Day 2 (3): Basic Clinical Evaluation of the Lacrimal Drainage System

Question 1

What are the parts of the lacrimal system?

Answer 1

1. Secretory system: main lacrimal gland, accessory lacrimal glands (of Krause and Wolfring)
2. Drainage system: puncta, canaliculus, lacrimal sac, NLD
3. Lid-Globe apposition: tendons
4. Lacrimal pump mechanism: OO

Question 2

What are the general causes of excessive tearing?

Answer 2

1. Increased production: hypersecretion overwhelms drainage
2. Decreased drainage: anatomically compromised drainage system
3. Poor lid-globe apposition: tear lake does not align with the puncta
4. Dysfunctional lacrimal pump mechanism: OO palsy

Question 3

Why is lid-globe apposition important for tear drainage?

Answer 3

1. Directs tears across the ocular surface into the puncta
2. Prevents excessive exposure of ocular surface and minimizes tear film evaporation

Question 4

Differentiate epiphora from lacrimation.

Answer 4

Lacrimation:
- aka Hypersecretion/Hyperlacrimation/Reflex Tearing
- increased tear production WITH normal tear transport or drainage
- produced tears overwhelm drainage system
- causes: corneal or conjunctival irritation, emotions

Epiphora:
- tear production is normal BUT tear transport or drainage is impaired
- overflowing tears (tears on the cheeks)

Question 5

Differentiate anatomic from functional lacrimal drainage dysfunction

Answer 5

Anatomic:
- (+) gross STRUCTURAL abnormality
- partial (stenosis) OR complete blockage

Physiologic:
- failure of FUNCTIONAL mechanisms BUT lacrimal drainage system remains patent

1. Poor lacrimal pump mechanism
   - OO weakness due to CN 7 palsy
2. Poor lid-globe apposition
   - lower lid laxity due to aging or CN 7 palsy

Question 6

What are the causes of lacrimation?

Answer 6

INCREASED TEAR PRODUCTION

1. Trigeminal nerve stimulation (reflex tearing): due to ocular surface irritation
   - blepharitis, trichiasis
   - conjunctival and cornea inflammatory diseases
   - foreign bodies, contact lens use
   - dry eye syndrome
   - neuralgia
   - ocular inflammation (uveitis)
   - allergies
2. Supranuclear: psychogenic (emotion)
3. Infranuclear:
   - CN 7 aberrant innervation: goes to lacrimal nerve instead
   - lacrimal gland stimulation
4. Bright lights, sneezing

Question 7

What are the causes of epiphora?

Answer 7

DECREASED TEAR DRAINAGE

1. Anatomic (stenosis or complete)
   - congenital
   - inflammatory +/- infectious
   - traumatic +/- burns
   - neoplastic
   - idiopathic
   - chronic ectropion
   - iatrogenic
   - nasal factors: allergic, iatrogenic, neoplastic
2. Functional
   - incorrect lid closure: lid laxity, lagophthalmos, traumatic, iatrogenic
   - eyelid malposition
   - punctal eversion or medialization

Question 8

What are the causes of combined lacrimation and epiphora?

Answer 8

1. Facial nerve palsy:
   - lacrimal pump failure from OO dysfunction (E)
   - lagophthalmos –> exposure keratitis/corneal irritation (L)
2. Lower lid ectropion:
   - punctal eversion (E)
   - conjunctival irritation (L)

Question 9

Parts of the evaluation of a tearing patient?

Answer 9

1. History
2. Comprehensive ophthalmic exam including:
   - eyelids
   - lacrimal system
   - nasal cavity
   - anterior segment

Question 10

Why is it important to differentiate lacrimation from epiphora?

Answer 10

Management:
Lacrimation - usually MEDICAL
Epiphora - usually SURGICAL

Question 11

What are the pertinent points to elicit in the history of a tearing patient?

