Terms Etiology the cause of a disease or abnormal condition The - PDF document

1/29/2016 Terms • Etiology – the cause of a disease or abnormal condition The Lacrimal System • Dacryocystitis – inflammation of the lacrimal sac Lynn E. Lawrence, CPOT, ABOC, COA • Epiphora – watering of eyes due to excess secretion of tears or obstruction of the lacrimal passage Tear Film Layers Lacrimal System: Tear Film Layers LIPID DEFICIENCY - evaporates TEAR DEFICIENCY – fails to hydrate properly oil oil aqueous aqueous snot snot What functions does each layer of the tear perform? What functions does each layer of the tear perform? What are functions of tears? Lacrimal Apparatus Tear Components • Sometimes a person cannot produce natural tears they might • Lipid Layer – prevents need punctal plugs to prevent the tears from draining off the eye. evaporation • Faucet • Aqueous Layer - hydration • Action • Mucus Layer – sticks tear to the eye • Drain • Other components Obstructive – vs- non-obstructive 1

1/29/2016 Two Primary Forms of Dry Eye Tear Production – Secretory • Lacrimal gland – Reflex tearing – Too much tearing…epiphora • Gland of Krause – Superior fornix • Gland of Wolfring 800 nm 8,000 nm – Superior tarsal plate 100 nm The two primary forms of dry eye are Evaporative Dry Eye, also known as Meibomian Gland Dysfunction or MGD and Aqueous Dry Eye. The majority of dry eye sufferers have MGD. Oil & Water Remember science class? Oil floats. Oil does not mix with water, but rather sits on top of water. Oil is what keeps water from Need three volunteers evaporating. TEST TIME http://optometrytimes.modernmedicine.com/optometrytimes/news/treating-dry-eye- lipid-based-eye-drops Lipid Secretion: Meibomian Glands Mucin Secretion: Goblet Cells Left: Transillumination of eyelid showing meibomian glands Right: Superficial layer of bulbar conjunctiva. Secretion of lipid Goblet cells violet, epithelial cells blue. at lid margin • Soluble mucins – Lower surface tension allowing tear film to spread over surface • The lipid layer restricts evaporation to 5-10% of tear flow Lipid Aqueous Mucin – Also helps lubricate 2

1/29/2016 A complex mixture of Healthy Tears Anatomy proteins, mucins, and electrolytes coated by a lipid layer • Antimicrobial proteins • Growth factors & suppressors of inflammation • Soluble mucin helps stabilize tear film • Electrolytes for proper Punctum osmolarity (295-300) What function does the punctum have? – pH slightly alkaline (7.4) Lacrimal Apparatus Anatomy and Physiology • Sometimes a person cannot produce natural tears that they of the ocular adnexa might need some punctal plugs. • Faucet • Eyelids • Eyebrows • Eyelashes • Action • Accessory glands • Lacrimal Apparatus • Drain What is the opening between Obstructive – vs- non-obstructive the upper and lower lid called? Tear Production – Secretory Causes of Tearing • Punctal agenesis/stenosis • Lacrimal gland • Poor/blocked drainage – Reflex tearing • Trichiasis …minor entropion – Too much • Superficial foreign bodies tearing…epiphora • Poor pump action • Gland of Krause – Eyelid mal-positions – Lid distraction/punctal laxity – Superior fornix – Eyelid disease • Gland of Wolfring • Tear deficiency /instability – Superior tarsal plate – Aqueous deficiency – Lipid deficiency • Trigeminal nerve irritation 3

1/29/2016 Causes of Tearing Cont… Fluid Pools and Connections • Foreign body sensation • Pools • Hypersecretion – Lacrimal secretion and drainage imbalance – Eye – Primary or reflex tearing (reflex tearing is more common with ocular • Lacrimal lake surface irritation) • Lacrimal pump failure – Lacrimal Sac • Lacrimal drainage obstruction • Punctum location – Nose • S/P Surgery (nasal too) • Broke nose A tear lake higher than 2mm indicative of obstruction The Connections What is in a blink? • Connections • Lateral side higher than medial side – Lacrimal gland • Starts laterally and moves to the eye towards the medial and goes down the punctum – From the eye to • The lid continues to close the lacrimal sac depressing the lacrimal sac and pushing tears towards – From the the nasal duct lacrimal sac to • This action also causes a the nose suction for new tears Caniculitis can cause the blockage With Every Blink Meibomian Gland Dysfunction • Cleansing • Removal of old flora • New fresh flora • Draining of a tear • Use of the lacrimal system • Eye, nose, and throat #1 cause of Dry Eyes 4

