3. INTRODUCTION
Lacrimas in latin : a tear
Lacrimal gland is
exocrine gland
Secretes aqueous
component of tear
It is located under the
superotemporal
orbital rim in a shallow
fossa of the frontal bone.
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4. EMBROYOLOGY
Lacrimal gland
Starts to develop from multiple solid ectodermal buds
arising from the basal cells of conjunctiva in the
superotemporal region of fornix at 6th-7th weeks
Mesenchyme surrounds these buds and proliferates to form
the parenchyma of the lacrimal gland
Buds branch and canalize to form ducts and alveoli
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5. At 5th month of gestation lateral horn of levator
aponeurosis divides it into palpebral and orbital part
Lacrimal glands do not function fully until
approximately 6th week of life
Accessory lacrimal glands are formed from
ectodermal invagination of conjunctiva which
detected at 6 to 7 months
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7. Nasolacrimal duct
Maxillary process grows medially to override paraxial
mesoderm of the nasolacrimal process
Nasooptic fissure is thus formed
Surface ectoderm within the fissure thickens in a
cord-like fashion
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8. cords of epithelium invaginate at the upper and lower
lid margins, eventually forming the canaliculi. These
epithelial cords fuse to form the nasolacrimal
drainage system.
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12. Main lacrimal gland (Tear gland)
SITE- in lacrimal fossa formed by
orbital plate of frontal bone in the
anterolateral roof of orbit
SHAPE-almond shaped
TYPE-exocrine
PART-superior orbital and inferior
palpebral part
Separated by lateral horn of
aponeurosis of levator muscle.
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13. Structure of lacrimal gland
Branched tubulo-alveolar gland
Similar to salivary gland
Microscopically, it has glandular
tissue, stroma & septa.
1)Glandular tissue: consists of acini
and ducts arranged in lobes and
lobules. This lobules joins to form
intralobular ducts which finally
joins to form extralobular ducts.
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14. 2)Stroma: connective
tissue, elastic tissue,
lymphoid tissue,
plasma cell, nerve
terminals and blood
vessels
3)Septa: fibrovascular in
nature and separates
lobes and lobules from
each other
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15. Acinar unit (secretory unit)
Columnar or pyramidal
shaped secretory cells
(luminal surface of the
secretory cell has
microvilli)
Central lumen
Surrounding basal layer
of myoepithelial cells (aid
in expulsion of secretion )
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16. Clinical significance
1. Acute dacryoadenitis
Inflammation of lacrimal gland.
Develop as primary inflammation of the
gland or secondary to some local
infection as in trauma,
conjuctivitis(especially gonococcal and
staphylococcal) and orbital cellulitis or
systemic infection like mumps,
infleunza, measles.
Clinical feature: inflammation of
palpebral part, painful swelling in
lateral part of upper lid, typical S-
shaped curve of lid.
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17. 2. Chronic dacryoadenitis (mikulicz’s syndrome)
A chronic enlargement of lacrimal gland secondary to
systemic disease and associated with salivary gland
enlargment
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19. Accessory Lacrimal gland
Glands of Krause:
In the subconj. tissue near fornices.
About 40-42 in upper lid,
6-8 in lower lids.
More numerous laterally.
Supply aqueous phase of
basal tear film.
Glands of wolfring:
Situated near upper border of
superior tarsus plate, 2-5 in upper lid.
lower border of inferior tarsus, 2-3 in lower lid
Supply aqueous phase of the basal tear film.
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20. LACRIMAL DUCTS
10-12 lacrimal ducts
2-5from orbital portion
6-8 from palpebral portion
The ducts from the orbital portion joins with the
palpebral portion & finally open into the superior fornix
approx.5mm above the lateral tarsus border
Clinical importance: Removal or damage even only
to the palpebral portion of the gland amounts to the
excision of the entire gland as far as secretory function is
concerned
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21. Clinical importance
Lacrimal ductal cyst(dacryops)
Cystic swelling , which occur due to retention of
lacrimal secretion following blockage of the lacrimal
ducts
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22. Blood supply:
Supplied by lacrimal artery - ophthalmic artery –
internal carotid artery.
Sometimes transverse facial artery & infraorbital artery
supplies
The lacrimal vein joins to the superior ophthalmic vein
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26. Lacrimal punctum
Small rounded or oval opening.
