Causes and Management of Acquired Obstruction of Nasolacrimal

7/30/2019 Causes and Management of Acquired Obstruction of Nasolacrimal

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Causes and management

of acquired obstruction ofnasolacrimal passages

Dr. Ayesha Amin

DOMS I


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Punctal stenosis


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Primary punctal stenosis

Occurs in the abcense of punctal eversion

Causes:

Idiopathic Herpes simplex lid infection

Irradiation of malignant lid tumors

Cicatrizing conjunctivitis and trachoma

Cytotoxic drugs like 5-FU Topical drugs: idoxouridine ,prednisolone, pilocarpine,

tropicamide and the longterm use of naphazoline


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Management: primarily surgical

1 snip procedure. This is performed after instillling localanesthetic.the punctum is dilated with punctal dilator and vertical

segment of the canaliculus is incised approximately 1 to 2 mm.

Traditional two-snip techniques rely on the use of two connecting

snips made along the conjunctival side of the punctum, excising a

triangular wedge of tissue. Punctoplasty : anesthetizing the lid as with the I snip procedure.

The punctum is dilated and a V-shaped incision along the posterior

wall of the punstum is performed. Intubation of the canaliculi is then

performed and the stent left in place for 3 to 6 months.

Insertion of canalised plugs into inferior punctum.There is no pharmacologic treatment for punctal stenosis with the

exception that discontinuation of an offending medictaion may cause

the punctal stenosis to reverse in rare cases


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Secondary Punctal stenosis

One of the most common causes of acquired punctal stnosis is punctal

ectropion with keratinization of peripunctal tissue.

Management:

Cautery burns : applied to the palpebral conjuctiva 5mm below thepunctum, subsequent cicatrization inverts the punctum.

Medial conjunctivoplasty: excision of a diamond shaped piece of

tarsoconjunctiva parallel to inferior canaliculus and punctumfollowed by approximation of superior and inferior wound margins

with sutures.


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Canalicular

obstruction


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Canalicular obstruction:may follow one of

the following conditions

Cicatrizing ConjunctivitisObstruction or atresia of the canaliculi may follow infections such asherpes simplex, herpes zoster, trachoma, infectiousmononucleosis,or inflammations such as the Stevens-Johnsonsyndrome or ocular pemphigoid.

Trauma

Chemical or thermal burns, dog bites, and other lacerations may alsocause obstruction or atresia of the canaliculi.

Acute lacerations of the canaliculi may occur after sharp penetratingwounds or as a result of shearing or ripping wounds of the eyelid

The location of the lid laceration medial to the lacrimal punctum shouldheighten the suspicion of the possibility of a canalicular laceration.


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Irradiation.

Occlusion of the canaliculi and puncta occurs afterirradiation for basal cell carcinoma almost 100% of the

time, although intubation with silicone tubing mayprevent this problem in some cases.

Tumors

Skin cancer may involve the canalicular system, butintrinsic canalicular tumors such as papillomas may

occur, producing occlusion and secondary inflammation. Use of Eye Drops

Echothiophate (Phospholine) iodide has been incriminatedas a cause of canalicular stenosis as well as ocularpemphigoid syndrome, and idoxuridine toxicity may

cause temporary occlusion of the punctum andcanaliculus.

Repeated Probing

One of the most common causes of stenosis of the lacrimalcanalicular system is repeated and traumatic probing of

the canalicular system for whatever reason.


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Management


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Lacerations

Internal splinting of the canaliculus with a soft, pliablematerial is mandatory to repair the laceration. End-to-

end anastomosis of the canaliculi is ideal with 7-0 or 8-0

Vicryl sutures.

Crawford lacrimal intubation set

Monoka monocanalicular lacrimal intubation system


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Common Canalicular Stenosisfollowing repeated probing, DCR orinflammations such as herpes simplex.

If the problem is a very localized narrowing of the common internalpunctum, silicone tube intubation can be attempted without the needfor an open surgical procedure. Silicone lacrimal tubes arecommonly left in position for at least 6 months.