Answer 11

1. Laterality (uni- or bi-)
2. Onset and duration (congenital or acquired)
3. Frequency (constant or intermittent)
4. History of masses or bleeding from punctum (malignancy)
5. History of recurrent lacrimal sac inflammation (leading to NLDO)
6. Associated burning, grittiness or FB sensation (DES)
7. Previous trauma or surgeries to the eyes, nose or face
8. Use of medications (ophthalmics, chemotherapy, radiotherapy)
9. History of ocular surface infections (conjunctiva, cornea)
10. Allergies

Question 12

Pertinent findings to note in the FACE when doing external eye examination:

Answer 12

Facial asymmetry
- Brow ptosis (frontalis)
- Lagophthalmos (OO)

Question 13

Pertinent findings to note in the EYELIDS when doing external eye examination:

Answer 13

Eyelid margin position
- Ectropion: outward turning of margin –> exposure keratopathy
- Entropion: inward turning of margin –> corneal and conjunctival irritation

Question 14

Pertinent findings to note in the EYELASHES when doing external eye examination:

Answer 14

Eyelash position and dandruff-like scales
- Trichiasis: misdirected eyelashes towards ocular surface
- Distichiasis: eyelashes grow from Meibomian gland orifices
- Collarettes: dandruff-like scales at base of lashes (blepharitis)

Question 15

Pertinent findings to note in the PUNCTUM when doing external eye examination:

Answer 15

1. Size
2. Malposition
   - Ectropion: punctum everted away from tear lake
   - Medialization: punctum more medial away from tear lake
3. Stenosis/occlusion/overlying membrane
4. Pouting or swelling
   - Canaliculitis +/- Concretions
5. Abnormal surrounding structures
   - Conjunctivochalasis: loose, redundant, non-edematous conjunctiva occluding the lower punctum
   - Enlarged lacrimal caruncle

Question 16

Pertinent findings to note in the MEDIAL CANTHAL AREA when doing external eye examination:

Answer 16

1. Inflammation (swelling, redness, warmth, tenderness)
   - Does not cross horizontal midline
   - Acute dacryocystitis: inflammation of lacrimal sac and NLD due to obstruction
   - Dacryocystocele: congenital bluish cystic mass filled with mucoid material and amniotic fluid
2. Masses
   - Lacrimal sac tumor: crosses horizontal midline
   - Frontoethmoidal Encephalocele
   - Ethmoidal Mucocele

Question 17

Pertinent findings to note in the OCULAR SURFACE when doing external eye examination:

Answer 17

Examine with slit lamp biomicroscopy and fluorescein dye.
- INCREASED fluorescein dye uptake on ABNORMAL surface
- abrasions, erosions, keratitis/keratopathy, foreign bodies

Remember:
Any conjunctival or corneal irritation, mechanical or inflammatory, causes lacrimation

Question 18

What is elicited with palpation/compression of the lacrimal sac?

Answer 18

1. Pain/Tenderness: sign of ACUTE inflammation
2. Expression of mucopurulent discharge from the puncta
   - (+) ROPLAS: Regurgitation On Pressure over the LAcrimal Sac
   - sign of CHRONIC and REPEATED inflammation causing NLDO

DDX:
1. Dacryocystitis: inflammation of the lower system
- punctum and canaliculus is NORMAL
- inflammation is more MEDIAL

2. Canaliculitis: inflammation of the upper system
   - punctum and canaliculus is INFLAMED (more LATERAL)

Question 19

What are the different ANATOMIC excretory tests for epiphora?

Answer 19

Goal: Look for location of obstruction

1. Lacrimal Apparatus Irrigation/Syringing
2. Canalicular probing
3. Jones II Test
4. Nasal Endoscopy

Question 20

What are the different PHYSIOLOGIC excretory tests for epiphora?

Answer 20

Indication: To confirm diagnosis of epiphora, assess tear flow and for pts where anatomical tests are not possible (e.g. children)

1. Fluorescein dye disappearance
2. Jones I Test
3. Saccharin Test

Question 21

What are the different SECRETORY tests to assess lacrimation?