In upper and lower eyelid at
junction of ciliary and lacrimal
portion of lid margin
Upper-6mm and lower 6.5mm
later to inner canthus
On closure of eyelid punctum
do not overlap
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27. Contd…
Each punctum sits on
top of an elevated
mound known as the
papilla lacrimalis.
They are relatively
avascular in comparison
to the surrounding
tissue, giving them a pale
appearance, which is
accentuated with lateral
traction of the lid.
This pallor can be
helpful in localizing a
stenosed punctum.
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28. Lacrimal canaliculi
LENGTH-Each are 8-12mm long
LENGTHCOURSE-2mm vertical&8-10mm
horizontal.
UNION-90% they unite as a common
canaliculus and in about
10% opens separately in lateral
wall of the orbital sac.
VALVE-Valve of Rosenmuller,a mucosal
fold overhangs the junction
between common canaliculi
and prevents reflux.
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29. ANGLE- between the vertical and horizontal segments
is approximately 90 degrees, and the canaliculi dilate
at the junction to form the ampulla..
LININGS-by nonkeratinized stratified
squamous epithelium and are surrounded by
elastic tissue, which permits dilation to 2 or 3
times the normal diameter.
CLINICAL SIGNIFICANCE
An incompetent valve of rosenmullar is observe
clinically as air escaping From the lacrimal
puncta when the indivisual blows his or her
nose
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30. Canaliculitis
Inflammation of canalaiculi.
Casuative agent: actinomyces israelii.
Presentation: unilateral epiphora with chronic
mocopurulent conjuctivitis.
Signs: pouting punctum, pericanalicular
inflammation, mucopurulent discharge on pressure
over the canaliculus. Concretions consisting of sulphur
granules can be expressed.
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31. Oedema and pouting of
punctum
Expressed concretions with
sulphur granules
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32. LACRIMAL SAC
Site lacrimal fossa: (anterior part of medial orbital
part) where sac is encovered by lacrimal fasica
(periorbita i.e periosteum lining of orbit)
Length: 15mm
Volume : 20cc
Parts :fundus (3-5mm) , body (10-12mm) & neck
Lining of double layer epithelium (upper is columnar
and deeper is falter)
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33. Relations
Medial to sac separated by periorbita and bone lie –
anterior ethmoidal sinuses
Below it lies: nasal middle meatus
Lateral to it lies skin ,part of orbicularis oculi,
lacrimal fascia
Anteriorly lies the medial palpebral ligament &
angular vein
Posterior to sac lies lacrimal fasica & septum orbitale
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39. Contd…
Lower end- opens into the nose through an ostium
under the inferior turbinate, covered by valve of
Hasner.
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40. Blood supply and nerve supply to
lacrimal passage
Superior and inferior palpebral arteries (ophthalmic
artery) and also by infraorbital artery , angular artery
&branch of sphenopalatine artery
Infratrochlear nerve – ophthalmic division of
trigeminal nerve and also by anterior superior alvolar
nerve
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41. CLINICAL IMPORTANCE
CNLDO (Congenital nasolacrimal duct
obstruction)-failure of the canalization of the NLD after
birth
In fetus, the NLD is a solid cord of cells, which gets
canalized at birth. In 30% of new borns canalization is
delayed. This congenital NLD blockage causes epiphora
predisposing to congenital dacryocystitis.
PANDO (primary acquired nasolacrimal duct
obstruction)-an entity of nasolacrimal duct obstruction
caused by inflammation or fibrosis without any
precipitating cause.. studies have revealed inflammation,
vascular congestion, and edema of the nasolacrimal duct in
the early phases and, ultimately, fibrosis with complete
occlusion of the nasolacrimal duct's lumen in the late
phases.
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42. SALDO(secondary acquired lacrimal
drainage obstruction)
has some etiology : infectious Bacteria such as
• Actinomyces
• Fusobacterium
• Bacteroides
• Mycobacterium
• Chlamydia
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43. Congenital nasolacrimal duct obstruction
Epiphora and matting
Infrequently acute dacryocystitis
Massage of nasolacrimal duct
and antibiotic drops 4 times
daily
Improvement by age 12
months in 95% of cases
If no improvement - probe at
12-18 months
Results - 90% cure by first
probing and 6% by second
Treatment
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44. Remnants of epithelium within the cords form inconsistent
valve like folds which are diagrammatically represented
.
