CHAPTER 1

INTRODUCTION

Lacrimal system is consists of the secretory and excretory system. Secretory

system is consists of the lacrimal glands and the accessory lacrimal glands. Excretory

system is consist of the puntum, canaliculi, the lacrimal saccus, and the nasolacrimal

duct.

Under normal circumstances, the quantity of tears secreted should equal the

quantity eliminated. If this cycle not equal, so may occur obstruction or blocage in

excretory system. Obstruction or blockage of the lacrimal excretory system may

occur either in the punctum, the canaliculus or the nasolacrimal duct, resulting in

tearing. Very often, the obstruction or blockage occurs in the nasolacrimal duct and

this secretion may cause the lacrimal sac to become chronically infected (chronic

dacryocystitis). The patient complains of persistent watering in the eye with reflux of

mucopurulent material when pressure is applied on the lacrimal sac. If the condition

persists, an operation (dacryocystorhinostomy) to create a new drainage channel may

have to be performed. In acute dacryocystitis, systemic antibiotics and surgical

drainage of the pus are required.

CHAPTER 2

LITERATURE REVIEW

2.1 Anatomy And Physiology Lacrimal System

The lacrimal system comprises structures involved in the production and

drainage of tears. The secretory component consists of the glands that produce the

various ingredients of tear fluid, which is distributed over the surface of the eye by

the action of blinking. The canaliculi, lacrimal sacs, and nasolacrimal ducts form the

excretory elements of the system, secretions ultimately draining into the nose.

Fig.1 Lacrimal system

2.1.1 Lacrimal Secretory System

The largest volume of tear fluid is produced by the lacrimal gland located in

the lacrimal fossa in the superior temporal quadrant of the orbit. This almond-shaped

gland is divided by the lateral horn of the levator aponeurosis into a larger orbital lobe

and a smaller palpebral lobe, each with its own system of ductules emptying into the

superior temporal fornix. The palpebral lobe can sometimes be visualized by everting

the upper lid. Innervation of the main gland is from the pontine lacrimal nucleus

through the nervus intermedius and along an elaborate pathway of the maxillary

division of the trigeminal nerve. Denervation is a common consequence of acoustic

neuroma and other tumors of the cerebellopontine angle.

The accessory lacrimal glands, although only one-tenth the mass of the major

gland, have an essential role. The glands of Krause and Wolfring, identical in

structure to the lacrimal gland but lacking ductules, are located in the conjunctiva

mainly in the superior fornix. Unicellular goblet cells, also scattered throughout the

conjunctiva, secrete glycoprotein in the form of mucin. Modified sebaceous

meibomian and zeisian glands of the lid margin contribute lipid to the tears. The

glands of Moll are modified sweat glands that also add to the tear film.

Secretions from the lacrimal gland are triggered by emotion or physical

irritation and cause tears to flow copiously over the lid margin (epiphora). The

accessory glands are known as the "basic secretors," their secretions normally being

sufficient to maintain the health of the cornea. Loss of goblet cells, however, leads to

drying of the cornea even with profuse tearing from the lacrimal gland.

Disorders of the secretory system include is alacrima, lacrimal hypersecretion,

paradoxic lacrimation ("Crocodile Tears"), bloody tears, dacryoadenitis.

2.1.2 Lacrimal Excretory System

The excretory system is composed of the puncta, canaliculi, lacrimal sac, and

nasolacrimal duct. With each blink, the eyelids close like a zipper—beginning

laterally, distributing tears evenly across the cornea, and delivering them to the

excretory system on the medial aspect of the lids. Under normal circumstances, tears

are produced at about their rate of evaporation, and for that reason few pass through

the excretory system. When tears flood the conjunctival sac, they enter the puncta

partially by capillary attraction. With lid closure, the specialized portion of pretarsal

orbicularis surrounding the ampulla tightens to prevent their escape. Simultaneously,

the lid is drawn toward the posterior lacrimal crest and traction is placed on the fascia

surrounding the lacrimal sac, causing the canaliculi to shorten and creating negative

pressure within the sac. This dynamic pumping action draws tears into the sac, which

then pass by gravity and tissue elasticity through the nasolacrimal duct into the

inferior meatus of the nose. Valve-like folds of the epithelial lining of the sac tend to

resist the retrograde flow of tears and air. The most developed of these flaps is the

"valve" of Hasner at the distal end of the nasolacrimal duct. This structure is

important because when imperforate in infants it is the cause of congenital

obstruction and chronic dacryocystitis.

