Congenital NLD obstruction (Infantile dacryocystitis)

Etiology: Imperforate hasener’s valve (Most common).
Symptoms: Epiphora, 2-3 weeks after birth, is reported by the mother.
Signs
1. Regurgitation test clear fluid, mucous or frank pus.
2. Recurrent conjunctivitis.
Treatment
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.
2. Antibiotics.
3. Probing: Of great success rate.
4. Repeated syringing & irrigation.
5. Intubation of the lacrimal drainage system (Silicone tube).
6. Dacryocystorhinostomy (DCR).VGZGQ6DMSXZD

Chronic dacryocystitis

Definition: Chronic inflammation of the lacrimal sac secondary to
obstruction of the nasolacrimal duct. This is the commonest lacrimal sac disorder.
Etiology
Predisposing factors:
• Nasolacrimal duct obstruction. • Acute dacryocystitis.
Causative agent:
• Pneumococci: 80% of cases.
• Staph, Strept, Trachoma & Fungi.
• TB & Syphilis: Rare.
Symptoms
1. Watery eye. 2. Discharge.
Signs
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.
Complications
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.
Investigations: The same as epiphora.
Treatment
Aim:
1. Restore communication between the lacrimal sac & the nose.
2. Treatment of infection.
Lines:
1. Treatment of the cause of obstruction.
2. Dacryocystorhinostomy:
Principle: Connecting the lacrimal sac to the nasal mucosa bypassing the obstructed NLD.
Indications:
• Chronic dacryocystitis.
• Mucocele of the lacrimal sac.
• Lacrimal fistula (+ fistulectomy).
Contraindications:
• Extensive adhesions & neglected cases.
• Nasal pathology e.g. atrophic rhinitis.
• T.B. & lacrimal sac tumours.
• Hypopyon ulcer.
3. Dacryocystectomy:
Principle: Removal of the lacrimal sac.
Indications: Neglected cases, when DCR is contraindicated.

Acute dacryocystitis

Definition: Acute suppurative inflammation of the lacrimal sac.

Etiology
Predisposing factors:
• Nasolacrimal duct obstruction   • Chronic dacryocystitis.
Causative agent:
• Pneumococci
• Staphylococci
• Streptococci.
Symptoms
1. Severe pain.
2. Fever.
3. Epiphora.
Signs
1. Tender swelling of the lacrimal sac.
2. Marked edema & redness of the skin over the sac.
3. Regurgitation test: Reflux of pus, unless pericystitis occurs.
4. Abscess formation with fluctuation.
Complications
1. Lacrimal fistula: Anterior bursting of the sac through the skin.
2. Pyocele: Obstruction of the canaliculi ===> distension of the sac with pus.
3. Orbital cellulites: Ending in optic nerve atrophy  blindness.
4. Cavernous sinus thrombosis (CST).
5. Chronic dacryocystitis.
Treatment
1. During the acute phase:
• Systemic & topical antibiotics.
• Hot fomentations.
• Lotions: To clear pus.
• Incision & drainage: If an abscess forms.
2. After subsidence of the acute attack:
Dacryocystorhinostomy (DCR) with or without fistulectomy.

Dacryocystitis (Inflammation of the lacrimal sac)

1. Adult dacryocystitis:
• Acute dacryocystitis.
• Chronic dacryocystitis.
2. Infantile dacryocystitis (Congenital NLD obstruction).

Canaliculitis

Definition: Inflammation of the lacrimal canaliculi with ‘pyogenic organism, (trachoma, specific organism or fungs.
Commonest cause is mycotic canaliculitis, caused by actinomyces Israeli.
Symptoms: Persistent epiphora, not responding to treatment.
Signs:
• Chronic conjunctivitis, most marked at the medial canthus.
• Prominent & dilated lacrimal punctum (Patulous).
• Regurgitation test: Muco-purulent discharge which may concretions.
Treatment:
Canaliculotomy: Slit the posterior wall of the canaliculus, curettage of the fungal masses & irrigation with slaine.