1/29/2016 Eyelid Disease Hypersecretion = Pump Failure • Anterior blepharitis - lids • Crocodile-tears • Posterior blepharitis - Syndrome glands • Gustatory • Entropion Hyperlacrimation or • Ectropion Gustatory epiphora or Gustolacrimal reflex • Droopy Eyelid Syndrome (could be congenital) • Cancer of the lids • Ocular Surface • Cyst or lesions Irritation • NLDO • Demodex Eyelid Positions Disease: • Trichiasis • Entropion … drain • Ectropion …drain • Tear deficiency / instability • Trigeminal nerve (5 th CN) irritation 1/29/2016 Pinguecula vs Pterygium Lacrimal Pump • Pump Action – Lids • Lateral/medial • Muscles • Disease – Punctum – Canniculli • Lacrimal Sac Little Penguin Big Pterodactyl • Nasolacrimal Duct • Facial Nerve Palsy (7 th CN) 5

1/29/2016 Nasolacrimal Obstruction Stones • Primary Acquired Nasolacrimal Duct Obstruction (PANDO) • Nasolacrimal examination • Office testing Chief Complaint • Distinguish welling of tears Causes Cont… from epiphora • Anatomy • Insufficient tear production • HPI = Onset, severity, • Ocular surface disease consistency, frequency, nature of discharge, morning – Demomdex mucus, environmental • Meibomian Gland factors, aggravating or Dysfunction alleviating factors • Improper blink rate • Smoking • Ask about punctal plugs • Ceiling fans • Medications (OTCs too) • Hx of broken nose, sinus • Chronic Diseases (thyroid, surgery, and location of tears diabetes, etc…) • Contact Lens Wear • Ocular Surgery (CRS) Clinical Presentation Screening Questions • Do activities like • Do you sleep under a • Chief Complaint watching TV, looking at ceiling fan or work/ sit • History of present computers, reading a under a ceiling fan? book make you eyes illness uncomfortable or hurt? • Do your eyes ever feel • Past medical history uncomfortable? • Dry your eyes feel dry • Clinical examination ever? In the morning or • Do you ever find late evening? • Nasal Examination yourself rubbing your eyes 6

1/29/2016 Nasal Lacrimal Duct Obstruction NLDO Test: Lacrimal Irrigation • Correct through surgery called a DCR • Nose inspections • Stones in the lacrimal • S-Tubes 3-4 sac months • Stenosis of the punctum • Jones Tubes Treatments Is this possible? You be the judge • Medications/artificial tears…moisture/oil • Punctal Plugs • Botulinum Toxin Injections into the lacrimal gland (pg 979) • Surgery…lids, DCR, tubes Gee-Whiz Facts Testing • Florescein staining • Children don’t start • Schirmer Tear Quantity tearing until they are 6 Tests (paper in 1901) weeks old • Lissimine Green • 5% of children have NLDO (conjunctival staining) • Prognosis is decreased in • TBUT (tear quality test) children after 13 months • “SJO” Test (Sjogrens test) • Congenital glaucoma can • Tear Lab cause reflex tearing due • Lipi-flow to photophobia • RPS 7

1/29/2016 Testing Schirmer Testing • Florescein staining • Schirmer Tear Quantity • The human eye maintains a stable tests (paper in 1901) level of moisture and eliminates • Lissimine Green foreign particles by producing tears. (conjunctival staining) When your eyes are too dry or too • TBUT (tear quality test) wet, you may be given Schirmer’s test. • Tear Lab This test will show whether your eyes produce too few or too many tears to • Lipi-flow maintain optimal eye health. • RPS Schirmer’s test is primarily used to • “SJO” Test (Sjogrens diagnose dry eye conditions. • Schirmer’s test is also known as a dry test) Schirmer 1 – dry strip eye test, tear test, tearing test, or • Rose Bengal Schirmer 2 – anesthetic Basal secretion test. Schirmer Test Results Lissimine Green • If your eyes are healthy, each test paper should contain more than 10 millimeters of moisture. Less • Staining is a really great than 10 millimeters of moisture indicates that your way to identify surface eyes are dry. The diagnosis of dry eyes could mean that you have other health issues, such as defects rheumatoid arthritis or a bacterial infection. More tests will likely be required to diagnose the specific cause of your dry eyes. If your eyes produce far more than 10 to 15mm of moisture, further tests may also be required to determine the cause of your watery eyes. Causes of Excess Tearing Treatments • a strong emotional response (crying) • Artificial tears • climate (including cold and/or windy weather) • Medications (Restasis, • allergies doxycycline , …) pregnant!! • infections • Cyclosporine • blocked tear ducts • complications from dry eyes • Azithromycin (Azasite) $$$ • irritation of the eye (from stray eyelashes or other debris) • Punctal Plugs • ingrown eyelashes • Ammino grafs (Bio-Tissue) • relaxation of eye muscles (limits the eye’s ability to drain) • Lipi-flow • the common cold • Supplements (start early) • pink eye (conjunctivitis) • Humidifiers • reactions to certain medications (antihistamines, eye drops, diuretics, sleeping pills, etc.) • Lid scrubs 8