lacrimal gland

1. Presentation • lacrimal gland • dr .mohamed Hasan • dr.anas abdiwali ali

2. Lacrimal system • the lacrimal system of each eye consists of.... secretory system –which secrets the tear -main lacrimal gland -accessory lacrimal gland 2.excretory system –which drains the tears -lacrimal puncta -lacrimal canaliculi -lacrimal sac -nasolacrimal duct

3. Lacrimal gland • 1.main lacrimal gland • it is an exocrine gland approximately the size and shape of an almond • anteriorly the lateral horn of levator aponeurosis indents the gland and divides it into upper orbital and lower palpebral lobe • about 10-12 ducts drain the secretion of lacrimal gland and open into upper fornix of the conjunctive . it is composed of secretory epithelial cells • the ocular surface irritation activates tear production from the lacrimal gland • blood supply –lacrimal artery • venouns drainge –returns into superior ophthalmic vein • lymphatic drainage-retuns to the preauricualar lymph nodes

4. LACRIMAL GLAND

5. CONT... • nerve supply .sensory –lacrimal narve branch of ophthalmic division of the trigeminal nerve . • .sympathetic vasomotor fibers originate from superior cervical ganglion • .parasympathetic secretomoter fibers from facial nerve via pterygopalatine ganglion

6. 2.accessory lacrimal gland • these are very small gland of same epithelial structure as lacrimal gland • GLANDS OF KRAUSE .these are located within the stroma of conjunctive in the upper and lower fornix • GLANDS OF WOLFERING.these are located near the upper border of the superior tarsal plate and along the lower border of the inferior tarsal

7. • EXCRETORY SYSTEM • LACRIMAL PUNCTI-THESE ARE TOO SMALL ROUNDED OPENINGS -0.3MM DIAMETER • ON UPPER AND LOWER LID MARGINS ABOUTE 6MM TEMPORAL TO THE INNER CANTHUS .EACH PUNCTUM IS SITUSTED ON A SMALL ELEVATION CALLED PAPILLA • LACRIMAL CANALICULI--THE SUPERIOR AND INFERIOR CANALICULIE JOIN THE PUNCTA TO THE LACRIMAL SAC.EACH CANALICULUS HAS TOW PART VERTICAL*1-2MM*AND HORIZONTAL*6-8MM* • THE TWO CANALICULI MAY OPEN SEPARATELY OR MAY JOIN TO FORM COMMON CANALICULI*ON AVERGE 2MM*WHICH OPENS INTO THE OUTER WALL OF THE LACRIMAL SAC. • LACRIMAL SAC –THE LACRIMAL SAC LIES WITHIN A BONY FOSSA THAT IS BORDERED BY ANTERIOR AND POSTERIOR LACRIMAL CRESTS,LOCATED IN THE ANTERIOR PART OF THE MEDIAL ORBITAL WALL.THE LACRIMAL FOSSA IS FORMED BY LACRIMAL BONE AND FRONTAL PROCESS OF MAXILLA LIES POSTERIOR THE MEDIAL CANTHAL TENDON .THA LACRIAMAL SAC IS ABOUT 12-15MM IN LENGTH AND 5.6MM IN BREADTH.

8. CONT... • LACRIMAL PUNCTI-THESE ARE TOO SMALL ROUNDED OPENINGS -0.3MM DIAMETER • ON UPPER AND LOWER LID MARGINS ABOUTE 6MM TEMPORAL TO THE INNER CANTHUS .EACH PUNCTUM IS SITUSTED ON A SMALL ELEVATION CALLED PAPILLA • LACRIMAL CANALICULI--THE SUPERIOR AND INFERIOR CANALICULIE JOIN THE PUNCTA TO THE LACRIMAL SAC.EACH CANALICULUS HAS TOW PART VERTICAL*1-2MM*AND HORIZONTAL*6-8MM* • THE TWO CANALICULI MAY OPEN SEPARATELY OR MAY JOIN TO FORM COMMON CANALICULI*ON AVERGE 2MM*WHICH OPENS INTO THE OUTER WALL OF THE LACRIMAL SAC. • LACRIMAL SAC –THE LACRIMAL SAC LIES WITHIN A BONY FOSSA THAT IS BORDERED BY ANTERIOR AND POSTERIOR LACRIMAL CRESTS,LOCATED IN THE ANTERIOR PART OF THE MEDIAL ORBITAL WALL.THE LACRIMAL FOSSA IS FORMED BY LACRIMAL BONE AND FRONTAL PROCESS OF MAXILLA LIES POSTERIOR THE MEDIAL CANTHAL TENDON .THA LACRIAMAL SAC IS ABOUT 12-15MM IN LENGTH AND 5.6MM IN BREADTH.