1, valve of RosenMuller
2, valve of Krause
3, spiral valve of Hyrtl
4, valve of Taillefer
5, valve of Hasner or
plica lacrimalis.
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46. Secretion of tears
Continously secreted through out the day by main
&accessory lacrimal gland
Rate of tear production -1.2microl/min
tear vol.-7 micro lit
2 Components:
Basic Secretors
Reflex Secretors
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47. Basic Secretors
mucin secreting goblet cell
of conjunctiva
Accessory lacrimal gland of
krause & Wolfring
tarsal gland
Gland of Zeiss & Moll
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48. Reflex secretion
due to irritation of 5th cranial nerve in response to
sensation from cornea and conjunctiva.(mainly by lacrimal
gland)
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50. Lacrimal pump mechanism
The secreted tear flows over the ocular surface and
reaches marginal tear strip running along the ciliary
margin of each eyelids and collects as lacrimal lacus in
inner canthus.
From there it is drained to nasal cavity via lacrimal
excretory system by active lacrimal pump mechanism.
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51. Working of lacrimal pump
mechanism
Operates with the
blinking movements.
Performed by orbicularis
muscle of eyelid.
Two major events
• Eyelid closure
• eyelid open
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52. On eyelid closure following events occur
concomitantly
Contraction of pretarsal fibres of orbicularis compress the
ampulla and shortens the canaliculi.
This movement propels the tear fluid present in the
ampulla and horizontal part of canaliculi toward the
lacrimal sac
Contraction of preseptal fibres pulls the lacrimal fascia
and lateral wall of the sac laterally thus opening the
normally closed lacrimal sac.
This produces negative pressure and draws the tear from
canaliculi to lacrimal sac.
At the same time inferior portion closes more tightly thus
preventing aspiration of air from nose.
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53. On eyelid opening following events occur
concomitantly
Relaxation of pretarsal fibres allows canaliculi to
expand and reopen. This draws the tearfluid through
the punctum from the lacrimal lake.
Relaxation of preseptal fibres allows the lacrimal sac to
collapse which inturn expels the fluid downard into
open NLD.
At the same time puncta moves laterally, canaliculi
lengthens and is filled with tears.
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55. Drainage into the nasal cavity
Gravity
Air current movement within the nose
Final entry of tears into the nose :facilitated by
opening of Valve of Hasner which widens
synchronously with opening of lids
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56. Tear film
It consist of three layars
1. Mucous layer: subconjunctival
goblet cells
2. Aqueous layer: main and
accessory lacrimal glands
3. Lipid layer :Meibomian gland
Gland of Zeis and Moll
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57. Lipid layer
Outermost layer
Secreted by meibomian gland, zeiss and moll gland
Thickness-0.1micrometre
Consist of polar and nonpolar lipid
This layer prevents the overflow of tear and also
evaporation of tear
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58. Aqueous layer
Middle layer.
Secreted by lacrimal gland and accessory gland of
krause.
Thickness: 6.5-7.5 micrometre.
Constitute main bulk of tear.
Consist of inorganic salts, glucose, urea, and various
biopolymers like proteins(Ig A), antibacterial agent(
lysozyme, lactoferrin).
This layer serves to provide atmospheric oxygen to
epithelium,washes away debris and noxious agent,
maintain the normal level of electrolyte over occular
surface epithelium.
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59. Mucin layer
Innermost layer
Secreted by conjuctival goblet cells
This layer makes the hydrophobic corneal surface
hydrophilic overwhich the aqueous and lipid layer get
adheres. Thus plays a vital role in stability of tear film
Act as lubricant during eye movement
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60. Tear film abnormalities
Dry Eye
It is the state of abnormal tear film that can be caused
by number conditions which alter its composition and
affect stability.
Normal tear Tear in dry eye
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61. Tear film abnormalities classification on
the basis of physiological consideration:
(holly and lemp )
Aqueous deficiency
Mucin deficiency
Lipid abnormality
Impaired lid function
epitheliopathy
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62. Tests for tear film adequacy
Schirmer test:
assess aqueous tear
production.
Performed with whatmann 41
filter paper.
