Ординатура / Офтальмология / Английские материалы / Moorfields Manual of Ophthalmology_Jackson_2007

with definition (anatomic versus symptomatic), symptoms (≈100% cure from mucocele stickiness with correctly

performed external DCR), and underlying disease (mucocele > functional NLDO ≈ 70–80% > canalicular block ≈ 60–80%).

■Risk : With a correctly placed external DCR incision, 2–3% have a visible scar at 1 year; 1–2% have significant postoperative epistaxis that might require nasal packing, admission, and monitoring for hypovolaemia.

Postoperative care No hot drinks for 12 hours; no nose blowing for 1 week. Prescribe chloramphenicol 0.5% and prednisolone 0.3% drops, both q.d.s. 2 weeks, then b.d. 2 weeks. If bilateral surgery or major infection, add cephalexin 250 mg q.d.s. p.o. 1 week.

Follow-up Remove sutures at 7–10 days and stent at 4–6 weeks, unless C-DCR (2–3 months) or retrograde canaliculostomy (2–3 weeks).

LACRIMAL 2 Chapter

Lester jones tube

Lester Jones Tube

Provides a permanent fistula connecting the conjunctival sac to nose. Requires prior DCR and carunculectomy. Use a ‘bull-horn’ dilator followed by passage of the LJT down the dilated tract; place the LJT just behind the medial canthus, angled slightly inferiorly (Fig. 2.5). Avoid abutting the nasal septum. Avoid nose blowing for 1 week postoperative because of the risk of the tube coming out, and review at 6 weeks. Advise the patient to place finger over the tube if sneezing or blowing nose, and perform daily ‘sniff’ test to confirm patency (inhale through nose with ipsilateral nostril blocked; sniffing water into nose may aid cleaning by ‘rinsing’ effect). Attend within 1–2 days if tube dislodges when replacement without GA is sometimes successful. Review annually for internal cleaning and saline irrigation.

Fig. 2.5: Lester Jones tube (arrow).

Congenital Nasolacrimal

Duct Obstruction

Background The lacrimal system usually canalizes at 8 months of fetal life. In the first year postpartum, 96% of cases of nasolacrimal duct obstruction resolve; a further 60% resolve in the second year with some slow resolution thereafter.

Examination Perform the fluorescein disappearance test (p. 58). Check for an expressible mucocele and dacryocele (a tense, bluish sac swelling usually in the first month of life). Look for fistulae, typically in the medial lower lid; these may drain fluorescein (Fig. 2.6).

Differential diagnosis

■Watery eye: atopy, punctal atresia (rare), conjunctivitis.

■Lacrimal sac mass: dermoid; haemangioma; meningoencephalocele; rhabdomyosarcoma (all very rare).

Management Explain the natural history. Massage the sac six times daily by firm pressure on medial upper lid, behind anterior lacrimal crest; demonstrate to parents. Use topical antibiotics for episodes of conjunctivitis. Defer probing until 12 months, unless acute/recurrent dacryocystitis, but only probe when the acute episode has resolved (Box 2.3).

Follow-up Review as required if first probing, 6–8 weeks if redo. Consider intubation if multiple endoscopically monitored probings fail.

Box 2.3: Syringe and probe (probing) procedure

1.Explain the procedure:

■Benefit: Complete symptom resolution: >90% if done age 1 year, 90% at 2 years, 80% at 3 years, 70% at 4 years, 40% at 5 years.

■Risk: False passage, bleeding, failure, bronchospasm.

2.Examine (under GA) lids, conjunctiva, puncta, look for fistulae, and expressible mucocele.

3.Perform dacryocystogram if redo to clarify anatomy.

4.Inject saline and fluorescein mixture using a lacrimal cannula. Feel for resistance. If not able to easily introduce cannula, dilate puncta gently. Place a fine suction catheter up nose to look for

LACRIMAL 2 Chapter

Congenital nasolacrimal duct obstruction

Box 2.3: Syringe and probe (probing) procedure—cont’d

5.Consider probing even if patent to syringing, e.g. if significant symptoms or prior failed probing. Try to start with a ‘0’ Bowman for lower punctum, ‘00’ for upper. Try to avoid smaller probes or sizes larger than ‘1’.

6.Insert probe vertically (2 mm) then horizontally with lid on lateral traction. Feel for ‘hard stop’ as probe contacts medial sac wall against nasal bones. Otherwise, compressed tissue results in a ‘soft stop’.

7.Direct probe vertically down into the nasolacrimal duct (NLD), angled slightly posteriorly and medially. Feel for a ‘pop’ as the probe perforates the membrane of a nonpatent NLD.

8.Check probe is below inferior turbinate – feel using large probe along floor of nose or look with an endoscope.

9.Repeat syringing. This also assists sac washout.

10.Prescribe prednisolone 0.1% and chloramphenicol drops, both q.d.s. 2–3 weeks.

Fig. 2.6: Accessory lacrimal opening (Courtesy D. Verity).

Canaliculitis

Background Canaliculi become grossly dilated with intraluminal deposits caused by low-grade infection, classically Actinomyces, but also fungi.

