Dry Eye and Punctum Plugs Impact of Tear Drainage

The Dry Eye Workshop 2004, at the Puerto Rico TFOS (Tear Film and Ocular Surface Society) conference, defined dry eye (also termed sicca syndrome or keratoconjunctivitis sicca) as a multi-factorial disorder of tears and the ocular surface, associated with Table 2.3. Summary of dry eye disease Multifactorial disorder of tears and the ocular surface Associated with symptoms of discomfort and or visual disturbance Pathological features include increased epithelial stratification and proliferative...

Instrumentation

In 1994 Song et al. first described fluoroscopic-guided insertion of plastic stents into the nasolacrimal duct as an alternative to surgical procedures. Initially so-called mushroom stents have been used in the treat- 1 Fig- 13.6. a Lateral dacryocystography of the left nasolacrimal duct system shows incomplete obstruction of the nasolacrimal duct straight arrow with contrast medium reflux to the eyelid curved arrow . b Radiograph lateral view obtained during balloon inflation 3-mm balloon...

Surgical Technique

Surgery was performed under general anesthesia 3-5 . Procedures under local anesthesia only are feasible in those cases when general anesthesia is not recommended or the patient preferred local anesthesia. Surgery under general anesthesia includes topical anesthesia of the nasal fossa, performed with neuro-surgical cottonoids soaked in topical anesthetic and adrenaline 1 100,000 , applied 10-15 min prior to surgery in order to achieve a good vasoconstriction. Fig. 5.4. Situation after an acute,...

Operative Technique

Nasolacrimal Duct Probing

After induction of general anesthesia, neurosurgical cottonoids moistened with oxymetazoline hydrochlo-ride 0.05 Afrin spray are placed medial and lateral to the inferior turbinate for vasoconstriction to im- Fig. 4.2. The punctal dilator is used to dilate the inferior punctum, and then the superior punctum Fig. 4.2. The punctal dilator is used to dilate the inferior punctum, and then the superior punctum Fig. 4.3. Bowman probe 0 or 00 is passed horizontally with lateral lower eyelid traction...

Contraindications for Endoscopic Laser Dacryocystorhinostomy

The endonasal approach is inappropriate in the presence of malignant lesions of the lacrimal system or the surrounding tissues. In active Wegener's granulo-matosis any instrumentation induces marked adhesions and stenosis, and a DCR by any method is con-traindicated. Dacryoliths usually require an external approach for removal. A relative contraindication is a history of trauma as the bone medial to the sac may be thick. The indications and contraindications for laser DCR are summarized in...

Innate Immune Mechanisms

Muc16 Skin

Similar to conjunctiva and cornea, the mucosa of the nasolacrimal ducts has a number of different nonspecific defense systems that can protect against dacryocystitis Table 1.2 thus, the epithelial cells produce a spectrum of different antimicrobial substances, such as lysozyme, lactoferrin, and secretory phospholipase A2, as well as defensins which protect against the physiological germ flora inside the lacrimal passage. With threatened infectious and or inflammatory dacryosistis, changes in...

Diagnostic Probing

Syringing Nasolacrimal Hard Stop

Probing is generally performed only if the syringing and other tests demonstrate an obstruction and the location and extension of the obstruction is to be described Table 3.5 . The obstructions may be located in the canaliculi and their assessment is an essential goal in patients with epiphora. If fluid regurgitates through the opposite punctum, the obstruction of common canaliculus or more distal structures are suggested and it must be distinguished between them with probing. Probing can be...

Hornblass Taste Test

Gonnering RS 1994 Dacryocystorhinostomy and con-junctivodacryocystorhinostomy. In Dortzbach RK ed Ophthalmic plastic surgery prevention and management of complications. Raven Press, New York, pp 237-250 2. Guzek JP et al. 1996 Lacrimal testing the dye disappearance test and the Jones test. Ann Ophthalmol 28 357-363 3. Hagele E, Guzek JP, Shavlik GW 1994 Lacrimal testing. Ophthalmology 101 612-617 4. H hnel S, Hansen O, Zake S et al. 1995 Der Wert der Spi-ral-CT zur Diagnose von Stenosen der...

Lacrimal Excretory System

Lacrimal Excretory System Anatomy

A 46-year-old patient with large glabellar laceration, an avulsed laceration of the upper and lower eyelids, and extensive laceration of the distal canaliculi and common canalicular structures. Establishment of the integrity of the globe is the primary responsibility of the surgeon prior to reconstructing the eyelids and the lacrimal system Fig. 9.3. A 46-year-old patient with large glabellar laceration, an avulsed laceration of the upper and lower eyelids, and extensive laceration of...

