome include:
• Anti-gout medications, such as allopurinol
• Medications to treat seizures and mental illness (anticonvulsants and antipsychotics)
• Medications to fight infection, such as penicillin
• The rash caused by Stevens-Johnson syndrome can lead to inflammation in your eyes. In mild cases,
this may cause irritation and dry eyes. In severe cases, it can lead to extensive tissue damage and
scarring

10. Steven-johnson syndrome

11. 3- Ocular cicatricial pemphigoid:
It is autoimmune disease.
Cicatrical=caused by a scar pemphigoid= autoimmune blistering skin
disease, ocular= eye
This is a subclass of mucous membrane pemphigoid affecting
predominantly the conjunctiva. OCP is a Type II hypersensitivity
response with antibodies binding at the basement membrane zone,
leading to the activation of complement and recruitment of
inflammatory cells. The release of cytokines causes fibroblast (play
role in healing) activation with consequent progression to scarring.
Type2– antibody binding with membrane—activation of
complement—recruitment of inflammatory cells– release
cytokines—causes fibroblast(healing process)--- scar formation.

12. Ocular cicatricial pemphigoid

13. • 4- Chemical injury / corneal chemical burn:
• Acid tends to cause less severe injury than
alkali. Acid denatures and precipitates
proteins, which form a barrier to further
penetration. Alkali denatures but does not
precipitate proteins, and also saponifies fats
(disrupts lipid membranes), causing deeper
penetration into ocular tissues.

14. • Symptoms:
• Symptoms may be dependent upon the etiology. For most patients, the common
symptoms include:
Redness
• Tearing
• Burning sensation
• Foreign body sensation
• Photophobia
• Lid heaviness
• Blepharo-spasm
• Diplopia is the simultaneous perception of two images of a single object that may
be displaced horizontally, vertically, diagonally (i.e., both vertically and
horizontally), or rotationally in relation to each other.
• Entropion is a medical condition in which the eyelid (usually the lower lid) folds
inward. It is very uncomfortable, as the eyelashes continuously rub against the
cornea causing irritation.
• and inadequate lid closure.

15. • Treatment:
• Copious (vast) irrigation
• checking pH level,
• Debridement (any necrotic conjunctiva and particulate matter),
• frequent lubrication,
• topical antibiotic and
• Cycloplegic drugs
(Cycloplegic drugs are generally muscarinic receptor blockers. These
include atropine, cyclopentolate, homatropine, scopolamine and
tropicamide. They are indicated for use in cycloplegic refraction (to
paralyze the ciliary muscle in order to determine the true refractive
error of the eye)
Ciliary muscle: enable the lens to change shape for focusing

16. • Symblepharon lysis
• Symblepharon lysis is performed with a glass rod.
• Mild to severe based on degree of corneal damage and
ischemia(an inadequate blood supply to an organ or
part of the body):
• Grade I: corneal epithelial damage, no ischemia
• Grade II: iris details visible, ischemia < 1/3 of limbus
• Grade III: total corneal epithelial loss, iris obscured
• Grade IV: opaque cornea, ischemia > 1/2 of limbus

17. • Schematic illustration and clinical photographs showing the 3 strategies for fornix reconstruction. In
mild symblepharon (A), after symblepharon lysis, AM (black) is used to cover the denuded sclera up
to the recessed conjunctiva (green) with fibrin glue (B) or sutures. In moderate symblepharon (C),
anchoring suture (red) is used to secure the recessed conjunctival edge (green) to the skin with a
bolster (red circle); one double-armed 4-0 silk suture is used per quadrant (D). In severe
symblepharon (E), additional OMG (orange) is used to cover the tarsal plate and secured with fibrin
glue (F) and sutures.

