Lacrimal drainage system

Causes: (a) idiopathic, (b) chronic marginal blepharitis, (c) herpetic (simplex, zoster) lid infection, and (d) conjunctival cicatrization.

Diagnosis: narrow inferior punctum in the absence of punctal malposition.

Treatment: dilatation alone ( Fig. 2.1 ) rarely confers long-term improvement; surgical punctoplasty is usually necessary ( Figs. 2.2 and 2.3 ).

Diagnosis: narrow inferior punctum associated with punctal eversion ( Fig. 2.4 ).

Treatment

• Retropunctal cautery: for pure punctal eversion.

• Medial conjunctivoplasty: for medial ectropion without lid laxity ( Fig. 2.5 ).

  

• Wider lid positional abnormalities: addressed as appropriate ( Fig. 2.6 ).

  

Causes: (a) congenital and (b) acquired (e.g. trauma, herpes simplex infection, drugs, irradiation, chronic dacryocystitis).

Diagnosis: site of obstruction will usually be evident on lacrimal irrigation as a ‘soft stop’ ( Fig. 2.7a ).

Treatment

• Intubation: silicone stents for partial obstruction.

• Canaliculodacryocystorhinostomy (CDCR): for total individual canalicular obstruction when there is 6–8 mm of patent normal canaliculus between the punctum and the obstruction.

• Lester Jones tube insertion: when it is not possible to anastomose the functional canaliculus to the sac (see below).