Download FB sub-tarsal - Vision 2020 UK

Version 2 (06.05.08)
Name: Wormald/Astbury
CONDITION
Aetiology
Predisposing
factors
NASOLACRIMAL DUCT OBSTRUCTION (NASOLACRIMAL
DRAINAGE DYSFUNCTION) (DISORDERS OF THE
COMMENTS
LACRIMAL DRAINAGE SYSTEM)
Congenital
- some babies have a persistent membranous obstruction
at opening of nasolacrimal duct into nose; unilateral or
bilateral
Acquired
- usually idiopathic (i.e. no established cause)
- usually involutional (i.e. age-related change) stenosis (i.e.
abnormal narrowing) of nasolacrimal passages
- punctal or canalicular stenosis/occlusion
- post-infective (chlamydia, herpes simplex/zoster,
staphylococcal)
- post-cicatricial disease (ocular pemphigoid, StevensJohnson)
- post-conjunctivitis medicamentosa (e.g. long term
medications.preservatives in glaucoma or tear
deficiency)
- iatrogenic (eg repeated probing, eyelid surgery)
- secondary to ectropion or punctal eversion
- mechanical (trauma, tumours, obstruction by foreign
matter e.g. lashes, dacryoliths [calcium stones],
punctal/canalicular plugs)
- infection of canaliculi (canaliculitis)
- rarely, due to Actinomyces (streptothrix sp.) – a
Gram-positive bacillus
- such cases usually unilateral
Often with ‘pouting’ punctum (NJA)
- local infection (chronic sinusitis, dacryocystitis)
Age: congenital in babies, acquired in later life
Other factors: see above
Version 2 (06.05.08)
Name: Wormald/Astbury
CONDITION
Symptoms
Signs
NASOLACRIMAL DUCT OBSTRUCTION (NASOLACRIMAL
DRAINAGE DYSFUNCTION) (DISORDERS OF THE
LACRIMAL DRAINAGE SYSTEM)
Epiphora
Irritation
Blurred vision due to excessive tear meniscus, especially on
downgaze, e.g. when reading
Congenital
- epiphora and sticky discharge
- pressure over lacrimal sac may cause reflux of purulent
material from puncta
Acquired
Check puncta for
- size (normally 0.5 to 2.0 mm diameter)
- apposition to the globe and marginal tear strip
- contact with opposite lid on eye closure
Differential
Congenital
diagnosis
- congenital glaucoma (acute)
- punctal atresia (congenital absence or abnormal
narrowing of puncta)
Acquired
Rule out inflammation or infection (pain, discharge, swelling,
redness, mucus reflux on syringing in adults, history of sinusitis)
- canaliculitis - chronic mucopurulent conjunctivitis, pouting
punctum expresses chalky concretions, redness &
tenderness over canaliculi
- dacryocystitis – distended tender lacrimal sac
Tumour of lacrimal sac or canaliculi (rare)
- can produce lacrimal obstruction
- swelling at or below inner canthus (± blood in tears)
Bell’s palsy (lacrimal pump failure due to orbicularis weakness)
Management by Optometrist
COMMENTS
Overlap here with acute/chronic dacryocystitis (RW)
Version 2 (06.05.08)
Name: Wormald/Astbury
CONDITION
Non-pharmacological
NASOLACRIMAL DUCT OBSTRUCTION (NASOLACRIMAL
DRAINAGE DYSFUNCTION) (DISORDERS OF THE
LACRIMAL DRAINAGE SYSTEM)
Congenital
Diagnostic test
Fluorescein disappearance test
- a drop of 1% fluorescein should disappear from the tear
meniscus in 5-10 minutes (cobalt blue light, room lights
off); any longer suggests partial or complete obstruction
Therapy
- do not syringe or probe
- instruct parent in massage. Gentle pressure with finger
over common canaliculus, stroking downwards firmly to
raise pressure in lacrimal sac and encourage opening of
valve. Suggest ten strokes, four times daily
- regular cleaning of discharge from lids
Acquired
Diagnostic tests
Lacrimal syringing
- instil a drop of topical anaesthetic
- gently dilate punctum with punctal dilator
- syringe with normal saline via lacrimal cannula
- if saline passes into nose (patient swallows and tastes
salt) - nasolacrimal system is patent
- if there is resistance to the passage of the cannula and
reflux from opposed canaliculus - common canaliculus is
stenosed
- if no saline passes into nose - complete lacrimal duct
obstruction
Jones fluorescein dye test
- significant amount of fluorescein remaining in tear
meniscus two minutes or more after instillation indicates
restricted drainage
- check for appearance of fluorescein in the nose (examine
COMMENTS
Are we suggesting optoms should do s and p? and indeed
Jones tests? (RW)
Version 2 (06.05.08)
Name: Wormald/Astbury
CONDITION
Pharmacological
NASOLACRIMAL DUCT OBSTRUCTION (NASOLACRIMAL
DRAINAGE DYSFUNCTION) (DISORDERS OF THE
LACRIMAL DRAINAGE SYSTEM)
tissue after nose blow; if fluorescein present, lacrimal
system is patent)
- place anaesthetic-soaked cotton bud in nose under
inferior turbinate (if bud stained with fluorescein after 5
min, lacrimal system is patent)
Therapy
Punctal dilation
- instil a drop of topical anaesthetic
- dilate puncta with progressive diameter punctal dilator
- take care not to traumatise tissues
- periodic repetition may be required
Lacrimal lavage (saline syringing) may be effective in cases of
- local (discrete) obstruction
- subacute inflammation or infection
- less likely to be effective:
- in stenosis in the elderly
- where there is an underlying disease (inflammation,
tumour)
Congenital
Topical broad spectrum antibiotic e.g. chloramphenicol drops
(only if clinical evidence of infection)
Acquired
Topical broad spectrum antibiotic e.g. chloramphenicol drops
(only if clinical evidence of infection)
For Actinomyces infection, ofloxacin drops (generally in
conjunction with curettage of ‘sulphur granules’)
Initial management (including drugs) followed by routine referral
(B1)
COMMENTS
Regular massage of sac in babies? (RW)
Version 2 (06.05.08)
Name: Wormald/Astbury
NASOLACRIMAL DUCT OBSTRUCTION (NASOLACRIMAL
DRAINAGE DYSFUNCTION) (DISORDERS OF THE
CONDITION
COMMENTS
LACRIMAL DRAINAGE SYSTEM)
Possible management by Ophthalmologist
Possible management by Ophthalmologist
Probing (through puncta, canaliculi, sac, to nasolacrimal duct)
- congenital, not until 1 year of age to allow for
spontaneous canalisation
- in resistant acquired cases has more limited success and
risk of aggravation
Canalicular curettage
- for Actinomyces infection
Surgical removal of posterior wall of vertical limb of canaliculus
- considered when repeated punctal dilatation ineffective
X-ray imaging of radiopaque liquid injected into the lacrimal
drainage system (dacryocystogram, DCG)
- pinpoints any obstructions and guides surgery
Surgery in canalicular or nasolacrimal duct obstruction includes
- dacryocystorhinostomy, DCR (communication made
between the lacrimal sac and the nose by removing the
intervening bone and suturing lacrimal sac to nasal
mucosa)
- if other measures have failed, insertion of a Lester-Jones
tube
Is this congenital or acquired? (RW)
Is probing contraindicated in all congenital occlusions because
of risk of iatrogenic damage (RW)
Congenital:
(Oxford Centre for Evidence-based Medicine Level of Evidence
= 4)
Are you referring to cohort studies here? (RW)
Mention endolaser as well (NJA)
Evidence base