18. • Management: may require oculoplastics procedure to
release the symblepharon
• Oculoplastics, or oculoplastic surgery, includes a wide
variety of surgical procedures that deal with the orbit (eye
socket), eyelids, tear ducts, and the face. It also deals with
the reconstruction of the eye and associated structures
• Prevention:
• Minimize the cause definitely you will able to stay away the
disease, such as
• Chemical burns
• Trauma
• Disease (conjunctivitis)

19. Herpes Zoster
• Definition: Herpes zoster is infection that results
when varicella-zoster virus reactivates from its
latent (hidden) state in a posterior spinal ganglion
(a structure containing a number of nerve cell
bodies).
• Synonym: Shingles, Zoster
• Shingles, also known as zoster or herpes zoster,
is a viral disease characterized by a painful skin
rash with blisters in a localized area

20. Shingles

21. • Location: Although shingles can occur
anywhere on your body, it most often
appears as a single stripe of blisters that
wraps around either the left or the right side
of your body or face (eye).
• Most cases of shingles clear up within two to
three weeks.
• Shingles rarely occurs more than once in the
same person

22. • Causes:
• Shingles is caused by the varicella-zoster virus, the
same virus that causes chickenpox. Anyone who's had
chickenpox may develop shingles. After you recover
from chickenpox, the virus can enter your nervous
system and lie dormant (inactive) for years.
• Eventually, it may reactivate and travel along nerve
pathways to your skin — producing shingles.
• Note: But, not everyone who's had chickenpox will
develop shingles.

24. • The reason for shingles is unclear.
• But it may be due to lowered immunity to infections as you
grow older. Shingles is more common in older adults and in
people who have weakened immune systems.
• Mostly shingles occur after 50 years of age.
• Virus which causes the disease:
• Chickenpox and herpes zoster are caused by the varicella-
zoster virus (human herpesvirus type 3) a double-
stranded DNA virus related to the herpes simplex virus
• chickenpox is the acute invasive phase of the virus, and
herpes zoster (shingles) represents reactivation of the
latent phase.

25. Are you contagious?

26. • Ans:
• A person with shingles can pass the varicella-
zoster virus to anyone who isn't immune to
chickenpox.
• This usually occurs through direct contact with
the open sores of the shingles rash.
• Once infected, the person will develop
chickenpox, however, not shingles.

27. • Risk factors:
• Anyone who has ever had chickenpox can develop shingles.
• Factors that may increase your risk of developing shingles include:
• Being older than 50. Shingles is most common in people older than 50.
The risk increases with age. Some experts estimate that half the people
age 80 and older will have shingles.
• Having certain diseases. Diseases that weaken your immune system,
such as HIV/AIDS and cancer, can increase your risk of shingles.
• Undergoing cancer treatments. Radiation or chemotherapy can lower
your resistance to diseases and may trigger shingles.
• Taking certain medications. Drugs designed to prevent rejection of
transplanted organs can increase your risk of shingles (these are
immunosuppressant drugs)
• as can prolonged use of steroids, such as prednisone. (prolong use of
steroids can increase high blood sugar, thinning bones(osteoporosis),
clouding of lens in one/both eyes, increase risk of infections.

28. • Symptoms:
• Localized burning, tingling, itching, prickling pain that starts days to weeks before
the rash appears.
• A widespread rash
• Rash in the eye
• Fluid-filled blisters that scab within 7 to 10 days and resolve within 2 to 4 weeks
• Sensitivity to touch or light
• The rash may be accompanied by fever, fatigue, or headache.
• The rash will not cross the mid-line of your body.
• Pain is usually the first symptom of shingles. For some, it can be intense.
Depending on the location of the pain, it can sometimes be mistaken for a
symptom of problems affecting the heart, lungs or kidneys. Some people
experience shingles pain without ever developing the rash.

29. • Transmission of disease:
• The varicella zoster virus can spread through
direct contact with herpes zoster lesions
which have not yet crusted over
• or via the airborne route over distances of
greater than 3 feet.

