LECTURE No. 8. Diagnosis, clinic and treatment of pathologies of the lacrimal organs

1. General diagnostic questions

With the pathology of the lacrimal gland, there may be increased tearing or, conversely, dry eyes. However, pain and size change are more often determined. There are dacryadenitis in the form of sharp inflammatory changes in the eyelids and conjunctiva or cysts of the lacrimal gland, resembling translucent tumors of various sizes.

Palpation of the lacrimal gland area is performed through the skin of the upper eyelid, while determining its consistency, size and location.

More often, changes are noted in the lacrimal ducts. The study of their condition begins with an examination of the lower lacrimal opening. It usually faces the eyeball and becomes visible if you bend the lower eyelid slightly. Atresia of the lacrimal openings, their dislocation, and narrowing may be detected, which is accompanied by impaired absorption of tears and the appearance of lacrimation. In old age, inversion of the lacrimal punctum is often observed. If there are no changes in the lacrimal opening, then lacrimation may be due to pathology of the lacrimal canaliculi or other parts of the lacrimal ducts. To determine the state of the main function of the lacrimal ducts (the passage of tears through the lacrimal canaliculi and its discharge into the nose), a color test is used. The tubular test is carried out as follows. Drops of a 3% solution of collargol are instilled twice into the conjunctival sac. The patient is asked to make blinking movements. With normal patency of the lacrimal canaliculi and unchanged suction function of the lacrimal sac, the conjunctival cavity is freed from collargol within 30 seconds. Such a tubular test is regarded as positive. But in some cases it may be significantly delayed or become negative. After 23 minutes, if the patency of the nasolacrimal canal is not impaired, collargol appears in the nose, and it can be detected by inserting a cotton swab on a probe under the inferior turbinate. If the collarhead test is delayed or negative, it is necessary to rinse the lacrimal ducts with saline solution. Passing a blunt needle or conical probe into the lacrimal sac before washing it also serves as a diagnostic technique, as it allows one to judge the presence of narrowing of the tubule or obstacles in it. Rinsing is carried out after instillation of a 0,5% solution of dicaine (1% lidocaine) into the conjunctival cavity. With good patency of the lacrimal ducts, liquid flows out of the nose in frequent drops or streams. If there is obstruction, it flows back past the cannula or through the superior lacrimal opening.

2. Acute dacryoadenitis (dacryoadenitis acuta)

Dacryoadenitis inflammation of the lacrimal gland. It can be both acute and chronic. It occurs mainly due to endogenous infection with measles, scarlet fever, mumps, typhoid fever, rheumatism, tonsillitis, influenza. The process is often one-sided.

If there is edema in the lateral part of the upper eyelid, according to the localization of the lacrimal gland, and the upper eyelid acquires an S-shape, palpation in this area is marked by induration and soreness, when the eyelid is raised, an enlarged palpebral part of the lacrimal gland is visible, swelling of the mucous membrane of the eyeball (chemosis) is noted, sometimes yellowish areas of suppuration of the gland or opened abscesses from the side of the conjunctiva are visible, purulent contents are released into the conjunctival cavity, and the mobility of the eye upwards and outwards is limited, regional lymph nodes are enlarged and painful, this indicates dacryoadenitis. It can occur in children after infectious diseases (mumps, etc.).

clinical picture. Sharp swelling, soreness, redness of the outer part of the upper eyelid. The palpebral fissure takes on an altered shape. There is redness and swelling of the conjunctiva of the eyeball in the upper outer section. Downward and inward displacement of the eye and limitation of its mobility can be observed. The anterior regional lymph nodes are enlarged and painful. However, more often the disease proceeds benignly, the infiltrate undergoes regression by the tenth and fifteenth day.

Treatment. The goal of treatment is to combat the general disease. In case of an acute process, antibiotics (ampicillin, oletethrin, metacycline in four doses), sulfonamides, and symptomatic drugs are prescribed. Physiotherapy with dry heat, UHF, UV irradiation, iodine electrophoresis, washing of the conjunctival cavity with furatsilin at a dilution of 1: 5000, ointments with sulfonamides and antibiotics (for example, 1% tetracycline ointment) are indicated locally.

3. Canaliculitis (canaliculitis)

With canaliculitis, there is a slight swelling in the area corresponding to the lacrimal openings and tubules. In addition, hyperemia of the skin, lacrimation and purulent discharge are revealed, and when pressing on this swelling with a finger or a glass rod, a mucous or purulent plug is released from the lacrimal opening. In some cases, the squeezed out contents of the tubule is a crumbly yellowish secret containing grains of fungal calculus. It is necessary to subject the discharge to bacteriological examination.

Treatment. Antibiotics and sulfonamides are used locally; sometimes dissection of the affected tubule is used, scraping out the contents with a sharp spoon, followed by treatment of the cavity with a 12% solution of lapis, iodine tincture.

