Lacrimal System

Lacrimal Gland

Tumours - Benign

The most neoplasms of lacrimal gland proved out to be inflammatory in origin therefore, treated by medical therapy. Benign mixed tumour is the most common lacrimal gland tumour, usually affecting a male aged 20-50 years of age. After performing a biopsy a wide surgical excision is carried out as it is well known for recurrence.

Tumours - Malignant

Malignancies consist of 50 percent of the epithelial tumours of lacrimal gland. They are very fast growing tumours from weeks to months. Adenoid cystic carcinoma being the commonest apart from adenocarcinoma, squamous cell carcinoma, mucoepidermoid carcinoma may also occur. Malignant mixed tumour is rare. In spite of major exenterations supplemented with radiotherapy recurrences are not uncommon.

Inflammatory Condition

Acute dacryoadenitis is a disease of childhood. The causes are mumps, measles or infectious mononucleosis. the other simulations may be orbital cellulitis or abscess. Depending upon the cause, treatment usually consists of hot compresses and appropriate antibiotics. Abscess may need surgical intervention.

Chronic dacryoadenitis is commoner than acute form. The causes can be end stage of the acute disease, tubercle bacilli, syphilis, Sarcoidosis, Mikulitcz's syndrome. Treatment is mainly medical as per the cause.

Conjunctival Sac 

Dry Eye

Tear film which keeps ocular surface including cornea continuously wet.      Tear film is constituted by three layers. The outer most reduces the evaporation of tear film providing longevity or period of stay at ocular surface secreted by Glands of Zeiss. The middle aqueous layer is the main bulk of the film contributed by Lacrimal and Accessory Lacrimal Glands. The inner most mucous layer is secreted by Goblet cells present at the ocular surface. This is very important as this acts as coupling device between ocular surface and tear film. This is by far the most important and commonly involved layer encountered in practice. Because of this most dry eye patients have complaint of watering as there is sufficient amount of tears but not able to be adhered with ocular surface perceived as dry eye and watering. The common causes are Chemical burns leading to destruction of Goblet cells, Steven Johnson' Syndrome, Thermal Burn, Severe Conjunctival loss / laceration, prolonged exposure to irritants or heat or computers. Medical treatment in form of replacements of tears, lubricants, cyclosporine or surgical in the form of amniotic membrane graft, rectal / mucous membrane graft or limbal stem cell transplants are very effective.    

Lacrimal Puncta -

Punctal Stenosis

Lacrimal punctum gets stenosed secondary to chronic inflammation, trauma, surgically induced trauma etc. This becomes more symptomatic (watering) if lower punctum is involved.

Atresia

Congenital absence of punctum leads to watering and on examination one confirms the absence.

Scarring

Secondary to trauma leads to scarring and thereby stenosis or disappearance of the puncta. Snip procedures or stenting with silicone rod or sponge with some antimitotic drugs good results.

Lacrimal Canaliculi

Traumatic Laceration

Lacrimal canalicular anastomosis and repair are challenging but if done properly and silicone intubation gives very good results as high as 75% in my hands.

Lower / Upper Blockage

UPPER OR LOWER CANALICULI ARE 1-2 MM INVERTICAL PART AND 6-7 MM HORIZONTAL PART. BECAUSE OF GRAVITY LOWER CANALICULUS PLAYS MORE IMPORTANT ROLE IN DRAINING TEARS. THERFORE BLOCKAGE OF LOWER CAUSES MORE SYMPTOMS TO THE PATIENTS. SINCE IT IS VERY NARROW THEREFORE RECANALIZATION IS NOT ABLE TO KEEP IT PATENT. CONJUNCTIVO-RHINOSTOMY IS THE PROCEDURE OF CHOICE MAY BE PERFORMED IN THESE CASES.

Common Canaliculus

Blockage

UPPER AND LOWER CANALICULI JOIN TOGETHER TO FORM COMMON CANCLICULUS WHICH OPENS INTO LACRIMAL SAC. BLOCKAGE IN THIS PART FEELS SOFT ON PROBING. CANALICULO-DACRYOCYSTORHINOSTOMY OR CONJUNCTIVO-RHINOSTOMY MAY BE CONSIDERED FOR TREATING THESE CASES.

Lacrimal Sac

Acute Dacryocysitis

IN CASES OF CHRONIC INFLAMMATIONS WHEN THERE ARE VIRULENT EXACERVATIONS OR LOWER IMMUNITY OF THE PATIENTS, IT IS CHARACTERIZED BY PAINFUL ACUTELY INFLAMMMED SWELLING AT LACRIMAL SAC AREA. IT IS TENDER, REDDISH AND HOT. IT IS TO BE TREATED MEDICALLY AND OPERATED FOR DCR AFTER 4-6 WEEKS OF ACUTE STAGE FOR PERMANENT CURE.

Mucocele , Pyocele,  Lacrimal Abscess

Swelling in lacrimal sac area, but still empties in conjunctival sac on regurgitation. If this continues for long time may progress to encysted mucocele, Lacrimal pyocele and abscess formation. All these conditions can easily be managed by surgery with individual and slight variations in surgical steps with very high success rate.

Lacrimal Fistula

WHEN LACRIMAL ABSCESS BURSTS AT THE SKIN AND PUS IS DRAINED FORMS A TRACK WHICH EVENTUALLY EPITHELISE, CALLED FISTULA. DURING DCR OPERATION FISTULOUS TRACK HAS TO BE EXCISED FULLY.

Lacrimal Tumour

Though uncommon but if they are present it is advisable to go for Dacryocystectomy (DCT). Commonly they are benign but it is pertinent to remove them.

Nasolacrimal Duct

Blockage

The most common site to get involved in chronic inflammations. The DCR provides very good results. A lot of other options are being tried to get rid of so called cumbersome procedure for common Ophthalmologist but so far conventional surgery gives the best results. The options are endonasal endoscopic DCR, Holmium YAG Laser DCR, Intra- canalicular diode Laser DCR etc with variable results.

 Congenital Dacryocystitis

Watering since birth due to delayed canalization of nasolacrimal duct. A protocol of management must be followed to get desired results in form of wait and watch with antibiotic drops, lacrimal massage, probing and syringing and in unfortunate cases DCR.