30. • Diagnosis:
• Most cases of shingles can be diagnosed with a physical examination of
rashes and blisters. Your doctor will also ask questions about your medical
history. (if you had chickenpox as a child, you might recall the itchy,
spotted rash that popped up on your face and body.)
• In rare instances, your doctor may need to test a sample of your skin or
the fluid from your blisters.
This involves using a sterile swab to
collect a sample of tissue or fluid.
Samples are then sent to a medical
laboratory to confirm the presence
of the virus.
• Blood test: The most popular test detects VZV-specific IgM antibody in
blood; this appears only during chickenpox or shingles and not while the
virus is dormant

31. Treatment
Type Purpose Drug frequency Method
anti-viral medications,
including acyclovir, valacyclovir, and famciclovir
to reduce pain
and speed
recovery
2 to 5 times
daily, as
prescribed by
your doctor
oral
anti-inflammation drugs, including ibuprofen
to ease pain and
swelling
every 6 to 8
hours
oral
narcotic medications or analgesics to reduce pain
likely to be
prescribed once
or twice daily
oral
anticonvulsants or tricyclic antidepressants
to treat
prolonged pain
once or twice
daily
oral
antihistamines, such as diphenhydramine (Benadryl) to treat itching every 8 hours oral
numbing creams, gels, or patches, such as lidocaine to reduce pain
can be applied
as needed
topical

32. • Complications:
• The pain and rash occur near an eye. If left untreated,
this infection
can lead to
permanent eye
damage.
• The affected area
becomes secondarily
infected with bacteria.
Nerve problems such as brain swelling, facial paralysis,
hearing problems, and problems with balance

33. • Preventions:
• There are several shingles vaccines that reduce the risk
of developing shingles or developing severe shingles if
the disease occurs.
• The Centers for Disease Control and Prevention (CDC)
recommend that people over 60 years old are
vaccinated with the shingles vaccine at least once.
The varicella-zoster shot, known as Zostavax, or VZV, is
approved by the Food and Drug Administration (FDA)
for those over 50 years old.
• There are vaccines that reduce the risk of developing
chickenpox.

34. Lacrimal Apparatus
• The lacrimal apparatus is the physiological system & a
set of connected anatomical structures located within
the orbit that are responsible for the production and
drainage of tears.
• The lacrimal apparatus include the following
structures:
• lacrimal gland
• lacrimal canaliculi
• lacrimal sac
• nasolacrimal duct.

36. • Lacrimal gland
• This gland is about the size of an almond, and sits
within the lacrimal fossa, located in the superior and
outer edge of the orbital roof. The gland is divided into
two sections anatomically. These are the small
palpebral portion that lies closer to the eye, and
the orbital portion that forms around four ducts. These
ducts then combine with the 6 ducts of the palpebral
portion, and are secreted onto the surface of the eye.
• Composition: The lacrimal gland is composed of cells
that produce proteins and electrolytes, and cause
water to follow by osmosis.

38. • Lacrimal canaliculi/canals
• These are small channels that lie in each eyelid, and commence at
the puncta lacrimalia;
• small openings where
the tears are drained
from the surface of the eye.
These canaliculi are divided
into the superior duct and
the inferior duct that drain
into the lacrimal sac. They
are lined with stratified
squamous epithelium.
• The lacrimal canaliculi convey the tears to the lacrimal sac

39. • Lacrimal sac
• This is the upper dilated end of the nasolacrimal duct.
• Function: It connects to the
lacrimal canaliculi,
which function to
drain the tears from
the eyes surface to
the nasal cavity via the
nasolacrimal duct.
• The cells that line these canaliculi are stratified columnar
epithelium, with goblet cells.

40. • nasolacrimal duct:
• which is the final part of the lacrimal
apparatus and
• Location: opens into the nasal cavity.
• If there is excess of tears, it drains via the
nasolacrimal duct into the nasal cavity, thus
causing what is called a runny nose.
• The cells that line this duct are stratified
columnar epithelium.

41. • Innervation:
• The innervation of the lacrimal apparatus involves both the
a sympathetic supply through the carotid plexus of nerves around
the internal carotid artery,
• and parasympathetically from the lacrimal nucleus of the facial
nerve. (7th cranial neve)
• Vasculature
• The main arterial supply to the lacrimal gland is from the lacrimal
artery, which is derived from the ophthalmic artery – a branch of
the internal carotid artery.
• Venous drainage is via the superior ophthalmic vein, and
ultimately empties into the cavernous sinus.
• Lymphatic drainage is to the superficial parotid lymph nodes. They
empty into the superior deep cervical nodes.

