lacrimal apparatus

Dr. P.GEETHA MBBS, MS , DO ,
ASSISTANT PROFESSOR,
RIOGOH ,
CHENNAI



 The lacrimal apparatus include structures concerned
with:

a) Formation of tears - Lacrimal Gland and accessory
lacrimal glands

b) Tear distribution - Blinking of Eye lids distrubutes and
propels the tear meniscus
c)Tear collection and drainage - Tears enter the puncta and
drains through upper and lower lacrimal drainage system
( Upper- Puncta , Canaliculi and common canaliculus )

( Lower – Lacrimal sac , NLD )





 Venous drainages :

Ophthalmic Vein

 Lymphatic drainage :

Joins that of conjunctiva & drain into the
preauricular lymph nodes.

Nerve supply

Parasympathetic

 The parasympathetic secretomotor fibres are
derived from the lacrimal nucleus of facial nerve

 They reach the Sphenopalatine ganglion via the
Greater superficial petrosal nerve

 The postganglionic fibres join the Maxillary nerve
then through its Zygomatic nerve and further
through the lacrimal nerve – lacrimal gland



Lacrimal puncta

 Two small, round or oval openings one each on the
Upper and lower eyelid

 Normally they face slightly posteriorly and can be
inspected by everting the medial aspect of the lids.

The Canaliculi
 Hollow tubes of 0.5 mm in diameter
 connecting the puncta to the Lacrimal sac.
 It has :
i) Vertical Part - 2mm in length
ii) Horizontal part - 8-10 mm in length

 Upper canaliculi is slightly shorter than the
lower
 There is a dilatation at the junction of these 2
parts- called AMPULLA

Lacrimal sac

 It is 10–12 mm long and lies in the lacrimal fossa
 The lacrimal bone and the frontal process of the

maxilla separate the lacrimal sac from the middle
meatus of the nasal cavity.
 Parts:

fundus (portion above the opening of canaliculi)
body(middle part)

neck (lower part opening into nasolacrimal duct)







The naso-lacrimal duct

 It is 12–18 mm long and is the inferior continuation of
the lacrimal sac.

 It is directed downwards, backwards and laterally

 Parts : intraosseous part and intrameatal part

 It opens into the nasal cavity in the inferior nasal
meatus

 The opening of the duct is partially covered by a
mucosal fold (valve of Hasner)

Physiology
 Tear drainage:
Tears are drained from conjunctival sac by two
mechanisms:
1. Gravity.
2. Active pump mechanism

Gravity plays a small part and most of the tears are
drained by active pump
Tear enters the puncta at a rate of 0.6 micro litres / min

Active pump (Suction )

 70% of the tears are drained through the lower punctum
and 30% through the upper punctum

 Upper and lower marginal strips of tears go medially

 The tears enter the puncta by capillary action and
suction.

 Pretarsal orbicularis oculi splits into superficial and deep
heads around the ampulae and some fibres are attached
to the sac.

Lacrimal pump mechanism

 Brought about by preseptal fibres of orbicularis oculi
muscle (Horner’s muscle)

 On eyelid closing

Contraction of preseptal fibres of orbicularis (Horner’s
muscle) pulls the lacrimal fascia and wall of lacrimal sac

 Opens the lacrimal sac create negative pressure draws
tears from canaliculi into lacrimal sac

 When the eyelid opens

 Relaxation of preseptal fibres of orbicularis (Horner’s
muscle Allows the lacrimal sac to collapse create
positive pressure expels fluid downwards into
nasolacrimal duct



Characterised by overflow of tears from the conjunctival
sac

Mechanisms

Excessive secretion of tears ( Hyper Lacrimation )
 Primary Lacrimation
 Reflux Lacrimation
 Central Lacrimation
Defective drainage [epiphora]
Due to a compromised lacrimal drainage system

Lacrimal pump failure – lower lid laxity

Mechanical Obstruction
Obstruction at any point along the drainage system,
from the punctual region to the valve of Hasner.
 Causes
Specific
Involving
 Puncta - Eversion , Obstruction
 Canaliculi - FB , Trauma , Canaliculitis
 Lacrimal sac - Dacryocystitis , Tumors , Trauma
 Nasolacrimal duct - Non - canalization , Strictures ,

Stenosis

Evaluation of “ Watering Eye “

 Slit- lamp examination with diffuse illumination
 Regurgitation test

apply steady pressure with index finger
look for regurgitation of mucopurulent discharge
from the puncta
indicates patent canalicular system with block
in lower end of sac or NLD

Lacrimal Syringing Test
 If fluid passes into the nose without reflux out of the

opposite canaliculus – Patent
 If fluid passes into the nose with resistance and reflux

occurs through the opposite canaliculus
Anatomically patent but physiologically stenotic
( partially occluded)

 If no fluid passes into the nose but it all comes back
through opposite punctum

Nasolacrimal Duct Obstruction

JONES TEST 1
 Jones 1 test or primary dye test, investigates lacrimal

outflow under normal physiologic conditions.

