Anatomy of lacrimal apparatus

ANATOMY OF
LACRIMAL APPARATUS
DR.SIDDHARTH GAUTAM

 The lacrimal apparatus comprises the structures
concerned with formation of tears i.e the main lacrimal
gland and accessory lacrimal glands and its transport
 Components of lacrimal apparatus
 Lacrimal gland
 Lacrimal puncta
 Lacrimal cannaliculi
 Lacrimal sac
 Naso lacrimal duct

COMPONENTS OF
LACRIMAL APPARATUS

LACRIMAL GLAND
 It is situated in the fossa for lacrimal gland,formed by the
orbital part of frontal bone,in the anterolateral part of
orbit.The gland is divided in its anterior aspect by the
lateral horn of aponeurosis of the levator muscle into two
parts:
1. Superior Orbital
2. Inferior Palpebral,which are continuous with each other
posteriorly

PARTS OF THE LACRIMAL GLAND
 The larger Orbital part is in a depression, the lacrimal
fossa, in the frontal bone;
 The smaller Palpebral part is inferior to levator
palpebrae superioris ,in the superolateral part of the
eyelid

ORBITAL PART OF
LACRIMAL GLAND
 It is large about the size and shape of a
small almond. It has:
 Two Surfaces: Superior & Inferior
 Two Borders: Anterior & Posterior
 Two Extremities: Medial & Lateral

 Superior surface
 Convex
 Lies in contact with the periorbita lining the part of the
frontal bone forming the fossa for lacrimal gland
 Attached to periorbita by fine trabeculae.
 Inferior surface
 Concave
 Lies on the levator palpebrae superioris muscle and
the lateral horn of the levator aponeurosis.

 Anterior border
 Sharp
 Within and parallel to the orbital margin,upto the
zygomatico-frontal suture
 Lies in contact with the septum orbitale.
 Posterior border
 Round
 Continuous with the palpebral part of the gland
 Lies in contact with orbital pad of fat.

 Lateral extremity
 Rests on the lateral rectus muscle.
 Medial extremity
 Related to levator palpebrae superioris muscle.
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PALPEBRAL PART OF
LACRIMAL GLAND
 One-third the size of orbital part
 Consists of only 2-3 lobules.
 Situated upon the course of the ducts of orbital part from
which it is separated by the levator palpebrae
superioris muscle,which is related to it superiorly.

 Inferiorly the gland lies in relation to the superior fornix.
 Gland is compressed from above downwards and can
be seen through the conjunctiva when the lid is everted.
 Posteriorly it is continuous with the orbital part.
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 Lacrimal gland is drained by a series of 8-12 small
ducts.
 Ducts open into the lateral part of the superior
conjunctival fornix.1-2 ducts also open into the lateral
part of the inferior fornix.
 Since all the ducts pass through the palpebral part of the
gland, therefore excision of the palpebral part alone
amounts to excision of the entire gland as far as
secretory function of the gland is concerned.
 The secretions from the gland is spread over the surface
of the eye by the action of the lids.

STRUCTURE OF LACRIMAL GLAND
 Lacrimal gland is a branched tubulo-alveolar (serous
acinous) gland, similar in structure to the salivary
glands.
 Microscopically, it consists of glandular tissue, stroma
and septa. It is lined by a capsule as the outermost limit.
 Glandular tissue consists of acini and ducts arranged in
lobes and lobules separated from each other by the
fibrovascular septa.

 Acini are lined by a single layer of pyramidal cells
mounted on a basement membrane. These cells are
surrounded by a layer of flattened myoepithelial cells.
 The pyramidal cells are of the serous type with
eosinophilic secretory granules and a round nucleus
situated towards the base.
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 These cells secrete the tears, expelled by the
contraction of myofibrils. The secretion of the acinar
units is drained by connecting channels which to begin
with are intralobular, then these become extralobular
and lastly open in the ducts.
 The stroma of the lacrimal gland is formed by
mesodermal tissue which contains connective tissue,
elastic tissue, lymphoid tissue, plasma cells, rich nerve
terminals and blood vessels.
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 Blood supply
 Main lacrimal gland is supplied by lacrimal artery
branch of ophthalmic artery. Sometimes a branch of the
transverse facial artery may also supply the gland.
 The lacrimal veins draining the gland join the ophthalmic
vein.
 Lymphatic drainage
 It is along the conjunctival drainage into the pre-auricular
lymph nodes.