42. • The function of the lacrimal apparatus
• 1- is to produce tears,
• 2- channel them to the surface of the eye where they maintain moisture,
• 3- flush debris and waste material from the ocular surface.
• Tear: Tears have an integral role in the functioning of the eye. They protect
the eye from infection, lubricate the movements of the eye and eyelid,
and also ensure the presence of a thin transparent layer on the surface of
the conjunctiva.
• There are three types of tears.
• Basal tears are normally present and maintain lubrication and a general
functioning of the eye.
• There are reflex tears that are generated due to irritation of the eye from
dirt of debris.
• The third type is psychic tears/crying, which are formed under emotional
control.

43. Dry Eyes
• Definition: Dry eye is a condition in which a person doesn't have enough quality
tears to lubricate and
nourish the eye,
• or if you produce
poor-quality tears.
• After a long day of
staring at your computer
screen, your eyes are shot.
You may feel your vision to
get blurry or have a burning
sensation in your eyes. Perhaps
in the course of your normal
routine you experience a sharp pain in your eye or have excessive watering.
• These are all symptoms of the dry eyes syndrome
People with dry eyes either do not produce enough tears or their tears are of a poor
quality

44. • Cause:
• Dry eyes are caused by a lack of adequate tears. tears are a complex mixture of water, fatty oils
and mucus. This mixture helps make the surface of eyes smooth and clear, and it helps protect
your eyes from infection.
• For some people, the cause of dry eyes is decreased tear production. For others it's increased tear
evaporation and third is an imbalance in the makeup of your tears.
• 1- Decreased tear production
• Dry eyes can occur when you're unable to produce enough tears. The medical term for this
condition is keratoconjunctivitis sicca.
• Common causes of decreased tear production include:
• Aging
• Tear gland damage from inflammation or radiation
• Certain medical conditions, including diabetes, rheumatoid arthritis, Sjogren's syndrome, and
vitamin A deficiency
• Certain medications, including antihistamines, decongestants, hormone replacement therapy,
antidepressants, and drugs for high blood pressure, acne, birth control and Parkinson's disease

45. • In Sjögren’s Syndrome, the glands in your eyes and mouth that typically produce
mucus and moisture no longer produce effectively.
• Rheumatoid arthritis (RA) is a chronic autoimmune disease that causes pain,
swelling, stiffness, and loss of function in the joints. The ends of your bones are
covered by elastic tissue called cartilage, which supports and helps protect the
joints during movements. A tissue known as synovium or synovial membrane lies
next to the cartilage. The synovium produces synovial fluid, a substance that acts
as a lubricant and provides nourishment to the cartilage.
• In people with RA, the autoimmune process causes the synovium in certain joints
to become inflamed. The tissue swells and becomes painful with every movement
of the affected joints.
• diabetic patients complain of typical dry eye symptoms, such as burning and/or
foreign body sensation due to retinopathy
• Vitamin A helps form and maintain healthy teeth, skeletal and soft tissue, mucus
membranes, and skin. It is also known as retinol because it produces the pigments
in the retina of the eye. Vitamin A promotes good eyesight, especially in low light

46. • 2- Increased tear evaporation
• Common causes of increased tear evaporation include:
• Wind, smoke or dry air
• Blinking less often, which tends to occur when you're concentrating, for
example, while reading, driving or working at a computer
• Eyelid problems, such as out-turning of the lids (ectropion) and in-turning
of the lids (entropion)
• 3- Imbalance in tear composition
• The tear film has three basic layers: oil, water and mucus. Problems with
any of these layers can cause dry eyes. For example, the oil film produced
by small glands on the edge of your eyelids (meibomian glands) might
become clogged.
• Blocked meibomian glands are more common in people with
inflammation along the edge of their eyelids (blepharitis), rosacea or
other skin disorders.

