Lacrimal system

Lacrimal system composed of 2 system

1- Secretory system
1- main Lacrimal glands 2- accessory Lacrimal glands 3-goblet cells

2- Drainage system
1- Two puncti 2- Two canaliculi

3- Lacrimal sac 4- Nasolacrimal duct

Secretory system

1- main lacrimal gland

Site Outer upper corner of orbit
Parts (1)- orbital part :- superior & larger
(2)- Palpebral part :- inferior &smaller (inferior portion is about
1/2 the size of orbital portion)
Nerve supply 3 types
1- sensory :- lacrimal nerve (branch from ophthalmic nerve of
Trigeminal nerve)
2- sympathetic :- from superior cervical ganglion
3- parasympathetic ( secretory ) :- 7th cranial nrve (facial
nerve)
Lymph drainage Pre-auricular lymph nodes
Function Responsible for reflex secretion.

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 2- Accessory lacrimal glands
(A) glands of Krause :- open in conjunctiva

(B) glands of wolfring :- open in conjunctiva

Function :- responsible for basic secretion

N.B Any damage or surgical removal of main lacrimal gland not lead to xerophthalmia
because it's not responsible for basic secretion. it's responsible for reflex secretion.

3- Goblet cells of conjunctiva.

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 Drainage system

1- Two puncti (upper - lower)

not visible except if lid are pulled away from eye or in ectropion.

2- Two canaliculi (upper - lower )

Definition These are tubes carry tears from puncti to lacrimal sac ,Each
canaliculi open separately into the lacrimal sac (( sometimes may
join to form common canaliculus ))
Parts Each canaliculi formed of 2 portions:-
A- Vertical part 2 mm
B- Horizontal part 6-8 mm
3- Lacrimal sac

Site Lacrimal fossa of medial wall of orbit

Parts (1)- Fundus :- upper part (above the opening of the canaliculi)
(2)- Body :- main part (between Fundus & neck )
(3)- Neck :- terminal narrow part of lacrimal sac & continuous with
nasolacrimal duct.

4- Nasolacrimal duct (NLD) MCQ

Definition it's tube which carry tears from lacrimal sac to the nose
Length 12-18 mm
Terminate open in inferior meatus. It's opning in the nose is guarded by valve
(hasner's valve)
Direction Downward , Backward , Laterally.
N.B More wider in male than female .so it's obstruction more common in female

 Lymphatic drainage of drainage system

to sub maxillary & sub mandibular lymph node.

 Elimination of tears

A- During day

1- (50% -75%) By Conduction to nose

2- (25% - 50%) By Evaporation

B- During night

1- (100% ) By Conduction to nose

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N.B Normally rate of basic tear secretion = rate of drainage
4
 Tear
Tear secretion 2 types

(1)- Basic

(2)- Reflex due to stimulation of corneal &conjunctival nerve by irritation or

dryness.

MCQ

 Pre corneal tear film

Layer Glands responsible for Function of layer

synthesis of layer
1- Outer oily layer Meibomian glands 1- Prevent overflow of tear
2- prevent evaporation,
3- lubrication.
4- Decrease surface tension.
2- Middle Watery layer Lacrimal glands 1 -Lubrication
(main , accessory) 2 -Nutrition function
((Form main layer 90% (supply O2 to epithelium of cornea)
Of whole pre corneal tear 3 -Protection function
film.)) 1-contain lysozyme & IgA
2- washing away irritant material
4 -optical function
(abolish any minute irregularity of
anterior corneal surface)
3- Inner Mucin layer Goblet cell of conjunctiva Change corneal epithelium from
hydrophobic to hydrophilic

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  Pre corneal tear film stability depend on

1- Normal blinking reflex 2- Normal corneal epithelium 3- Normal tear film layer

4- Direct contact between lid & cornea

 Composition of Tears MCQ

**Albumin accounts for 60% of the total protein in tear luid. Globulin and
lysozymes are divided equally in the remainder (i.e. Globulin accounts for 20% ,
lysozyme accounts for 20% ).