Answer 21

Goal: Test secretory function of the lacrimal glands and integrity of the tear film

1. Tear Break-up Time
2. Schirmer’s Test
3. Rose Bengal Test
4. Tear Lysozyme Test

Question 22

How is the Saccharin test done?

Answer 22

1. A drop of 2% saccharin is placed in the conjunctival fornix.
2. 90% of patients with a patent lacrimal system will taste it in 15 minutes.

Question 23

How is the Fluorescein Dye Disappearance Test done?

Answer 23

• Evaluation of the residual fluorescein in the eye following instillation into the UNANESTHETIZED conjunctiva.
• High sensitivity
• Usually done in CHILDREN
• DOES NOT localize the obstruction

1. A drop of 2% fluorescein is placed in the fornix
2. The volume of the tear meniscus and fluorescein remaining in the conjunctival cul-de-sac is examined with the cobalt blue light after FIVE minutes.
3. The amount of remaining fluorescein can be graded using a scale from 0 to 4:
   - 0: no remaining dye [+ FDDT/Normal]
   - 1: minimal dye remaining [+ FDDT/Normal]
   - 2/3: subjective [- FDDT/Abnormal]
   - 4: all the dye remains [- FDDT/Abnormal]
4. Compare both sides simultaneously.

Result:
+ FDDT: lacrimal drainage dysfunction unlikely
- FDDT/Retention: delay in tear flow

Question 24

Describe how lacrimal apparatus irrigation test is done.

Answer 24

• Performed immediately AFTER a NEGATIVE FDDT to localize level of obstruction
• Not a physiologic test because it uses higher hydrostatic pressure than normal tear outflow
• CONTRAINDICATIONS: acute infection (dacryocystitis or canaliculitis)

1. Instillation of topical anesthetic
2. Dilation of punctum with lacrimal dilator
3. Blunt cannula attached to a 3 cc syringe is placed into the inferior punctum (vertically for 2 mm then horizontally with the eyelids stretched to straighten the canaliculus)
4. Advance cannula for 3-7 mm into canaliculus and irrigate with sterile water or normal saline.

Question 25

How is canalicular probing done?

Answer 25

- INDICATION: LAI demonstrates obstruction and determination of location/extent of block - CONTRAINDICATION: Acute infection (dacryocystitis/canaliculitis) 1. Instillation of topical anesthetic and dilation of punctum done during LAI 2. Lacrimal probe is advanced 2 mm vertically then horizontally while keeping the eyelid stretched laterally. 3. Advance probe until obstruction OR lacrimal bone is encountered. Result: Hard Stop: lacrimal bone; obstruction in the NLD Soft Stop: spongy feeling; obstruction in CC or kinking of canaliculus (always maintain traction on eyelids to straighten) RUC/RLC/LUC/LLC: ___ mm hard/soft stop Note: if > 10 mm of probe advanced, already in lacrimal sac

Question 26

Interpretation of LAI and Lacrimal Probing test results.

Answer 26

(+) Fluid in nose/pharynx, (-) Reflux, Hard stop: PATENT (normal or physiologic dysfunction) (+) Fluid in nose/pharynx, (+) Reflux in OPPOSITE PUNCTUM, Hard stop: INCOMPLETE BLOCK/STENOSIS anywhere in the system (-) Fluid in nose/pharynx, (+) Reflux in SAME PUNCTUM, Soft stop: COMPLETE CANALICULAR BLOCK (-) Fluid in nose/pharynx, (+) Reflux in OPPOSITE PUNCTUM --> PROBING --> Hard stop: COMPLETE NLDO Soft stop: COMPLETE COMMON CANALICULAR BLOCK

Question 27

When is PHYSIOLOGIC DYSFUNCTION or FUNCTIONAL DISORDER of lacrimal drainage system suspected?