2.2 Dacryocystitis

2.2.1 Definition

Dacryocystitis is an infection of the lacrimal sac that usually results from

obstruction of the nasolacrimal duct. Dacryocystitis usually produces localized pain,

edema, and erythema over the lacrimal sac. This clinical pattern must be

distinguished from acute ethmoid sinusitis, although purulent discharge from the

puncta almost always indicates an infection within the sac. Irrigation and probing

should usually not be performed during an acute infection. This disorder usually

responds to warm, moist compresses, together with topically and systemically

administered antibiotics. A distended lacrimal sac should be incised and drained only

if the infection does not respond to conservative therapy or if an abscess begins to

point.

Dacryocystitis may be classified as acute or chronic. It may be localized in the

sac, extend to include a pericystitis, or progress to orbital cellulitis. When

dacryocystitis is localized to the sac, a palpable painful mass occurs at the inner

canthus , and obstruction is present at the junction of the nasolacrimal sac and duct. A

preexisting dacryocystocele may or may not be present. When the infection develops,

the lateral expansion of the nasolacrimal sac tends to push on the common canaliculus

and produce a kink within it, with the result that the sac is no longer reducible. This

allows a buildup of material within the sac and a chronic stasis, which leads to an

exacerbated infection and more stasis. Approximately 40% of initial attacks do not

recur, but in the other 60% of patients, repeated attacks occur. Chronic dacryocystitis

may be the end stage of acute dacryocystitis, but it may present initially as a

subclinically infectious cause of nasolacrimal duct obstruction. A common organism

involved is Staphylococcus aureus. In some cases, especially in young women, stones

may develop that lead to intermittent attacks of dacryocystitis; this has been termed

acute dacryocystic retention syndrome.

2.2.2 Etiology

In acute dacryocystic the cause is usually a stenosis within the lacrimal sac.

The retention of tear fluid leads to infection from staphylococci, pneumococci,

Pseudomonas, or other pathogens.

In chronic dacryocystic, obstruction of the nasolacrimal duct is often

secondary to chronic inflammation of the connective tissue or nasal mucosa.

In neonatal dacryocystitis, approximately 6% of newborns have a stenosis of

the mouth of the nasolacrimal duct due to a persistent mucosal fold (lacrimal fold or

valve of Hasner). The resulting retention of tear fluid provides ideal growth

conditions for bacteria, particularly staphylococci, streptococci, and pneumococci.

2.2.3 Clinical Findings

The chief symptoms of dacryocystitis are tearing and discharge. In the acute

form, inflammation, pain, swelling, and tenderness are present in the tear sac area.

Purulent material can be expressed from the sac. In the chronic form, tearing is

usually the only sign. Mucoid material usually can be expressed from the sac. It is

curious that dacryocystitis is seldom complicated by conjunctivitis even though the

conjunctival sac is constantly being bathed with pus exuding through the lacrimal

puncta. Corneal ulcer occasionally occurs following minor corneal trauma in the

presence of pneumococcal dacryocystitis. Chronic dacryocystitis increases the risk of

endophthalmitis after cataract surgery.

2.2.4 Differential Diagnosis

Facial cellulitis involving the medial canthus: No discharge from punctum

with pressure over lacrimal sac. The lacrimal drainage system is patent on

irrigation.

Dacryocystocele: Mild enlargement of a noninflamed lacrimal sac in an

infant. Present at birth but may not be detected until later. Caused by

nasolacrimal duct obstruction or entrapment of mucus or amniotic fluid in the

lacrimal sac. Usually unilateral. If bilateral, assess breathing to rule out nasal

obstruction. Conservative therapy with antibiotic ointment and warm

compresses is usually sufficient for nonobstructive cases.

Acute ethmoid sinusitis: Pain, tenderness, nasal obstruction, and erythema

over the nasal bone, just medial to the inner canthus. Patients may be febrile.

Imaging is diagnostic.

Frontal sinus mucocele/mucopyocele: The swelling typically occurs well

above the medial canthal tendon. Proptosis and external ophthalmoplegia are

often present. Imaging is diagnostic.

2.2.5 Diagnosis

In most patients, physicians make a clinical diagnosis of dacryocystitis.

Supportive laboratory analysis includes a complete blood count to assess the degree

of leukocytosis; however, this rarely may assist in the determination of leukemia as

an etiology of the lacrimal sac infection. Blood cultures and cultures of the ocular

surface, nose, and lacrimal sac discharge may prove useful in determining the

appropriate antibiotic therapy. Antineutrophil cytoplasmic antibody testing may be

useful in ruling out Wegener granulomatosis as a cause of dacryocystitis and

nasolacrimal duct obstruction. Antinuclear antibody (ANA) testing may be useful in

the very rare cases of dacryocystitis caused by lupus involvement of the lacrimal

drainage system with resultant obstruction and infection.

2.2.5.1 Imaging studies

Plain films may be useful in elucidating facial skeletal anomalies or foreign

bodies as the cause of the lacrimal disorder. In addition, occasionally, posttraumatic

etiologies and mass lesions are noted on plain films as the cause of dacryocystitis.

