Lecturer: Dr. Yasser A. Khan, McMaster University and University of Toronto
DR KHAN: Okay. Let’s start with some pretest questions. Which of the following is not… So those of you who were not here yesterday, I’m very big on vital signs, but not just the vital signs you’re familiar with. There are lacrimal vital signs. What I mean by that is the most important parts of a lacrimal or tearing exam. So what is not an important part of the lacrimal exam? So true or false, is watery eye the same as epiphora? Okay? The most common cause of congenital epiphora is? Nasolacrimal duct obstruction, entropion, blocked valve of Hasner, and punctal stenosis? Which eyelid disorder does not commonly cause epiphora? Does everybody know what this means? Dermatochalasis? Okay. Ectropion, entropion, caruncle hypertrophy, caruncle, and conjunctival chalasis? Okay. So this is the objectives. Okay. So: Anatomy. Okay? So you all know the lacrimal gland is the main way in which the tears are produced. They exit the lacrimal gland through these tiny ducts on the conjunctival side, inside the eyelid. And the tears float around the eyes. Right? And they drain through the lacrimal system. You get the punctum, upper and lower punctum, you get the very thin tubes, the canaliculi, that enter into the common internal punctum, the lacrimal sac, which is located at the medial canthus, right there. And then you get the nasolacrimal duct that goes into the nose, and exits at the inferior turbinate. So memorize this. Because it is very important to know this. So when it comes to the lacrimal system, there’s three things you should always think of. Patients come to my office crying all the time, with tears falling down. When it comes to tears, there’s production, distribution, and drainage. Okay? And all three things can cause tearing. Disruption of all three things can cause tearing. So, for example, production. Okay? So if you have dry eye, you get irritation, you get reflexive tearing, and that’s one way. So always look at the ocular surface. Look at the cornea, conjunctiva, to make sure there’s nothing going on. So by distribution, I’m just going through all these three. Okay? So by distribution, it’s really the tear film. And you know the tear film has three parts, right? The most important one is the aqueous. Then there’s the mucin produced by conjunctival cells, and then there’s the lipid layer that’s produced by the eyelid glands. Right? So if there is abnormality in any of these, you get — autoimmune diseases like rheumatoid arthritis, lupus, Sjogren’s, sarcoid — all these things can cause trouble with this layer. You can get dry eye, then you get tearing. Blepharitis can cause trouble with this. And of course any kind of conjunctival disease. Pterygium, trachoma, infection can cause trouble with the mucin layer and can cause tear film trouble and then more tearing. Though usually when we think of lacrimal, we always think of this. But really, you should never forget that production and distribution can also cause tearing. So obviously the thing that we think about is blocking of drainage, of the toilet. You know? And basically that can happen because of two things. The most common thing is obviously obstruction of the nasolacrimal duct. But also, the lacrimal pump. Anybody know what the lacrimal pump is? You guys know what the lacrimal pump is, right? So, you know, the way that tears go into our system is by really blinking. As we blink, the orbicularis contracts, and it squeezes the lacrimal pump, and it also creates pressure where the tears are sucked in. And so if anything is wrong with the eyelid blink, or the orbicularis, that will cause tearing. Okay. So just for distribution and drainage, you need normal eyelid. Like I said. If eyelid is not normal, then you may have tearing problems. Like ectropion, entropion, trachoma, whatever. Facial nerve palsy. Things like that. So these are examples of things with the eyelids that can cause tearing. So sometimes fixing the eyelid — you can fix the tearing. So this is an entropion. Okay? And obviously these eyelashes are rubbing against the cornea. The eyelid muscles, like the retractors, are loose. And so this patient will have tearing. This is a patient with 7th nerve palsy. They have lagophthalmos. They have a paralysis ectropion. So their lacrimal pump — they can’t blink, so they can’t push the tears into the system. So they will have tearing. This is a patient with ectropion. Okay? So obviously she will have tearing. And another example of the same patient with lagophthalmos. Okay? So two causes of a tearing eye could be reflex tearing. So that’s distribution and poor lacrimal pump function. Okay. I will skip this. I mentioned this before. So punctum, canaliculi, common internal punctum. Where is it? Okay. So punctum, canaliculi, common internal punctum, lacrimal sac, nasolacrimal duct, inferior meatus, and valve of Hasner. Right in the inferior meatus, in the inferior turbinate, is a valve. Usually when we’re born, the valve is closed. As we grow, the valve opens up. Sometimes in kids, that valve does not open up, and we have congenital tearing. So if you know all these parts, then you can figure out: Where is the blockage? Yeah. So basically what’s called the fundus or the top of the lacrimal sac comes just above the medial canthus. Okay? The nice thing is that the — and it doesn’t show here, unfortunately — but the lacrimal sac is surrounded by the anterior part of the medial canthal tendon and the posterior part. They basically sandwich the lacrimal sac. And as long as you know your anatomy, you know that the lacrimal sac is slightly deeper. Right? And so when making your incision, you just have to be careful. You know that in this area, the top of the lacrimal sac comes in. So you have to be careful in your dissection. The other thing is that the lacrimal sac is contained — is it here? It’s contained in the lacrimal sac fossa. I see your point. So what I normally do when I’m working is that I put a probe in this, to protect it. So then I know exactly where it is. I put a probe in and then do my surgery around the probe. So if I see the metal, I know I’m going too deep and I stop. What is the difference between a watery eye and a tearing eye? So for my diagnostic purpose, I make them different. Why? Because it helps me treat the patient. Okay? So I have made it different. I treat the watery eye and the tearing eye or epiphora different. Okay? I call a tearing eye true epiphora. So when a patient comes in, and they say: My eye is watery, my eye is wet, okay, I define that as a watery eye. When they say: Doctor, my tears are coming out of my eyes and falling onto my cheeks, that’s what I call usually epiphora. That’s a good clinical way of diagnosing the two. Okay? So the first thing I always ask is: Do your tears come down your cheek? Or do they stay in the eye? That’s the first question I ask any patient who comes in with tearing.
