disorders of the lacrimal system
TRANSCRIPT
DISORDERS OF THE LACRIMAL SYSTEM
Dr Russell J Watkins
Lacrimal System Disorders Tear film disorders (all phases)
The dry eye The wet eye
Drainage obstruction Lacrimal gland inflammation Lacrimal gland tumours Lacrimal sac tumours
Keratoconjunctivitis Sicca Aqueous phase deficiency Symptoms
Redness Burning sensation Gritty sensation “Stiff lids” - difficulty with initial opening 2° epiphora in some cases
Keratoconjunctivitis Sicca Signs
Tear meniscus TF debris; TBUT Corneal epithelial filaments SPE; frank ulceration Vital staining with rose Bengal 1% Abnormal Schirmer’s test (type I & type 2)
Keratoconjunctivitis Sicca Other investigations
Reduced lysozyme activity in Sjögren’s syndrome
Tear osmolarity (normal = ~300mosmol/l; Aqueous deficiency = ~340mosmol/l)
Keratoconjunctivitis Sicca Causes of aqueous deficiency
Idiopathic/age related 1° & 2° Sjögren’s syndrome Inflammatory or infiltrative lesions e.g. Lymphoma, TB,
sarcoidosis Congenital/iatrogenic absence of lacrimal gland CN V defect (sensory arc) CN VII defect (motor arc; anticholinergics) ADRs (antihistamines; -blockers; phenothiazines; OCP)
Mucin Deficiency Signs
TBUT Bitot’s spots: interpalpebral conjunctival
foamy patches associated with severe vitamin A & xerophthalmia
Causes Vitamin A deficiency Cicatrising disease (loss of conjunctival goblet
cells): trachoma, SJS, cicatricial pemphigoid, chemical burns
Oily Layer Abnormalities Meibomianitis, MGD Blepharitis, often staphylococcal & compounding
aqueous deficiency
Management of Dry Eyes
Artificial tears - if used very frequently, consider preservative free preparations
Lid toilet and compresses with occasional use of topical antibiotics
Mucolytics for filamentary keratitis Vitamin A supplements in xerophthalmia
(topically is experimental) Punctal plugs - optometric role? Stop exacerbating medication Surgery to lid deformities/punctal occlusion
Epiphora Causes
Exclude eye disease• Allergic/infective/irritative conjunctivitis• Trichiasis, distichiasis• Corneal disease
Dry eye with compensatory hypersecretion Lacrimal pump failure (e.g. CN VII palsy) Lid-globe incongruity such as ectropion Lacrimal drainage system obstruction Hypersecretion
Epiphora Assessment of the patient with epiphora
Exclude dry eye Check punctal position & patency Apply lacrimal sac pressure looking for reflux
(mucocele) Test lacrimal drainage patency
Epiphora Specific tests of patency
Fluorescein disappearance test Jones’ test - staining of nasal swab after
instillation of fluorescein into fornix Syringing & probing - diagnostic & therapeutic
(optometric role?) Ophthalmologists may also perform CT & MRI
scans, radionucleotide scans
Lacrimal Drainage System Obstruction
Causes: Congenital
• Absence/atresia of the canaliculi &/or puncta
• Incomplete opening of the nasolacrimal duct
• Associated with craniofacial anomalies Senile: punctal stenosis or associated with
chronic infection Ectropion or conjunctival cicatrisation
Lacrimal Drainage System Obstruction
Causes (continued) Trauma (physical or radiation) Inflammation (sarcoid, Wegener’s) Drug induced (pilocarpine, idoxuridine,
adrenaline et al) Infection
• Acute or chronic dacryocystitis• Canaliculitis (HSV, VZV, actinomyces
israelii)• Sinusitis
Lacrimal Drainage System Obstruction
Causes (continued) Lacrimal sac tumours
• 1° (e.g. papillomata, SCC)• 2° (e.g. BCC, lymphomata, sinus tumours)
Lacrimal Drainage System Obstruction
Treatment depends on site of obstruction & falls into the ophthalmologists realm Puncta may be dilated (± snips) Lid malposition correction Recanalisation operations Treat infectious causes (e.g. canaliculitis,
dacryocystitis) Recurrent dacryocystitis requires DCR Probing atretic nasolacrimal ducts, DCR =
mainstay of treatment of NLD obstruction
Lacrimal Gland Inflammation Viral dacroadenitis e.g mumps, glandular fever Acute bacterial dacryoadenitis often 2° to
conjunctivitis Chronic bacterial e.g. TB, syphilis Inflammatory conditions e.g. Sjögren’s,
sarcoidosis, Wegener’s Reactive lymphoid hyperplasia, lymphoma
Lacrimal Gland Tumours 50% are inflammations & lymphoid proliferations Pleomorphic adenoma (benign mixed cell
tumour) Epithelial origin 20-60 yrs Painless, usually with long history (>1yr) Palpable hard nodular mass Non-axial proptosis; ROEM; astigmatism Surgical removal en bloc rather than biopsy Good prognosis if completely removed
Lacrimal Gland Tumours Carcinoma
Epithelial origin Painful, usually short history Causes local bony erosion Usually biopsied after trial of antibiotics If biopsy +ve, requires radical local resection
with RT Poor prognosis
Lacrimal Sac Tumours Features
Rare Painless swelling Punctal reflux of pus & blood Can be SCC, adenocarcinoma
DISORDERS OF THE SCLERA & EPISCLERA
Dr Russell J Watkins
Episcleritis Inflammation of episclera & overlying
conjunctiva, occasionally associated with systemic disease (HZO, RA)
Nodular or diffuse Benign & self-limiting More common in young adults, M=F Mild ache, tenderness, burning Blanches with phenylephrine
Episcleritis Treatment
None (self-limiting) Topical corticosteroids Systemic/topical NSAIDs
Scleritis Less common but more serious than episcleritis Can be very painful; occasionally painless Pain can be worse at night Older age group; F>M
Scleritis Systemic disease associated with scleritis
HZO RA SLE PAN Wegener’s granulomatosis Behçet’s syndrome Ankylosing spondylitis IBD et al
Scleritis Classified as
Anterior scleritis Posterior scleritis
Anterior scleritis further subclassified Diffuse non-necrotizing Nodular non-necrotizing Necrotizing, without inflammation Necrotizing with inflammation
Anterior Scleritis Diffuse non-necrotizing
Segmented or widespread inflammation Oedema Treat with oral NSAIDs e.g. flurbiprofen
Nodular non-necrotizing Focal inflammation & oedema Nodule is immobile Treat with oral NSAIDs e.g. indomethacin
Anterior Scleritis Necrotizing, without inflammation
Scleromalacia perforans Seen in RA Painless scleral thinning with marked
ischaemia Perforation rare Treatment is difficult
Anterior Scleritis Necrotizing, with inflammation
Progressive, painful Injected ++ Scleral ischaemia & non-perfusion Focal or diffuse Associated anterior uveitis Scleral thinning
Anterior Scleritis Necrotizing, with inflammation (cont.)
25% 5-yr mortality from associated disease Severe complications e.G. Peripheral corneal
melt, cataract, glaucoma Treat with high dose systemic steroids
±immunosuppressants
Posterior Scleritis Features
Diffuse or focal thickened inflamed posterior sclera ±pain
Anterior segment may be unaffected Easily missed Exudative RD; choroidal folds Posterior vitritis; disc & macular oedema Uveal effusion syndrome Proptosis Ocular myositis with ophthalmoplegia Usually no associated systemic disorder
Posterior Scleritis Investigations
CT scan or USS(B) Treatment
High dose systemic steroids ±immunosuppression