Ординатура / Офтальмология / Английские материалы / Rapid Diagnosis in Ophthalmology Series Oculoplastic and Reconstructive Surgery_Nerad, Carter, Alford_2008

Obstruction Congenital System:• 6LacrimalSECTIONthe of Disorders

Congenital Nasolacrimal Duct Obstruction

Key Facts

•Failure of nasolacrimal duct at valve of Hasner to open at birth

•Tearing or chronic discharge appearing in first several weeks of life

•Unilateral or bilateral, but most are unilateral

•Most will resolve within first year

•Can usually be managed with medical therapy

Clinical Findings

•Children present with epiphora and mattering of eyelids due to chronic low-grade dacryocystitis (Fig. 6.1)

•Epiphora or eyelid mattering may worsen with upper respiratory infections because of nasal mucosa swelling and further duct obstruction

•Acute dacryocystitis unusual but can occur (Fig. 6.2)

•Diagnosis made by observation of an increased tear lake, especially if:

•unilateral

•mattering of eyelids

•delayed dye disappearance test (DDT)

•Evaluate for presence of the puncta to ensure that the normal upper lacrimal drainage anatomy is normal

Ancillary Testing

•DDT:

•2% fluorescein dye is instilled into both inferior cul-de-sacs

•delay in clearance noted after 5 min (Fig. 6.3)

Differential Diagnosis

• Punctal agenesis or imperforate membrane over puncta

•Canalicular agenesis, stenosis, or obstruction

•Tears arising from lacrimal sac fistula

•This tearing is different, as it originates from the fistula located below the eyelid on the cheek (may be associated with nasolacrimal duct obstruction)

•Chronic conjunctivitis

•Reflex tearing due to:

•epiblepharon

•distichiasis

•other causes

Fig. 6.1 Chronic dacryocystitis: less aggressive bacteria cause a chronic low-grade infection with mucopurulent discharge.

Fig. 6.2 Acute infection presents as a painful cellulitis surrounding the lacrimal sac.

Fig. 6.3 Dye disappearance test.

Obstruction Duct Nasolacrimal Congenital

Obstruction Congenital System:• 6LacrimalSECTIONthe of Disorders

Congenital Nasolacrimal Duct Obstruction (Continued)

Treatment

•Observation and lacrimal sac massage allows resolution in most patients

•If still symptomatic at or around 1 year of age, nasolacrimal system probing to break the membrane occluding the valve of Hasner

•Earlier probing if problem is very bothersome

•Probing

•Probe with a No. 0 or 1 Bowman probe (Fig. 6.4A)

•Infracture inferior turbinate if inferior meatus is narrow

•Irrigate lacrimal system after probing to confirm opening of membrane

•For failed probing, place nasolacrimal duct stents

•Repeat probing and place bicanalicular silicone stents through lacrimal system and retrieve from beneath the inferior turbinate (Fig. 6.5)

•Monocanalicular stents placed down through valve of Hasner as an alternative

•Leave stents in place for 3–6 months

•Dacryocystorhinostomy (DCR):

•for the rare case of stent failure

•for failure of nasolacrimal duct to develop

Prognosis

•Most nasolacrimal duct obstructions resolve in first year

•Probing treats 90% of children who remain symptomatic beyond 1 year

•Probing with stent placement treats up to 90–95% of children who fail probing

•DCR is rarely needed

A B

Fig. 6.4 Nasolacrimal duct probing. (A) A Bowman probe is placed into the canaliculus until a “hard” stop is palpated. Lateral traction on the lower eyelid helps to prevent “snagging” of the canaliculus. (B) The probe is rotated and passes into the nose. Patency is proved by irrigation or direct visualization of probe under the inferior turbinate.

Fig. 6.5 Silicone stents in place. The knot rests in the inferior meatus.

(continued) Obstruction Duct Nasolacrimal Congenital

Obstruction Congenital System:• 6LacrimalSECTIONthe of Disorders

Dacryocystocele

Key Facts

•Mass in medial canthus, present at birth

•Results from nasolacrimal blockage proximally at valve of Rosenmüller and distally at valve of Hasner

•Mucoid secretions distend the lacrimal sac

• Possibly containing amniotic fluid

•Can resolve spontaneously or require probing

•Also called mucocele, dacryocele, or amniocele

Clinical Findings

•Bluish mass at medial canthus in a newborn (Fig. 6.6)

•Initially sterile but can become infected

•Distention of lacrimal system may extend inferiorly into duct and present with a nasal mass in the inferior meatus

•This cyst is visible with a nasal endoscope (Fig. 6.7)

•Because newborns are obligate nasal breathers, these cysts can cause airway obstruction

Ancillary Testing

•CT scan if mass extends above medial canthal tendon, because of the concern of a possible meningoencephalocele

Differential Diagnosis

•Capillary hemangioma (Fig. 6.8)

•Meningoencephalocele

Treatment

•Massage and topical antibiotics

•Probing of the nasolacrimal duct if infection occurs or does not resolve in 2 weeks

•Some surgeons probe at initial presentation

Prognosis

•Lacrimal sac massage can lead to resolution in some cases

•Nasolacrimal duct probing is successful in resolving the obstruction in infants who fail lacrimal sac massage

•Lacrimal duct cysts require removal with endoscopic visualization

Epiphora of Causes Acquired System:• 7LacrimalSECTIONthe of Disorders

Canalicular Trauma

Key Facts

•Eyelid trauma involving the canalicular system

•Can occur with any facial trauma, blunt or sharp

•The medial portion of the eyelid (canaliculus) is weak and tears easily when lateral tractional forces are placed on the eyelid

• Fist injuries to the cheek can tear the canalicular portion of the eyelid

Clinical Findings

•Suspect canalicular trauma with any medial eyelid laceration or avulsion (Fig. 7.1)

•Close inspection may be required to identify the lacerated canaliculus

•Probing or irrigation of the involved canalicular system may be necessary to diagnose the injury and identify the proximal cut end (Fig. 7.2)

•Most are avulsion-type injuries from indirect facial trauma

•Occasionally, the canalicular system sustains a laceration from a sharp object

Ancillary Testing

• Probing of the canalicular system

Differential Diagnosis

• Medial upper or lower eyelid injury without lacrimal system injury

Treatment

•Locate the cut ends of the canaliculus using a microscope or loupes

•Repair with pigtail probe and canalicular stent (can be done under local anesthesia) (Fig. 7.3)

•Place probe through the intact canaliculus around the common canaliculus and out the proximal cut end of the involved canaliculus. The probe must pass posterior to the anterior limb of the medial canthal tendon

•Thread a piece of silicone tubing 2.5 cm long over a 6-0 nylon suture

•Place the end of the nylon suture through the eye at the end of the pigtail probe

•Pull the probe and the suture with the silicone tubing through the cut end and out of the intact canalicular system

•Dilate the punctum of the lacerated canaliculus and slide the pigtail through the distal cut end of the canaliculus