All right here, we are continuing down
into deeper structures within the eye
to look at the various pathologies that can occur.
This session is all about
diseases of the lacrimal structures.
So by way of a quick review, remember
that the lacrimal gland that sits up kind of
in the upper outer portion
of the eyes, of the external eyes,
is where we are going to generate fluid and that
fluid includes mucin, aqueous components and fat,
And its job is to lubricate
the anterior surface of the eye.
That fluid is going to move from the
lacrimal gland as it gets secreted,
wash across the eye and then exit from
the lacrimal caruncle at the medial canthus
into the superior, inferior lacrimal canaliculi.
From there, those little tiny ducts,
we're going to go into the lacrimal sac
and then it's going to drain out into the nose.
Remember that if you have excess tearing,
you're crying, you also end up with a runny nose.
Well, that's because those tears are washing
across, going out the various little canaliculi
to the lacrimal sac and out your nose, and
that's, you're draining tears from your nose.
We're going to talk about inflammation
of the structures
and in particular, inflammation of the
lacrimal sac and this is going to be dacryocystitis.
There is also inflammation that can
occur more upstream in the lacrimal gland
called dacryoadenitis, but
that's relatively uncommon.
Won't be on the boards for you.
And we're going to just say, yeah, that can
happen there, too.
Of course it can.
But we're going to focus on the inflammation
of the lacrimal sac.
So there are a couple of different ideologies
that we need to consider.
One is congenital and one is acquired, broad strokes.
So you can have stenosis.
Remember those little canaliculi?
Well, they can become stenotic, or the
drainage from the lacrimal sac can become stenotic,
or can be stenotic just the way that it developed.
That's your dacryostenosis.
You can also have a dacryocystocele.
In other words, an abnormal dilation of
those little canaliculi or dilation of the sac.
And we get kind of a little puddle
and accumulation of stagnant tears
that aren't draining effectively.
And all it takes is a few bacteria to wander in
there and all that mucin and fat and aqueous stuff.
That's a wonderful culture medium, and they grow.
So they can grow in that stagnant tear
pool happening when there is obstruction
of the little duct work or if we
have a little abnormal outpouching.
Okay, those are the congenital causes.
There can also be acquired causes.
So if you think about it, any tumor
kind of in the nose, in the lacrimal sac
and in the various sinuses as we're draining
out of the lacrimal sac and into the nose,
is potentially going to block outflow.
And again, we're going to get inflammation
behind that as that becomes infected.
So you get punched in the nose,
that can actually impinge on those
very delicate little canalicular structures.
You can develop a stone, so the material that is
draining or is being produced by the lacrimal gland,
in fact can become dehydrated, can become
viscous, and you can actually get a little lith,
a little stone, a dacryolith, and it can sit in
that in our various little drainage pathways
and cause an obstruction.
So a dacryolith.
You can have inflammatory disease, so
sarcoidosis and other inflammations, that
specifically or just unfortunately impact on
either the lacrimal sac or the canaliculi
will cause obstruction of flow.
And then finally, sinusitis.
Any inflammation, particularly in the ethmoid or
maxillary sinuses, are going to impact on the ability
to get what's in the lacrimal sac out because
the inflammation, the sinusitis is causing edema,
which is going to end up compressing extrinsically,
all of those passages out of the lacrimal sac.
So in all those cases, what is happening is
that we've got an accumulation, a puddle,
a stagnant tear pool that we can't drain effectively.
And again, it will become infected.
Okay, prepare yourselves because the next pictures
are not pretty, but are important that you recognize.
This is what it looks like.
And basically, we are looking mostly at the
inner canthus, the top three pictures, A, B and C,
we're looking at the inner canthus.
That's where the lacrimal sac is.
And in these cases, it's become
inflamed, infected, it's full of pus.
Okay, so it's going to be red.
That's inflammation, right?
Erythema, rubor, there's going to be edema.
So there's going to be swelling or tumor.
It's going to be tender.
Oh my goodness.
I'm just looking at this, I, I hurt.
Okay, so there's, it's going to be quite painful.
Again, this is part and parcel of
the normal inflammatory process.
There will be a purulent discharge so
frequently, these areas of swelling,
it's basically a big abscess behind
there, will come to a head and burst
and you will get yellow bacterial
and neutrophilic discharge.
Because we are blocking the normal
flow of tears out across the eye and then
down through the canaliculi into
the tear sac, that will accumulate.
It has no place to go.
So the eyes will feel like they're constantly tearing.
We're not draining appropriately.
And if we get damage to the walls of
the canaliculi or damage to the sac itself,
we can develop a mucocele.
So if we currently have inflammation
there, we will get weakening of the wall
or we'll have a little outpouching.
And then you may be prone to the
dacryocystitis over and over and over again.
Complications of this.
Clearly, if we are accumulating
bacteria there in our drainage pathway,
we are going to and we have infection there,
we're going to get likely bacterial conjunctivitis.
So we will get now bacteria that
are backing up into the conjunctiva.
We will get orbital cellulitis.
So we will get infection that extends not
only from just underneath the medial canthus,
but up into the all the way around the eyes.
Importantly, because there are structures
right behind the eyes called the brain,
you can get meningitis and you can get sepsis.
This can progress to the point
where you are having bacteremia
and systemic inflammatory
responses to a very nasty infection.
So how do we treat this?
So fortunately, typically, with time,
the openings that have been blocked
either by a little stone or inflammation
or a variety of other things will open
and we'll get drainage and it'll go away.
That's if it's not as bad as we were
looking back on those pictures A, B, C and D.
You can put on warm compresses.
By doing that, you will cause dilation of the
ductwork and hopefully get better drainage.
And then finally, if you've got really
severe kind of involvement and you've got,
you've got conjunctivitis or you've got
cellulitis, you need to have antibiotics.
And in some cases, with really
severe nasal lacrimal duct obstruction,
surgery may be necessary and that's why
we have the scalpel blade standing there.
Okay, with that, we finished
looking at inflammatory processes,
infections mostly involving the lacrimal apparatus.