9. PHYSIOLOGY TEARS SECRETED BY THE MAIN LACRIMAL GLANDS PASS ACROSS OCULAR SURFACE.THE 10-20 OF THE TEARS ARE ELIMINATED THROUGH EVAPORATION . THE REMAINING 80-90% OF TEARS ARE ACTIVELY PUMPED FROM THE TEAR LAC BY ACTION OF THE ORBICULARIS MUSCLE THROUGH PUNCTI CANALICULI LACRIMAL SAC NASOLACRIMAL DUCTI INTO THE NASAL CAVITY

10. TEARS • TEARS IS A SECRETION FROM THE LACRIMAL GLAND . • THE SECRETION OF TEAR BEGINS 3-4 WEEKS AFTER BIRTH • THE TEAR SECRETION IS COMPOSED OF WATER ,SMALL QUANTITIES OF SALTS,SUCH AS SODIUM CHLORIDE ,SUGAR ,UREA PROTEIN AND LYSOZYME ,A BACTERICIDAL ENZYME. • THE AVERAGE NORMAL SECRETION RATE IS 1-2 MICROLITER • IT IS SLIGHTLY ALKALINE AND THE NORMAL PH OF TEAR IS 7.5.

11. THREE LAYERS OF TEAR FILM • MUCUS LAYER.IT IS THE INNER MOST AND THINNEST LAYER OF TEAR FILM . • IT CONSISTS OF MUCIN SECRETED BY CONJUNCIVAL GOBLET CELLS GLAND OF HENLE AND GLANDS OF MANZ .IT CONVERTS THE HYDROPHOBIC CORNEAL SURFACE INTO HYDROPHILIC. • LIPID OR OILY LAYER .IS THE OUTER MOST LAYER OF TEAR FILM WHICH CONSIST MAINLY CHOLESTEROL ESTERS AND LIPID SECRETED BY MEIBOMAIN,ZEIS AND MOLL GLANDS .IT PREVENTS OVERFLOW OF TEARS,RETARDS THEIR EVAPORATION AND LUBRICATES THE EYELIDS • AQUEOUS LAYER . IS THICKEST INTERMEDIATE LAYER OF TEAR FILM WHICH CONSISTS OF TEARS SECRETED BY THE LACRIMAL GLANDS

12. FUNCTIONS OF TEAR FILM • IT MAINTAINS THE HEALTH OF THE OCULAR SURFACE AND TRANSPARENCY BY PROVIDING THE MOIST ENVIRONMENT ESSENTIAL FOR THE CORNEAL AND CONJUCTIVAL EPITHELIAL CELLS. • IT MAINTAINS THE CLEAR VISION BY MAKING THE ANTERIOR CORNEAL SURFACE SMOOTH AND REGULAR FOR REFRACTION . • NUTRITIONAL ROLE. IT IS THE SOURCE OF NUTRITION AND OXYGEN SUPPLY TO THE AVASCULAR CORNEA EPITHELIUM. • ANTIMICROBIAL .IT HAS ANTIBACTERIAL ACTIVITY DUE TO PROTEINS SUCH AS LYSOZYME AND LACTOFERIAL . • SERVES AS A MEDIUM FOR THE REMOVAL OF DEBRIS AND NOXIOUS IRRITANTS . • LUBRICATES THE CORNEA EYELID INTERFACE

13. DISEASES OF THE DRAINAGE SYSTEM • NASOLACRIMAL DUCT OBSTRUCTION • CONGENITAL • ACQUIRED • DACROCYSTITIS • ACUTE DACROCYSTITIS • CHRONIC DACROCYSTITIS

