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THE LACRIMAL SYSTEM

Dr. Prima Maya Sari, SpM


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The lacrimal system anatomy &

physiology.

production, distribution, and drainage of tears

protects the ocular surface to optimal vision.distribute tears and transport tears to the puncta.

drains tears from the lacus lacrimalis (Lid tear lake)


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The lacrimal system anatomy &

physiology

The main lacrimal gland is located in the superiorlateral portion.

divides the lacrimal gland into an orbital andpalpebral lobe laying beneath the levatoraponeurosis.

The orbital lobe contains approximately two thirdsof the volume of the lacrimal gland, and the

palpebral lobe constitutes the remainder.


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Tear Production

to keep the eye moist is provided by acontinuous secretion from the accessory

lacrimal glands

Excessive production of tears, as incrying, is due mainly to reflex nervous

stimulation of the main lacrimal gland.

tear production just exceeds that lost by

evaporation; the remainder passes down

the nasolacrimal duct.


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Tear Film

The precorneal tear film is composed of threelayers:

(1) thethin,superficial oily layer measuring about o.9to 0.2 Mm. is produced predominantely by the tarsal

(meibomian) glands and to a slight extent by thesebaceous glands (Zeis) and sweat glands (Moll);

(2) the thick, watery layer, measuring about 6.5 to 7.5

Mm, is secreted by the lacrimal glands;

(3) the thin mucin measuring about 0.5 Mm, is

secreted by the conjunctival gobletcells and from thelacrimal gland cells.


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Lacrimal System Disorders

Tear film disorders (all phases)

The dry eye

The wet eye

Drainage obstruction

Lacrimal gland inflammation

Lacrimal gland tumours

Lacrimal sac tumours


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Keratoconjunctivitis Sicca

Aqueous phase deficiency

Symptoms

Redness

Burning sensation

Gritty sensation

Stiff lids - difficulty with initial opening

epiphora in some cases


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Keratoconjunctivitis Sicca

Causes of aqueous deficiency

Idiopathic/age related

1 & 2 Sjgrens syndrome

Inflammatory or infiltrative lesions e.g. Lymphoma, TB,sarcoidosis

Congenital/iatrogenic absence of lacrimal gland

CN V defect (sensory arc)

CN VII defect (motor arc; anticholinergics) ADRs (antihistamines; -blockers; phenothiazines; OCP)


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Epiphora

Causes Exclude eye disease

Allergic/infective/irritative conjunctivitis

Trichiasis, distichiasis

Corneal disease

Dry eye with compensatory hypersecretion

Lacrimal pump failure (e.g. CN VII palsy)

Lid-globe incongruity such as ectropion

Lacrimal drainage system obstruction

Hypersecretion


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Epiphora

Specific tests of patency

Fluorescein disappearance test

Jones test - staining of nasal swab after

instillation of fluorescein into fornix

Syringing & probing - diagnostic & therapeutic

(optometric role?)

Ophthalmologists may also perform CT & MRIscans, radionucleotide scans


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Lacrimal Drainage System Obstruction

Treatment depends on site of obstruction:

Puncta may be dilated ( snips)

Lid malposition correction

Recanalisation operations

Treat infectious causes (e.g. canaliculitis,

dacryocystitis)

Recurrent dacryocystitis requires DCR

Probing atretic nasolacrimal ducts, DCR = mainstay

of treatment of NLD obstruction


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Lacrimal Gland Inflammation

Viral dacroadenitis e.g mumps, glandular fever

Acute bacterial dacryoadenitis often 2 to

conjunctivitis

Chronic bacterial e.g. TB, syphilis

Inflammatory conditions e.g. Sjgrens,

sarcoidosis, Wegeners

Reactive lymphoid hyperplasia, lymphoma


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Lacrimal Gland Tumours

50% are inflammations & lymphoid proliferations

Pleomorphic adenoma (benign mixed celltumour)

Epithelial origin 20-60 yrs

Painless, usually with long history (>1yr)

Palpable hard nodular mass

Non-axial proptosis; ROEM; astigmatism Surgical removal en bloc rather than biopsy

Good prognosis if completely removed


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CONGENITAL NASOLACRIMAL DUCT OBSTRUCTION &

RECURRENT ACUTE CONJUNCTIVITIS

Congenital NLDO presentedwith recurrent acuteconjunctivitis.

Medical Management ofNLDObstruction

There is general agreement that

the best initial management ofan NLD obstruction is acombination of nasolacrimal sacmassage and topical antibioticsto reduce the amount ofmucopurulent discharge.

Massage of the nasolacrimal sachas been shown to be effectivein increasing the rate ofspontaneous resolution of thedistal membranous nasolacrimalduct obstruction.


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AQUIRED(ADULTS) NASOLACRIMAL DUCT OBSTRUCTION

WITH LACRIMAL SAC INFECTION(DACRIOCYSTITIS)

Acute on chronic or recurrent acute

Dacryocystitis due to chronic

NLDObstruction in adults.

Treatment with antibiotics

topically(drops+ointments) with systemic

antibiotics oral or parenteral.

Drainage of abscess & finally DCR

DACRIOCYSTORHINOSTOMY

(DCR),(CREATE ARTIFICIAL DRAIN

TO THE NOSE).

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