KELAINAN APARATUS

LAKRIMALIS
dr. Sahilah Ermawati, SpM
 Physiology
• Evaporation accounts for approximately 10% of tear
elimination in the young and for
20% or more in the elderly.
Most of the tear flow is act ively pumped from the tear lake
by the actions of the orbicularis muscle.
In the mechan ism described by Rosengren-Doane,
• the contraction of the orbicularis provides the motive power
(Fig 12-2).
• The contraction  produce positive pressure in the tear
sac, forcing tears into the nose.
• As the eyelids open and move laterally, negative pressure is
produced in the sac.
• This pressure is initially contained by opposition of the
eyelids and therefore the puncta.
• When the eyelids are fully opened, the puncta pop open and
the negative pressure draws tears into the canaliculi.
 Abnormalities of the Lacrimal
Secretory and Drainage Systems
• Evaluation
• The evaluation of congenital tearing is
straightfo rward in most cases: the patient's
parents give a history of tea ring or
mucopurulent discharge (or both) beginning
shortly after birth. In rare cases, distension of
the sac is present, suggesting a congenital
dacrycystocele.
 Evaluation

• constant tearing with minimal mucopufulence. which

suggests an upper system block caused by punctal or
canalicular dysgenesis

• constant tearing with frequent copufulence and matting

of the lashes. which suggests complete obstruction of the
NLD

• intermittent tearing with mucopurulence, which suggests

intermittent obstruction of the NLD, most likely the result
of impact ion of a swoll en inferi or nasal turbinate, such
as in association with an upper respiratory tract infection
 Abnormalities of the Lacrimal
Secretory and Drainage Systems
1. Abnormalities of the Lacrimal Secretory and
Drainage Systems
- caused by a membranous blockage of the
valve ofHasner cover ing the nasal
- 50% of newborn in fants. Most obstructions
open spontaneously with in 4-6 weeks after
birth.
 ODNL
- Conservative options incl ude observation,
lacrimal sac massage, and topical antibiotics.
The long-term use of topical antibiotics may be
needed to suppress chronic mucoid discharge
with matting of the lashes.
- Surgery : probbing- after 1year
DCR
 Abnormalities of the Lacrimal
Secretory and Drainage Systems
2. Dacryosistocel
Mucoceles may form
within the lacrimal sac
or within the nasal cavity
as a consequence
of congenital NLD
obstruction.
 Acquired lacrimal Drainage
Obstruction
• Evaluation
History
• Tearing patients can be loosely divided into 2
groups: those with hypersecretion of tears
(lacrimation), and those with impairment of
drainage (epiphora).
• The initial step in evaluating the tearing
patient is differentiat ing between the 2
conditions.
 the assessment of the patient with
tearing
• constant versus intermittent tearing
• periods of remission versus no remission
• unilateral or bilateral condition
• subjective ocular surface discomfort
• history of allergies
• use of topical medications
• history of probing during childhood
• prior ocular surface in fections
• prior sinus disease or surgery, midfacial trauma, or nasal fracture
• previous episodes of lacrimal sac in flammation
• clear tears versus tears with discharge or blood (blood in the
tear meniscus may indicate malignancy)
 examination
1. Tear meniscus
2. Tear breakup time.
3. CorneaL and conjunctivaL epithelium
evaluation. Topical rose bengal and
lissamine green can detect subtle ocular
surface abnormalities
4. Schirmer T.
5. Corneal irritation.
 Infection
1. Lacrimal Gland (Dacryoadenitis)
• Acute inflammation of the lacrimal gland
(dacryoadenitis) is most often seen in sterile
inflammatory disease and occasionally is the
consequence of malignancy, such as Iymphoproli
ferative disease. Dacryoadenitis is extremely
rare, and occurrence of gross purulence and
abscess formation are even more uncommon.
• Most cases are the result of bacterial infection,
which may develop secondary to an adjacent in
fection, after trauma, or hematogenously.
• There are numerous reports of dacryoadenitis
related to tubercu losis. with
• the formation of discrete tuberculous in
several cases. Epstein Barr virus is the
frequently reported viral pathogen.
2. Canaliculus (Canaliculitis)
• 3. lacrimal Sac (Dacryocystitis)
• The following are guidelines for treating acute dacryocystitis:
1. Irrigation or probing of the canalicular system should be avoided until the
infection
subsides.
2. Topical antibiotics are of limited value.
3. Oral antibiotics are effective in most infections. Gram-positive bacteria
are the most common cause of acute dacryocystitis. However, the clinician
should suspect gram-negative organisms in patients who are diabetic
4. Parenteral antibiotics are necessary for the treatment of severe cases,
especially if cellulitis or orbital extension is present.
5. Aspiration of the lacr imal sac may be performed if a pyocele- mucocele is
locali zed and approaching the skin. Information regarding appropriate
systemic antibiotic
6. The incised abscess is packed open and allowed to heal by second
intention.
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