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Lacrimal Drainage System

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Lacrimal Drainage System

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    1. Lacrimal Drainage System Congenital Anomalies

    2. Lacrimal Drainage System Primitive Cord of cells derived from surface ectoderm, sequestered in the naso-maxillary groove, forms the future lacrimal drainage system.

    4. Lacrimal Drainage System Upper and lower puncta Upper and lower canaliculi Common canaliculus (90%) Lacrimal sac Nasolacrimal duct

    5. Lacrimal Drainage System Palpebral-Canaliculur Pump Theory Lacrimal Pump Theory, (Jones)

    6. Lacrimal Drainage System 1. Double puncta on the same canaliculus 2. Double puncta with double canaliculi 3. Canaliculus slit 4. Lacrimal fistulae - Canaliculus fistula - Sac fistula 5. Diverticulae - Canalicular diverticulae - Sac diverticulae

    7. Lacrimal Drainage System 6. Obliterated punctum or puncta 7. Absent canaliculus or canaliculi, partial or complete 8. Absent valves (Rosenmuller & Hasner) 9. Obliterated NLD - failure to canalize - blind pouching

    8. Lacrimal Drainage System 1. Double puncta 2. Double canaliculi 3. Slit on canaliculus - mostly on the lower canaliculus - very rare - mostly asymptomatic

    9. Lacrimal Drainage System Lacrimal fistulae - very rare - usually symptomatic and associated with NLD obstruction - surgical excision during probing - if not symptomatic can be excised at later age under local anaesthesia if disfiguring.

    10. Lacrimal Drainage System lacrimal diverticuli usually asymptomatic in the paediatric age if symptomatic – can be excised

    11. Lacrimal Drainage System Nasolacrimal duct obstruction Failure to canalize Blind pouching

    12. Lacrimal Drainage System Clinical presentations Amniotocele Acute dacryocystitis (pyocele) Acute mucocele Tearing and discharging eye (most common)

    13. Lacrimal Drainage System Present at birth Can be bilateral Due to trapped amniotic fluid in the sac by Rosenmuller valve with NLD obstruction Nasal cysts

    14. Lacrimal Drainage System Management: May resolve spontaneously, gentle massage Office probing of Rosenmuller valve or aspiration, NLD probing Nasal cyst excision if present

    15. Lacrimal Drainage System Presents shortly after birth Retained normal mucus secretion of the sac.

    16. Lacrimal Drainage System Acute mucocele Management: - Office probing of Rosenmuller valve or aspiration through the canaliculus. If not ? NLD.

    17. Lacrimal Drainage System Acute Pyocele (Daryocystitis) - Acute infection and swelling of the lacrimal sac in the neonatal period due to NLD obstruction.

    18. Lacrimal Drainage System Acute Pyocele Management: Fibrile, toxic neonate ? Aspiration through canaliculus or probing in office If comfortable, not toxic ? conservative

    19. Lacrimal Drainage System The most common presentation of congenital NLD obstruction.

    20. Lacrimal Drainage System Incidence At birth 30 – 50% all neonates have blocked NLD. 25% bilateral 95% open spontaneously in the first month. 2 – 5% will have symptoms in the first year. Most of them still will open spontaneously from the first year. Less than 1% will need probing by end of the first year.

    21. Lacrimal Drainage System Probability of spontaneous resolution 1 month - 96% 7 months - 64% 2 months -93% 8 months - 49% 3 months -90% 9 months - 36% 4 months -86% 10 months - 23% 5 months -82% 11 months - 5% 6 months -75% 12 months - 0%

    22. Lacrimal Drainage System Onset of symptoms – 1 – 3 weeks after birth.

    23. Lacrimal Drainage System Time of presentation to ophthalmologist 3 – 6 months of age

    24. Lacrimal Drainage System Management of a child with tearing eye: Evaluation Treatment plan

    25. Lacrimal Drainage System Evaluation of a child with tearing eye: Careful history Physical examination

    26. Lacrimal Drainage System History taking of a child with tearing eye: Onset of symptoms Within one month ? congenital More than one month – acquired Infections Drugs history

    27. Lacrimal Drainage System History taking of a child with tearing eye: Continuous tearing vs. intermittent Continuous -- complete Intermittent – stenosis, (partial) nasal allergy, infection of upper respiratory tract

    28. Lacrimal Drainage System Presence of discharge ? complete block Absence of discharge ? ? hyperlacrimation Frequency of discharge ? early or late probing ? ± intubation

    29. Lacrimal Drainage System Rubbing eye Photophobia Hyperlacrimation vs. epiphore

    30. Lacrimal Drainage System History taking of a child with tearing eye: Swelling in the lacrimal sac area How frequent? ? early probing.