Symptoms Chronic discharge. Epiphora is often mild but worse in mornings.

Signs Swollen inflamed lid medial to prominent ‘pouting’ punctum. Features may be subtle (Fig. 2.7).

Management Canaliculotomy: dilate and open 5 mm of horizontal canaliculus. Use a fine chalazion curette to remove deposits. Send for microbiology. Prescribe G. chloramphenicol q.d.s. 1–2 weeks ± penicillin 250 mg p.o. q.d.s. for 1–2 weeks if severe. Penicillin G drops (100 000 U/mL) may be used if there is a poor response to surgery, but canalicutomy is all that is required for most patients.

Fig. 2.7: Canaliculitis (Actinomyces).

LACRIMAL 2 Chapter

Acute dacryocystitis/lacrimal sac abscess

Acute Dacryocystitis/

Lacrimal Sac Abscess

Background A purulent lacrimal sac infection/abscess with surrounding cellulitis, often associated with nasolacrimal duct obstruction. Caused by superinfection of a mucocele. May fistulize to skin.

Clinical features Tense, painful erythematous swelling below the medial canthal tendon, often with a history of stickiness and epiphora (Fig. 2.8).

Management Hot compresses 4–6 times daily, G. chloramphenicol q.d.s. until resolved, and cephalexin 250–

500 mg p.o. q.d.s. 1–2 weeks or until cellulitis resolve. If febrile or acutely unwell treat as preseptal cellulitis (p. 85). Incise and drain if fails to respond to above measures after 5–7 days, or if worsens. Apply topical skin anaesthetic (e.g. EMLA) for 30 minutes, then inject LA slowly around the abscess. This is often very painful, so consider GA. Incise with a blade, drain, send pus to microbiology and pack with ribbon gauze if large abscess. Arrange definitive treatment with dacryocystorhinostomy when cellulitis resolves.

Children with nonresolving acute dacryocystitis or infected dacryocele require systemic antibiotics, examination under anaesthesia, and drainage via nasal cavity.

Optometry and General

Practice Guidelines

Most lacrimal problems are nonurgent. Reassure patients who have very mild watering, e.g. only outdoors in cold, windy weather. In those with troublesome epiphora, treat or refer any sinonasal disease (e.g. rhinitis, polyps, mass) before referral to an ophthalmologist, preferably one experienced in lacrimal disorders. Also consider epiphora secondary to eye disease and ask if the eye becomes red and painful or if vision is blurred. Treat or refer any readily identifiable ocular surface problem (e.g. tear film deficiency, blepharitis, allergic conjunctivitis, trichiasis). Look specifically for eyelid/lash malpositions, e.g. lower lid ectropion/entropion.

A firm, nonreducible mass below the medial canthal tendon (for anatomy see p. 1) or blood-stained tears suggest lacrimal sac neoplasm, so refer urgently. Any swelling presenting in the region above the medial canthal tendon is neoplasia until proven otherwise.

Instruct parents of children with congenital nasolacrimal duct obstruction to massage firmly over the nasolacrimal sac (not the side of the nose) six times daily. Refer if symptoms fail to resolve after a year, or sooner if episodic conjunctivitis is present.

The following guide to referral urgency is not prescriptive, as clinical situations vary.

Same day

■Acute dacryocystitis/lacrimal sac abscess (commence G. chloramphenicol q.d.s. and systemic antibiotics,

Urgent (within 1 week)

Routine

■A child with epiphora since birth warrants routine referral unless suspected dacryocele, recurrent

LACRIMAL 2 Chapter

69

Preseptal

space Orbital

septum

Postseptal space

Subperiosteal space

Intraconal Extraconal space space

Fig. 3.1: Surgical spaces of the orbit (axial view).

ORBIT 3 Chapter

History and examination

History and Examination

History

Ask about the following:

1.Proptosis.

2.Pain: causes include inflammation, infection, acute pressure changes (e.g. haemorrhage), and bony / neural invasion.

3.Progression: symptoms may occur over minutes (e.g. haemorrhage); hours–days (e.g. inflammation); weeks– months (e.g. malignancy); months–years (e.g. benign tumour).

4.Past medical history: in particular thyroid disease, malignancy, and sinusitis.

5.(Perceptual) visual problems: diplopia, blurring, altered colour perception and refractive change.

6.Palpable or visible mass.

7.Periorbital abnormalities: including sensory change (paraesthesiae, numbness), redness, tenderness, watering, and lid anomalies.

Examination

Note the following:

1.General inspection (‘Panoramic’): note facial scars, asymmetry, swellings/masses, and goitre or thyroidectomy scar. Old photos (e.g. driver’s licence) may clarify disease onset.

2.Visual function (‘Perception’): VA, colour vision (Ishihara), red desaturation, reduced brightness perception and confrontation testing/formal perimetry if relevant.

3.Pupils: Test for RAPD.

4.Exophthalmometry (Proptosis?): For a rough estimate look from above and behind the patient, but perform exophthalmometry as follows if proptosis or enophthalmos is suspected:

■Check the location and symmetry of the lateral orbital rims (often recessed following orbitofacial fracture).

■Rest an exophthalmometer gently against each lateral