 Nerve supply
 Sensory nerve supply comes from the lacrimal nerve,
a branch of ophthalmic division of the fifth cranial nerve.
 Sympathetic nerve supply comes from the carotid
plexus of the cervical sympathetics.
 Secretomotor fibres are derived from the superior
salivary nucleus.
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ACCESSORY LACRIMAL GLANDS
 Same structure as main lacrimal gland
 Very small in size
 Glands of Krause:
 Upper lid-40-42
 Lower lid-6-8
 Deeply situated in the conjunctiva near the fornix on
lateral side

 Glands of Wolfring:
 Few in number
 Situated near the upper border of the tarsal plate
 Rudimentary accessory lacrimal glands:
 Present in the caruncle,plica semilunaris and infraorbital
region.
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LACRIMAL DRAINAGE SYSTEM
 Comprises of :
1. The Puncta :
 Small, round to oval orifices of 0.2 mm in diameter.
 Situated on the summit of an elevation, the Papilla
Lacrimalis that lies near the medial end of eyelid
margins at the junction of its ciliated & non-ciliated
parts.
 The puncta being avascular is paler than its
surrounding structures.
 The puncta are surrounded by a ring of dense
fibrous tissue which keeps them patent.
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2. 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.
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 The canaliculi unite at an angle of 25 degrees to form
common canaliculus (0.5mm).
 The common canaliculus is directed an angle of 45
degrees with the sac before entering it.
 This acute entry into the Lacrimal Sac creates a
potential mucosal flap or valve across the opening,
The Valve of Rosenmuller.
 The point of entry of common canaliculus into the
Lacrimal sac is called the Lacrimal sinus of Maier.
 The canaliculi are lined by stratified squamous
epithelium.

3. THE LACRIMAL SAC:
Dimensions : 12-15 mm in length
4-6 mm anteroposteriorly
2-3 mm wide
Situation : Lies in the lacrimal fossa formed by the
lacrimal bone & frontal process of maxilla in the anterior
part of the medial wall of the orbit which is continuous
below with the Nasolacrimal duct.

RELATIONS OF LACRIMAL SAC
 Medially- Lacrimal sac is related to anterior ethmoid
sinus in the upper part and middle meatus of the nose in
the lower part.
 Anterolateral relations of the sac from deep to
superficial include:
 Lacrimal fascia and few fibres of the inferior oblique
muscle which arise from it.
 Lacrimal fibres of the orbicularis muscle (Horner's
muscle).
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 Medial palpebral ligament, which covers only the upper
part of the sac. Therefore, distension of the sac always
occurs in lower part which is covered by few fibres of the
orbicularis and skin. Lacrimal abscess and fistula also
open in the lower part owing to less resistance.
 Palpebral fibres of orbicularis.
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 Angular vein which crosses the medial palpebral
ligament about 8 mm from the medial canthus. Many a
time a tributary of the angular vein runs between it and
the medial canthus. Therefore, to avoid profuse bleeding
during sac surgery the shouldnot be made more than 3
mm medial to the medial canthus.
 Skin is the most anterior relation of the lacrimal sac.

 Posteriorly , i.e. behind the sac from anterior to
posterior important structures are:
Lacrimal fascia
Fibres of lacrimal part of orbicularis
Septum orbitale which separates the sac from
the orbital fat and check ligament of the medial
rectus muscle.
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4.NASOLACRIMAL DUCT:
Continuation of Lacrimal sac.
 It is divided into 2 parts :
a) An Interosseous Part : 12.5 mm
b) An Intermeatal Part : 5.5 mm
The opening of Nasolacrimal duct has a
mucosal fold , the Valve of Hasner, which
prevents air from entering the lacrimal sac
on sudden blowing the nose.