    31. Lacrimal Drainage System History taking of a child with tearing eye: Previous history of illness in the eye, use of drugs.

    32. Lacrimal Drainage System History taking of a child with tearing eye: Previous probings.

    33. Lacrimal Drainage System Physical examination of a child with tearing eye:

    34. Lacrimal Drainage System Physical examination of a child with tearing eye:

    35. Lacrimal Drainage System Physical examination of a child with tearing eye:

    36. Lacrimal Drainage System Physical examination of a child with tearing eye:

    37. Lacrimal Drainage System Physical examination of a child with tearing eye:

    38. Lacrimal Drainage System Objectives: To give a good chance for spontaneous perforation. To maintain clean eye during waiting period. Good timing for probing under safe anaesthesia.

    39. Lacrimal Drainage System Swab for C/S Organism: - Streptococci - H. influenzae - Staphylococci

    40. Lacrimal Drainage System Antibiotic - Ofloxacillin Therapy - Fucithalmic - Gentamicin, Neomycin - Polymixin, Bacitracin Gramicidin, Tobramycin - Cephalosporines - Vancomycin - Erythromycin

    41. Lacrimal Drainage System Massage To evacuate the sac prior to antibiotic drop instillation. To help to open the duct.

    42. Lacrimal Drainage System Pre-operative evaluation Discharge, tearing ± Dye tests Irrigation

    43. Lacrimal Drainage System Office or OR probing Probing ± intubation Repeat probing + intubation Failure ? DCR > 3 yr. of age

    44. Lacrimal Drainage System 9 – 12 months

    45. Lacrimal Drainage System Probing the first line of treatment till the age 2 yrs.

    46. Lacrimal Drainage System 97% - 1st yr. 76% - < 2 yrs. 33% - > 2 yrs.

    47. Lacrimal Drainage System Consider intubation Repeated probing in the same sitting Feeling of crushing Previous probing After the age of 2 yrs. with long standing infection.

    48. Lacrimal Drainage System Select proper dilator Sharp, long dilator can be dangerous

    49. Lacrimal Drainage System

    50. Lacrimal Drainage System Dilator made horizontally in the same line of canaliculus The lid made tight Now start rotating dilator

    51. Lacrimal Drainage System To confirm obstruction Forceful irrigation to possibly open the duct Dye in the nose – no probing

    52. Lacrimal Drainage System Select the proper probe (small, olive tip, malleable)

    53. Lacrimal Drainage System Insert probe vertically in the upper punctum Then horizontally insert through tight lid Then vertically and slightly posteriorly Pass gently to overcome the obstruction

    54. Lacrimal Drainage System Resistance Crushing feeling Watch the length of the probe

    55. Lacrimal Drainage System Dye irrigation retrieved from nose with ease. If no dye, repeat probing. Consider turbinate fracture.

    56. Lacrimal Drainage System Select the proper intubation set 5 cm long malleable Silicon tube – not solid Tube cover the whole probe

    57. Lacrimal Drainage System Probe passed as before Retrieve with mosquito forceps

    58. Lacrimal Drainage System Two knots Tied with 6 ‘0’ black silk Length of tube up to outside opening of the nostril

    59. Lacrimal Drainage System 2 – 6 months depending on Age of child Difficulty of probing Appearance of complications

    60. Lacrimal Drainage System (upper punctum)

    61. Lacrimal Drainage System Extrusion Slitting of canaliculus Granuloma

    62. In conclusion - careful evaluation - careful examination - careful manipulation Good outcome.

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