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Disorders of the Lower Lacrimal System
Inflammation of the lacrimal sac is themost frequentdisorder of the lowerlacrimal system. It is usually the result of obstruction of the nasolacrimal duct and is unilateral in most cases.
Epidemiology: The disorder most frequently affects adults between the agesof 50 and 60.
Etiology: The cause is usually astenosis within the lacrimal sac. The retentionof tear fluid leads to infection from staphylococci, pneumococci, Pseudo-monas, or other pathogens.
Symptoms: Clinical symptoms include highly inflamed, painfulswelling inthe vicinity of the lacrimal sac (Fig. 3.9) that may be accompanied by malaise, fever, and involvement of the regional lymph nodes. The pain may be referred asfar as the forehead and teeth. An abscess in the lacrimal sac may form in advanced disorders; it can spontaneously rupture the skin and form a drain-ing fistula.
Acute inflammation that has spread to the surrounding tissue of the eyelids and cheek entails a risk of sepsis and cavernous sinus thrombo-sis, which is a life-threatening complication.
Diagnostic considerations: Radiographic contrast studies or digital sub-straction dacryocystography can visualize the obstruction for preoperative planning. These studies should be avoided during the acute phase of the dis-order because of the risk of pathogen dissemination.
❖ Hordeolum (small, circumscribed, nonmobile inflamed swelling).
❖ Orbital cellulitis (usually associated with reduced motility of the eyeball).
Treatment: Acute casesare treated withlocal and systemic antibioticsaccording to the specific pathogens detected. Disinfectant compresses (such as a 1:1000 Rivanol solution) can also positively influence the clinical course of the disorder. Pus from a fluctuating abscess is best drained through a stab inci-sion following cryoanesthesia with a refrigerant spray.
Treatment after acute symptoms have subsided often requires surgery (dacryocystorhinostomy; Figs. 3.10a – c) to achieve persistent relief. Also known as a lower system bypass, this operation involves opening the lateral wall of the nose and bypassing the nasolacrimal duct to create a direct con-nection between the lacrimal sac and the nasal mucosa.
Etiology: Obstruction of the nasolacrimal duct is often secondary to chronicinflammation of the connective tissue or nasal mucosa.
Symptoms and diagnostic considerations: Theinitial characteristicofchronic dacryocystitis is increased lacrimation. Signs of inflammation are not usually present. Applying pressure to the inflamed lacrimal sac causes largequantities of transparent mucoid pus to regurgitate through the punctum.
Chronic inflammation of the lacrimal sac can lead to a serpiginous cor-neal ulcer.
Treatment: Surgical intervention is the only effective treatment in the vastmajority of cases. This involves either a dacryocystorhinostomy (creation of a direct connection between the lacrimal sac and the nasal mucosa; see Figs. 3.10a – c) or removal of the lacrimal sac.
Etiology: Approximately 6% of newborns have a stenosis of the mouth of thenasolacrimal duct due to a persistent mucosal fold (lacrimal fold or valve of Hasner). The resulting retention of tear fluid provides ideal growth conditions for bacteria, particularly staphylococci, streptococci, and pneumococci.
Symptoms and diagnostic considerations: Shortly after birth (usuallywithin two to four weeks), pus is secreted from the puncta. The disease con-tinues subcutaneously and pus collects in the palpebral fissure. The conjunc-tiva is not usually involved.
❖ Gonococcal conjunctivitis and inclusion conjunctivitis (see Fig. 4.3).
❖ Silver catarrh (harmless conjunctivitis with slimy mucosal secretion fol-lowing Credé’s method of prophylaxis with silver nitrate).
Treatment: During the first few weeks,the infant should be monitored forspontaneous opening of the stenosis. During this period, antibiotic and anti-inflammatory eyedrops and nose drops (such as erythromycin and xylo-metazoline 0.5% for infants) are administered.
If symptoms persist, irrigationorprobingunder short-acting general anes-thesia may be indicated (see Figs. 3.7a – c).
Often massaging the region several times daily while carefully applying pressure to the lacrimal sac will be sufficient to open the valve of Hasner and eliminate the obstruction.
This usually involves inflammation of the canaliculus.
Epidemiology and etiology: Genuine canaliculitisisrare.Usually a stricturewill be present and the actual inflammation proceeds from the conjunctiva. Actinomycetes (fungoid bacteria) often cause persistent purulent granular concrements that are difficult to express.
Symptoms and diagnostic considerations: The canaliculus region is swol-len, reddened, and often tender to palpation. Pus or granular concrements can be expressed.
Treatment: The disorder is treated with antibiotic eyedrops and ointmentsaccording to the specific pathogens detected in cytologic smears. Successful treatment occasionally requires surgical incision of the canaliculus.
Epidemiology: Tumors of the lacrimal sac arerarebut areprimarily malig-nant when they do occur. They include papillomas, carcinomas, and sar-comas.
Symptoms and diagnostic considerations: Usually the tumors cause uni-lateral painless swelling followed by dacryostenosis.
Diagnostic considerations: The irregular and occasionally bizarre form ofthe structure in radiographic contrast studies is typical. Ultrasound, CT, MRI, and biopsy all contribute to confirming the diagnosis.
Differential diagnosis: Chronic dacryocystitis (see above), mucocele of theethmoid cells.
Treatment: The entire tumor should be removed.
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