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PRESENTER : SURENDRA PRASAD SAHM.OPTOM (2 N D SEM)

(16 /03 /2015)

Epiphora

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Epiphora implies to overflowing of tears due to impairment lacrimal drainage.

OR due to a disruption in the balance between tear

production and tear loss.

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Causes

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Anatomical complete or partial punctal canalicular or NLD obstruction

Functional Lacrimal pump failure due to Anatomical deformity (Laxity, orbicularis weakness)

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Eyelids

Horizontal laxity and floppy lids

Lower lid entropion with orb.oculi overriding

Lower lid ectropion with ineffective orb.oculi

Loss of skin / orbicularis

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Punctal Causes Occlusion

Infection/radiation

Systemic: phemphigoid,SJS,Burns

Tumours

Medial displacement

Medial ectropion

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Canaliculi

Congenital absence/fistula Acquired Intrinsic Canaliculitis Trauma/ Post radiation Trauma/ Post radiation Tumours

Extrinsic Compression by adjacent tumours

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Lacrimal Sac Abnormality

Sac inflammationPerilacrimal fibrosisDacryolithiasis Sac tumours (rare in pediatric age group) Adnexal tumours pressing on lacrimal sac or drainage pathway

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Nasolacrimal duct

Congenital: NLD obstruction Delayed opening of Hasner’s valve, Cranio facial anomalies Agenesis.Acquired: Primary obstruction Secondary obstruction: tumour, traumaNASAL CONDITIONS Severe Deviated Nasal Septum or Turbinate Hypertrophy

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Excessive tears production

Reflex lacrimation in response to various factors Trichiatic cilia Severe entropionRaised IOP Allergic conjunctivitisCorneal exposure Drugs irritation Environmental irritants likes pollution

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Others

Ocular surface disorders like chronic KCS, conjunctivochalasis, cicatricial ocular surface pemphigoid, symblephron.

Neurogenic hypersecretory disorders like compressive irritation of parasympathetic lacrimal fibres, Aberrant regeneration of facial nerve following trauma.

Facial palsy

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Evaluation

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Evaluation

Careful history

External examination

Slit lamp biomicroscopy

Syringing and probing

Imaging

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DIAGNOSTIC TESTS

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Anatomical tests

These tests helps in localization of obstruction

Syringing / irrigation

Diagnostic probing

Dacryocystography

CT/MRI

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Functional tests

To access functioning of lacrimal apparatus under physiologic conditions

Performed only when there is no evidence of obstruction in anatomical tests

Flourescein dye disappearance test Jones dye test (jones primary and secondary )

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Imaging technique

Contrast Dacryocystography Lacrimal dacryocystography CT/MRI

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Managements

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Eyelids

Treatment of the causeEctropion surgery.Tarsorraphy

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Punctal Causes

Dilation of punctum Punctoplasty Ziegler cautery Medial conjunctivoplasty Lower lid tightening

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Canaliculi

Depends on the site and degree of obstruction

Intubation Anastomosis of the patent part of the

canaliculus into the lacrimal sac and intubation

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Nasolacrimal duct

Massage of the lacrimal sac increases the hydrostatic pressure and may rupture membranous obstruction

Probing of the lacrimal system

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Lacrimal surgery

Dacryocystorhinostomy (DCR) Indicated for obstruction beyond the medial

opening of the common canaliculus Anastomosing the lacrimal sac to the nasal mucosa

of the middle nasal meatus Procedure is performd under general hypotensive

anaesthesia

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Excessive tears production

Epilation Entropion lid surgery Deceased IOP Treatment of conjunctivitisSunglass

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Conclusion

Diagnosis of the condition and ruling out the cause is important.

Treatment of the cause will depend on the cause of watering.

Optometrist should treat the causes to anterior segment disease.

Cases requiring surgery should be referred to ophthalmologist.

Cases of systemic disease should be referred to physician.

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References

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BooksThimothy L. Jackson Moorfields manual of

ophthalmology ,1:212-228Mark W Leitman Manual for eye

examination and diagnosis.7th ed.Ak khurana Comprehensive

Ophthalmology 5th ed, 1 :271 :302Kanski J Jack Clinical ophthalmology a

systematic approach 2011,7th ed,1: 151-172

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Question

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How can you evaluate patient having Epiphora

How can you treat pediatric patient having epiphora

What are causes punctum

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Epiphora ,s.sah 3/16/2015