LACRIMAL DRAINAGE SYSTEM

LACRIMAL DRAINAGE SYSTEM Presented by- Dr. Mohd. Khalil Mansuri

Moderator- Dr. Eva Tirkey (M.S.)

definitionThe lacrimal system is the physiological system contaning the orbital structures for tear production and drainage.

Embryology 1. Lacrimal glands- 8 wedge shaped epithelial buds. End of 2nd month2. Lacrimal sac- Surface ectoderm. Lies in form of solid column of cells. Canalization starts in Sac-3rd month NLD-6th month Puncta-7th month

LACRIMAL systemIt comprises the structures concerned with the :- 1) Formation of tears- Main lacrimal gland Accessory lacrimal glands

2) Transport of tears- by lacrimal passage Includes- Puncta Canaliculi Lacrimal sac Nasolacrimal duct.

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LACRIMAL GLAND LOCATION-

Main Lacrimal Gland lies in the fossa for lacrimal gland (FOSSA LACRIMALIS) of the frontal bone which lies in upper and outer corner of orbit.

Inferiorly gland rests on globe of eye.

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LACRIMAL GLAND

Lateral horn of aponeurosis of the levator muscle divides it into two parts.

1. SUPERIOR ORBITAL PART - large, almond shaped.2 surfaces-superior & inferior .2 borders-anterior & posterior.2 extremes-medial & lateral. INFERIOR PALPEBRAL PART Small consists of 2-3 lobules.

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DUCTS of lacrimal gland About 10-12 ducts.Passes downwards from the main lacrimal gland.Open in the lateral part of superior fornix.

Some also open in the lateral part of inferior fornix.

Since all the ducts traverse the palpebral lobe , excision of this lobe is functionally equivalent to the excision of the whole gland.

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Accessory Lacrimal Gland1. Glands of Krause:- sub conjunctival tissue of fornices about 40-42 in the upper fornix and 6-8 in lower fornix.

2. Glands of Wolfring:- Along the upper border of Superior tarsus (2-5) and lower border of inferior tarsus (2-3).

3. Rudimentary accessory Lacrimal Glands Present in caruncle, plica semilunaris and Infraorbital region.

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BLOOD SUPPLY & LYMPHATIC DRAINAGE Blood supply- lacrimal artery. (branch of ophthalmic artery)

Venous drainage- lacrimal vein. (drains into the superior ophthalmic vein)- AV shunts are also present in periglandular connective tissue.

Lymphatic drainage- preauricular lymph node.

NERVE SUPPLY

SENSORY - lacrimal branch of ophthalmic division of trigeminal nerve.

SYMPATHETIC postganglionic cervical sympathetic fibers , associated with internal carotid artery (carotid plexus).

SECRETOMOTOR (facial nerve) superior salivary nucleus situated in the brain stem (pons).

LACRIMAL PASSAGE Divided into two parts- A) BONY LACRIMAL PASSAGE B) MEMBRANOUS LACRIMAL PASSAGE

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1) LACRIMAL FOSSA 6.5 mm broad 16.5 mm long Lower part of the medial wall of orbital margin.

formed by- Lacrimal bone Frontal process of maxilla. Lacrimal crest of maxilla. Lacrimal crest of Lacrimal bone. BONY LACRIMAL PASSAGE

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2) NASOLACRIMAL CANAL extends from lacrimal fossa to inferior meatus.

OUTER wall-lacrimal sulcus of maxilla.

INNER wall- - descending process of lacrimal bone. - ascending lacrimal process of inferior turbinate. Avg. length of canal is 12.4 mm.

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It includes

Lacrimal puncta Lacrimal canaliculi Lacrimal sac Nasolacrimal ductMEMBRANOUS LACRIMAL PASSAGE

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LACRIMAL PUNCTA Two in number (one in each lid )

Each puncta situated upon a straight elevation called PAPILLA LACRIMALIS, which becomes prominent in old age .

Puncta are surrounded by a ring of fibrous tissue which keep them patent.

Upper punctum is 6mm. Inferior punctum 6.5 mm.lat. To medial canthuswhen the eyelids are closed puncta do not overlap each other.

