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 zipperbeginning 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.

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

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.

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 Sex Age : Mrs. EE : Female : 23 years old

Address : Jl. Tanjung Raya 1, Gaya Baru, Gg. Orde Baru 4 Pontianak Ethnic Job : Melayu : Housewife

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

3.2 Anamnesis
Main complaint side. : Swelling on the between cantus media to nasal right

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 Awareness Vital Signs Heart Rate Respiration freq. Blood Pressure : 76 x/minute : 22 x/minute : 110/60 mmHg : Good : Composmentis

Temperature (axilla) : 36,5oC

3.3.1 Ophthalmological status

Visual acuity: OD OS : 6/6 : 6/6

Right eye Ortho ptosis (-), lagoftalmos (-), edema (-) Redness (-), discharge (-), fibrovascular growth (-) Clear, edema (-), ulcer (-), infiltrate (-) Clear, deep Iris colour : brown Eye ball position

Left eye Ortho ptosis (-), lagoftalmos (-), edema (-) Redness (-), discharge (-), fibrovascular growth (-) Clear, edema (-), ulcer (-), infiltrate (-) Clear, deep Iris colour : brown

Palpebra

Conjungtiva

Cornea COA Iris and pupil

Pupil: circular, 3mm, reactive to light Clear Clear Red Reflex (+), Cup to disc ratio 1:3 , Macula : normal, Ratio A/V : 2/3 Exudate (-), Fundus Lens Vitreous

Pupil: circular, 3mm, reactive to light Clear Clear Red Reflex (+), Cup to disc ratio 1:3 , Macula : normal, Ratio A/V : 2/3 Exudate (-),

hemorrhage (-)

hemorrhage (-)

Visual field test (confrontation) ODS :Normal Corneal Sensibility test ODS : Positive Shadow Test ODS :Positive Eye ball movement OD + + + + + + OS + + +

+ +

+ +

3.3.2

Localize Assesment 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

3.4 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

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 Ad functionam : bonam : bonam

Ad sanactionam : malam

CHAPTER 4 DISCUSSION

CHAPTER 5 SUMMARY

REFERENCES

1. Vaughan and Asburys, 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 Dukers 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