4. Dacryocystitis (dacryocystitis)

Dacryocystitis inflammation of the lacrimal sac. It occurs in acute and chronic form.

When examining children in the first weeks of life, a slight lacrimation and lacrimation are sometimes detected, and in some cases a purulent discharge is detected. If, moreover, when pressing on the area of ​​the lacrimal sac, the mucous or purulent contents of the sac are released from the lacrimal puncta into the conjunctival cavity, then the diagnosis of neonatal dacryocystitis becomes obvious. If dacryocystitis exists for a long time, then a strong stretching (dropsy) of the lacrimal sac occurs, swelling is observed, a significant protrusion of tissues in the area of ​​the lacrimal sac.

Often, dacryocystitis is complicated by the development of phlegmon of the lacrimal sac. At the same time, pronounced swelling and a sharp painful infiltration of surrounding tissues appear. The palpebral fissure may close completely.

Etiology and pathogenesis. The development of chronic dacryocystitis occurs due to stenosis of the nasolacrimal duct, leading to stagnation of tears and discharge from the mucous membrane of the lacrimal sac. There is a gradual stretching of the wall of the bag. The contents that accumulate in it are a favorable environment for the development of pathogenic microflora (streptococcus, pneumococcus, etc.). Conditions are created for the progression of a sluggish inflammatory process. The transparent secretion of the lacrimal sac cavity becomes mucopurulent. The most common damage to lacrimal openings and canaliculi is caused by eyelid injuries.

Clinical picture and diagnosis. Complaints of persistent lacrimation, purulent discharge from the eye. There is an excess of tears along the edge of the lower eyelid, a soft protrusion of the skin at the inner edge of the eye. When pressing on the area of ​​the lacrimal sac, mucous or mucopurulent contents flow out abundantly from the lacrimal openings. The lacrimal sac can be stretched so much that the grayish contents can be seen through the thinned skin. This condition is called hydrocele of the lacrimal sac.

For diagnosis, biomicroscopy, tubular and nasal samples are used. In case of insufficient clarity of the test results, washing and bougienage of the lacrimal ducts are done, which makes it possible to clarify the level and extent of the lesion. Subsequently, a contrast x-ray of the lacrimal ducts is performed.

Treatment. Chronic dacryocystitis is treated only surgically. A dacryocystorhinostomy is necessary to create a direct fistula between the lacrimal sac and the nasal cavity.

5. Dacryocystitis of newborns

A complex of factors plays a role in the etiology and pathogenesis of dacryocystitis in children: anatomical and topographical features of the lacrimal ducts, nasal pathology, and impaired nasal breathing. Dacryocystitis is often caused by obstruction of the nasolacrimal duct due to changes in the lacrimal sac, bones or nasal mucosa.

Clinical picture, treatment. Mucopurulent discharge, lacrimation, redness of the conjunctiva, swelling in the area of ​​the lacrimal sac. A sign of the disease is the release of mucopurulent contents through the lacrimal openings when pressing on the area of ​​the lacrimal sac.

Treatment of dacryocystitis in newborns, even if they have not caused abscesses or cellulitis in the past, consists of acupressure of the lacrimal sac area, followed by washing it with a disinfectant solution containing lidase. However, usually these manipulations do not lead to a cure. Probing should be performed in the first month of the child's life. It is also indicated in children under the age of two or three years, if for some reason it was not carried out earlier.

For chronic dacryocystitis in children three years of age and older, if probing does not restore the patency of the nasolacrimal ducts, dacryocystorhinostomy is indicated. It consists of creating an anastomosis between the lacrimal sac and the middle meatus. Before surgery, an X-ray examination of the lacrimal ducts is required. Bismuth nitrate or iodolipol (more often) is used as a contrast agent, injected into the lacrimal sac using a cannula needle.

Treatment is carried out in stages and sequentially:

1) massage of the lacrimal sac every two to three weeks;

2) washing the lacrimal ducts in one to two weeks;

3) retrograde probing of the nasolacrimal duct for up to two to three weeks;

4) probing of the nasolacrimal ducts from above for up to two to three weeks;

5) endonasal dacryocystorhinostomy from two to three years.

Author: Shilnikov L.V.

<< Back: Congenital pathologies and neoplasms of the eyelids (Ankyloblepharon). Coloboma of the eyelid (coloboma palpebrae). Epicanthus (epicanthus). Entropion of the eyelids (entropium palpebrarum). Eversion of the eyelids (ectropium palpebrarum). Lagophthalmos, or "hare's eye" (lagophthalmus paralyticus). Dermoid cyst. Hemangioma of the eyelids. Neurofibromatosis (Recklinghausen's disease)

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