If attempted probing of the canaliculi reveals that the segment ofocclusion is quite wide, an open surgical procedure is necessary toattempt to reconstruct this region. Following the exposure of theoccluded common internal punctum,the area of stenosisis eithercored out or a wider excision of the canaliculus and common internalpunctum may be required. Microsurgical closure combined withsilicone lacrimal tube intubation left in place for 6 months maximizesthe chances for ultimate reepithelialization of an intact membranouslacrimal conduit.


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Canalicular Tumors

Tumors of the canaliculi are rare and arebest treated by complete surgical excision.

full-thickness resection of the eyelid

margin along with the affected portion ofthe canaliculus with Frozen-section

monitoring of the margins during surgery

to ensure complete excision of any lesion.


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Obstruction of the

Nasolacrimal Duct


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PRIMARY ACQUIRED NASOLACRIMAL DUCT OBSTRUCTION

(PANDO)

Most common clinical syndrome of acquired nasolacrimalduct obstruction in adults.

Presentation: chronic epiphora, conjunctivitis, and low-

grade infections or acute dacryocystitis.Most common in elderly white women.

Pathophysiology: Inflammation with partial ductalobstruction leads to accumulation of cellular debris,which aggravates the ongoing inflammation and creates

a vicious cycle that leads to permanent cicatrization ofthe nasolacrimal duct lumen.

Histopathology reveal inflammation, vascular congestion,and edema of the nasolacrimal duct in the early phasesand, ultimately, fibrosis with complete occlusion of the

nasolacrimal duct's lumen in the late phases.


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In patients with symptoms of relatively short duration (less than 1year), the inflammation and edema functionally occlude thenasolacrimal duct. A potential space does remain within the lumen.PANDO may be reversible in patients with symptoms of short duration.

Patients with PANDO and chronic symptoms (greater than 2 to 3 years'duration) demonstrate dense fibrous scar tissue and cicatrization of

the nasolacrimal duct as a sequela of chronic inflammation, edema,and stasis of cellular debris. In these patients, the lumen of thenasolacrimal duct is permanently obliterated by scar tissue.


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Non inflammatory obstruction Although most adult nasolacrimal duct

obstructions represent the syndrome of PANDO,noninflammatory infiltrative disorders canocclude the nasolacrimal duct.

High index of suspicion in patients with knownsystemic disorders such as sarcoidosis,lymphoma, or leukemia.

In these situations, distal nasolacrimal sac ornasolacrimal duct biopsy is an important part ofthe DCR surgery.


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Intranasal Disorders: Intranasal scarring with inferior turbinate adhesions may

occur as a sequela of trauma, radiation therapy, orsurgical procedures

Allergic rhinitis may be associated with nasal mucosal

hypertrophy.

In some individuals, an abnormally wide nasal vestibuleis associated with compensatory hypertrophy of the

inferior turbinate that occludes the valve of Hasner

Tumors are uncommon and can be benign, such as

granulomas or nasal polyps, or malignant, such assquamous cell carcinoma.


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Trauma: Sequela of midfacial fractures involving the bony

nasolacrimal canal.

Severe crushing nasal orbital fractures and the Lefort II andLeFort III fractures

Bony fractures may initiate an inflammatory, cicatrizingprocess that results in symptomatic nasolacrimal ductobstructions many years after the original injury.

A number of cases of dacryostenosis have beenreported after cosmetic rhinoplasty.

Other sinus and nasal operations may also injure thenasolacrimal duct.

Prior midfacial or nasal radiation therapy may result innasolacrimal duct obstructions.


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Management


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Patients with symptoms of relatively shortduration (less than 1 year), may be candidatesfor either medical therapy with anti inflammatory

drugs or nasolacrimal duct intubation withsilicone tubes to maintain patency of the ductuntil the inflammation subsides or has beentreated.

In patients with chronic symptoms (greater than2 to 3 years' duration) DCR remains thetreatment of choice.

PANDO


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Thank you

Documents

Causes and Management of Acquired Obstruction of Nasolacrimal