STRUCTURE OF THE LACRIMAL
SAC AND NASOLACRIMAL DUCT
 Epithelium:The lacrimal sac and NLD are lined by 2
layers of cells.The superficial layer is of non-ciliated
columnar cells.The deep layer is of flattened cells.
 Subepithelial tissue contains lymphocytes which may
aggregate in pathological condition to form follicles.
 Fibroblastic tissue of the lacrimal sac becomes
continuous wilh that of the canaliculi.
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 Plexus of vessels is well developed around the NLD,
forming an erectile tissue resembling in structure with
that on the inferior concha. Engorgement of these
vessels is said to be sufficient lo cause obstruction of
the NLD and produce epiphora.
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 Blood supply of the lacrimal passages:
 Arterial supply to the lacrimal passage is derived from
superior and inferior palpebral arteries (branches of
ophthalmic artery), angular branch of facial artery,
infraorbital artery and nasal branches of sphenopalatine
artery.
 Venous drainage occurs into the angular vein and
infraorbital vein from above and into the nasal vein from
below.
 Lymphatics drain into the submandibular and the deep
cervical glands.

 Nerve supply
 Sensory nerve supply to the lacrimal sac and NLD
comes from the infratrochlear nerve and the anterior
superior alveolar nerves.
 Probably, there is a reflex relation between the nerve
supply of the lacrimal gland and the lacrimal sac,
because extirpation of the latter greatly diminishes the
tear production.
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PHYSIOLOGY
 Tear drainage:
Tears are drained from conjunctival sac by two
mechanisms:
1. Gravity.
2. Active pump mechanism.
1. By Gravity:
Gravity plays a small part and most of the tears are
drained by active pump.

2. 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.

 During closure of the eye:
*Ampulae is compressed.
*Horizontal canaliculus shortens.
*Puncta move medially.
*Deep head of the orbicularis (attached to sac)
causes dilatation of the sac.
 All these causes a negative pressure in the sac and
tears are sucked into the sac.
 When the eye closes, the sac goes to its original
volume, forcing the tears into the nasolacrimal duct, and
the puncta move laterally sucking tear into it.

THE WATERING EYE
 It is characterised by overflow of tears from the conjunctival sac.The
condition may occur due to excessive secretion of tears
(hyperlacrimation) or may result from obstruction to the outflow of
normally secreted tears (epiphora).
 Hyperlacrimation
1. Primary hyperlacrimation: It is a rare condition which occurs due to
direct stimulation of the lacrimal gland. It may occur in early stages
of lacrimal gland tumours and cysts and due to the effect of strong
parasympathomimetic drugs.
2. Reflex hyperlacrimation: It results from stimulation of sensory
branches of fifth nerve due to irritation of cornea or conjunctiva. It
may occur in multitude of conditions which include:
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 Affections of the lids: Stye, hordeolum internum, acute
meibomitis, trichiasis, concretions and entropion.
 Affections of the conjunctiva: Conjunctivitis which may be
infective, allergic, toxic, irritative or traumatic
 Affections of the cornea: These include corneal abrasions,
corneal ulcers and non-ulcerative keratitis.
 Affections of the sclera: Episcleritis and scleritis.
 Affections of uveal tissue: Iritis, cyclitis, iridocyclitis.
 Acute glaucomas.
 Endophthalmitis and panophthalmitis.
 Orbital cellulitis.
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3. Central lacrimation (psychical lacrimation):
It is seen in emotional states, voluntary lacrimation and
hysterical lacrimation.
 Epiphora
 Inadequate drainage of tears may occur due to
physiological or anatomical (mechanical) causes.
 Physiological cause is 'lacrimal pump' failure due to
lower lid laxity or weakness of orbicularis muscle.
 Mechanical obstruction in lacrimal passages may lie at
the level of punctum, canaliculus, lacrimal sac or
nasolacrimal duct.
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 1. Punctal causes:
 Eversion of lower punctum: It is commonly seen in old
age due to laxity of the lids. It may also occur following
chronic conjunctivitis, chronic blepharitis and ectropion.
 Punctal obstruction:There may be congenital absence of
puncta or closure following injuries, burns or infections.
Rarely a small foreign body concretion and cilia may
also block the punctum. Prolonged use of drugs like
idoxuridine and pilocarpine is also associated with
punctal stenosis.
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 Causes in the canaliculi: Canalicular obstruction may be
congenital or acquired due to foreign body, trauma,
strictures and canaliculus.
 Causes in the lacrimal sac: These include congenital
mucous membrane folds, traumatic strictures,
dacryocystitis, specific infections like tuberculosis and
syphilis, dacryolithiasis, tumours and atony of the sac.
 Causes in the nasolacrimal duct: Congenital lesions
include noncanalization, partial canalization or
imperforated membranous valves. Acquired causes of
obstruction are traumatic/inflammatory strictures,
tumours and diseases of the surrounding bones.
45

