Examination of patients with lacrimal disease

Careful examination of the eyelids and ocular surface should exclude causes of hypersecretion such as marginal blepharitis (Figure 10.12),

Rotten Accidentes
Figure 10.12 Epiphora caused by severe blepharo-keratitis in a patient with acne rosacea.

trichiasis, dry eyes, pingueculum and corneal pathology.

The normal punctum is directed into the tear lake and, although frank lower lid ectropion is easily recognisable, mild punctal ectropion may be missed and is often associated with secondary punctal stenosis. A pouting punctum with a plug of stringy pus that is almost impossible to express is suggestive of Actinomyces canaliculitis (Figure 10.13). Eyelid laxity, even in the absence of lid or punctal malposition, can result in troublesome epiphora due to lacrimal pump failure and "gravitation" of the tear-line on the sagging lower lid margin. Facial weakness should be noted and the presence of aberrant

Figure 10.13 Stringy, non-expressible pus at the punctum of a canaliculus affected by Actinomyces.

muscular movements suggests aberrant reinnervation and the possibility of "crocodile tears" as a cause of the patient's symptoms. The presence of a lacrimal sac mucocoele or a mass may only become evident after palpation of the lacrimal sac fossa; a readily expressible mucocoele suggests a patent canalicular system with nasolacrimal duct obstruction and requires no further investigation.

Each tear film should be stained with a partial drop of 2% fluorescein and the height of the tear meniscus and stability (break-up time) of the tear film assessed. Corneal staining suggests the possibility of episodic reflex hypersecretion due to unstable tear film or reduced background tear secretion. The rate of dye disappearance from the conjunctival sac, particularly useful in children, gives a good indication of lacrimal drainage especially when both sides are compared (Figure 10.14).

Lacrimal syringing is invariably performed as part of the assessment of the adult patient with epiphora. Good technique is essential not only to obtain maximum information, but also to avoid canalicular damage and subsequent fibrosis; it is possible that many canalicular obstructions are iatrogenic. After instilling a topical anaesthetic, the punctum may be dilated without rupturing the surrounding ring of connective tissue or annulus. Lateral traction is applied to the eyelid to straighten the canaliculus and a fine lacrimal cannula on a 2ml saline-filled syringe is used to gently probe the appropriate canaliculus (Figure 10.15). In cases of canalicular obstruction a

Figure 10.14 Asymmetrical tear lines and dye disappearance in a child with nasolacrimal duct stenosis.

Figure 10.13 Stringy, non-expressible pus at the punctum of a canaliculus affected by Actinomyces.

Figure 10.14 Asymmetrical tear lines and dye disappearance in a child with nasolacrimal duct stenosis.

Nasolacrimal Cannula

Figure 10.15 Analysis of lacrimal probing and syringing: (a) "hard stop" with a patent canalicular system; (b) medial "soft stop" with obstruction of common canaliculus; (c) lateral "soft stop" due to lower canalicular obstruction.

Figure 10.15 Analysis of lacrimal probing and syringing: (a) "hard stop" with a patent canalicular system; (b) medial "soft stop" with obstruction of common canaliculus; (c) lateral "soft stop" due to lower canalicular obstruction.

"soft stop" is reached. Reflux of clear fluid through the same punctum in individual canalicular obstruction or through the opposite punctum in common canalicular obstruction: with individual canalicular obstruction, the point of obstruction may be assessed by grasping the cannula at the punctum with fine forceps before withdrawing it from the canaliculus. In the absence of canalicular disease a "hard stop" is felt as the cannula reaches the medial wall of the lacrimal sac and, in such cases, the irrigation fluid that reaches the nose if the nasolacrimal duct is patent or only partially obstructed; reflux of fluorescein-stained fluid, with or without mucus, from opposite punctum and failure of fluid to reach the nose indicates total nasolacrimal duct obstruction.

Intranasal examination (with a headlight and speculum or, ideally, an endoscope) may be performed, looking for the presence of fluorescein in the inferior meatus, polyps, allergic rhinitis, septal deviation, turbinate impaction (rare), or other intranasal diseases (Figure 10.16). Preoperative nasal endoscopy is essential in the assessment of patients for endonasal lacrimal procedures.

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