epiphora
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Epiphora ,s.sah
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PRESENTER : SURENDRA PRASAD SAHM.OPTOM (2 N D SEM)
(16 /03 /2015)
Epiphora
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Epiphora implies to overflowing of tears due to impairment lacrimal drainage.
OR due to a disruption in the balance between tear
production and tear loss.
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Causes
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Anatomical complete or partial punctal canalicular or NLD obstruction
Functional Lacrimal pump failure due to Anatomical deformity (Laxity, orbicularis weakness)
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Eyelids
Horizontal laxity and floppy lids
Lower lid entropion with orb.oculi overriding
Lower lid ectropion with ineffective orb.oculi
Loss of skin / orbicularis
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Punctal Causes Occlusion
Infection/radiation
Systemic: phemphigoid,SJS,Burns
Tumours
Medial displacement
Medial ectropion
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Canaliculi
Congenital absence/fistula Acquired Intrinsic Canaliculitis Trauma/ Post radiation Trauma/ Post radiation Tumours
Extrinsic Compression by adjacent tumours
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Lacrimal Sac Abnormality
Sac inflammationPerilacrimal fibrosisDacryolithiasis Sac tumours (rare in pediatric age group) Adnexal tumours pressing on lacrimal sac or drainage pathway
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Nasolacrimal duct
Congenital: NLD obstruction Delayed opening of Hasner’s valve, Cranio facial anomalies Agenesis.Acquired: Primary obstruction Secondary obstruction: tumour, traumaNASAL CONDITIONS Severe Deviated Nasal Septum or Turbinate Hypertrophy
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Excessive tears production
Reflex lacrimation in response to various factors Trichiatic cilia Severe entropionRaised IOP Allergic conjunctivitisCorneal exposure Drugs irritation Environmental irritants likes pollution
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Others
Ocular surface disorders like chronic KCS, conjunctivochalasis, cicatricial ocular surface pemphigoid, symblephron.
Neurogenic hypersecretory disorders like compressive irritation of parasympathetic lacrimal fibres, Aberrant regeneration of facial nerve following trauma.
Facial palsy
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Evaluation
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Evaluation
Careful history
External examination
Slit lamp biomicroscopy
Syringing and probing
Imaging
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DIAGNOSTIC TESTS
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Anatomical tests
These tests helps in localization of obstruction
Syringing / irrigation
Diagnostic probing
Dacryocystography
CT/MRI
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Functional tests
To access functioning of lacrimal apparatus under physiologic conditions
Performed only when there is no evidence of obstruction in anatomical tests
Flourescein dye disappearance test Jones dye test (jones primary and secondary )
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Imaging technique
Contrast Dacryocystography Lacrimal dacryocystography CT/MRI
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Managements
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Eyelids
Treatment of the causeEctropion surgery.Tarsorraphy
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Punctal Causes
Dilation of punctum Punctoplasty Ziegler cautery Medial conjunctivoplasty Lower lid tightening
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Canaliculi
Depends on the site and degree of obstruction
Intubation Anastomosis of the patent part of the
canaliculus into the lacrimal sac and intubation
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Nasolacrimal duct
Massage of the lacrimal sac increases the hydrostatic pressure and may rupture membranous obstruction
Probing of the lacrimal system
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Lacrimal surgery
Dacryocystorhinostomy (DCR) Indicated for obstruction beyond the medial
opening of the common canaliculus Anastomosing the lacrimal sac to the nasal mucosa
of the middle nasal meatus Procedure is performd under general hypotensive
anaesthesia
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Excessive tears production
Epilation Entropion lid surgery Deceased IOP Treatment of conjunctivitisSunglass
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Conclusion
Diagnosis of the condition and ruling out the cause is important.
Treatment of the cause will depend on the cause of watering.
Optometrist should treat the causes to anterior segment disease.
Cases requiring surgery should be referred to ophthalmologist.
Cases of systemic disease should be referred to physician.
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References
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BooksThimothy L. Jackson Moorfields manual of
ophthalmology ,1:212-228Mark W Leitman Manual for eye
examination and diagnosis.7th ed.Ak khurana Comprehensive
Ophthalmology 5th ed, 1 :271 :302Kanski J Jack Clinical ophthalmology a
systematic approach 2011,7th ed,1: 151-172
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Question
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How can you evaluate patient having Epiphora
How can you treat pediatric patient having epiphora
What are causes punctum
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Epiphora ,s.sah 3/16/2015
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