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The Tear Evaluation

The Tear Evaluation. Lynn E. Lawrence, CPOT, ABOC. Terms. Etiology – the cause of a disease or abnormal condition Dacryocystitis – inflammation of the lacrimal sac Epiphora – watering of eyes due to excess secretion of tears or obstruction of the lacrimal passage. Tear Film Layers. oil.

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The Tear Evaluation

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  1. The Tear Evaluation Lynn E. Lawrence, CPOT, ABOC

  2. Terms • Etiology – the cause of a disease or abnormal condition • Dacryocystitis – inflammation of the lacrimal sac • Epiphora – watering of eyes due to excess secretion of tears or obstruction of the lacrimal passage

  3. Tear Film Layers oil aqueous snot What functions does each layer of the tear perform?

  4. Tear Components • Lipid Layer – prevents evaporation • Aqueous Layer - hydration • Mucus Layer – sticks tear to the eye • Other components

  5. Left:Transillumination of eyelid showingmeibomian glands Lipid Secretion: Meibomian Glands Right: Secretion of lipid at lid margin • The lipid layer restricts evaporation to 5-10% of tear flow • Also helps lubricate

  6. Mucin Secretion: Goblet Cells Superficial layer of bulbar conjunctiva. Goblet cells violet, epithelial cells blue. • Soluble mucins • Lower surface tension allowing tear film to spread over surface

  7. Healthy Tears A complex mixture of proteins, mucins, and electrolytes coated by a lipid layer • Antimicrobial proteins • Growth factors & suppressors of inflammation • Soluble mucin helps stabilize tear film • Electrolytes for proper osmolarity (295-300) • pH slightly alkaline (7.4)

  8. Anatomy Punctum What function does the punctumhave?

  9. Anatomy and Physiologyof the ocular adnexa • Eyelids • Eyebrows • Eyelashes • Accessory glands • Lacrimal Apparatus What is the opening between the upper and lower lid called?

  10. Is this possible? You be the judge

  11. Lacrimal Apparatus • Sometimes a person cannot produce natural tears that they might need some punctal plugs. Obstructive – vs- non-obstructive

  12. Tear Production – Secretory • Lacrimal gland • Reflex tearing • Too much tearing…epiphora • Meibomian Gland • Gland of Krause • Superior fornix • Gland of Wolfring • Superior tarsal plate

  13. Causes of Tearing • Punctal agenesis • Poor/blocked drainage • Trichiasis • Superficial foreign bodies • Poor pump action • Eyelid mal-positions • Eyelid disease • Tear deficiency or instability • Meibomian gland dysfunction • Trigeminal nerve irritation

  14. Eyelids are the pump for tears • Punctum • Tear coverage • Exposure issues • Diagnosis assistance

  15. Causes of Tearing Cont… • Foreign body sensation • Hypersecretion • Lacrimal secretion and drainage imbalance • Primary or reflex tearing (reflex tearing is more common with ocular surface irritation) • Lacrimal pump failure • Lacrimal drainage obstruction • S/P Surgery

  16. Fluid Pools and Connections • Pools • Eye • Lacrimal lake • Lacrimal Sac • Nose A tear lake higher than 2mm indicative of obstruction

  17. The Connections • Connections • Lacrimal gland to the eye • From the eye to the lacrimal sac • From the lacrimal sac to the nose Caniculitis can cause the blockage

  18. What is in a blink? • Lateral side higher than medial side • Starts laterally and moves towards the medial and goes down the punctum • The lid continues to close depressing the lacrimal sac and pushing tears towards the nasal duct • This action also causes a suction for new tears

  19. Hypersecretion = Pump Failure • Crocodile-tears Syndrome • Gustatory Hyperlacrimation or Gustatory epiphora or Gustolacrimal reflex (could be congenital) • Ocular Surface Irritation

  20. Eyelid Positions Disease: • Trichiasis • Entropion • Ectropion • Tear deficiency / instability • Trigeminal nerve (5th CN) irritation

  21. Lacrimal Pump • Pump Action • Lids • Lateral/medial • Muscles • Disease • Punctum • Canniculli • Lacrimal Sac • Nasolacrimal Duct • Facial Nerve Palsy (7th CN)

  22. Lacrimal Pump • Pump Action • Lids • Lateral/medial • Muscles • Disease • Punctum • Canniculli • Lacrimal Sac • Nasolacrimal Duct • Facial Nerve Palsy (7th CN)

  23. Nasolacrimal Obstruction • Primary Acquired Nasolacrimal Duct Obstruction (PANDO) • Nasolacrimal examination • Office testing

  24. Clinical Presentation • Chief Complaint • History of present illness • Past medical history • Clinical examination • Nasal Examination

  25. The Tear Lake

  26. Chief Complaint Cont… • Distinguish welling of tears from epiphora • HPI = Onset, severity, consistency, frequency, nature of discharge, morning mucus, environmental factors, aggravating or alleviating factors • Ask about punctal plugs

  27. Treatments • Medications/artificial tears…moisture/oil • Fish oil supplements can take up to 6 months to work • Punctal Plugs • Botulinum Toxin Injections into the lacrimal gland (pg 979) • Surgery…lids, DCR, tubes

  28. Stones 3rd Surgery

  29. Gee-Whiz Facts • Children don’t start tearing until they are 6 weeks old • 5% of children have NLDO • Prognosis is decreased in children after 13 months • Congenital glaucoma can cause reflex tearing due to photophobia

  30. labeling

  31. Reference • Endoscopic Surgery of the Orbit and Lacrimal System 2006… Acquired Nasolacrimal Duct Obstruction David M. Mills M.D., Dale R. Meyer M.D. FACS • Images from EyeImaginations

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