Primary CDCR with Jones Tube with Endonasal Approach

The procedure consists of two steps endonasal da-cryocystorhinostomy and tube placement. The sac is incised with a sickle knife and opened and the medial wall of the sac is removed or the mucosal flap of the lacrimal sac can sometimes be placed posteriorly to keep the sac widely opened. Fig. 12.4. Dacryocystorhinostomy is carried out as an initial concha right prevents postoperative complications. b The bone part of the procedure. It can be performed from the endonasal is removed with the help...

Instrumentation Drainage Bypass Tubes

Putterman Tube

Tubes of different materials have been used for the procedure polyethylene, silicone, Teflon, polypropylene, and glass . The materials of tubes should be of some special qualities, i.e., they should not be porous and hydrophobic and must have some rigidity so that they do not collapse and no reaction in the surrounding tissues causes arises. The best thing seems to be Pyrex glass tube, which is used most commonly Fig. 12.3 . We have our personal experience with sili-cone and glass tubes, and we...

Terminology

Temporary epiphora outside in cold and windy weather Permanent epiphora outside and inside Differentiation between anatomical obstructions and functional disorders dysfunctions of the lacrimal system is required before beginning a treatment plan Anatomical obstructions are those in which some pathological changes and irregularity in the lacrimal drainage system are found, i.e., canalicular stenosis, canalicular blockade, lacrimal sac deformation, obstruction of the nasolacrimal duct,...

Indications for Dacryocystography

The indications for dacryocystography are as follows 1. Complete obstructions the size of the sac determination of the exact location of an obstruction common canaliculus, sac 2. Incomplete obstructions and intermitent tearing location of the stenosis diverticuli stones and no anatomical pathology functional disorders 3. Failed lacrimal surgery size of the sac The DCG is performed in the supine position under topical anesthesia. The puncta are dilated and a can-nula irrigation canula attached...

Dacryocystography

Dacryocystography

Digital subtraction dacryocystography DCG . a A DCG set-up. Patient lying on a bed contrast material injection is given by examiners. b Normal lacrimal system on the right and dilated lacrimal sac with the complete obliteration at sac-duct junction on the left side. c Dacryocystography. Patient with a left-sided obstruction following dacryocystorhinostomy a tiny sac is visualized. d A 35-year-old patient with intermitent tearing. The dacryocystogram demonstrates defect, and...

Conjunctival and Cartilage Containing Nasal Septal Flap

Palpebral Reconstruction Flap

After osseous perforation, incision of the conjunctiva, and creation of a connecting subcutaneous tunnel, an U-shaped incision is done to fashion a posterolateral based nasal mucosal flap of about 1x2-cm dimension Fig. 11.3 a Arden 1990 . The flap is rotated upward to reconstruct the superoposterior wall of the new conduit. For complete mucosal lining of the new conduit a medially based flap is elevated from the medial conjunctiva. It is rotated downward repairing the anteroinferior side of the...

Schirmers Tests

Quantification of tear production in the office setting is routinely done with Schirmer test strip. Table 3.7. Evaluation of Schirmer tests Table 3.7. Evaluation of Schirmer tests 10-35 under 40 years, gt 15 mm over 40 years, lt 10 mm Under 40 years, 10 mm over 40 years, 5 mm White Whatman filter paper in 35x5-mm strips is folded 5 mm from one end which is placed into the inferior fornix at the junction of the medial two-thirds and the other lateral one-third of the lower eyelid. In...

Instrumentation Anesthesia and Operative technique

Dacryocystography Diagnostic

For DSD a DSA run is performed, while contrast medium CM is injected through a DCG catheter. To make the patient more relaxed and decrease blinking and lacrimation, it is preferred to instill a short-acting topical anesthesic into the conjunctival sac e.g., Novesine 0.4, CIBA Vision Ophthalmics, Germering, Germany . For intubation of the lacrimal punctum, a 22 G polyvinylchloride tubing catheter Dacryocys- Fig. 13.1. Continued c Drawing of the normal anatomy of the nasolacrimal duct system NLDS...

Nuclear Lacrimal Scintigraphy

Nuclear lacrimal scintigraphy is a simple, noninvasive physiological test that evaluates patency of the lacrimal system. Scintigraphy uses a radiotracer technetium-99m pertechnetate , which is very easily detectable with a gamma camera Fig. 3.9 . While a DCG is usually preferred especially in a complete obstruction, scintigraphy is useful only in those patients whose lacrimal system is patent to syringing in the presence of constant epiphora. The test A drop ot technetium-99m is instilled into...

