Lacrimal dilation and syringing - Optometry Today

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Lacrimal dilation and syringing b) Slit lamp examination Inspect the puncta for poor position, narrowing or blockage - pouting suggests canaliculitis. A high marginal tear strip may indicate epiphora. If fluorescein is instilled in the conjunctival sac, it should disappear within two minutes - retention suggests there is a problem with lacrimal drainage. c) Irrigation 1) Lacrimal dilation Several types of dilators are available, for example the double-ended stainless steel type in Figure 5 (see Appendix I) or those incorporated in punctum plug inserters. Their use may effect a cure by releasing mucous plugs or concretions. Dilation may produce temporary relief in a case of stenosis of the punctum. Lacrimal dilation is also used prior to inserting punctum plugs and syringing. Procedure 1. Wash your hands. 2. Some practitioners may wish to put on surgical gloves. 3. Instil a drop of anaesthetic on the inferior punctum. 4. Sterilise the lacrimal dilator with a Medi-Swab. 5. Insert the dilator vertically downwards up to 2mm whilst gently rotating clockwise and anticlockwise (Figure 6). 6. Pull the lower lid temporally to straighten the ampulla and line up the vertical and horizontal canaliculi (Figure 7). 7. Rotate the dilator horizontally and insert the dilator as required. 2) Lacrimal syringing As well as irrigating the lacrimal system, syringing may be necessary to dislodge intracanalicular punctum plugs. Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Figure 9 Figure 10 Procedure 1. Wash your hands. 2. Some practitioners may wish to put on surgical gloves. 3. Dilate the punctum and canaliculus (see under ‘Lacrimal dilation’). 4. Open the sterile packets of disposable syringe and cannula and connect them together as in Figure 8. 5. Remove the plunger and fill the syringe with sterile saline. 6. Re-insert the plunger, and with the syringe pointing upward, squeeze out any remaining air together with some saline. 7. Insert the cannula into the vertical canaliculus (Figure 9). 8. Pull the lower lid temporally to straighten the ampulla and line up the horizontal canaliculus. Rotate the syringe horizontally whilst inserting until a ‘hard’ or ‘soft’ stop is felt (see over), then pull back about 2mm (Figure 10). 9. Press slowly and gently on the plunger. 10. Ask the patient to report when they taste saline or feel it in their nose. 30 FEBRUARY 26 • 1999 OPTOMETRY TODAY
Lacrimal dilation Figure 11 Figure 12 Hard stop: If the cannula touches the medial wall of the lacrimal sac and lacrimal bone, a definite end point is reached. This is a ‘hard stop’ (Figure 11) and indicates that there is no complete obstruction in the canalicular system. Soft stop: If a spongy end point is felt, this is termed a ‘soft stop’ (Figure 12) and indicates that the cannula has been prevented from entering the lacrimal sac. Therefore, there is a blockage in the canalicular system and there will be no distension of the lacrimal sac when the plunger is pressed. Detailed diagnosis from lacrimal syringing • If saline refluxes from the inferior canaliculus, the blockage is there. • If saline refluxes from the superior canaliculus, the blockage is in the common canaliculus. • If saline passes into the nose, the problem is hypersecretion of tears or failure of the lacrimal pump or partial obstruction of the nasolacrimal system. • If saline does not reach the nose, there is a total obstruction of the nasolacrimal duct and saline may appear from the superior punctum - the saline may be purulent if infection is present - and the lacrimal sac may be distended. • An attempt may be made to close the superior punctum with a dilator or cotton bud and a further effort made to clear the obstruction. Functional obstruction Sometimes, the lacrimal drainage system may appear patent when syringing proceeds uneventfully. However, there may be a functional obstruction. This means that under the low-pressure circumstances of normal tear drainage, all or part of the lacrimal pathway may collapse. Jones dye tests may be used to distinguish between patent systems and functionally blocked ones. JONES DYE TESTS PRIMARY AND SECONDARY Procedure 1. Instil one drop of fluorescein into the conjunctival sac (Figure 13). 2. Put a cotton bud soaked in anaesthetic in the inferior meatus. 3. If fluorescein is detected after five minutes, the system is patent (positive Primary Jones Test). 4. If no fluorescein is discovered, this is a negative Primary Jones Test (Figure 14) and the functional obstruction could be anywhere from the punctum to the Valve of Hasner. 5. Next, wash the excess fluorescein from the conjunctival sac and syringe. If fluorescein is detected, then this shows it had entered the sac and constitutes a positive Secondary Jones Test (Figure 15) and suggests a functional obstruction of the nasolacrimal duct. 6. If no dye is found on the cotton bud after syringing, this is termed a negative Figure 13 Figure 14 Figure 15 Figure 16 FEBRUARY 26 • 1999 OPTOMETRY TODAY 31
Page 1: David P. Austen, MSc, BSc (Hons), F

Lacrimal dilation and syringing - Optometry Today

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