**Immunoglobulins IgA (IgA predominates ), IgG, and IgE are present. In certain
allergic conditions such as vernal conjunctivitis, the IgE concentration of tear
fluid increases

**K+, Na+, and Cl– occur in higher concentrations in tears than in plasma.

**Tears also contain a small amount of glucose & urea, and changes in blood
concentration parallel changes in tear glucose and urea levels.

**The average pH of tears is 7.35

**The normal tear volume is estimated to be 7 ± 2 µL in each eye

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 Dry eye (xerophthalmia)
Definition dryness of eye (cornea , conjunctiva)

Etiology MCQ + Slide

1. Congenital absence of lacrimal gland
2. Inflammation of lacrimal gland ((e.g. granulomatous inflammation
1- Deficiency of middle watery layer

(sarcoidosis) ))
3. Tumor of lacrimal gland
4. Keratoconjunctivitis sicca(K.C.S)
Autoimmune atrophy & fibrosis of the lacrimal gland (main & accessory), more in female

K .C.S may be:-

1- Pure K.C.S:- in which only the lacrimal gland involve.

2- Primary Sjogren syndrome: K.C.S + dry mouth (xerostomia)

3- Secondary Sjogren syndrome: - primary sjogren syndrome + associated with ((C.T.D))

Connective Tissue Disease (Rheumatoid arthritis , systemic lupus erythromatosis (SLE) ,
systemic sclerosis )

Sjogren syndrome more common in female (9:1 female: male) a er menopause

5- senile or idiopathic atrophy
6- destruction or damage to lacrimal glands as result of radiation , post orbital
surgery
7- obstruction of lacrimal ductules due to Conjunctival scarring due to trachoma
, chemical burn , ocular cicatricial pemphegoid
2- Deficiency 1.vit A de iciency
of inner 2.Conjunctival scarring :- due to trachoma , chemical burn , ocular cicatricial
Mucin layer pemphegoid ((Benign mucous membrane pemphegoid)), stevens-johnson
syndrome.
3- Deficiency meibomian gland dysfunction.
of outer lipid
layer
4-poor Lid paralysis.
spread of
tear film

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5- exposure Lagophthalmos.
of eye

Symptoms irritation , foreign body sensation, photophobia

symptoms are worse in the afternoon & evening and better on awakening.
Symptoms are worse in dry & dusty environment, contact lens wearers
Symptoms are worse in low humidity environments, such as those with central
air & in airplane ,during prolonged reading & driving with decreased blink rate
due to increased concentration, and windy condition.
Signs deficient of pre-corneal tear film , Conjunctival injection
Bitot spots :- white foamy triangular in shape on bulbar conjunctiva toward
outer canthus , due to Vit A deficiency

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Complication 1.keratitis 2.conjunctivitis 3.keratinization of cornea & conjunctiva
4.symblypharon 5.bleparitis 6.band keratopathy
Investigation 1- Tear break up time TBUT ((This is test for the stability of the tear film))

-instill fluorescein into the lower fornix, ask patient to blink several times & then
stop. TBUT is the time from last blink to development of dry spot noted by black
spot in fluorescein film.
Normal range (15 -35)
diminish (Less Than 10 Second) indicate impaired of secretion
2- Rose bangal

stain the degenerative & ulcerated corneal & conjunctival epithelium red

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 N.B this dye has affinity for dead or devitalized epithelial cells and mucus
3- Schirmer's test

- Measuring the amount of lacrimal gland secretion by measuring the wetting of

special filter paper , inserted into the lateral portion of inferior fornix
- The ilter paper is left for 5 minute
- measure the amount of wetting of the filter paper :-
1- over 15mm is Normal offender
2- between 6 & 10mm is borderline
3- less than 6mm indicate impaired in secretion
Treatment 1- Treat underlying cause e.g. vit A systemic in vit A deficiency
E.g. Systemic steroid for autoimmune disease
2- Artificial tear :- eye drop (day) , eye ointment (night)
3- Protective glasses
4- Punctum occlusion to decrease drainage of tear