Echography rarely is used. In most cases, it demonstrates enlargement and

engorgement of the lacrimal sac. Rarely, lacrimal sac foreign bodies or masses are

noted on echography. 7,8,9,10,11

CT scans are useful in patients suspected of harboring an occult malignancy

or mass as a cause of dacryocystitis. In addition, posttraumatic causes of

dacryocystitis usually are noted with CT scans. MRIs are not as useful as CT scans

but can be helpful in differentiating cystic lesions from solid mass lesions. MRIs can

be useful in identifying patients with lacrimal sac diverticuli, which can cause

recurrent dacryocystitis without epiphora and failure of surgical correction.

Dacryocystography (DCG) and dacryoscintigraphy are useful adjunctive diagnostic

modalities when anatomical abnormalities of the nasolacrimal drainage system are

suspected. Subtraction DCG with CT scan is also very sensitive to study the anatomy

of the lacrimal sac and surrounding structures. 7,8

2.2.5.2 Schirmer basic secretor testing

Ensure that epiphora is not related to hypersecretion or abnormal lid function

or position. Baseline tear secretion can be measured with the Schirmer basic secretor

test.

Dye disappearance testing: A somewhat subjective test, it is used to assess the

disappearance of fluorescein dye when placed in the eye. The ocular surface is

evaluated at the slit lamp to determine disappearance of the fluorescein dye. This test

is useful in children. 10,11,12

2.2.5.3 Jones dye test

With the Jones I dye test, functional and anatomical obstruction of the

nasolacrimal system can be assessed.

a. A positive result indicates no anatomical or functional blockage to tear flow.

b. A negative result indicates a lacrimal drainage system problem (ie, anatomical

or functional blockage).

A Jones II dye test is used to determine the presence or absence of anatomical

obstruction of the nasolacrimal outflow system. Positive Jones II dye test (colored

fluid from the nose) indicates a patent system anatomically.

In light of a negative Jones I dye test, a positive Jones II dye test indicates

either partial obstruction of the nasolacrimal system or a false-negative Jones I test.

Negative Jones II eye test (clear fluid from the nose) indicates functional blockage of

the nasolacrimal system. This is common with horizontal laxity of the lower eyelid or

flaccidity of the canalicular system. If no fluid can be irrigated with the Jones II test,

complete nasolacrimal obstruction is present.

Nasal endoscopy is frequently useful in assessing the etiology of

dacryocystitis. Tumors, papillomas, hypertrophy of the inferior turbinate, nasal septal

deviation, and inferior meatal narrowing may be noted as causes of dacryocystitis.

2.2.6 Treatment

Systemic antibiotics in the following regimen:

Children:

o Afebrile, systemically well, mild case, and reliable parent:

Amoxicillin/clavulanate (e.g., Augmentin) 20 to 40 mg/kg/day p.o. in

three divided doses.

o Alternative treatment: Cefaclor (e.g., Ceclor) 20 to 40 mg/kg/day p.o.

in three divided doses.

o Febrile, acutely ill, moderate to severe case, or unreliable parent:

Hospitalize and treat with cefuroxime, 50 to 100 mg/kg/day

intravenously (i.v.) in three divided doses.

Adults:

o Afebrile, systemically well, mild case, and reliable patient: Cephalexin

(e.g., Keflex) 500 mg p.o., q6h. Alternative treatment:

Amoxicillin/clavulanate (e.g., Augmentin) 500 mg p.o.

o Febrile, acutely ill: Hospitalize and treat with cefazolin (e.g., Ancef) 1

g i.v.

o The antibiotic regimen is adjusted according to the clinical response

and the culture/sensitivity results. The i.v. antibiotics can be changed

to comparable p.o. antibiotics depending on the rate of improvement,

but systemic antibiotic therapy should be continued for a full 10- to

14-day course.

Topical antibiotic drops [e.g., trimethoprim/polymyxin B (e.g., Polytrim)

q.i.d.] may be used in addition to systemic therapy. Topical therapy alone is

not adequate.

Apply warm compresses and gentle massage to the inner canthal region q.i.d.

Administer pain medication (e.g., acetaminophen with or without codeine)

p.r.n.

Consider incision and drainage of a pointing abscess.

Consider surgical correction (e.g., dacryocystorhinostomy with silicone

intubation) once the acute episode has resolved, particularly with chronic

dacryocystitis.

CHAPTER III

CASE REPORT

3.1 Patient Identity

Name : Mrs. EE

Sex : Female

Age : 23 years old

Address : Jl. Tanjung Raya 1, Gaya Baru, Gg. Orde Baru 4 Pontianak

Ethnic : Melayu

Job : Housewife

Religion : Islam

Patient was admitted to the hospital and examined on October 18th, 2012.