14. AETIOLOGY • IT IS A COMMON CONGENITAL LACRIMAL DRAINAGE ANOMALY CAUSED BY NON-CANALIZATION OF THE MEMBRANE AT THE LOWER END OF THE NASOLACRIMAL DUCT. • AT BIRTH THE LOWER END OF THE NASOLACRIMAL DUCT IS FREGUENTY NON-CANALIZED AND BECOMES PATENT SPONTANEOUSLY DURING THE FIRST FEW WEEKS OF LIFE FAILURE OF THIS CAUSES EPIPHORA AND SECONDARY INFECTION • MALDEVELOPMENT OF PUNCTUM AND CANALICULI

15. CLINICAL FEATURES • IT OCCURS IN ABOUT 5% OF FULL TEAR NEW BORN • IT MAY BE UNILATERAL OR BILATERAL THE BILATERAL INVOLVEMENT IS MORE COMMON. • SYMPTOMS BECOME MANIFESTED BY AGE OF 3 TO 4 WEEKS IN 80 TO 90% OF CASES. • TYPICALLY THE SYMPTOMS ARE WATERY EYES AND STICKY MUCOID OR MUCOPURULENT DISCHARGE THAT ACCUMULATES ON THE EYELID MARGIN AND LASHES NEAR THE MEDIAL CANTHUS. • REGURGITATION TEST NAY BE POSITIVE –GENTLE PRESSURE OVER THE LACRIMAL SAC CAUSES REFLUX OF FLUID OR MUCOPURULENT MATERIAL FROM THE PUNCTA.

16. COMPLICATIONS • MUCOCELE • CONJUNCTIVITIS • ACUTE DACRYOCYSTITIS • CHRONIC DACRYOCYSTITIS • FISTULA FORMATION

17. Right eye Acute dacryosy stitis nasolacrimal duct bloked

18. DIFFERENTIAL DIAGNOSIS • PUNCTAL ATRESIA • CONJUNCTIVITIS E.G.CHLAMYDIA • CONGENITAL GLAUCOMA-IT IS IMPORTANT TO EXCLUDE CONGENITAL GLAUCOMA WITH WATERY EYE • KERATITS AND UVEITIS

19. TREATMENT • CONSERVATIVE • SPONTANECOUS PATENCY –OCCURS IN 90% CASES WITHIN 6 MONTHS,AND IN 95% CASES WITHIN • 9 MONTHS THEREFORE ,PROBING MAY BE DELAYED UNTIL THE AGE OF 6-9 MONTHS. • MASSAGE OF THE LACRIMAL SAC-DIGITAL PRESSURE APPLIED OVER THE SAC INCREASES THE HYDROSTATIC PRESSURE AND THUS MAY RUPTURE THE MEMBRANOUS OBSTRUCTION .TEN STROKES 4 TIMES A DRY ARE APPLIED

20. Cont...... • ANTIBIOTICS • TOPICAL ANTIBIOTIC DROPS ARE USED TO CONTROL THE SECONDARY INFECTION TILL PATENCY OF THE DUCT OCCURS. • SYSTEMIC MAY BE REQUIRED WHEN THERE IS COMPLICATION

21. SURGICAL • IT IS INDICATED AFTER 4-6 MONTHS WHEN CONSERVATIVE TREATMENT FAILS. • PROBING-IT IS DONE UNDER GENERAL ANAESTHESIA.A PROBE IS PASSED THROUGH THE PUNCTUM,CANALICULUS AND LACRIMAL SAC INTO THE NASOLACRIMAL DUCT TO OVERCOME THE OBSTRUCTIVE MEMBRANE AT THE LOWER END OF THE NASOLACRIMAL DUCT. • SYRINGING-IRRIGATION. IT IS DONE TO CONFIRM THE OPENING AND FUNCTIONING OF THE LACRIMAL DRAINAGE SYSTEM.THE RESULTS OF PROBING ARE EXCELLENT AND 90% OF CHILDREN ARE CURED BY THE FIRST PROBING AND FURTHER 6% BY SECOND PROBING .THE FAILURE IS USUALLY DUE TO ABNORMAL ANATOMY. • OTHER OPTIONS-ARE INDICATED WHEN REPEATED PROBING IS FAILURE. • INTUBATION WITH SILASTIC TUBE • BALLOON CATHETER DILATATION OF NASOLACRIMAL DUCT