Watery eye
Watery eye is overflow of tear over check due to Lacrimation or Epiphora

Lacrimation
Definition overflow of tear over check , due to over secretion of tear
Etiology 1- Emotional condition
2- Reflex: foreign body , keratitis , conjunctivitis
3- Pathological :- inflammation of lacrimal gland (dacryoadenitis) or tumor
4- Drug :- parasympathomimetic (( pilocarpine)) or sympathomimetic
5- Idiopathic :- cough , vomiting

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 Epiphora MCQ + Slide
Definition overflow of tear over check , due to inadequate drainage .
it may be due to lacrimal pump failure or obstruction of lacrimal passages
Etiology **1. lacrimal pump failure
-Ectropion -Facial nerve palsy

**2- loss of sharpness of posterior border

-blepharitis -lid coloboma

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 **3.Obstructive epiphora
A- Puncti
-Congenital absence -Post traumatic fibrosis
-Post inflammatory fibrosis -foreign body
B- Canaliculi
-Congenital stenosis ,occlusion -Post traumatic fibrosis
-Post inflammatory fibrosis -Fungal canaliculitis
C- lacrimal sac
-Congenital absence -Dacryocystitis (acute , chronic )
-Fracture of orbit -Tumor of lacrimal sac - TB
D- Nasolacrimal duct
-Congenital imperforation -Tumor
-Post inflammatory fibrosis -Post traumatic fibrosis
E- Nose
-Adenoids &nasal polyps -Deviated nasal septum
-Hypertrophy of inferior meatus -Rhinoscleroma -nasopharyngeal tumor

N.B Bilateral watering of the eye is usually due to lacrimation , while unilateral watering is
usually due to epiphora

Clinical evaluation of watery eye

1.History to exclude cause of lacrimation

2.Examination Eye lid :- exclude Trichiasis , ectropion , blepharitis

Lacrimal sac :- dacryocystitis
Nose :-polyps & deviated nasal septum

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3- Investigation 1- Regurgitation test
- press on the lacrimal sac against the lacrimal bone
+ ve regurge :- reflux of pus or tear from puncti NLD obstruction
- ve regurge :- NO reflex patent lacrimal passage

2- Jones test
Type 1 ( primary)

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 instill a drop of fluorescin stain in conjunctival sac & insert a cotton swab
under the inferior meatus
Results
1. the cotton is stained with luorescin patent lacrimal passage
2. NOT stained (obstruction) proceed to jones test type 2
22% of normal individual manifest a negative primary jones test
Type2 (secondary)
After type 1 irrigate the lacrimal passage with saline
Results
1. if luorescin is recovered : there is partial obstruction of the passages.
2. if fluorescin is not recovered : there is complete obstruction of the
passages.

3- Radiological examination
A- Dacryocystography :-
X-ray after lipidol injection into canaliculi for stenosis or for localization of
obstruction level.
-failure of dye to reach the nose indicate anatomical obstruction.

Normal dacryocystography in the presence of epiphora indicate either

partial obstruction or or lacrimal pump failure.

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 B. Plain x ray
to detect tumor & fracture
4- Diagnostic probing
5- Tuberculin test of TB
6- ENT examination

Treatment
1.Treatment of the cause e.g. ectropion
2.Obstruction of puncti -Dilatation & probing
-One snip ampullotomy
3.Obstruction of canaliculi -canaliculoplasty.
-canaliculodacryocystorhinostomy
4.Nasolacrimal duct 1. Congenital obstruction (Congenital epiphora)
obstruction A- Hydrostatic massage
MCQ + Slide instruct the mother to press on the lacrimal sac in downwards
direction. This may help opening hasner's valve (for 1st year)
B-Probing
probing of the lacrimal system should be After the age 12

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 months because spontaneous canalization occur in about 95%
of cases .
C-Dacryocystorhinostomy
performed between the ages of 3 & 4 years.

