Lacrimal disorder

Question 1

What are the 3 lacrimal disorders ?

Answer 1

• Infection
• Disorders of tear drainage
• Dry eye

Question 2

What does the lacrimal system consist of ?

Answer 2

• structure which produces the tears and structure which drains the tears
• could be involved with pathology.

Question 3

What does it mean with cryo infront of the word ?

Answer 3

• disorder of the lacrimal system

Question 4

What is the symptoms of lacrimal gland infection (dacryoadentitis) ?

Answer 4

• acute discomfort - of the eyelid (particularly in the upper temporal quadrant, where the lacrimal gland is located )
• clinical signs - ptosis with hyperaemia and oedema (most pronounced in upper temporal quadrant)
• Injection of superotemporal conjunctiva

Question 5

Why is it difficult to deal with a px with dacryoadenitis?

Answer 5

• would need systemic antibiotics - might look like a orbital cellulitis - so better to refer ?
• this is an infection of the LACRIMAL GLAND

Question 6

What can be outflow lacrimal obstruction ?

Answer 6

• Punctal stenosis

- Canaliculitis

Question 7

How does punctual stenosis occur ?

Answer 7

-This can follow conjunctival scarring from trauma, or as a result of an infection or inflammation (e.g. herpes simplex)
-also could be from drug therapy (e.g. anti-virals)
Punctal stenosis - when pathway is blocked (puncta) causes build up of tears/water- causing watery eye

Question 8

How does canaliculitis occur ?

Answer 8

• can have blockage in the canaliculi
• Infection of canaliculus, e.g. by Actinomyces israelii (around 2% of cases of epiphora)- this bacteria tends to cause this canaliculus infection and in the process it blocks the canaliculi causing outflow obstruction

Question 9

What is a common cause of outflow obstruction ?

Answer 9

• Congenital outflow obstruction - tear outflow pathway at birth hasn’t been formed fully
• 20% of eyes of babies shows evidence of symptomatic outflow obstruction

-Symptoms include epiphora and mucopurulent discharge

• 70% of affected children are symptom-free by 3 months of age, and over 90% by their first birthday
• could be mistaken for bacterial conjunctivis

Question 10

What else causes outflow obstruction ?

Answer 10

a infection in the lacrimal sac

Question 11

What are the diseases of infection in the lacrimal sac ?

Answer 11

dacryocystitis

Question 12

What is the infection of the lacrimal gland ?

Answer 12

dacryoadenitiis

Question 13

What is acute dacryocystitis and how does it resolve ?

Answer 13

accumulation of tears and mucus within the lacrimal sac which becomes inflamed
-resolves with topical/systemic antibiotics and warm compresss

Question 14

What can acute dacryocystitis lead to ?

Answer 14

chronic dacryocystitis- where patients need to undergo surgery - as they have a. permanent blockage - so need surgery to unblock for tear drainage

Question 15

What is the treatment for dacryocystitis?

Answer 15

-Systemic antibiotics

• Incision and drainage where appropriate
• Follow-up may include dacryocystogram (DCG) and surgery e.g. dacryocystorhinostomy (DCR-used silicone tubing to create. nw drainage channel- drill a hole in nasal bones- creates artificial outflow pathway

Question 16

What is dry eye disease ?

Answer 16

• most common disease to see in routine practice

Question 17

What is dry eye ( LONG DEFINITION )?

Answer 17

• a multifactorial disease of the ocular surface characterised by a loss of homeostasis of the tear film, and accompanied by ocular symptoms, in which tear film instability and hyperosmolarity, ocular surface inflammation and damage, and neurosensory abnormalities play aetiological role
• TEAR FILM is UNSTABLE- associated with the increase of osmolarity in tear film - hyperosmolarity.
  ocular surface associated with varying degrees of inflammation which could lead to ocular surface image

Question 18

What diseases is tear deficient dry eye caused by ?

Answer 18

A Sjogren’s Syndrome (SS)
B Non-Sjogren’s Syndrome

-it happens as a result of age

Question 19

What is Evaporative dry eye caused by ?

Answer 19

• produce normal tear volume however the tears are unstable due to meibomian gland oil is insuffienct and of the wrong compensation
  A Oil deficient
  B Lid related - position of eyelid
  C Surface change- tears evaporate to quickly
  D Contact lens-related

Question 20

What do most patients show sign of in dry eye disease ?

Answer 20

evidence of both tear deficiency and evaporative dry eye

Question 21

What is Sjogren’s Syndrome ?

Answer 21

• is an autoimmune disorder
  consisting of dry eye (KCS) and dry mouth (xerostomia), which often involves nasal and vaginal mucous membranes
  -However tends to attack the lacrimal gland

Question 22

What is the SS associated with commonly?

Answer 22

with systemic (autoimmune_ diseases such as rheumatoid arthritis and systemic lupus erythematosus (SLE)

Question 23

How to truly diagnose SS px ?

Answer 23

• good clinical history - to ask if they have a dry mouth as well as a dry eye

Question 24

what is the other cause of lacrimal deficiency?

Answer 24

acquired primary lacrimal disease

Question 25

what is acquired primary lacrimal disease?

Answer 25

. commonest cause of tear deficient dry eye . only lacrimal glands involved . histology shows infiltration by inflammatory cells, loss of normal structure , atrophy and fibrosis . blood tests normal

Question 26

what symptoms do mild dry eye px have?

Answer 26

``` . irritation . itching . soreness . burning . intermittent blurred vision ```

Question 27

what symptoms do moderate dry eye px have?

Answer 27

. increased discomfort and frequency symptoms | . visual effects more consistent

Question 28

what symptoms do severe dry eye px have?

Answer 28

. increasing frequency of symptoms or constant symptoms | . visual symptoms may be disabling

Question 29

what are the signs of acquired primary lacrimal disease?

Answer 29

``` . conjunctival injection . conjunctival staining . corneal staining . reduced tear meniscus . filaments . reduced tear BUT . reduced schirmer score . meibomian gland disease ```

Question 30

what is schirmer test?

Answer 30

. use strips of specialized filter paper that hook over the lower eyelid . you are measuring how far the tears spread along those filter paper in 5 mins

Question 31

what is acquired primary lacrimal disease management?

Answer 31

``` . lubricants- OCULAR LUBRICANTS . tear preservation . lid hygiene . oral antibiotics . immunosuppresants . alternative therapies ```

Question 32

what are ocular lubricants?

Answer 32

. ocular lubricants in the form of eye drops, gels and ointments are used to treat discomfort associated with condition in which the tear film is reduced or unstable

Question 33

what is tear preservation?

Answer 33

. plugs are put into the puncta . a dilator is used to open up the puncta to allow you to put the plug . blocks the puncta . we want to maximize tears produced by px

Question 34

what os blockage of the tear drainage system associated with?

Answer 34

. epiphora - watering of the eye