22. Cont.... • DACRYOCYSTORHINOSTOMY-DCR-.IT IS INDICATED WHEN SYMPTOMS OF EPIPHORA PERSIST AFTER THE FAILURE OF ABOVE PROCEDURES.IT MAY BE NECESSARY TO PERFORM DCR OPERATION PREFERABLY.AFTER 5 TO 6 YEARS OF EGE.

23. RIGHT EYE AMNIOTOCELE

24. CONT..... • AMNIOTOCELE –CONGENITAL DACRYOCELE- • IT IS BLUISH –GRAY CYSTIC SWELLING OF THE LACRIMAL SAC DUE TO THE COLLECTION OF AMNIOTIC OR MUCOUS WITHIN THE LACRIMAL SAC AS A CONSEGUENCE OF CONGENITAL NASOLACRIMAL DUCT BLOCK AT THE LEVEL OF VALVE OF HASNER .WHICH IS A FOLD OF MUCUS MEMBRANE AT THE LOWER END OF NASOLACRIMAL DUCT

25. CONT.... • ACQUIRED NASOLACRIMAL DUCT OBSTRUCTION • CAUSES • INVOLUTION STENOSIS –IDIOPATHIC – IS PROBABLY THE MOST COMMON CAUSE .FEMALES ARE AFFECTED MORE THAN MALES . • TRAUMA-NASAL AND ORBITAL FRACTURES INCLUDING NASAL AND SINUS SURGERY • INFLAMMATORY DISEASE SUCH AS SARCOIDOSIS AND WAGNER GRANULOMATOSIS. • INFILRATION BY NASOPHARYNGEAL TUMOURS • DACRYOLITH OR CAST FORMATION WITHIN THE LACRIMAL SAC

26. CONT.. • CLINICAL FEATURES • EXCESSIVE TEARING • MUCOID OR MUCOPURULENT DISCHARGE • RECURRENT ATTACKS OF DACRYOCYSTITIS • RECURRENT ATTACK OF CONJUNCTIVITIS

27. CONT.... • TREATMENT • DACRYOCYSTORHINOSTOMY –DCR- OPERTION.IN THIS PROCEDURE, APASSAGE IS CREATED BETWEEN THE LACRIMAL SAC AND NASAL CAVITY THROUGH BONY OSTIUM, WHICH DRAINS TEARS FROM CANALICULI TO THE LATERAL WALL OF THE NOSE IT IS 90 TO 95% SUCCESSFUL

28. TYPES OF DCR • EXTERNAL DCR IS PERFORMED THROUGH SKIN APPROACH IT IS THE PREFERRED PROCEDURE WITH SUCCESS RATE USUALLY ABOVE 90% • ENDOLASER [TRANSNASAL LASER] DCR IS PERFORMED THROUGH NASAL APPROACH .IN THIS PROCEDURE OPENING IN THE LATERAL WALL OF THE NOSE IS MADE BY LASER THROUGH NASAL CAVITY WITHOUT GIVING AN INCISION TO THE SKIN . THE SUCCESS RATE IS LESS THAN SKIN APPROACH,ABUT THERE IS NO SKIN SCAR.

29. CONT.. • ACUTE DACRYOCYSTITIS –IT IS THE ACUTE INFLAMMATION OF THE LACRIMAL SAC. • AETIOLOGY • IT MAY ARISE DE NOVO OR MORE COMMONLY AS A SECONDARY INFECTION AFTER NASOLACRIMAL DUCT OBSTRUCTION • PYOGENIC ORGANISMS SUCH AS STAPHYLOCOCCUS,STEPTOCOCCUS AND PNEUMOCOCCUS ETC.INVADE THE LACRIMAL SAC

30. CONT.... • CLINICAL FEATURES • SYMPTOMS • PRESENTATION IS WITH SUB-ACUTE ONSET OF A PAINFUL REDNESS AND SWELLING AT THE MEDIAL CANTHUS ASSOCIATED WITH EPIPHORA. • ON EXAMINATION • SWELLING AT THE MEDIAL CANTHUS WHICH IS REDDISH AND TENDER ON TOUCH • REGURGITATION TEST IS DIFFICULT TO PERFORM BECAUSE OF TENDERNESS • ABSCESS FORMATION MAY OCCUR IN UNTREATED CASES .