If it’s watery eyes, usually it’s a problem with the eyelid or the eye surface. If it’s true epiphora, that gives you a hint that there may be some lacrimal system obstruction going on. So epiphora really means — by definition — means obstruction of the lacrimal system. Which means an operation will be required to correct this. So often I call myself a plumber. Because we’re really working with pipes and opening up blockages. And, again, just to summarize this, you know, tears overflowing — so epiphora is tears coming on cheek. Suggests lacrimal duct obstruction. Surgical condition. Watery eyes is no tears on cheek. Very non-specific. Patient comes in — oh, doctor, I’m tearing. They have a very poor tear quality. And they have blepharitis. So you would treat this medically. Again, just to emphasize clues to lacrimal system obstruction that I use are: Epiphora, if it’s unilateral, then most likely, it’s a lacrimal system obstruction. So, you know, obstruction in the punctum, the canaliculus, the lacrimal sac, the duct. Okay? If they have dacryocystitis, infection of the lacrimal sac… Okay. In your case, trachoma and conjunctivitis are probably common causes of lacrimal system obstruction. Right? Because it blocks up the punctum of the canaliculus. But facial fracture and nasal surgery. Let’s skip this. So basically, in kids, any kind of tearing eye plus mattering — what I mean by mattering is here. All this sort of pus-y, crusty discharge. Okay? I basically consider that to be congenital nasolacrimal duct obstruction. Usually occurs within one to two months of life. And so you diagnose it early. And there’s a blocking of the valve of Hasner, which I showed you, in the inferior turbinate. 90% resolve in the first year of life. A classic, classic example of a child with nasolacrimal duct obstruction. I will go through treatment of that later. Okay. We already discussed this, again. But if you — so this is — when looking at the lacrimal system, I separate it into the upper system and the lower system. The upper system is the punctum and the canaliculus. The lower system is the lacrimal sac and nasolacrimal duct obstruction. So in the upper system, usually if they have obstruction in the punctum or the canaliculus, it usually causes only tearing. Obstruction here causes tearing plus mucous discharge. Just to quickly talk about physical exam. The physical examination starts when a patient like this walks into your office, crying. I have already said this, but I’ll emphasize it. You know, obviously look at the ocular surface for any tearing patient. As eyecare providers, you have to look at everything. So you look at the cornea, conjunctiva, look at the eyelid, eyelash, and the lacrimal system. Yeah. So we already spoke about ectropion, entropion, trichiasis — how common is trachoma here? Very common, right? Yeah. So trachoma is a big cause of tearing and entropion and eyelid problems, obviously. And ocular surface problems, yeah. Look for lacrimal pump problems. Anything that prevents the eyelid from blinking and pushing those tears down the system. So eyelid deformity, scar tissue, facial nerve palsy. And age-related stuff. So ectropion, entropion. So there are two eyelid tests that I do, when examining a patient, to determine whether tightening their eyelid will make a difference or whether eyelid looseness is causing their tearing. So one is called a snapback test. Where you basically push their eyelid down and ask them not to blink, and if the eyelid comes up very slowly, then that’s a loose eyelid. Because you can see — to me, if I go like this, it comes up right away. So that’s called the eyelid snapback test. The eyelid distraction test is if you push the eyelid out, and it stretches all the way down. Anything more than a centimeter is a very loose eyelid. So doing an ectropion repair will help their tearing and help their ocular surface. And that’s called the eyelid distraction test. And I always tell my patients that: Why we all get — everybody, any race, all countries, all cultures — why we get ectropion is that usually when we cry or rub our eyes, we always rub down. Right? And if you rub down for 20, 30 years, you get an ectropion at the end of it. So always rub up. So whenever you rub and rub your tears, always rub up, and you won’t get an ectropion. When you have tears. Then you won’t come to me in 20 years. Okay. Good. So looking at punctal problems, okay, when a patient comes in tearing, look at the eyelid. You look at a punctal ectropion. So sometimes if you look at the punctum, the punctum could be out. That can cause tearing. You look at punctal stenosis. Patients with trachoma, glaucoma, who are on glaucoma medications, those medications can cause punctal stenosis. So look for that. Sometimes in congenital cases, children are born with a membrane on the punctum or no punctum. Look for that. So that’s an example of a punctal ectropion. You can see the punctum is out. It’s not draining any tears. Sometimes some patients