EPIPHORAEVALUATION

SIVA TEJA CHALLA

• Epiphora implies overflowing of tears due to impairment lacrimal drainage.

• due to a disruption in the balance between tear production and tear loss.

CAUSES

• Anatomical complete or partial punctal canalicular or NLD obstruction

• Functional Lacrimal pump failure due to Anatomical deformity (Laxity, orbicularis weakness)

Eyelids

• Horizontal laxity and floppy lids• Lower lid entropion with orb.oculi

overriding• Lower lid ectropion with ineffective

orb.oculi• Loss of skin / orbicularis

Punctal Causes

Congenital agenesis/imperforate

Acquired : • OcclusioN• Infection/radiation• Systemic: phemphigoid,SJS,Burns• Tumors

Mal position• Medial displacement • Medial ectropion

Canalicular• Congenital absence/fistula• Acquired

Intrinsic• Canaliculitis

• Trauma/ Post radiation Trauma/ Post radiation

• Tumours

Extrinsic• Compression by adjacent tumours

Lacrimal Sac Abnormality

o Sac inflammation

o Perilacrimal fibrosis

o Dacryolith

o Sac tumors (rare in pediatric age group)

o Adnexal tumors pressing on lacrimal sac or drainage pathway

NASOLACRIMAL DUCT OCCLUSIONCongenital: • NLD obstruction

• Delayed opening of Hasner’s valve,

• Cranio facial anomalies

• Agenesis.

Acquired:• Primary obstruction

• Secondary obstruction: tumour, trauma

NASAL CONDITIONSo Severe Deviated Nasal Septum or Turbinate Hypertrophy

Excessive tears productionReflex lacrimation in response to various factors

Trichiatic cilia severe entropion,

raised IOP allergic conjunctivitis,

corneal exposure, drug irritation

environmental irritants like pollution

OTHERS• Ocular surface disorders like chronic KCS,

conjunctivochalasis, cicatricial ocular surface pemphigoid, symblephron.

• Neurogenic hypersecretory disorders like compressive irritation of parasympathetic lacrimal fibres, Aberrant regeneration of facial nerve following trauma.

• Facial palsy

CLINICAL EVALUATION OF A PATIENT WITH

EPIPHORA

• Careful history• External examination• Slit lamp biomicroscopy• Syringing and probing• Imaging

HISTORY• constant versus intermittent tearing• periods of remission versus no remission• unilateral or bilateral condition• subjective ocular surface discomfort• history of allergies• use of topical medications• history of probing during childhood• prior ocular surface infections• prior sinus disease or surgery, midfacial trauma, or nasal

fracture• previous episodes of lacrimal sac inflammation• clear tears versus tears with discharge or blood

EXTERNAL EXAMINATION

The eyelids : malpositions, entropion, ectropion,or lid laxity

The puncta : malpositions, stenosis, agenesis,atresia or accessory puncta.

SLIT LAMP BIOMICROSCOPY:• abnormalities of eyelids,• position of punctas,size and patency,discharge,• size of caruncle, • eyelid laxity, blinking mechanism,• marginal tear strip, • Tearfilm debris, • papillae or follicles• pinguecula,pterygium, conjunctival chelosis.• Ocular cicatricial pemphigoid.

Nasal Examination• Anatomic Abnormalities• Hypertrophied turbinates• Nasal polyps• Deviated septum• Atrophic rhinitis

DIAGNOSTIC TESTS

Anatomical testsThese tests helps in localization of obstruction● Syringing / irrigation● Diagnostic probing● Dacryocystography● CT/MRI

Functional tests● To access functioning of lacrimal

apparatus under physiologic conditions● Performed only when there is no evidence

of obstruction in anatomical tests

Flourescein dye disappearance test Scintigraphy Jones dye test I

DYE DISAPPERANCE TEST• heavily relied upon in children, in whom

lacrimal irrigation is impossible without deep sedation

• Instillation of fluorescein drops 2% into the conjunctiva of both eyes then examine after 5 minutes .