Bipedicled Nasal Mucosal Flap

According to the dacryo-fornix-rhinostomy described by Murube del Castillo 1992 a cranially pedicled nasal mucosal flap extending from the orbital rim to the nasal valve area is fashioned Fig. 11.2 a therefore, the nasal mucosa inferior, medial, and lateral to the osseous perforation is detached from the overlying bone using an blunt spatula with a curved end. The flap is externalized through the osseous window and divided into two parts a superiorly based superome-dial flap for reconstruction...

Primary Aquired Nasolacrimal Duct Obstruction

Idiopathic or primary acquired daryostenosis, synonymous with primary acquired nasolacrimal duct obstruction PANDO , is a syndrome of unknown origin. Of all non-traumatic forms, it accounts for most cases observed in adults. Pathological studies of the nasolacrimal passage have indicated that PANDO is caused by fibrous obstruction secondary to chronic inflammation 4, 13, 14 . Nevertheless, the pathophysiology of functional dacryostenosis, i.e., patients with epiphora despite patent lacrimal...

Adaptive Immune Mechanisms

Lymphoid Tissue Mantle

Subepithelially, lymphocytes and other defense cells are amply present inside the efferent tear ducts, sometimes aggregated into follicles Fig. 1.8 . Aggregated follicles are present in nearly a third of nasolacrimal ducts from unselected cadavers with no known history of disease involving the eye, efferent tear ducts, or the nose. These aggregations and the surrounding tissue fulfill the criteria for designation as mucosa-as-sociated lymphoid tissue MALT . They consist of organized mucosal...

Conjunctivodacryocystorhinostomy

Syringing Lacrimal Ducts

Conjunctivodacryocystorhinostomy CDCR with the insertion of a bypass tube Table 12.1 is a procedure in which a new lacrimal route from the conjunctival sac into the nasal cavity is created and a drainage tube is inserted between the inner canthus and the nasal cavity Fig. 12.1 . The tube in place is considered a life-long prosthesis. The procedure is mostly indicated if the upper and lower ipsilateral canaliculi are completely obstructed 11, 23 . The success rate of the procedure varies from 80...

Tube Placement

Medial Canthal Ligament

The following steps are taken for tube placement 1. Caruncle bipolar electrocautery is performed prior the tube placement to reduce the caruncle Fig. 12.5 . It gives a better access to the entry at the medial canthus. Electrocautery is preferred to cutting a caruncle because it makes hemo-stasis, and the conjunctiva has a less tendency to cover later the tube. 2. A needle or a guide wire is passed in the medial canthus from the site of the caruncle or anterior inferior caruncle into the nasal...

Excretory Tests

Eye Nosalcrimal Duct Labeling

The goal of excretory tests is to describe the drainage function and lacrimal system patency. 3.3.3.1 Fluorescein Dye Disappearance Test Fluorescein dye disappearance test fluorescein dye retention test is a very useful essential physiological test in which the lacrimal system is not instrumented and the marker fluorescein flows through the system mixed with tears 2, 18, 29, 30 . The principle of the test is in the evaluation of the residual fluorescein in the eye following instillation of one...

Immediate Postoperative Care and Followup

Lacrimal System Endoscopy

The piece of Merocel is removed between days 5 and 7 after surgery. This period seems to be enough to produce a steady scarring of the mucosal flap onto the partially exposed bony wound. Instead of just pulling the Merocel, it seems better to rotate it, to prevent laceration of the mucosal flap. On the left side, rotation should be performed counterclockwise, on the right side clockwise. Fibrin clots and crusts, if any, are Fig. 5.12. Once the site has been cleaned, the opening of the sac may...

Info

Watzke Sleeve

Endoscopic view of the transilluminated lateral nasal wall indicates the site of the lacrimal sac Fig. 7.4. Endoscopic view of the transilluminated lateral nasal wall indicates the site of the lacrimal sac Fig. 7.5. Endonasal view shows diffuse light from within the lacrimal sac due to the presence of an agger nasi cell Fig. 7.5. Endonasal view shows diffuse light from within the lacrimal sac due to the presence of an agger nasi cell pends on the thickness of the bone formed by the...

Osteology

Anterior Lacrimal Crest

Regarding anatomical considerations 19-21 , the bony aspects of the nasolacrimal excretory system exist at the medial wall of the anterior orbit and extend to the lateral wall of the nasal wall. The lacrimal fossa of the orbit is composed of the maxilla anteriorly and the lacrimal bone posteriorly. The lacrimal fossa is a shallow depression bounded by the anterior lacrimal crest and the posterior lacrimal crest. The maxillo-lacrimal suture runs vertically within the lacrimal fossa. At the...

External Examination and Palpation

Mass Inferior Medial Canthal Tendon

A careful history must be combined with the external exmination of the lacrimal system that begins with an inspection of the face, external ocular surface, and eyelid structure including the position and contour of the eyelid and eye blink Table 3.4 . Periorbital and facial asymmetry are looked for, as well as the lid malposition, bulges in the medial canthal area, facial nerve palsy, etc. Table 3.4. Watering patients external inspection and palpation Table 3.4. Watering patients external...