47. • There are two main types of dry eye.
• Aqueous tear-deficient dry eye is when the tear glands are unable
to produce enough of the fluid component of tears to clean the
surface of the eye properly.
• This type of dry eye is also sometimes called "painful blindness
dry eye." It is caused by damage to the tear gland by factors, such
as aging, pollution, or side effects from some medicines.
• The other main type of dry eye is known as "evaporative dry eye."
This type is caused by inflammation of another set of glands
located in the eyelids, the meibomian glands. The inflammation
prevents these glands from producing enough of an oil that helps
stop tears from evaporating too quickly.

48. • Symptoms:
• These are some of the symptoms and causes of dry eye syndrome,
which can damage the surface of the eyes and impair vision if not
treated immediately:
• A painful or itchy feeling in your eyes.
• Stringy mucus in or around your eyes.
• Sensitivity to light.
• Redness of the eye.
• Feeling like something is stuck in your eyes.
• Difficulty in applying contact lenses.
• Problem while driving in the night.
• Excessively watery eyes.
• Blurred vision.

49. • Risk factors
• Factors that make it more likely that you'll experience dry eyes include:
• AGE: Being older than 50. Tear production tends to diminish as you get
older. Dry eyes are more common in people over 50.
• GENDER: Being a woman. A lack of tears is more common in women,
especially if they experience hormonal changes (prolactin &
adrenocorticotropic hormone- stress level) due to pregnancy, using birth
control pills or menopause.
• DIET: Eating a diet that is low in vitamin A, which is found in liver, carrots
and broccoli, or low in omega-3 fatty acids, which are found in fish,
walnuts and vegetable oils
• Environmental conditions. Exposure to smoke, wind and dry climates can
increase tear evaporation resulting in dry eye symptoms. Failure to blink
regularly, such as when staring at a computer screen for long periods of
time, can also contribute to drying of the eyes.
• OTHER FACTORS: Wearing contact lenses

50. • Diagnosis:
• comprehensive eye examination:
• Dry eyes can be diagnosed through a comprehensive eye examination. This eye
exam that includes a complete history to determine the patient's symptoms and
to note any general health problems, medications or environmental factors that
may be contributing to the dry eye problem.
• External examination of the eye, including lid structure and blink dynamics.
• Evaluation of the eyelids and cornea using bright light and magnification
• Other procedures are:
• Measuring the volume of your tears. Your doctor may measure your tear
production using the Schirmer test. In this test, blotting strips of paper are placed
under your lower eyelids. After five minutes your doctor measures the amount of
strip soaked by your tears.
• Determining the quality of your tears. Other tests use special dyes in eyedrops to
determine the surface condition of your eyes. Your doctor looks for staining
patterns on the corneas and measures how long it takes before your tears
evaporate.

51. • Treatment
• Tear glands and tear ducts
• For most people with occasional or mild dry eye symptoms,
it's enough to regularly use over-the-counter eye drops
(artificial tears). If your symptoms are persistent and more
serious, you have other options. What you do depends on
what's causing your dry eyes.
• Treating the underlying cause of dry eyes
• In some cases, treating an underlying health issue can help
clear up the signs and symptoms of dry eyes. For instance,
if a medication is causing your dry eyes, your doctor may
recommend a different medication that doesn't cause that
side effect.

52. Medications
• Prescription medications used to treat dry eyes include:
• Drugs to reduce eyelid inflammation. Inflammation along the edge of your eyelids
can keep oil glands from secreting oil into your tears. Your doctor may recommend
antibiotics to reduce inflammation. Antibiotics for dry eyes are usually taken by
mouth, though some are used as eyedrops or ointments.
• Eyedrops to control cornea inflammation. Inflammation on the surface of your
eyes (cornea) may be controlled with prescription eyedrops that contain the
immune-suppressing medication cyclosporine (Restasis) or corticosteroids.
Corticosteroids are not ideal for long-term use due to possible side effects.
• Eye inserts that work like artificial tears. If you have moderate to severe dry eye
symptoms and artificial tears don't help, another option may be a tiny eye insert
that looks like a clear grain of rice. Once a day, you place the hydroxypropyl
cellulose (Lacrisert) insert between your lower eyelid and your eyeball. The insert
dissolves slowly, releasing a substance that's used in eyedrops to lubricate your
eye.