Answer 27

1. Presents with epiphora 2. (-) FDDT: delayed/abnormal 3. LAI: (+) Fluid in nose or pharynx, (-) Reflux 4. Probing: Hard stop on probing Suspect: Lacrimal Pump Insufficiency/Dysfunction

Question 28

Describe the Jones I Test

Answer 28

- Evaluates lacrimal outflow under PHYSIOLOGIC conditions (normal hydrostatic pressure) similar to FDDT - only an ANATOMICALLY and FUNCTIONALLY PATENT system will produce a (+) result - Rarely performed due to HIGH FALSE NEGATIVE (dye may be difficult to retrieve since procedure is somewhat blind) 1. 2% Fluorescein instilled into UNANESTHETIZED conjunctiva 2. Cotton-tipped applicator inserted beneath the inferior turbinate at the level of the NLD ostium at 2 MINUTES then at 5 MINUTES. (+): dye in applicator --> similar to (+) FDDT --> patent and functionally adequate (-): no dye --> similar to (-) FDDT --> delayed transit time --> anatomic or physiologic problem

Question 29

Describe the Jones II Test

Answer 29

- Performed after a (-) Jones I test (anatomic or functional problem) - Almost similar to LAI 1. Residual fluorescein in flushed from ANESTHETIZED conjunctiva by irrigation with normal saline through one canaliculus using a lacrimal cannula. 2. Pt to blow or spit any fluid that passes into the nose or pharynx into a clean tissue (+): recovery of saline + some reflux - if dye-stained: STENOSIS of lacrimal sac or NLD (pooling of fluorescein within the sac) - if clear: STENOSIS of puncta or canaliculus (most fluorescein from Jones I was not able to enter drainage system) (-): no saline recovered + reflux; COMPLETE obstruction but CANNOT LOCALIZE

Question 30

Interpretation of results of the Jones I and Jones II Tests

Answer 30

(+) Jones I, (+) Jones II - DYE: Patent (Normal vs Low-grade Stenosis) (-) Jones I, (+) Jones II - CLEAR: Punctal or Canalicular stenosis vs Functional (-) Jones I, (+) Jones II - DYE: Lacrimal Sac or NLD stenosis vs Functional (-) Jones I, (-) Jones II, (+) Reflux of SALINE in OPPOSITE punctum: Complete Common Canalicular Obstruction (-) Jones I, (-) Jones II, (+) Reflux of SALINE in SAME punctum: Complete Canalicular Obstruction (-) Jones I, (-) Jones II, (+) Reflux of DYE in OPPOSITE punctum: Complete NLDO (-) Jones I, (-) Jones II, (+) Reflux of DYE in SAME punctum: Complete NLDO + Complete Opposite Canalicular Obstruction In summary: Patent and Functional: (+) Jones I, (+) Jones II Partial/Stenosis or Dysfunctional: (-) Jones I, (+) Jones II Complete/Obstruction: (-) Jones I, (-) Jones II

Question 31

Why do nasal endoscopy in cases of lacrimal drainage system obstruction?

Answer 31

To rule out nasal pathologies causing lacrimal symptoms: 1. Nasal/paranasal tumors 2. Hypertrophy of inferior turbinate 3. Septal deviations Steps: 1. Pharmacologic decongestion with Oxymetazoline 2. Insertion of rigid 4 mm or 3.7 mm endoscope Note: poor view from speculum and headlight

Question 32

What are the goals when examining a tearing patient?

Answer 32

Differentiate between: Epiphora: lacrimal drainage dysfunction VS Lacrimation: ocular surface irritation AND Anatomic: mechanical obstruction Physiologic: lacrimal pump failure In most: HX and PE are enough.

Question 33

Most clinically useful tests in lacrimal drainage dysfunction?

Answer 33

1. Fluorescein Dye Disappearance Test: establish diagnosis of epiphora and estimate of severity 2. Lacrimal Apparatus Obstruction and Canalicular Probing: localize level of obstruction once diagnosis is established