Download
1 / 52

LACRIMAL SYSTEM: CLINICAL ANATOMY, PHYSIOLOGY, CONGENITAL DISORDERS AND EVALUATION - PowerPoint PPT Presentation


  • 142 Views
  • Uploaded on

O , my sustainer! Open my Heart and make my task easy for me and loosen the knot from my tongue so that, they might understand my speech Surah Taha (16:25-290)____Al Quran. LACRIMAL SYSTEM: CLINICAL ANATOMY, PHYSIOLOGY, CONGENITAL DISORDERS AND EVALUATION. DR. FAIZUR RAHMAN

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about ' LACRIMAL SYSTEM: CLINICAL ANATOMY, PHYSIOLOGY, CONGENITAL DISORDERS AND EVALUATION' - inari


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript

O , my sustainer! Open my Heartandmake my task easy for meand loosen the knot from my tongueso that, they might understand my speechSurahTaha (16:25-290)____Al Quran


Lacrimal system clinical anatomy physiology congenital disorders and evaluation

LACRIMAL SYSTEM: CLINICAL ANATOMY, PHYSIOLOGY, CONGENITAL DISORDERS AND EVALUATION

DR. FAIZUR RAHMAN

Professor of Ophthalmology

PESHAWAR MEDICAL COLLEGE


Learning objectives
LEARNING OBJECTIVES

BY THE END OF THE SESSION THE STUDENTS

WOULD BE ABLE TO:

  • Correlate the structure of the lacrimal system with its function and clinical presentation in common clinical disorders.

  • Outline the clinical examination protocol for the assessment of lacrimal system in patient presenting with epiphora.


Lacrimal system
Lacrimal System

  • Consist of two parts:

    Tear production

    Tear drainage

  • Tear production:

    *Main Lacrimal gland

    *Accessory lacrimal glands

    Glands of Krause

    Glands of Wolfring


Lacrimal glands
LACRIMAL GLANDS

  • Serous glands

  • Situated at the upper and outer angle of the orbit, just within the orbital margin, in a depression on the orbital plate of the frontal bone (Fossa for the lacrimal gland)


Embryology
Embryology

Lacrimal gland forms as a series of ectodermal buds that grow supero-laterally from the sup. fornix of the conjunctiva into the underlying mesenchyme. These buds then canalize forming the secretary units and multiple ducts of the gland.

Lacrimal sac and NLD develop as a solid cord of ectodermal cells between lat. nasal process &

maxillary process of the developing face.


Lacrimal glands anatomy
LACRIMAL GLANDS-Anatomy.

  • Anteriorly divided by aponeurosis of levator palpabrae superioris into:

    Upper orbital part

    Lower palpabral part

  • Ducts are 12 in number, pass through the palpabral part of the gland and open into the conjunctival sac, 4.5 mm above the upper border of the superior tarsus


Location
Location

  • LACRIMAL GLAND

    • LOCATION



Lacrimal gland1
LACRIMAL GLAND

12 ducts of the lacrimal gland pass from the orbital part through the palpebral part into the superior conjunctival fornix.

In addition to Lacrimal gland, small accessory glands are also present in the conjunctiva.

In case of non functioning of lacrimal gland, these glands keep cornea wet .


MICROSCOPIC STRUCTURE

Lacrimal gland is lobulated tubulo-acinar structure. On cross section, the acini are seen as round or tube shaped masses of columnar cells.

Acini cells 80% are surrounded by Myoepithelial cells for squeezing out the secreted fluid.


RELATIONS

Palpebral part of Lacrimal gland lies below the Aponeurosis of Levator palpebrae superioris.

It extends into the upper eye lid.

Superiorly=Aponeurosis of Levator Palpabrae

Superioris.

Inferiorly= Superior fornix- conjunctiva.


BLOOD SUPPLY

Is from Lacrimal artery ( a branch of Ophthalmic artery) ,

and from Infra orbital artery ( a branch of Maxillary

artery)

VENOUS DRAINAGE

Venous drainage is through Sup. Ophthalmic vein into

cavernous sinus.

LYMPHATIC DRAINAGE

Lymphatic drainage occurs into the superficial Parotid lymph nodes.


NERVE SUPPLY

Two types of nerve supply that is Autonomic and sensory nerve supply.

Autonomic nerve supply consist of Parasympathetic and sympathetic components.


In parasympathatic system, the Nervous intermedius from the secretomotor nucleus of Facial nerve join a branch of Great petrosal nerve to form nerve of Pterygoid canal which goes to Pterygo palatine ganglion. From here nerve fibers pass through Maxillary , Zygomatic N; Zygomatico temporal and finally Lacrimal nerve.


  • In sympathatic system, superior cervical sympathatic ganglion,Plexus of nerves around ICA, deep petrosal nerve, nerve of Pterygoid canal, Maxillary nerve, Zygomatic N .Zygomatico temporal nerve & Lacrimal nerveSensory nerve supply; Lacrimal nerve.


