Lacrimal drainage

• Punctum


  Posterior edge of the lid margin, faces slightly posterior and inspected by medial aspect with lid eversion, tearing can be due to punctal stenosis or malpositioning
• Canaliculi


  • Run vertically from the lid margin then turning medially, run horizontal to reach the lacrimal sac, canaliccular obstruction can occur which is difficult to treat
• Lacrimal sac


  10 - 12 mm long, lies in the lacrimal fossa between anterior and posterior lacrimal crests
• Nasolacrimal duct


  12 - 18 mm long, inferior continuation of the lacrimal sac
• When seeing a patient, one of the first things we need to do is take a history
• History for watery eye

  • Enquire about ocular discomfort and redness, drainage failure becomes worse in dry, cold and windy conditions, tears overflow onto the cheek likely indicates drainage failure
• External examination


  Examine punctum and eyelids
• Punctal stenosis


  Narrow inferior punctum, no punctal malposition, causes include idiopathic, chronic marginal blepharitis, herpetic lid infection
• Punctal stenosis treatment


  Dilation (temporary), surgical punctoplasty
• Causes of watery eye

  • Secondary to anterior segment disease e.g. dry eye
  • Inflammation, hypersecretion of tears
  • Malpositioning of lacrimal puncta
  • Obstruction of drainage system
  • Lacrimal pump failure due to lower lid laxity
• External examination of watery eye

  • Punctal obstruction - partial or full, presence of eyelash in ampulla, canaliculitis may cause a pouting punctum, chronic epiphora may cause scaly and red eyelids
• Fluorescein disappearance test


  Marginal tear strip evaluated with slit-lamp before manipulating eyelid or instilling topical medication, watery eyes do not always overflow but may have a high tear meniscus, fluorescein is instilled into fornices and should disappear after 5-10 minutes, prolonged retention indicates inadequate lacrimal drainage
• The layer of the cornea stained by fluorescein is the epithelium
• Lacrimal irrigation


  After ascertaining punctal patency, if punctum is absent or severely stenosed surgical enlargement is necessary before the canalicular and nasolacrimal duct patency can be confirmed, contra-indicated if the infection is acute, use local anaesthetic, dilate the punctum, follow the contour of the canaliculus
• Acquired obstructions


  • Conjunctivochalasis
  • Primary punctal stenosis
  • Secondary punctal stenosis
  • Canalicular obstruction
  • Nasolacrimal duct obstruction
  • Dacrocystitis
  • Dacroadenitis
• Conjunctivochalasis


  • One or more redundant folds of conjunctival tissue over the eyelid margin, worsens dry eye symptoms, contributes to epiphora, chronic, low-grade inflammation is likely to play a role, treatment is observation and lubricants, topical steroids or anti-inflammatories
• Chronic canaliculitis


  • Uncommon condition, caused by Gram+ bacteria, may lead to canalicular obstruction, presents with unilateral epiphora, mucopurulent discharge, no lacrimal sac involvement, concretions may often be expressed upon compression
• Dacryoadenitis


  • Acute, causes include idiopathic and systemic viral conditions e.g. thyroid disease, presents with rapid onset discomfort, reduced lacrimal secretion, swelling of lateral part of eyelid causing S-shaped ptosis, tenderness on overlying area