Definition : Chronic inflammation of the lacrimal sac secondary to obstruction of the nasolacrimal duct. This is the most common lacrimal sac disorder.
• Nasolacrimal duct obstruction.
• Pneumococci: 80% of cases.
• Staph, Strept, Trachoma & Fungi.
• TB & Syphilis: Rare.
1. Watery eye.
1. Red & hyperaemic inner canthus.
2. Swelling of the lacrimal sac: Below the medial palpebral ligament.
3. + ve regurgitation test: Regurgitation of mucous or pus. It becomes -ve on formation of a mucocele.
1. Chronic conjunctivitis.
2. Vicious circle of epiphora, eczema & ectropion.
3. Hypopyon ulcer.
4. Endophthalmitis: Following an intraocular operation.
5. Mucocele & pyocele: If the canaliculi are obstructed.
6. Acute dacryocystitis, abscess & lacrimal fistula.
Clinical evaluation & investigations of epiphora
1. History: Exclude lacrimation.
Bilateral watering of the eye is usually due to lacrimation, while unilateral watering is usually due to epiphora.
• Eyelids: Exclude trichiasis, ectropion & blepharitis.
• Lacrimal sac: Swelling & dacryocystitis.
• Nose: Polyps & deviated nasal septum.
1. Regurgitation test: Positive in cases with NLD obstruction.
2. Jones test.
4. Plain X-ray: Diagnosis of tumors & fractures.
5. Tuberculin test for TB.
6. Diagnostic probing & scintillography.
1. Regurgitation test: Press on the lacrimal sac against the lacrimal bone:
• + ve regurge: Reflux of pus or tears from the puncti NLD.
• -ye regurge: No reflux patent lacrimal passages.
2. Jones test:
I. Type I: Instill a
drop of fluorescin in the conjunctal sac & insert a coil on pellet soaked in xylocaine (Usneezing reflex) under the inferior nasal turbinate.
1. The cotton is stained with fluorescin patent lacrimal passages.
2. Not stained: Proceed to Jones test type II.
II. Type II: After type I, irrigate the lacrimal passage with saline.
1. If fluorescin is recovered: There is partial or functional obstruction of the passes.
2. If fluorescin is not recovered: There is complete obstruction.
Useful for detection of the following: Tumors & calculi appearing as filling defects. Time needed to fill & empty the sac.
4. Plain X-ray: To detect tumors & fractures.
1. Restore communication between the lacrimal sac & the nose.
2. Treatment of infection.
1. Treatment of the cause of obstruction.
2. Dacryocystorhinostomy :
Principle : Connecting the lacrimal sac to the nasal mucosa bypassing the obstructive NLD.
• Chronic dacryocystitis.
• Mucocele of the lacrimal sac.
• Lacrimal fistula (+ fistulectomy).
• Extensive adhesions & neglected cases.
• Nasal pathology eg atrophic rhinitis.
• TB & lacrimal sac tumors.
• Hypopyon ulcer.
3. Dacryocystectomy :
Principle : Removal of the lacrimal sac.
Indications : Neglected cases, when DCR is contraindicated.
Congenital NLD obstruction (Infantile dacryocystitis) Etiology : Imperforate hasener's valve (Most common).
Symptoms : Epiphora, 2-3 weeks after birth, is reported by the mother.
1. Regurgitation test clear fluid, mucous or frank pus.
2. Recurrent conjunctivitis.
1. Hydrostatic massage: Instruct the mother to press on the lacrimal sac in a downwards direction. This may help removing any epithelial remnants & opening hasener's valve.
3. Probing: Of great success rate.
4. Repeated syringing & irrigation.
5. Intubation of the lacrimal drainage system (Silicone tube).
6. Dacryocystorhinostomy (DCR).