Lacrimal System Disorders

Lacrimal A&P - Teary Terrain Tour

• Glands:
  • Main Lacrimal Gland: Orbital & Palpebral parts.
  • Accessory Glands: Krause (fornices), Wolfring (tarsal borders).
• Tear Film Layers (📌 LAMb - Outer to Inner):
  • Lipid: Outermost (Meibomian glands); prevents evaporation.
  • Aqueous: Middle (Lacrimal & accessory); volume, nutrition.
  • Mucin: Innermost (Goblet cells); adherence to cornea.
• Drainage Pathway:
  • Puncta → Canaliculi (Superior, Inferior → Common) → Lacrimal Sac → Nasolacrimal Duct (NLD) → Valve of Hasner (opens into inferior meatus).
• Innervation:
  • Parasympathetic: CN VII (via pterygopalatine ganglion) → secretion ↑.
  • Sympathetic: Superior cervical ganglion.
  • Sensory: Lacrimal nerve (CN V1).
• Tear Functions:
  • Optical clarity, lubrication, corneal nutrition, antibacterial (lysozyme, lactoferrin, IgA).

⭐ The lacrimal gland is a serous gland located in the superotemporal orbit.

Production Pathologies - Wet or Withered?

• Dry Eye (Keratoconjunctivitis Sicca - KCS): Insufficient tears.
  • Types:
    • Aqueous Deficient: ↓ production (e.g., Sjögren's).
    • Evaporative: ↑ loss (e.g., MGD).
  • Symptoms: Grittiness, burning, foreign body sensation, transient blur.
  • Tests:
    • Schirmer: Tear volume. Normal >10-15mm/5min.
    • TBUT (Tear Film Break-Up Time): Stability. Normal >10s.
    • Stains: Rose Bengal/Lissamine Green (devitalized cells); Fluorescein (epithelial defects).
  • Management: Artificial tears, punctal occlusion, cyclosporine, lifitegrast.
• Epiphora (Watering Eye): Excessive tearing.
  • Hypersecretion: Reflex (irritation, inflammation), emotional.
  • Outflow Obstruction: Anatomical (blockage), functional (pump failure).

⭐ Schirmer I test measures basic and reflex tear secretion; Schirmer II (after topical anesthetic) assesses basic secretion only.

Drainage Dilemmas - Clogged Canals Crisis

• Congenital Nasolacrimal Duct Obstruction (CNLDO)

  • Blockage: Valve of Hasner.
  • Symptoms: Epiphora, matting, ROP (+ve regurgitation).
  • Mgmt: Crigler massage; probing if no resolve by 9-12 months; DCR.

  ⭐ The most common cause of CNLDO is a membranous obstruction at the valve of Hasner.

• Acquired NLDO

  • PANDO: Idiopathic, middle-aged women.
  • SANDO: Trauma, infection, inflammation, tumor, iatrogenic.

• Investigations

  • FDDT, Jones I & II tests, DCG, Scintigraphy.

• Dacryocystitis (Lacrimal sac inflammation)

  • Acute: Pain, swelling, redness, fever (S. aureus, Strep). Mgmt: Systemic Abx, warm compress, I&D if abscess.
  • Chronic: Epiphora, mucoid discharge (S. epidermidis, Candida). Mgmt: DCR.

• Canaliculitis (Canaliculus inflammation)

  • Often Actinomyces israelii (sulfur granules).
  • Mgmt: Expression, Abx, canaliculotomy.

Glandular Growths - Lumpy Lacrimals

Lacrimal gland tumors: 50% epithelial, 50% lymphoid/inflammatory.

• Epithelial Tumors:

  Feature	Benign (Pleomorphic Adenoma)	Malignant (Adenoid Cystic Carcinoma - ACC)
  Commonest	Most common benign	Most common malignant (ACC)
  Symptoms	Painless proptosis	Pain, rapid growth
  CT	Smooth mass, bony erosion (smooth)	Infiltrative, bony destruction
  Key	Slow growth	Perineural spread (ACC)

  • Other malignant: Mucoepidermoid Carcinoma.

• Lymphoid/Inflammatory (Pseudotumor):

  • Often bilateral; good steroid response.

• Presentation: Superotemporal swelling, proptosis, diplopia. Pain suggests malignancy/inflammation.

• Diagnosis: CT/MRI; Biopsy is crucial.

⭐ Adenoid cystic carcinoma of the lacrimal gland is notorious for perineural invasion and has a poor prognosis.

High‑Yield Points - ⚡ Biggest Takeaways

• CNLDO: Commonest infant epiphora; Crigler massage first, resolves by 9-12 months.
• Acute Dacryocystitis: Painful, red swelling below medial canthus; Staph aureus common.
• Chronic Dacryocystitis: Persistent epiphora, mucopurulent reflux (ROPLAS +ve); DCR definitive.
• Canaliculitis: Actinomyces israelii (sulfur granules); pouting punctum, chronic discharge.
• DCR: Surgical bypass for acquired NLDO & chronic dacryocystitis.
• Jones I Test: Fluorescein in nose indicates patent lacrimal passage; differentiates causes of epiphora.