• Normally, very little or no dye present• significant residual dye or prolonged

retention is an indication of inadequate drainage of the dye

Fluorescein dye disappearance test

Dye test grading• 0=No fluorescein in the conjunctival sac• 1=Thin flurescing marginal tear drop

persists• 2=More fluorescein persists somewhere

between 1 and 3 grades• 3=Wide brightly fluorescein tear strip• Grades 0 and 1 are considered normal

JONES DYE TESTING

Jones I test, or primary dye test:• Differentiates partial obstruction from

hypersecretion of tears.• Fluorescein 2% drops instilled into the conjunctiva.• After about 5 minutes, cotton tipped applicator

inserted under the inferior turbinate.• Positive: Detection of fluorescein from the nose

means patency of the system.• Negative: No dye detected, means either a partial

or absolute obstruction or failure of the lacrimal pump.

Jones II test, or secondary dye test:

• the residual fluoresce in is flushed from the conjunctival sac following an negative jones 1 test.

• clear saline is placed in to the inferior canaliculus using syringe/cannula

• irrigant is retreived from nasal cavity• Positive: Recovery of dye stained saline from

the nose meaning a partial obstruction of the NLD.

• Negative: Recovery of unstained saline through the nose means total obstruction of the upper drainage system or a defective lacrimal pump mechanism.

Probing• After topical anaesthesia, curved lacrimal

cannula on a saline filled syringe is gently inserted into lower punctum & advanced

• Canula comes to either hard or soft stop

• Hard stop:it comes to stop at medial wall of sac through which rigid lacrimal bone is felt…this indicates obstruction of nasolacrimal duct

• Soft stop:it comes to stop at junction of common canaliculus & lacrimal sac(lateral wall)….

it indicates common canalicular block

Lacrimal Sac Syringing• most frequently performed immediately after a

DDT to determine the level of lacrimal drainage system occlusion

• After instil lation of topical anesthesia, the lower eyelid punctum is dilated

• The irrigating cannula is placed in the canalicular system.

• To prevent canalicular kinking and difficulty in advancing the irrigating cannula ,lateral traction of the lower eye lid

• clear saline is injected and the results noted

Complete canalicular obstruction. The cannula is advanced with difficulty, and irrigation fluid refluxes from the same canaliculus

Com plete common canalicular obstruction. A "soft stop" is encountered at the level of the lacrimal sac, and irrigated fluid ref luxes through the opposite punctum.

Soft stop is a spongy feeling due to canalicular obstruction

Complete nasolacrimal duct obstruction. The cannula is easily advanced to the medial wall of the lacrimal sac, then a "hard stop" is felt, and irrigation fluid ref luxes through the opposite punctum.

If the probe touches the medial orbital wall, this means Hard Stop.

Partial nasolacrimal duct obstruc tion. The cannula is easily placed, and irrigation fluid passes into the nose as well as refluxing through the opposite punctum.

Patent la crimal drainage system. The cannula is placed with ease, and most of the irrigation fluid passes into the nose .

IMAGING TECHNIQUES

Contrast Dacryocystography (DCG)• Technique: Plastic catheters are placed

into one canaliculus in both eyes, 1ml lipidol is simultaneously injected through both catheters

• Water's view radiographs are taken, 5 minutes later, an erect oblique film is taken.

• Results: The site of obstruction is usually evident. Diverticula, filling defects due to stones and strictures can be diagnosed.

Lacrimal scintillography• Scintillography is used to assess the

lacrimal drainage system under physiological conditions.

• Technique: Tchnetium-99 is delivered by a micropipette to the inferior conjunctival sac. The tracer is imaged using a gamma camera.

CT/MRI● Epiphora foll. Trauma with NLD obst.

R/o orb. Rim/ max. #● Infant with cystic mass at med. Can. Amniocele v/s meningocele● Suspected malignancy

Lacrimal Endoscopy• 1.0 mm diameter rigid endoscope or

fibroptic flexible endoscopes was inserted through the puncti and canaliculi to inspect the lining mucosa of lacrimal system, its contents and investigating DCR fistulae.

Epiphora in children

CAUSESEye lid problems• Blepharitis

• Distichiasis

• Poor lid closure

• entropion

Surface abnormalities• Conjunctivitis• Corneal abrasioN• Foreign body• keratitis

Lacrimal outflow abnormalitiesPunctal agenesis/stenosis congenital dacryoceleCanalicular obstruction nasolacrimal duct obstruction

WATERING IN ADULTS

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