53. • Tear-stimulating drugs. Drugs called cholinergics (pilocarpine, cevimeline) help
increase tear production. These drugs are available as pills, gel or eyedrops.
Possible side effects include sweating.
• Eyedrops made from your own blood. These are called autologous blood serum
drops. They may be an option if you have severe dry eye symptoms that don't
respond to any other treatment. To make these eyedrops, a sample of your blood
is processed to remove the red blood cells and then mixed with a salt solution.
• because they contain diluted concentrations of vitamins and growth factors that
are important for corneal epithelial health
• Other procedures
• Other procedures that may be used to treat dry eyes include:
• Closing your tear ducts to reduce tear loss. Your doctor may suggest this
treatment to keep your tears from leaving your eye too quickly. This can be done
by partially or completely closing your tear ducts, which normally serve to drain
tears away.
• Tear ducts can be plugged with tiny silicone plugs (punctal plugs). These are
removable. Or tear ducts can be plugged with a procedure that uses heat. This is a
more permanent solution called thermal cautery. (cautery- seal body tissues)

54. Punctal plugs

55. • Using special contact lenses. Some people with
severe dry eyes may opt for special contact lenses
that protect the surface of your eyes and trap
moisture. These are called scleral lenses or
bandage lenses.
• Unblocking oil glands. Warm compresses or eye
massages used daily can help clear up blocked
oil glands. A thermal pulsation device is another
way to unclog the oil glands, but it is unclear
whether this method provides any advantage
over warm compresses.

56. • Self care / Preventions:
• You can take the following steps to reduce symptoms of dry
eyes:
• Remember to blink regularly when reading or staring at a
computer screen for long periods of time.
• Increase the humidity in the air at work and at home.
• Wear sunglasses outdoors, particularly those with
wraparound frames, to reduce exposure to drying winds
and the sun.
• Nutritional supplements containing essential fatty acids
may help decrease dry eye symptoms in some people.
• Avoiding becoming dehydrated by drinking plenty of water
(8 to 10 glasses) each day.

57. Epiphora
• Definition: is a condition in which there is an
overflow of tears onto the face, often without a
clear explanation.
• Synonym: Watering eye,
tearing eye
• Epiphora can develop at
any age, but it is more
common in those aged
under 12 months or over
60 years. It may affect one or both eyes.

58. • Causes
• The two main causes of watering eyes are blocked tear ducts and excessive
production of tears.
• 1- Blocked tear ducts
• Some people are born with underdeveloped tear ducts. Newborns often have
watery eyes that clear up within a few weeks, as the ducts develop.
• The most common cause of watering
eyes among adults and older children is blocked ducts or ducts that are too narrow.
Narrowed tear ducts usually become so as a result of swelling, or inflammation.
• If the tear ducts are narrowed or blocked, the tears will not be able
• to drain away and will build up in the tear sac.
• Stagnant tears in the tear sac increase the
• risk of infection, and the eye will produce a sticky liquid,
• making the problem worse.
• Infection can also lead to inflammation on the side of the
• nose, next to the eye.

59. • 2- Over-production of tears
• Irritated eyes may produce more tears than normal as the body tries to
rinse the irritant away.
• The following irritants can cause the over-production of tears:
• some chemicals, such as fumes, and even onions
• infective conjunctivitis
• allergic conjunctivitis
• an injury to the eye, such as a scratch or a bit of grit (tiny pebble or piece
of dirt)
• trichiasis, where eyelashes grow inward
• ectropion, when the lower eyelid turns outward
• Some people have tears with a high fat, or lipid, content. This may
interfere with the even spread of liquid across the eye, leaving dry patches
which become sore, irritated and cause the eye to produce more tears.