Two type:
Schirmer I: without anesthesia
Normal lower limit is 10mm
of wetting after 5min
Schirmer II: use of anesthesia
Normal lower limit is 6mm
after 5min
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63. Tear film break-up time
Indicate adequacy of mucin
component of tear
It is the time interval between
complete blink and
appearance of first randomly
distributed dry spot on
cornea.
Done by instillation of
fluorescein drop 2% or
impregnated fluoresceinstrip.
Examined under cobalt blue
light of slit lamp.
TBUT value less than 10 sec is
said to be dry eye.
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64. Clinical correlation of lacrimal
apparatus
Watering eye
Implies overflow of the tears from conjuctival sac
Occur due to :
• Excessive secretion of tears(hyperlacrimation)
• Obstruction of lacrimal passage
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65. Clinical evaluation of watering eye
1. External Ocular examination with slit lamp:
Ectropion
entropion
Punctal obstruction by an eyelash
Large carauncle displacing punctum away from
globe
Pouting punctum
Any occular FB
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66. 2.Regurgitation test
A steady pressure with index finger over lacrimal sac
area is applied.
Punctal reflux of mucopurulent material on
compression indicates patent canalicular system with
obstruction at lacrimal sac or NLD
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67. 3. Fluorescein dye disappearance
test(FDDT)
Performed with instillation of 2% fluorescein dye in
both conjuctival fornices.
Observations made after 2 min.
No dye is seen in conjuctival sac-patent passage
Retention of dye –inadequate drainage due to atonia of
sac or mechanical obstruction.
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68. 4. Lacrimal syringing test
Local anesthetic(4% xylocaine) is instilled
Punctum is dilated if narrow
Gently curved, blunt tipped lacrimal cannula on a
2mm saline filled syringe is inserted into lower puncta
and advanced few mm following the contour of the
cannulus prior to irrigation
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69. Then after, normal saline is pushed into
lacrimal sac . The following conditions are
obtained:
1. Free passage of saline indicate patency of lacrimal
passage.
2. Clear fluid from same puncta indicate same pucta
block.
3. Clear fluid from opposite puncta indicate
common camnalicular block.
4. Mucoid fluid from opposite puncta indicate NLD
block.
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70. Probe test
The hard stop and soft stop is encountered
Hard stop indicates the patency of lacrimal canaliculi
Occurs when cannula enters the lacrimal sac but comes
to stop at the medial wall of sac
Soft stop indicates the non-patency of canaliculi
Occurs when cannula donot enter lacrimal sac and
presses the soft tissue of common canaliculus
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72. 5. Jones dye testing
Performed in patients with suspected partial obstruction of the
drainage system.
Type:
John testI: differentiate between watering due to partial
obstruction and hypersecretion of tear.
John test II: identifies probable site of partial obstruction. Done
after John I.
Two drops of 2% fluorescein dye is instilled in conjuctival sac and a
cotton bud dipped in 1% xylocaine is placed in inferior meatus after 5
min.
John test I:
Positive: fluorescien is recovered from the nose indicating
patency of drainage system. Watering is due to primary
hypersecretion.
Negative: no dye is recovered indicating a partial obstruction. In
this case John II is recommended.
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73. John test II:
Cotton bud is placed in inferior meatus and syringing
is performed after application of anesthetic.
Positive: fluorescein stained saline is recovered from
nose. Here fluorescein has entered in sac thus
conforming patency of upper lacrimal passage.
Negative: unstained saline is recovered from the
nose. It indicates no entry of dye in lacrimal sac and
implies partial obstruction of puncta, canaliculi or
common canaliculus.
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74. Introduction to obstruction of lacrimal passage
Punctal obstruction:
Primary punctal stenosis:
caused in absence of punctal
eversion e.g due to chronic
blepharitis, herpes simplex,
herpes zooster, cicatrizing
conjuctivitis, trachoma etc
Secondary punctal
obstruction: caused by
punctal eversion.
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75. Canalicular obstruction:
Occurs due to congenital
trauma, herpes simplex
infection, drugs and chronic
dacryocystitis.
Nasolacrimal duct
obstruction:
Congenital,idioapthic, naso-
orbital trauma,granulomatous
disease like
sarcoidosis,infiltration by
nasophyrangeal tumors.
Dacryoliathiasis: lacrimal stone
in any part of lacrimal system.
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