External Examination and Palpation

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

Eyelids

Lower lid laxity, ectropion, entropion, punctal eversion, trichiasis, blepharitis, snap-back test, pinch test, etc.

Medial canthus

Lacrimal sac enlargement below the medial canthal tendon (acute dacryoccystitis, mucocele, etc.), enlargement above the medial canthal tendon (neoplasm)

Palpation of the lacrimal sac

Reflux of mucopurulent material (mucocoele with an obstruction at the lower end of the sac or in the lacrimal duct and a patent canalicular system, or an obstruction of lower or upper canaliculi), pressure over the sac in acute dacryocystitis causes pain

Mass Inferior Medial Canthal Tendon

Fig. 3.2. External examination. a Involutional ectropion, a right medial ectropion with a dry inferior punctum. b Patient with facial palsy and severe lid laxity paralytic ectropion. c Red mass below the medial canthal tendon (acute dacryocystitis, treated with endonasal dacryocystorhinostomy). d Amniotocele in a newborn (From [14])

Fig. 3.2. External examination. a Involutional ectropion, a right medial ectropion with a dry inferior punctum. b Patient with facial palsy and severe lid laxity paralytic ectropion. c Red mass below the medial canthal tendon (acute dacryocystitis, treated with endonasal dacryocystorhinostomy). d Amniotocele in a newborn (From [14])

A slit-lamp examination is essential to determine a position of the upper punctum in relation to the lower punctum on blinking and a change in the position between the upper and lower eyelid, and to see if there is any lagophthalmus or evidence of orbicularis dysfunction [1, 9, 20]. The puncta should face slightly towards the lacrimal lake. The puncta, normally 0.3 mm in diameter, may appear phimotic, causing obstruction [7]. If puncta are present and open, the discharge from the puncta is sought. The papilla and eyelids along the canaliculi, if red or swollen, may indicate canaliculitis. Canaliculitis may be confirmed by expressing yellow cheesy material from the canaliculi by pressing on the swelling canaliculus with a cotton bud. This is not possible if there is severe tenderness.

The absence of puncta may be a congenital trait or evidence of previous inflammatory diseases.

A slit-lamp examination can reveal inferior punctate corneal staining, and epithelial filaments suggests an inadequate tear meniscus. There should be a 1-mm marginal tear strip along the lower lid, between the globe and lid margin. The size and character of the tear meniscus can be important. A small strip of fluorescein can be applied to the inferior fornix. The absence of any tear strip is suggestive of a dry eye syndrome. Conjunctival or corneal irritation, either inflammatory or mechanical, may cause hypersecretion with the resultant epiphora. Marginal blepharitis is a common condition associated with the increased lacrimation. In the absence of inflammation, an in-

creased tear meniscus is indicative of naso lacrimal duct obstruction.

Lid laxity with ectropion may lead to the corneal exposure and reflex lacrimal oversecretion, or to a physiological dysfunction due to a weakened orbicularis pump mechanism or punctal eversion (Figs. 3.2, 3.4).

The resiliency of the lid can be measured with the snap-back test [9, 20]. The lower lid is pulled down away from the globe, then released, and the speed with which the lid "snaps back" against the globe is observed, as well as whether there is a short gap between the lid and globe (Fig. 3.4).

Horizontal eyelid laxity may be estimated with the pinch test [9]. The lid is firmly pulled away from the globe and the distance between the lid and the eye is measured. More than 8 mm of distraction between the lid and the cornea is suggestive of laxity and a functional epiphora may exist.

Medial canthal tendon laxity and secondary partial or medical ectropion are assessed with the help of the lateral distraction test [20]. The lower puncta should remain in its position while the lid is pulled laterally. Up to 1-2 mm, the movement is normal in the young and adult, and up to 3-4 mm in the elderly.

Mass lesion in the medial canthal region may mechanically obstruct a lacrimal system. Redness, swelling, pain, and tenderness in the lacrimal sac area suggest an acute dacryocystitis (Fig. 3.2). Chronic dacryocysitis itself may manifest as the distention of the lacrimal sac. A normal lacrimal sac is not palpable. The lacrimal sac swelling is typically confined to the region below the medial canthal tendon; neoplasms usually extend above the tendon [14].

Mucopurulent material can be expressed through the punctum and canaliculi if the canaliculi and valve of Rosenmuller are patent and healthy, and if the lacrimal sac is palpated. It must be noted whether there is regurgitation through only one canaliculus or both; and the nature of the reflux as well: whether the reflux is clear, purulent, or bloody. The small finger is applied to the anterior lacrimal crest and rolled gently medially to expose muco-purulent reflux. When the sac or dacryocystocele is large and hard, pressure is not applied in order to minimize pain (Fig. 3.3).

Lagophthalmus

Fig. 3.3. a Mucopurulent discharge from the lacrimal system in chronic dacryocystitis. b Eczematized skin of the long-standing mucoporulent discharge of the eyelids. c Chronic lower actino-mycetes canaliculisis. Canaliculitis is confirmed by expressing cheesy material from the canaliculus with a cotton bud. (From [14])

Fig. 3.3. a Mucopurulent discharge from the lacrimal system in chronic dacryocystitis. b Eczematized skin of the long-standing mucoporulent discharge of the eyelids. c Chronic lower actino-mycetes canaliculisis. Canaliculitis is confirmed by expressing cheesy material from the canaliculus with a cotton bud. (From [14])

Red Eyelid Superior Fornix

Fig. 3.4. Examinations of the eyelids. a Snap-back test. If the lid does not immediately snap back after its pulling downward and releasing, one can assume a lacrimal pump dysfunction. b Dis traction test. The lid is grasped and pulled away from the globe. More than 8 mm distraction between the lid and the cornea is suggestive of laxity. (From [14])

Fig. 3.4. Examinations of the eyelids. a Snap-back test. If the lid does not immediately snap back after its pulling downward and releasing, one can assume a lacrimal pump dysfunction. b Dis traction test. The lid is grasped and pulled away from the globe. More than 8 mm distraction between the lid and the cornea is suggestive of laxity. (From [14])

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  • Dominik
    What is snap incision of lacrimal punctum?
    4 years ago
  • Dahlak
    What to look for when palpating the nasolacrimal duct?
    3 years ago
  • veronica
    HOW TO PALPATE PUNCTA?
    1 year ago
  • MAKDA
    HOW TO PALPATE THE LACRIMAL SYSTEM?
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