60. • Other causes
• There are many causes of watering eyes. The
following conditions among others can also lead
to an overflow of tears:
• an infection of the cornea
• corneal ulcer, an open sore that forms on the eye
• styes or chalazions, lumps that can grow on the
edge of the eyelid
• allergies, including hay fever

61. • Symptoms:
• Epiphora can cause your eyes to water slightly, or
excessively with a constant stream of tears. You may
also experience other symptoms in your eyes, such as:
• redness
• enlarged, visible blood vessels
• soreness
• eyelid swelling
• blurred vision
• light sensitivity

62. • Diagnosis:
• Diagnosis of epiphora is clinical by history presentation and
observation of the lids. Fluorescein dye can be used to examine for
punctal reflux by pressing on the canaliculi in which the clinician
should note resistance of reflux as it irrigates through the punctum
into the nose.
• Staining method : A piece of blotting paper containing the dye is
touched to the surface of your eye. You are asked to blink. Blinking
spreads the dye and coats the tear film covering the surface of the
cornea. The tear film contains water, oil, and mucus to protect and
lubricate the eye.
• The health care provider then shines a blue light at your eye. Any
problems on the surface of the cornea will be stained by the dye
and appear green under the blue light.

63. • Treatment
• Treatment depends on how severe the problem is and the cause.
• Different causes of watering eyes have specific treatment options:
• Irritation: If the watering eye is caused by infective conjunctivitis, the doctor may
prefer to wait for a week or so to see if the problem resolves itself
without antibiotics.
• Trichiasis: An inward-growing eyelash, or some foreign object that lodged in the
eye, the doctor will remove it.
• Ectropion: The eyelid turns outwards - the patient may need to undergo surgery in
which the tendon that holds the outer eyelid in place is tightened.
• Blocked tear ducts: Surgery can create a new channel from the tear sac to the
inside of the nose. This allows the tears to bypass the blocked part of the tear
duct. This surgical procedure is called dacryocystorhinostomy (DCR).
• If the drainage channels, or canaliculi, on the inside of the eye are narrowed but
not entirely blocked, the doctor may use a probe to make them wider. When the
canaliculi are completely blocked an operation may be required.

64. Dacryocystitis
• Definition: Dacryocystitis is an infection of the
tear sacs or lacrimal sacs in the lower, inner
corner of the eye
that can cause
pain, redness, and
discomfort.

65. Dacryocystitis

66. • The lacrimal glands underneath your upper eyelids
produce tears, Tears act as pathway to keep your eyes
hydrated, clean from dirt and free of bacteria.
• These tears travel through small openings to the front
of your eye. Every time you blink, the tears spread
across your eyes. To make room for new tears, the fluid
drains out of your eyes through small holes, called
puncta, in the corners of your upper and lower eyelids.
Then it drains through the nasolacrimal sac into the
tear duct (lacrimal duct) and into the back of your
nose.

67. • Pathophysiology: Tear ducts act as pathways that carry away the tears
that have washed away dirt on the surface of the eyes. As the used tears
move away from the eye through the tear ducts, fresh tears come in.
• When there is a blockage in the tear sacs or tear ducts, this process gets
disrupted, and used tears cannot travel away from the eye. Bacteria can
then collect in the area.
• Dacryocystitis is most common in infants. However, adults over the age of
40 also have a higher risk of developing dacryocystitis.
• Causes: Causes of dacryocystitis in older children and adults include:
• Sinusitis: some times called rhinosinusitis
• nasal abscess
• trauma to the region that causes a blockage (injury to the nose or eye,
such as a broken nose)
• tumors in the sinus , nasal passages
• bacteria that causes strep or staph infections