31. Lacrimal sac abscess left eye acute dacryostitis

32. CONT.... • COMPLICATION • PRESEPTAL CELLULITIS. • EXTERNAL FISTULA FORMATION

33. Dacryocystitis with fistula formation

34. CONT... • TREATMENT • CONSERVATIVE • ANTIBIOTICS • SYSTEMIC ANTIBIOTIC.TO CONTROL INFECTION • TOPICAL EYE DROPS ARE ALSO USED • ANALGESIC AND ANTI-INFLAMMATORY DRUGS TO CONTROL THE PAIN AND INFLAMMATION • HOT FOMENTATION GIVE SOOTHING EFFECT AND ENHANCES THE RESOLUTION

35. CONT....... • CHRONIC DACRYOCYSTITIS-IT IS CHRONIC INFLAMMATION OF THE LACRIMAL SAC • AETIOLOGY • THE IMPAIRED OUTFLOW OF THE SAC LEADS TO THE STASIS OF TEARS WHICH EVENTUALLY LEADS TO SECONDARY INFECTION BY LOW VIRULENCE ORGANISMS.

36. CONT.. • CLINICAL FEATURES • IT IS MORE COMMON THAN THE ACUTE VARIETY • IT PRESENTS WITH CONSTANT WATERING FROM THE EYE. • IT MAY PRESENT WITH SWELLING IN THE MEDIAL CANTHAL AREA AND WATERY EYE • IN RARE CASES THERE MAY BE BILATERAL NASOLACRIMAL DUCT OBSTRUCTION WITH BILATERAL LACRIMAL SAC SWELLING • REGURGITATION TEST MAY BE POSITIVE WITH REFLUX OF WATERY MUCOID OR MUCOPURULENT DISCHARGE FROM THE PUNCTI • MUCOCELE FORMATION MAY OCCUR IF THE SAC BECOMES DILATED AFTER BLOCKAGE OF COMMON CANALICULUS. • IT MAY BE ASSOCIATED WITH CHRONIC UNILATERAL CONJUCTIVIS.

37. CONT.... • TREATMENT • DACRYOCYSTORHINOSTOMY –DCR- • EXTERNAL APPROACH –DCR- • ENDOLASER-DCR-

38. CONT.......... • DISEASES OF THE LACRIMAL GLAND • ACUTE DACRYOADENITIS • CHRONIC DACRYOADENITIS • KERATOCONJUNCTIVITIS SICCA-DRY EYE

39. Acute dacryoadenitis • Acute dacryoadenitis..it is an acute inflammation of the lacrimal gland • Aetiology • It is usually caused by infection most commonly by viral infection • Viruses-epstein- bar virus cytomegalovirus mumps and infectious mononucleosis • Bacteria –staphylococcus,streptococcus and gonococcus • Fungi-histoplasma, blastomyces

40. Cont... • Clinical features • Pain and discomfort in the upper and outer portion of the orbit and eyelid • The eyelid becomes red and swollen with typical s-shaped curve of its margin • Painful proptosis with displacement of eyeball downward and inward may occur • Eversion of lid is painful and shows swollen and reddish gland • Pre-auricular lymph nodes may be enlarge and tender

41. Cont.. • Differential diagnosis • Eyelid abscess • Hordeolum internum –suppurative infection of meibomian gland • Hordeolum externum [stye] • Acute purulent conjunctivitis

42. Cont.. • Treatment • Hot compresses may be applied several times a day. • Systemic analgesic • Antibiotic –topical drops-systemic broad spectrum antibiotics • Incision and drainage when there is abscess formation

lacrimal gland

lacrimal gland

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