 CLINICAL EVALUATION OF A CASE OF ‘WATERING
EYE’
 Slit – Lamp Examination :
It is done for the evidence of following conditions:
Punctum : Patency, size,position,discharge, obstruction
by an eyelash, large caruncle, Pouting Punctum , Centurion
Syndrome
Ectropion
Lesions of eyelid margins as papillomas,
molluscum contagiosum,chalazia,nevi,
carcinoma
Signs of Blepharitis , Dry eye syndrome .
Conjunctival lesions as Pinguecula ,Pterygium,
Follicles , Papillae, allergic conjunctivitis.
Corneal Irregularities, Dystrophies
Volume of tear lake
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 ROPLAS TEST :
Regurgitation On Pressure Over Lacrimal Apparatus
System.
Also called as Palpation of Lacrimal Sac.
Punctal reflex of mucopurulent material indicates
mucocele with a patent canalicular system, but with
an obstruction at or distal to the lower end of
Lacrimal Sac. In acute dacryocystitis palpation &
compression are painful & should be avoided.
Rarely it reveals the presence of a stone or tumor.
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 Fluorescein Dye Disappearance test :
 It is a semiquantitaive test of delayed or obstructed
tearflow.
 It is of particular importance for evaluation of
congenital dacryostenosis in infants & toddlers
where lacrimal irrigation is impossible without
anaesthesia or deep sedation.
 1 drop of 2% fluorescein is instilled into the
unanaesthesised conjunctival sac of both the eyes.
 The volume of tear lake is then noted preferably
under cobalt blue light.
 The patient is instructed not to wipe the eyes & tear
lakes are examined 5 mins. later & relative volume is
determined.
48

Persistance of significant dye & especially asymmetric
clearance of the dye from the tear meniscus over a
5 minutes period indicates a relative obstruction
of the side retaining the dye.
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 Diagnostic Probing :
It provides information regarding the site of obstruction.
It is performed only after obstruction is demonstrated by
other tests
After topical anaesthesia of conjunctival sac,the
canaliculi are also irrigated by anaesthetics
A probe of appropriate size is inserted into the punctum,
turned medially & advanced untill it encounters the
lacrimal bone.
The probe is then withdrawn a few mm and rotated
inferiorly & slightly posterolaterally untill the proximal
part of NLD is felt.
The probe is then passed untill it strikes the floor of
the nose in the inferior meatus.
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If in between any obstruction is felt, the site of
obstruction is noted by grasping the probe with a
forceps at its entrance before withdrawing.
Obstruction can be felt as a “ Soft stop” in case of
canalicular stenosis or as a “ Hard stop” as the
probe hits the bone at the medial wall of lacrimal
sac.
Obstruction
< 8mm- canalicular obstruction
8-10mm-common canalicular obstruction
>10 mm- distal part i.e. sac & NLD
Probing in children :
It should be done through upper canaliculus.
Upto 1 yr of age , the distance from punctum to
NLD is 12mm & to the floor of nose is 20mm.
51

 Syringing :
Principle : It provides information regarding the patency
of canalicular system.
Procedure :
 1-2 drops of topical anaesthesia is instilled into the
conjunctival sac.
 The punctum is dilated gently by advancing the
Nettleship dilator, first vertically for about 2mm & then
horizontally with a twisting movement.
 Simultaneously lateral traction is applied to the eyelid.
52

 With the eyelid stretched, dilator is withdrawn
& the Lacrimal cannula attached with syringe filled
normal saline is advanced horizontally
through punctum & canaliculus.
 No resistance should be felt in its entire path.
 Irrigation is then done & the patient is asked to
respond if fluid passes into the oropharynx or nose.
53

 Inference :
If there is resistance to irrigation: obstruction is partial.
Regurgitation of fluid from same punctum indicates
that there is a canalicular block.
Regurgitation of fluid from upper punctum indicates
blockage at the level of common canalicular duct,
lacrimal sac or nasolacrimal duct.
Immediate regurgitation of clear fluid usually suggests
a common canalicular obstruction.
Relatively delayed regurgitation of fluid mixed with
mucous or pus usually indicates NLD blockage.
54