Secretory innervation
SECRETORY INNERVATION

  • LACRIMAL GLAND

    • SECRETORY INNERVATION

    • POSTGANGLIONIC SYMPATHATIC FIBRERS


Accessory lacrimal glands
Accessory lacrimal glands

  • Same structure as main lacrimal gland

  • Very small in size

  • Glands of Krause:

    20 in number, in the upper lid and 8 in the lower lid, deeply situated in the conjunctiva near the fornix on lateral side

  • Glands of Wolfring:

    are few in number, situated near the upper border of the tarsal plate


Physiology
Physiology

  • Secretes tear, a slightly alkaline serous fluid.

  • Consist of water and minute quantities of sodium chloride, sugar , urea and protein.

  • Contains lysozyme which is bactericidal

  • Starts 3-4 weeks after birth.


Tear drainage system
Tear drainage system

  • Consist of puncta, ampula, canaculi, lacrimal sac and nasolacrimal duct

    *Punctum:

    Situated near the medial end of each eyelid.

    Face slightly posterior in normal condition.

    slightly evert the medial end of the eyelid and the punctum will become visible.

    *Ampula: (Vertical canaliculus)

    The most proximal portion of the canaculus, measuring 2 mm.


Tear drainage cont
Tear drainage…cont.

*Horizontal canaliculus:

-8 mm long, in 90% the upper and lower unite to open in the lateral wall of the sac.

-In 10% both open separately.

-A flap of mucosa (valve of Rozenmuller) prevents regurg from the sac.


Tear drainage cont1
Tear drainage…cont.

*Lacrimal sac:

- It is 10 mm long and lies in the lacrimal fossa.

- Lacrimal bone and frontal process of Maxilla separate it from middle meatus of nose.

*Nasolacrimal duct:

-Passes down medially & posteriorly to open in the inferior meatus.

-Opening is gauded by a valve. (valve of Hasner)


Physiology1
Physiology

  • Tear drainage:

    Tears are drained from conjunctival sac by two mechanisms:

    1. Gravity.

    2. Active pump mechanism.

  • By gravity:

    Gravity plays a small part and most of the tears are drained by active pump.


Physiology2
Physiology

  • Active pump (Suction):

    -70% of the tears are drained through the lower punctum and 30% through the upper punctum

    -Upper and lower marginal strips of tears go medially

    -The tears enter the puncta by capillary action and suction.

    - Pretarsal orbicularis oculi splits into superficial and deep heads around the ampulae and some fibres are attached to the sac.


Physiology3
Physiology

-During closure of the eye:

*Ampulae is compressed.

*Horizontal canaliculus shortens.

*Puncta move medially.

*Deep head of the orbicularis (attached to sac) causes dilatation of the sac.


Physiology4
Physiology

All these causes a negative pressure in the sac and tears are sucked into the sac.

-When the eye closes, the sac goes to its original volume, forcing the tears into the nasolacrimal duct, and the puncta move laterally sucking tear into it.


Congenital disorders

Canalicular abnormalities:

Very rare and often undiagnosed.

Absence of punctum:

very rarely one or both the puncta may be absent congenitally, usually the site may be visible (congenital stenosis)

Congenital disorders.


Congenital disorders1
Congenital disorders.

  • Congenital NLD blockage:

    More common condition leading to epiphora in small children (non-canalization of the NLD cord)

    Managed by massages and simple antibiotics till the age of 6 months in the hope of spontaneous canalisation

    If no improvement in 6 months the probing is tried three times till the age of 2 years.


Congenital disorders2
Congenital disorders

After the age of 2 years the success of probing decreases and the child may require a DCR when he/she reaches the age of 6 years.


Evaluation
EVALUATION

  • History

    *watering, discharge, swelling and pain

    *usually prolonged, usually unilateral

  • Examination

    *Inspection

    ectropion, swelling, fistula

    *Palpation

    cystic swelling, any stones, regurg test


Evaluation cont
EVALUATION…Cont.

*Slitlamp exam

*Punctal exam for malposition, stenosis

*Press canaliculus for infection

*Examine marginal tear strip

*Froceful closure of lids—puncta may

evert—lids may overlap

*Fouroscein disappearance test—2

minutes


Evaluation cont1
EVALUATION…Cont.

  • Clinical tests

    Probing

    *Hard stop

    *Soft stop

    Irrigation

    *Canacular block

    *Partial block

    *NLD block



Jones tests
Jones tests

  • Jones I (Primary)

    Hypersecretion or

    Obstruction

  • Jones II (Secondary)

    Upper passages obstruction or

    Pump failure


Dacrocystography
Dacrocystography

Types:

  • Plain DCG

  • Distention DCG

  • Macro DCG

  • Cinematography

  • Dacroscintigraphy

  • Contrast DCG

  • Digital substraction DCG


Dacrocystography1
Dacrocystography

  • Radiopaque dyes:

    Lipoidal in water or lipoidal with olive oil

    Iodized oil

    Neohydroil angioraphin

    Dionosil aqueous

    Conray

    Diagonal viscous


Dacrocystography2
Dacrocystography

  • Conventional (Lipiodal ultra fluid is used)

    Dacrocystography

    Macrodacrocystography

  • Computerized:

    Subtsaction




Scintiligraphy
Scintiligraphy

  • Dynamic

  • Radioactive technetium is used

  • Site of obstruction can be documented




ad