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LACRIMAL CANALICULI Superior and inferior canaliculi. Joins the puncta to the lacrimal sac. Diameter- 0.5 mm & two parts VERTICAL-2mm.HORIZONTAL-8mm. These two parts lie at right angle to each other.90% -forms a common canaliculus. (internal common punctum)

Common canaliculus-opens in a small diverticulum of sac LACRIMAL SINUS OF MAIERIn 10% individuals each canaliculus enters the sac separately.

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Lacrimal SacPlaced in the Lacrimal fossa located in the ant. Part of Medial orbital wall.

Sac is closed above and open below where it is continuous with the Naso Lacrimal duct.

The Lacrimal sac enclosed by Lacrimal fascia which is the part of periorbital fascia.

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when distentened it is about 15 mm length and 5-6 mm in width with a capacity 20 cc.

Sac divided into three parts:-

A)Fundus:- it is about 3-5 mm.

B)Body :-10-12mm

C)Neck:- small and narrow part

Lacrimal Sac (RELATIONS)

Medially:- Upper Part- Ant. Ethmoidal air cells. Lower Part- Middle meatus of nose.

Anterolateral (from deep to superficial) (a) Lacrimal fascia and few fibers of inferior oblique muscle. (b) Horners muscles (c) medial palpebral ligament (d) palpebral fibres of orbicularis (e) Angular Vein

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Angular Vein:- Lying under the skin it crosses the medial palpebral Ligament 8mm from the medial canthus. therefore to avoid profuse bleeding during sac surgery incision should not be made more than 2-3 mm medial to the medial canthus. (f) skin is the most anterior relation.

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Posteriorly:- From the Ant to post-a)Lacrimal fasciab)Horners Musclec)Septum Orbitale-which separates the sac from the orbital fat .d)Ligament of the Medial Rectus Muscle.

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NASOLACRIMAL DUCT Length: - may varies from 12-24 mm Diameter:- About 3 mmDivided into two Parts:-a) Intra osseous part:- lying in the Naso-lacrimal canal (12.4 mm ).b) Intra Meatal Part:- lying within the mucous membrane of the lateral wall of the nose (5.32mm)

Direction of the NLD is downwards and backwards and laterally.

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NLD- inferior opening is called ostium lacrimali.

Lumen narrow and long in female.

Broad and short in male.

In females perimenopausal & menopausal changes causes shredding of epithelial cells, which may leads to blockage of NLD.

Dacryocystitis is more common in female.

Valves of NLDLumen of NLD is marked by numerous folds of mucous membrane called as valves.

Valve of ROSENMULLER.Valve of BOCHDALEK.Valve of KRAUSE or FERAUD.Valve of TAILLEFER.Valve of HASNER.Valve of FOLTZ.Valve of medial palpebral ligament.

HISTOLOGY Lacrimal sac and NLD are lined by- 1. Epithelium- two layers of cells Superficial Layer- Non-ciliated columnar cells and contains Goblet cells. Deep Layer- Flattened cells.

2. Subepithelial Tissue- contains lymphocytes.3. Fibroelastic Tissue.4. Plexus of vesseles-well developed around NLD.

Blood Supply of the Lacrimal PassageArterial supply :- Derived from three sources.1) From ophthalmic Artery.2) From the angular branch of facial artery.3) From the Internal maxillary Artery.

Venous Drainage:- angular vein and infra orbital vein from above and Nasal vein from below.

Lymphatics :-drain into the submandibular and deep cervical glands.

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Nerve Supply of the Lacrimal Passage1) Sensory :- Trigeminal nerve.Canaliculi, SAC, and upper part of duct- infrartroachlear Branch of nasocilliary nerve. Lower Part of the Duct- Ant. Superior alveolar Nerve.

2) Motor :- from the branch of facial nerve which supply the orbicularis muscles.

3) Sympathetic :- from sympathetic outflow of the orbit.

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Jones lacrimal pump

Tears flow-along the upper and lower marginal strips and enter the upper and lower canaliculi by capillarity and also by suction .

With each blink, the pretarsal orbicularis oculi compress the ampullae. Shortens the horizontal canaliculi and moves the puncta medially.