3.2 Anamnesis

Main complaint : Swelling on the between cantus media to nasal right

side.

History of disease : Patient complaint the swelling since two months ago.

The swelling appear suddenly. Beginning, the swelling is painfull, redness and

produce the pus. The pus is yellowish-white fluid and odorless. Afterwards,

she came to ophalmologist at September 2012 and has been treated. Now, the

swelling is not pain, not redness and decrease produce the pus. Sometimes

mucous and tears come out. She deny to fever.

Past clinical history:

Patient never got it before. But she often produce mucous and tears. No

traumatic and infection history.

Family history :

Neither family have the same complain.

3.3 General Physical Assessment

General condition : Good

Awareness : Composmentis

Vital Signs

Heart Rate : 76 x/minute

Respiration freq. : 22 x/minute

Blood Pressure : 110/60 mmHg

Temperature (axilla) : 36,5oC

3.3.1 Ophthalmological status

Visual acuity:

OD : 6/6

OS : 6/6

Right eye Left eye

Ortho Eye ball position Ortho

ptosis (-), lagoftalmos (-),

edema (-)Palpebra

ptosis (-), lagoftalmos (-),

edema (-)

Redness (-), discharge (-),

fibrovascular growth (-)Conjungtiva

Redness (-), discharge (-),

fibrovascular growth (-)

Clear, edema (-), ulcer (-),

infiltrate (-)Cornea

Clear, edema (-), ulcer (-),

infiltrate (-)

Clear, deep COA Clear, deep

Iris colour : brown Iris and pupil Iris colour : brown

OD OS

+

+

+

+

+

+

+

+

+

+

+

+

+

+

+

+

Pupil: circular, 3mm,

reactive to light

Pupil: circular, 3mm,

reactive to light

Clear Lens Clear

Clear Vitreous Clear

Red Reflex (+), Cup to

disc ratio 1:3 , Macula :

normal, Ratio A/V : 2/3

Exudate (-),

hemorrhage (-)

Fundus

Red Reflex (+), Cup to

disc ratio 1:3 , Macula :

normal, Ratio A/V : 2/3

Exudate (-),

hemorrhage (-)

• Visual field test (confrontation)

ODS :Normal

• Corneal Sensibility test

ODS : Positive

• Shadow Test

ODS :Positive

• Eye ball movement

3.3.2 Localize Assesment

3.4 Resume

A female 23 years old, came with swelling between cantus media to nasal

right side. Patient complaint the swelling since two months ago. The swelling appear

suddenly. Beginning, the swelling is painfull, redness and produce the pus. The pus

is yellowish-white fluid and odorless. Afterwards, she came to ophalmologist at

September 2012 and has been treated. Now, the swelling is not pain, not redness and

decrease produce the pus. Sometimes mucous and tears come out. She deny to fever.

Patient never got it before. But she often produce mucous and tears. No

traumatic and infection history. Neither family have the same complain.

Based on the general examination, there are no abnormalities. On localized

examination, there are swelling on the between cantus media to nasal right side.

Size: 3x1 cm, not pain, hard on the base, yellowish-white pus discharge, and

odorless. On the eye examination, there are no abnormalities, neither decrease visual

aquity.

3.5 Diagnose

Acute dacryocystitis

Dd: Acute ethmoid sinusitis

Inpection: swelling on the between cantus media to nasal right side, not red, size 3 x 1 cm.

Palpation: not pain, hard on the base, epiphora, yellowish-wehite pus discharge

3.6 Examination

Fluorecein test

CT- scan

3.7 Treatment

Keep hygine

Warm compress

Antibiotic systemic: Amoxicillin 3 x 500 mg p.o

Topical antibiotic drops: polymyxin B

Surgery: dacryocystorhinostomy

3.8 Prognosis

Ad vitam : bonam

Ad functionam : bonam

Ad sanactionam : malam

CHAPTER 4

DISCUSSION

CHAPTER 5

SUMMARY

REFERENCES

1. Vaughan and Asbury’s, General Ophthalmology ed.17. McGrawHill . 2007

2. Deborah, Pavan-Langston MD, FACS By Lippincott, Williams & Wilkins.

Manual of Ocular Diagnosis and Therapy 5th edition. 2002.

3. Yanoff, M. and Duker, JS.Yanoff and Duker’s Ophthalmology. 3rd Edition,

Mosby Elsevier, UK.. 2009

4. Lang GK. Ophthalmology. A Short Textbook. New York: Thieme Stuttgart,

2000.

5. Ehlers, Justis P. Shah, Chirag P. Wills Eye Manual, The: Office and

Emergency Room Diagnosis and Treatment of Eye Disease, 5th Edition

Copyright ©2008 Lippincott Williams & Wilkins