 JONES DYE TESTING :
It is rarely needed.
Indication : Patients with suspected partial
obstruction of drainage system. It is of
no value in context with total obstruction
These are the Dye tests for functional epiphora
where the lacrimal drainage system is found to be
patent on syringing.
Types : These are of 2 types :
a) Jones test I
b) Jones test II
55

 a) Jones test 1 :
It investigates the Lacrimal outflow under normal
physiological conditions.
It is also called as Primary test.
It differentiates the partial obstruction of lacrimal
passage from primary hypersecretion of tears
Procedure : First a drop of 2 % fluorescein is
instilled into the conjunctival sac.
After about 5 minutes a cotton tipped
bud moistened in a local anaesthetic
is inserted under the inferior turbinate
at the nasolacrimal duct opening.
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 Inference :
i)Positive test : If fluorescein is recovered from the
nose ( presence of dye in cotton )
it indicates patency of drainage
system.Watering is due to primary
hypersecretion & no further tests
are necessary.
ii ) Negative test : No dye recovered from nose
indicates a partial obstruction (site unknown )
or failure of lacrimal pump mechanism.
 In this case Jones Test II is performed immediately.

 b) Jones Test II: Also called Irrigation or secondary test
It is a non-physiological test.
Principle :It identifies the probable site of partial
obstruction, on the basis of whether the
fluorescein dye instilled for primary/Jones
test 1 entered the Lacrimal sac
Procedure :Topical anaesthetic is instilled & any
residual fluorescein is washed out
instilled during Jones test 1.The drainage
system is then irrigated with saline with
the cotton bud under inferior turbinate.
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 Inference :
a)Positive test : Fluorescein stained saline
recovered from the nose indicates
that fluorescein entered the lacrimal sac,
thus confirming functional patency of
upper lacrimal passages ( punctum,
canaliculi ). Partial obstruction of
Naso-lacrimal duct is inferred.
b)Negative test : Unstained saline recovered from the nose
indicates that fluorescein did not enter
the lacrimal sac. This implies partial
obstruction of puncta, canaliculi, common
canaliculi or defective lacrimal pump
mechanism.
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 Ancillary Radiological Investigations :
Radiological tests help in confirming the site of
obstruction or stenosis in case of blocked syringing,
confirm a functional cause of epiphora & delineate the
anatomical as well as the pathological process
pertaining to the problem.
a ) Dacryocystography:
DCG involves injection of radio-opaque dye into the
canaliculi & taking magnified images.
60

 Indications of DCG :
 To confirm the site of obstruction,especially prior to
lacrimal surgery.
 To aid diagnosis of diverticula, fistulae & filling
defects caused by stones & tumours.
61

 Technique :
The inferior puncta are dilated with a Nettleship
punctum dilator.
Plastic catheters are inserted into canaliculi on both
sides after instillation of anaesthesia.
Contrast medium, usually 1-2ml Lipiodol,0.5-2ml of
water soluble iodinated contrast medium is injected
simultaneously on both the sides & postero-anterior
radiographs are taken.
10 mins later an erect oblique film is taken to
assess the effect of gravity on tear drainage
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 Interpretation :
Failure of dye to reach the nose indicates an
anatomical obstruction, the site of which is usually
evident .
A normal DCG in the presence of epiphora indicates
either lacrimal obstruction or lacrimal pump failure,
especially if contrast is retained on the late film.
IN DCG both the sides are usually interpreted
simultaneously.

B)Nuclear Lacrimal Dacryoscintigraphy :
It is a sophisticated test which assesses tear drainage
under more physiological condition than a DCG.
The disadvantage as compared to DCG is that it
fails to show finer anatomical details.
Apart from being a non-invasive procedure,radiation
exposure to lens is minimal compared to DCG.
It is more sensitive in assessing incomplete blocks.

 Technique :
a) Radionuclide technitium 99 is delivered by a
micropipette to the lateral conjunctival sac as a 10
micro litre drop.The tears are thus labelled with this
gamma-emitting radioactive substance.
b) The tracer is imaged by a gamma camera focussed
on the inner canthus & a sequence of images is
recorded over 20 minutes.

c ) Computerised Tomography :
 Its role comes when anatomical or pathological
abnormalities are suspected as the underlying cause
of epiphora.
E.g. Cranio-facial injury, congenital deformities,
Lacrimal sac neoplasia.
 The paranasal sinuses especially the maxillary
sinuses are imaged for any abnormalities that might
be affecting the NLD.
 Preoperative assessment of cribriform plate to avoid
possible cerebrospinal leak at the time of injury.