will have conjunctival chalasis and caruncle hypertrophy. Do you guys know what they are? This is an example of caruncle hypertrophy. Okay? See how the caruncle is really large? It’s blocking the tears from getting into the punctum. And you can often — and, you know, this is actually a pretty important cause of tearing that a lot of people don’t think of, or miss. And so always look at the corner. And see what the corner of the — or the medial canthus, you know, looks like — and it may have something blocking. So what I do is I will actually trim or cut this caruncle off, to make more room in the corner here for the tears to go in. And what else does he have? This is conjunctival chalasis. It’s extra conjunctival tissue. And you can see here — you can also trim this tissue, and basically decrease the obstruction there. Obviously eyelash changes. Entropion, trichiasis, chronic blepharitis can all cause tearing. This is trachoma. You can see, if you check the fornix, you can see a lot of symblepharon and scarring. And of course, you know, rule out dacryocystitis. So we talked about the eyelid vital signs. Now we’ll talk about the lacrimal system vital signs. And there’s three that you check for in any patient that comes in with tearing. One is the dye disappearance test, or DDT. Palpation of the canaliculus. Okay? And the lacrimal irrigation. The DDT or the dye disappearance test — it’s a very useful thing to do, if you don’t want the hassle or you don’t have a cannula to inject the lacrimal system. It’s a really useful — and actually pretty accurate — way of diagnosing nasolacrimal duct obstruction. What you do is you take any kind of fluorescein. It doesn’t have to be 2% fluorescein. 2% is nice, but if you can get even a fluorescein strip, you put in the corner, and in the conjunctival fornix, and you wait about 5 minutes, and check to see how much dye is left in the eye. A normal result is something like this. An abnormal result is something like this, where the dye stays in the eye. Because sometimes you may not have time or you may not have the cannula to inject. Right? Or in a child — I mean, in a child, you can’t inject them. Right? They won’t let you. So you have to use this. The dye disappearance test. Yes. So this side has a — so this is after five minutes. This side has a nasolacrimal duct obstruction, and this side is normal. Same with the adult. This side is normal, because all the fluorescein has gone in. And this side has a nasolacrimal duct obstruction. And it actually is a pretty accurate test. They’ve done studies where they’ve irrigated these patients after, and they’ve have blockage. So it’s a very accurate test. Okay. This is canalicular palpation. Basically checking how open it is. You can either touch right here, and if something comes out, well, then, they’re blocked. Like pus comes out. Right? If you’re courageous and you have a lot of courage and you want to do this, you can also probe them to see if there’s a stricture, an obstruction, in the canalicular system. And, of course, the most common way of diagnosing nasolacrimal duct obstruction is lacrimal irrigation. Right? And this will tell you exactly where the blockage is. Whether you have partial obstruction, or it’s closed. I use a 27-gauge cannula. The nice thing with the 27-gauge cannula is that you do not need a punctal dilator. Because a 27-gauge cannula will fit into all sizes of punctum. Right? I use a 3-milliliter or CC syringe. We have pretty good water systems there. So I just use tap water. I don’t know what the water system is in Cameroon. You may want to use saline in Cameroon. So I use water. I stretch the eyelid. And I irrigate in the canaliculus, to see what’s going on. But this is an example. So notice my fingers here. I’m stretching the eyelid. Because if you don’t stretch the eyelid, then you can make a false passage. You can go right through the canaliculus and make a false passage. So make sure you stretch the eyelid, so that you stretch the canaliculus. You see I’m stretching? And with my other finger, I’m holding the upper punctum out, so I can see if there’s a blockage. Right? You can get an assistant to help you. I just do it myself. Any reflux or any stuff coming out is abnormal. So this is just an example of a full lacrimal exam. We’ve already talked about this. And this is the Toronto, Canada, skyline. I will end off with — and I’ll do the treatment part now. I will end off with one thing. It’s that: When it comes to tearing, you treat the patient, not the disease. So if the patient is not bothered by their tearing, and they’re okay with it, and there’s no infections going on, then you don’t have to do anything. Right? Only if they’re really bothered by the tearing and they’re getting infections and whatever — then you do something. So now you know the answer to this, don’t you? So it’s the eyelid distraction test. And you guys know that this is false. The most common cause of congenital epiphora is non-patent valve of Hasner.