 The examiner instills flourescein into conjuctival
fornices of each eye and recovers it in the inferior
nasal meatus by passing a cotton tipped wire
applicator into the region of ostium of NLD at 2 and 5
minutes.

JONES TEST 2
 Jones 2 test, determines the presence or absence of

flourescein in the irrigating saline fluid retrieved from
the nose.

 The residual flourescein is flushed from the
conjunctival sac following an unsuccessful jones 1
test.irrigation of lacrimal drainage system is performed
with clear saline, which is retrieved from the inner
aspect of the nose.



Diagnostic imaging
❖ Dacryocystography
❖ Computed tomography
❖ Endoscopy
❖ Lacrimal Scintillography



 Infection of the lacrimal sac is usually secondary to
obstruction of the nasolacrimal duct

 Congenital dacryocystitis

 Adult dacryocystitis

Acute or Chronic
 Common organisms - Staphylococcal , Streptococcal

,pneumococcal

Evaluation

 Parents report history of tearing

 Mucopurulent discharge beginning shortly after birth

 Congenital dacyocystocele

 Constant tearing with minimal discharge – Blockage of
upper system ( Puncta , canaliculi , common
canaliculus )

 Constant tearing with frequent discharge and matting
of eye lashes - complete obstruction of NLD

 Intermittent tearing with discharge – Intermittent
obstruction of NLD

Differential Diagnosis
 Ophthalmia neonatorum
 Congenital glaucoma

Management
90% of NLD obstruction resolve in 1st year of life. In others
the management is non- surgical or surgical

 Massage over sac area and topical antibiotics
 Lacrimal syringing
 Probing of NLD with bowman’s probe
 Balloon catheter dilatation
 Intubation with silicone tube
 DCR

 Probing is performed if symptoms persist at 1 yr of
age

 Rupture the membrane at the valve of Hasner.

 Upper system includes the punctum and
canaliculus while lower system includes sac and
NLD

 Soft Stop – resistance to passage of probe with
medial movement of eyelid soft tissue indicates
canalicular obstruction

 Hard Stop - if probe advances successfully through the
common canaliculus and lacrimal sac adjacent lacrimal
bone is encountered

 Probe rotated 90deg superiorly and then directed
posteriorly and laterally to push through the blockage
in NLD



Intubation - indications

 Children with recurrent epiphora following NLD
probing

 Useful for upper system abnormalities

 Performed with silicone stent.

DCR in children - indications

 Unresolved CNLDO after probing
( recurrent dacryocystitis )

 Canalicular atresia

 DCR- Better to wait until the child is 2-4 yrs of age

 Complications - wound infection, fistula, medial
corneal erosion, granulomas at rhinostomy.

Dacryocystocele
 Mucocele in the lacrimal sac also called as

amniotocele

 Amniotic fluid is trapped in the sac because of
functional block above the sac

 early probing is the treatment of choice

 DD -Meningo encephalocele or dermoid cyst.

ACUTE DACRYOCYSTITIS

Presentation

 Subacute onset of pain in the medial canthal area,
associated with epiphora

 A very tender, tense red swelling develops at the
medial canthus, commonly progressing to abscess
formation

 May be associated with preseptal cellulitis

 Stage of cellulitis - painful swelling with fever

 Stage of lacrimal abscess - redness and periorbital
edema and sac is filled with pus pointing down
and out

 Stage of fistula formation - discharges
spontaneously with fistula formation

Complications

 conjunctivitis
 corneal ulcer

 lid abscess
 osteomyelitis

 orbital cellulitis

Management
 Application of warm compresses and oral antibiotics

such as flucloxacillin or amoxiclav

 Incision and drainage – if pus points and an abscess is
about to drain spontaneously

 Dacryocystorhinostomy – after the acute infection has
been controlled

Chronic dacryocryocystitis
 more common than acute dacryocystitis occurs due to

chronic inflammation
Clinical feautures
 Stage of chronic catarrahal conjunctivitis
 Stage of lacrimal mucocele
 Stage of chronic suppurative dacryocystitis
 Stage of chronic fibrotic sac

 A mucocoele is evident as a painless swelling at the
inner canthus

 Pressure over the sac commonly results in
mucopurulent canalicular reflux

Management
 Dacryocystorhinostomy (DCR)

 Dacryocystectomy (DCT) in elderly persons and failed
DCR

 too young
 too old
 fibrotic sac
 TB , syphilis ,rhinosporidosis
 tumours of sac
 atrophic rhinitis , osteomyelitis