 Newer Modalities :
a) Chemiluminiscene test : Cyalume, a
chemiluminiscent material is injected with a
sialography catheter to demonstrate the patency of
outflow passeges.
b) Dacryoscopy : Dacryoscope, a mini rigid endoscope
allows the direct visualisation of the interior &
lining of lacrimal passages.
c) Standardised echography :Gross anatomical
structural defects can be evaluated.
d)Thermography : It is used in conjunction with
routine lacrimal irrigation to visualise the tear
ducts in normal subjects and in patients with
obstructive epiphora.

Dacryocystitis
 Inflammation of the lacrimal sac.
 It may occur in two forms:
Congenital dacryocystitis
Adult dacryocystitis
1)Acute
2)Chronic
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Congenital Dacryocystitis
 Inflammation of the lacrimal sac occurring in newborn
infants; and thus also known as dacryocystitis
neonatorum.
 Clinical Picture:
1.Epiphora, usually developing after seven days of birth. It
is followed by copious mucopurulent discharge from the
eyes.
2.Regurgitation test is usually positive, i.e., when pressure
is applied over the lacrimal sac area, purulent discharge
regurgitates from the lower punctum.
3.Swelling on the sac area may appear eventually.
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 Complications:If not treated in time it may be
complicated by recurrent conjunctivitis, acute on
chronic dacryocystitis, lacrimal abscess and
fistulae formation.
 Treatment: Depends upon the age at which the
child is brought
1. Massage over the lacrimal sac area and topical
antibiotics constitute the treatment of congenital NLD
block, up to 6-8 weeks of age.
1. Lacrimal syringing (irrigation) with normal saline and
antibiotic solution. It should be added to the
conservative treatment if the condition is not cured up
to the age of 2 months
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3. Probing of NLD with Bowman's probe. It should be
performed, in case the condition is not cured by the age of
3-4 months. Some surgeons prefer to wait till the age of 6
months.
4. Intubations with silicone tube may be performed if
repeated probings are failure. The silicone tube should be
kept in the NLD for about six months.
5. Dacryocystorhinostomy (DCR) operations: When the
child is brought very late or repeated probing is a failure,
then conservative treatment by massaging, topical
antibiotics and intermittent lacrimal syringing should be
continued till the age of 4 years. After this, DCR operation
should be performed.
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Chronic Dacryocystitis
 More common than the acute dacryocystitis
1. Stage of chronic catarrhal dacryocystitis
2. Stage of lacrimal mucocoele
3. Stage of chronic suppurative dacryocystitis
4. Stage of chronic fibrotic sac
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 Complications:
 Chronic intractable conjunctivitis, acute on chronic
dacryocystitis.
 Ectropion of lower lid, maceration and eczema of lower
lid skin due to prolonged watering.
 Simple corneal abrasions may become infected leading
to hypopyon ulcer.
 If an intraocular surgery is performed in the presence of
dacryocystitis, there is high risk of developing
endophthalmitis. Because of this, syringing of lacrimal
sac is always done before attempting any intraocular
surgery.
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 Treatment:
1. Conservative treatment by repeated lacrimal syringing.
2. Dacryocystorhinostomy (DCR)- It should be the operation
of choice as it re-establishes the lacrimal drainage.
3. Dacryocystectomy (DCT)- It should be performed only
when DCR is contraindicated.
Indications of DCT:
a)Too young(<4 yrs) or too old(>60 yrs)
b)Markedly shrunken or fibrosed sac
c)TB,syphilis,leprosy or mycotic infections of sac
d)Tumours of the sac
e)Gross nasal diseases Atrophic Rhinitis
4. Conjunctivodacryocystorhinostomy (CDCR)-
Performed in presence of blocked canaliculi
76

Acute Dacryocystitis
 Acute dacryocystitis is an acute suppurative
inflammation of the lacrimal sac, characterised by
presence of a painful swelling in the region of sac.
1. Stage of cellulitis
2. Stage of lacrimal abscess
3. Stage of fistula formation
77