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Simultaneously contraction of lacrimal part of orbicularis oculi causes expansion of lacrimal sac, thereby creating a negative pressure which sucks the tears from the canaliculi into the sac

When the eyes open the muscles relax, the sac collapses and a positive pressure is created which forces the tears down the nasolacrimal duct into the nose.

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Disorder of secretion-HYPERSECRETION:- Primary Hyperlacrimation-d/t direct stimulation of the lacrimal gland. eg.cysts, tumour. Reflex Hyperlacrimation results from stimulation of sensory branches of 5th cranial nerve d/o irritation of cornea or conjunctiva. Central Lacrimation-(psychical lacrimation)-seen in emotional stage and hysterical lacrimation.Applied aspects of Lacrimal Gland

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TEAR FILM Wolff (1946) first described detail structure of tear film and given the term precorneal film. Tear Film consist of three layers-1) Lipid Layer:- outermost secreted by meibomian, zeis & Moll glands(.1m) 2) Aqueous Layer:- Secreted by Lacrimal Glands (6.5-7.5m)

3) Mucin layer:- secreted by conjunctival goblet cells(.02-.05m)

HYPOSECRETION- Serious lack of tear may result into Dry eye - not a disease its a symptom complex occuring as a sequele to deficiency or abnormalties of tear film.

It is due to- Aqueous deficiency Mucin deficiency Lipid deficiency Impaired eyelid function epitheliopathy

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Drainage DysfunctionsEpiphora is overflow of tears onto the face, d/t insufficient tear film drainage from the eyes.

* Malposition of Lacrimal Puncta.* Obstruction anywhere in lacrimal passage.* Lacrimal Pump Failure.

Mass or swelling in the Region of medial canthus.

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Congenital anomalies of lacrimal glandAlacrimia-congenital deficiency or absence of tear secretion. Riley day syndrome Acoustic neuroma Anhydrotic Ectodermal dysplasia Surgery of CPA

Aplasia of lacrimal gland- may lead to congenital alacrimia.

Swelling in Lacrimal Gland

Dacryoadenitis -Inflammation of lacrimal gland.

b) Mikuliczs Syndrome:- Bilaterally symmetrical enlargement of Lacrimal and Salivary Glands.

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Dacryops:- cystic swelling in upper fornix due to retention of secretions following blockage of Lacrimal duct.

Tumors:- Pleomorphic adenoma is the commonest.

Swelling in Lacrimal Gland

Congenital Anomalies Of The Lacrimal Passage 1. Ectasia of lacrimal passage:- due to failure of normal fusion of nasal and maxillary process.

2. Atresia of Lacrimal Passage:- failure of canalization.

3. Congenital occlusion of NLD:- more common in lower end, causes epiphora .

In the foetus, NLD is a solid cord & gets canalized later. In about 30% cases this canalization is delayed or is absent at lower end.

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Congenital Dacryocele:- Collection of amniotic fluid and mucous in the Lacrimal Sac caused by imperforate valve of hasner.

Congenital Fistula of Lacrimal sac.

Congenital Anomalies Of The Lacrimal Passage

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During embryogenesis Canalization of solid columns of ectodermal cells takes place by degeneration and shredding of central cells.

Debris of these cells if remains may occlude sac and may cause congenital mucocoele.

Incomplete canalization causes blockage of NLD may leads to congenital dacryocystitis.

Anomalies Of The Lacrimal Passage

Congenital absence of punctum- d/t failure or incomplete outbudding of nasolacrimal core.

Punctal stenosis.

Supernumerary puncta and canaliculi.

Dacryoliths acquired NLD blockage.

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DISEASES OF LACRIMAL PASSAGEDacryocystitis - Inflammation of lacrimal sac.

Acute - Chronic-

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REFERENCESWolffs anatomy of eye and orbit (1968 ed.)Jack J. Kanski clinical ophthalmology. Duke Elder system of ophthalmology.Parsons diseases of eye.A. K. Khurana- anatomy and physiology of eye.H. V. Nema anatomy of eye and its adenexa.www.emedicine .com.www.ophthalmology.com.

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THANK YOU

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