- Clinical science
The lacrimal apparatus consists of the lacrimal gland, which secretes the aqueous layer of the tear film, the lacrimal sac, into which the tears drain, and the nasolacrimal duct, through which the tears drain into the nose. Inflammation of the lacrimal gland is called dacryoadenitis and is commonly caused by viral or bacterial infections. The condition typically presents with conjunctival hyperemia, S-shaped ptosis, mucopurulent discharge, and discomfort. Dacryostenosis refers to the congenital or acquired obstruction of the nasolacrimal duct (NLD) and presents with excessive tearing. NLD obstruction can cause stasis of tears in the lacrimal sac, which predisposes to secondary bacterial infection of the sac, known as dacryocystitis. The diagnosis is usually clinical, and may be supported by bacterial cultures, imaging (CT, x-ray), and probing of the nasolacrimal duct. Treatment is often conservative (e.g., NSAIDs, warm compresses), but may also require antibiotics in cases of bacterial infections or invasive procedures to remove obstructions (e.g., NLD dilation).
|Acute dacryoadenitis||Chronic dacryoadenitis|
|Clinical features|| || |
- Definition: nasolacrimal duct (NLD) atresia/obstruction in an infant caused by a developmental anomaly and characterized by epiphora (excessive tearing)
- Incidence: up to 6% of live births (common condition)
- Clinical features
Diagnostics: clinical diagnosis; syringing or probing of the duct to determine the site of obstruction and remove the obstruction, if necessary
- Fluorescein dye disappearance test: A time > 5 min for dye to disappear is diagnostic of NLD obstruction.
- Lacrimal syringing: reflux of saline irrigated into the lacrimal punctum indicates NLD obstruction.
- Lacrimal duct probing: to determine the site of the obstruction and recanalize the duct; a diagnostic and therapeutic procedure; indicated in infants with persistent epiphora despite lacrimal duct massage (see below)
Treatment: lacrimal sac massage; dilation or stenting of the duct; dacryocystorhinostomy if other measures fail
- Conservative management (lacrimal sac massage): indicated in all infants with congenital dacryostenosis
- Lacrimal duct probing: if epiphora persists longer than 6–10 months
- NLD intubation/stenting or balloon dilation of the NLD: in patients with recurrent/persistent symptoms
- Dacryocystorhinostomy (DCR): in patients with refractory symptoms despite other measures
- Complications (of untreated dacryostenosis): acute/chronic dacryocystitis
- Clinical features, diagnostics, and complications are similar to those of congenital dacryostenosis.
- Treatment of the underlying disorder
- Lacrimal duct probing/intubation: in all patients
- DCR: in refractory cases
|Acute dacryocystitis||Chronic dacryocystitis|
The lacrimal gland should not be probed during acute infection, since this may cause bacteria to spread to to other locations.
- Clinical features
- CT and/or MRI scan
- Biopsy of the lacrimal gland