B.Acquired obstruction
-Dilatation & probing
-Dacryocystorhinostomy (DCR)
-Dacryocystectomy (DCT)

Dacryocystitis

It's inflammation of lacrimal sac as result of obstruction of the nasolacrimal duct

It's may be acute or chronic and is most commonly caused by staphylococcus

aureus. Usually unilateral, More common in female

Acute dacryocystitis MCQ + Slide

Definition Acute suppurative inflammation of lacrimal sac

Etiology Due to nasolacrimal duct obstruction. (stasis followed by

infection )
Causative Pnumococcus , staphylococcus aureus , streptococcus in adult
organism Hemophilus influenza in children.

Clinical
feature

General (FAHM) Fever , Anorexia , Headache , Malaise

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 Local

- Painfull red swelling

- tenderness & Hotness of skin over sac
- Regurgitation test Negative
- Enlargement of Submaxillary & submandibular L.N.

Complication 1- Fistula formation. 2- Chronic dacryocystitis. 3- pyocele

4- Orbital cellulitis. 5- Cavernous sinus thrombosis
6- Osteomylitis

Treatment 1- Medical treatment

-Analgesic ,Hot compresses.
-Local & systemic antibiotic.
If abscess formed :- incision & drainage .

-Probing & irrigation or syringing not done in acute phase (Contra-

indication)

2- DCR is usually necessary After the acute infection has been controlled &
should not be delayed because of the risk of recurrent infection.

Chronic dacryocystitis
Chronic dacryocystitis of Adult
Definition Chronic suppurative inflammation of lacrimal sac.
Etiology due to nasolacrimal duct obstruction. (stasis followed by infection )

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Causative organism -Pnumococcus , staphylococcus , streptococcus.
-More common in elderly female

Symptoms epiphora , discharge

Signs swelling & redness of skin over sac ,+ve regurgitation
Complication 1- chronic conjunctivitis 2- hypopyon ulcer
3-endophthalmitis (following intra-ocular surgery )
4-acute dacryocystitis 5- lacrimal sac abscess
6-fistula 7- cicatricial ectropion

Treatment 1- medical Treatment :- antibiotic (local , systemic)

2- syringing
3- dilatation & probing
4- Dacryocystorhinostomy (DCR)
5-Dacryocystoectomy (DCT)

 Dacryocystorhinostomy (DCR) MCQ + Slide

Principle connecting the lacrimal sac to the nasal mucosa bypassing the
obstructed NLD
Indication 1-Early chronic dacryocystitis
2- Mucocele of the lacrimal sac
3- After acute attack of acute dacryocystitis
Contraindication -extensive adhesion of lacrimal sac (Fibrosis)
-Nasal pathology e.g. atrophic rhinitis
-Tb & lacrimal sac tumor
-Hypopyon ulcer
-during attack of acute dacryocystitis

 Dacryocystoectomy (DCT)
Principle Remove the lacrimal sac
Indication -Late (long standing) chronic dacryocystitis
( use when DCR -Tb & lacrimal sac tumor
contra-indicated) -Nasal pathology e.g atrophic rhinitis
-extensive adhesion of lacrimal sac
-old age

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 Infantile dacryocystitis
(Congenital NLD obstruction)
Etiology NLD obstruction (imperforate hasner's valve), up to 20% of children complain of
NLD in first year of life.

Symptoms epiphora , 2-3 weeks after birth

Signs +ve regurgitation , redness , swelling over skin of lacrimal sac

D.D 1- Ophthalmia neonatorum

2- Congenital glaucoma

Treatment Treat acute inflammation by

Analgesic ,Hot compresses , Local & systemic antibiotic

Then
1- Hydrostatic massage :- instruct the mother to press on the lacrimal sac in
downwards direction. This may help opening hasner's valve(through 1st year)
2-Probing :- probing of the lacrimal system should be delayed After the age 12
months because spontaneous canalization occur in about 95% of cases .
90% of children are cured by the first probing and future 6% by the
second

3-Dacryocystorhinostomy :- performed between the ages of 3 & 4 years.

N.B Spontaneous resolution occur in majority of cases

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