 Complications:
1. Acute conjunctivitis,
2. Corneal abraision which may be converted to corneal
ulceration,
3. Lid abscess,
4. Osteomyelitis of lacrimal bone,
5. Orbital cellulitis,
6. Facial cellulitis and acute ethmoiditis.
7. Rarely cavernous sinus thrombosis and very rarely
generalized septicaemia may also develop.
78

 Treatment:
During cellulitis stage:It consists of systemic and
topical antibiotics to control infection; and systemic
anti- inflammatory analgesic drugs and hot
fomentation to relieve pain and swelling.
During stage of lacrimal abscess: In addition to the
above treatment when pus starts pointing on the
skin, it should be drained with a small incision. The
pus should be gently squeezed out, the dressing
done with betadine soaked roll gauze.
79

 Later on depending upon condition of the lacrimal sac
either DCT or DCR operation should be carried out,
otherwise recurrence will occur.
Treatment of external lacrimal fistula: After
controlling the acute infection with systemic
antibiotics, fistulectomy along with DCT or DCR
operation should be performed
80

Surgical techniques of DCR
 Conventional external approach DCR
 Endonasal DCR
81

 Conventional external approach DCR
• Anaesthesia
• Skin incision
• Dissection of lacrimal sac
• Exposure of nasal mucosa
• Preparation of flaps of sac
• Fashioning of nasal mucosal flaps
• Suturing of flaps
• Closure
82

 Endonasal DCR
 Preparation and anaesthesia
 Identification of sac area
 Creation of opening in the nasal mucosa, bones
fossa and posteromedial walls forming the
lacrimal fossa and posteromedial wall.
 Stenting of rhinostomy opening
 Postoperative care and removal of sialistic
lacrimal stents

 SURGICAL TECHNIQUE OF
DACRYOCYSTECTOMY (DCT)
• Anaesthesia
• Skin incision
• Dissection of lacrimal sac
• Removal of lacrimal sac. After exposing the sac,
it is separated from the surrounding structures by
blunt dissection followed by cutting its
connections with the lacrimal canaliculi. It is then
held with artery forceps and twisted 3-4 times to
tear it away from the nasolacrimal duct (NLD).
 Curettage of bony NLD. It is done with the help of
a lacrimal curette to remove the infected parts of
membranous NLD.
 Closure. It is done as for external DCR
84

85
 SWELLINGS OF THE LACRIMAL GLAND
DACRYOADENITIS
Dacryoadenitis may be acute or chronic.
 I. Acute dacryoadenitis
 Etiology. It may develop as a primary
inflammation of the gland or secondary to
some local or systemic
infection. Dacryoadenitis secondary to local
infections occurs in trauma,conjunctivitis
(especially gonococcal and staphylococcal)
and orbital cellulitis. Dacryoadenitis
secondary to systemic infections is associated
with mumps, influenza, infectious
mononucleosis and measles.

 Clinical picture. Acute inflammation of the
palpebral part is characterised by a painful
swelling in the lateral part of the upper lid.
The lid becomes red and swollen with a
typical S-shaped curve of its margin. Acute
orbital dacryoadenitis produces some painful
proptosis in which the eyeball moves down
and in. A fistula in the upper and lateral
quadrant of the upper lid may develop as a
complication of suppurative dacryoadenitis.
 Treatment. It consists of a course of
appropriate systemic antibiotic, analgesic and
anti-inflammatory drugs along with hot
fomentation. When pus is formed, incision
and drainage should be carried out
86

 II. Chronic dacryoadenitis
 It is characterised by engorgement and simple
hypertrophy of the gland.
 Etiology. Chronic dacryoadenitis may occur: (i) as
sequelae to acute inflammation; (ii) in association
with chronic inflammations of conjunctiva and; (iii)
due to systemic diseases such as tuberculosis,
syphilis and sarcoidosis.
 Clinical features. These include (i) a painless
swelling in upper and outer part of lid associated with
ptosis; (ii) eyeball may be displaced down and in;
and (iii) diplopia may occur in up and out gaze. On
palpation, a firm lobulated mobile mass may be felt
under the upper and outer rim of the orbit.
 Differential diagnosis from other causes of lacrimal
gland swellings is best made after fine needle
aspiration biopsy or incisional biopsy.
 Treatment consists of treating the cause.
87

Anatomy of lacrimal apparatus

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Anatomy of lacrimal apparatus