Nasal Examination and Nasal Endoscopy

Nasal examination, especially nasal endoscopy, should be obligatory for every lacrimal patient 6, 9, 10, 14, 20, 26 . The examination of the lacrimal area with the nasal speculum and headlight provides only a poor view of this region and is not sufficient, endoscopy provides a clear diagnostic look for nasal polyps, imporant anatomic variations, tumors, and other pathological endonasal conditions such as septal deviation Fig. 3.10 . The nasal mucosa is topically decongested and anesthetized...

Results

During our first experiences with endoscopic DCR our rate of minor complications was high, although without severe sequelae. In 1996 we published an incidence of ecchymosis of the cheek in 44 , subcutaneous emphysema in 9 and orbital emphysema in 2.6 1 . Presently, these figures have been considerably reduced. We rarely see emphysemas at all, and if so, it is because the patient has sneezed with the mouth closed, or blown the nose before 1 week after surgery. Ecchymosis of the cheek appears...

Dacryolithiasis

Dacryolithiasis

Dacryoliths lacrimal stones or calculi of the nasolacrimal ducts Fig. 2.5 were described by Cesoni in as early as 1670 12 , and have been reported to occur in between 6 and 18 of patients with nasolacrimal duct obstruction who undergo dacryocystorhinosto-my DCR . They are one of the causes of PANDO. Dacryoliths may occur in any part of the nasolacri-mal system, albeit most commonly in the lacrimal sac. Several predisposing factors have been suggested, such as increased occurrence in females,...

Lacrimal Gland

The action of the palpebral part of the orbicularis eye porally to nasally at the same time moving the tear film to the muscle and resulting tear-film dynamics. Lid closure leads to a medial cantal region time shifted contraction of the orbicularis eye muscle from tem- Fig. 1.3. The action of the palpebral part of the orbicularis eye porally to nasally at the same time moving the tear film to the muscle and resulting tear-film dynamics. Lid closure leads to a medial cantal region time...

Insertion of the Tube

Jones Tube

Tunnel should be appropriately wide so that the fit between the tube and the tunnel should minimize post operative extrusion 10 . If the tunnel is too wide, a worse stability of the tube is received and its extrusion is supposed. On the other side, an overly tight tunnel makes insertion of a tube difficult. In standard Jones procedure a bypass tube placement passed over the Bowman probe is described as being inserted into the tunnel Fig. 12.9a . We were using this technique in the primary...

Absorption of Tear Fluid Components

Lacrimal Passage

Recent animal experiments have indicated that components of tear fluid are absorbed in the nasolacrimal passage and are transported into the surrounding cavernous body that is subject to autonomic control Fig. 1.11. The normally constant absorption of tear fluid components into the blood vessels of the surrounding cavernous body of the nasolacrimal ducts and their transport to the lacrimal gland by blood vessel connections 1 could be a feedback signal for tear fluid production 2 . From 19 Fig....

Mechanisms of Tear Drainage

Lacrimal Pump

Drainage of tears involves a number of different mechanisms Table 1.3 . Physical factors, such as gravity, respiration, and evaporation, have been suggested. A decisive role is played by capillary attraction, aided by contraction of the lacrimal portion of the orbicularis muscle with blinking, as well as distension of the lacrimal sac by the action of the orbicularis muscle 19 . The mucin diversity of the epithelium of the naso-lacrimal ducts together with TFF peptides that are able to...

Anatomy and Physiology of the Nasolacrimal Ducts

Lacrimal Duct Microscopy

Tear fluid is drained by the nasolacrimal ducts into the inferior meatus of the nose. The lacrimal passages consist of a bony passage and a membranous lacrimal passage. The bony passage is formed anteriorly by the frontal process of the maxilla and posteriorly by the lacrimal bone. The membranous lacrimal passages include the lacrimal canaliculi, the lacrimal sac, and the nasolacrimal duct Figs. 1.1, 1.4 . The upper and lower canaliculi are lined by pseu-dostratified and stratified columnar...

Of the Ocular Surface and Adnexa

Conjuntiva Bulbar

To understand the physiology of tear flow through the nasolacrimal passage, and also its pathophysiolo-gy Chap. 2 , basic knowledge of the whole lacrimal system is necessary. The ocular surface and its adnexa comprise the cornea, the conjunctiva with bulbar, for-nical and palpebral parts, the main lacrimal gland, and the glands of the eye lids, i.e., Meibomian, Moll, Zeis, and accessory lacrimal glands as well as the nasolacrimal system the latter consists of the upper and lower puncta, the...