69. • Types: : it can be either acute or chronic
• Acute dacryocystitis: Symptoms of acute dacryocystitis start suddenly
and often include fever and pus from the eye. Bacterial infections are
usually the cause of acute dacryocystitis,
• More serious sequela of acute dacryocystitis is the extension into the
orbit with formation of an abscess and development of orbital cellulitis.
• and antibiotic treatment usually resolves the infection within a few days.
• chronic dacryocystitis :
• In cases of chronic dacryocystitis, the onset of symptoms may be more
gradual. The symptoms are often less severe, and fever and pus may not
be present. However, some people may experience long lasting pain or
discomfort from the corner of the eye.
• Chronic dacryocystitis may be caused by an obstruction in the tear ducts.
Treatment: In some severe cases of chronic dacryocystitis, surgery to
widen the tear ducts may be needed to relieve symptoms

70. • Symptoms:
• Symptoms of dacryocystitis vary in intensity from person to person and
depend on the type.
• People with acute dacryocystitis often experience more severe
symptoms than those with chronic dacryocystitis.
• Both acute or chronic dacryocystitis can cause the following symptoms:
• pus and thick discharge from the eye
• pain in the lower outside corner of the eyelid
• redness and swelling near the lower outside eyelid
• watery eye
• excess tears
• Fever
• People with chronic dacryocystitis are less likely to experience pain,
redness, or swelling.

71. • Diagnosis
• Diagnosing dacryocystitis is relatively simple. During an exam, a doctor
may ask for a person's medical history and then access the eye for visible
signs of dacryocystitis, such as swelling or redness.
• A doctor may press on the lacrimal sac to see if pus comes out. If it does,
the doctor may collect a sample of the pus to test for bacteria.
• In some cases, a doctor may do a dye disappearance test. During this test,
the doctor will place yellow dye in the corner of the eye. In a healthy eye,
the yellow dye will disappear after a few minutes. If there is a blockage,
the dye will linger in the eye for much longer.
• The dye disappearance test can also indicate whether the tear ducts are
partially or entirely blocked.
• To check the level of blockage, a doctor will then swab inside the person's
nose on the side with the suspected blockage.
• Sometimes, imaging tests like CT scans are done to help the doctor look
for the cause of the blockage.

72. • Treatment
• The main treatment for dacryocystitis is antibiotics. These drugs
kill the bacteria that caused the infection. Usually you take
antibiotics by mouth, but if you have a severe infection, you may
get them through an IV. Your doctor might also prescribe antibiotic
eye drops or ointment.
• To relieve pain and swelling from the infection, hold warm
compresses to your eye a few times per day.
• After the infection clears, you may need a procedure called
dacryocystorhinostomy (DCR). This surgery bypasses the blocked
duct, usually by removing a nearby bone. It allows tears to drain
directly from the lacrimal sac into the nose.
• Widening the duct prevents you from getting infections in the
future.

73. • Complications
• An acute infection can become chronic if you don’t treat it quickly
enough.
• In babies with congenital dacryocystitis, the infection can spread
into the eye socket. This can lead to life-threatening complications
such as:
• Fistula formation
• Lacrimal sac abscess
• brain abscess, a collection of pus in the brain
• meningitis, or inflammation of the membranes around the brain
and spinal cord
• sepsis, a body-wide inflammatory response caused by infection

74. • Risk Factors:
• Dacryocystitis is most common in babies, who can be born with a
blockage of the tear duct. This is called congenital dacryocystitis.
• Middle-aged women are more likely than men to have a blockage
because their duct is naturally narrower. The condition becomes
more common as you age.
• Other risk factors for dacryocystitis include:
• deviated septum, when your septum (the thin wall between your
nostrils) is off-center, making one nostril smaller than the other
• inferior turbinate hypertrophy, or swelling of one of the bony
structures in your nose that help filter and humidify the air you
breathe

75. • Preventions/Home care:
If you or your child often gets tear duct
infections, one way to prevent them is to drain
the tear sac.
• Wash your hands, then hold a warm, wet
washcloth over the tear sac. Carefully place your
finger in the corner of your eye near your nose
and apply pressure to the tear sac.
• Fluid or pus should release from the sac.
Afterward, hold the warm compress to your eye
again