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Q1. Lacrimal Apparatus - Diagram & Diseases

Diagram of the Lacrimal Apparatus

Components of the Lacrimal Apparatus

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Diseases of the Lacrimal Apparatus

1. Dacryoadenitis

• Acute: Inflammation of the lacrimal gland; caused by viral (mumps, EBV, herpes) or bacterial infection. Presents with pain, swelling, and tenderness in the superolateral orbit with an S-shaped ptosis.
• Chronic: Associated with sarcoidosis, lymphoma, Sjogren syndrome, or tuberculosis.

2. Dacryocystitis

• Inflammation of the lacrimal sac, most often due to obstruction of the nasolacrimal duct.
• Acute: Red, painful swelling at the medial canthus; may form an abscess. Causative organisms: Staphylococcus aureus, Streptococcus pneumoniae.
• Chronic: Persistent epiphora (watering eye), mucopurulent discharge; regurgitation on pressure over the sac is diagnostic.
• Treatment: Acute - antibiotics + incision/drainage; Chronic - dacryocystorhinostomy (DCR).

3. Epiphora (Watery Eye)

• Excessive tearing due to either overproduction or impaired drainage (punctal eversion, canalicular block, nasolacrimal duct obstruction).

4. Nasolacrimal Duct Obstruction (NLDO)

• Congenital NLDO: Most common in neonates; due to failure of canalization of the valve of Hasner at the lower end. Presents with sticky/watery eye. Most resolve spontaneously. Probing is curative if persistent.
• Acquired NLDO: Age-related fibrosis or secondary to trauma, infection (chlamydial), tumors.

5. Canaliculitis

• Infection of the lacrimal canaliculus; usually caused by Actinomyces israelii (filamentous organism).
• Presents with medial lid swelling, foamy/purulent discharge, pouting of the punctum.

6. Dry Eye Syndrome (Keratoconjunctivitis Sicca)

• Deficiency of the aqueous layer of the tear film due to lacrimal gland dysfunction.
• Associated with Sjogren syndrome, rheumatoid arthritis, post-radiation.

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Q2. Examination of Eyelid & Diseases of Eyelid

Examination of the Eyelid

• Position: Look for ptosis (drooping), ectropion (eversion), entropion (inversion), lagophthalmos (inability to close)
• Lid skin: Redness, crusting, scaling, masses, lesions
• Lid margins: Position of lashes (trichiasis/distichiasis), meibomian gland orifices, punctal position

1. Upper eyelid: Check for ptosis - measure palpebral fissure height (normal ~9-10 mm), levator function (normal >12 mm excursion)
2. Lower eyelid: Check for ectropion (outward turn), entropion (inward turn)
3. Eyelashes: Trichiasis (misdirected lashes rubbing cornea), madarosis (loss of lashes)
4. Eyelid margin: Blepharitis - anterior (at lash base) or posterior (meibomian gland dysfunction)
5. Tarsal conjunctiva: Evert upper lid to inspect for follicles, papillae, foreign bodies, scarring
6. Meibomian glands: Palpate for chalazion; express secretions - clear (normal) vs. toothpaste-like (MGD)
7. Skin: Look for vesicles (herpes), erythema, indurated mass (BCC, SCC)

• Patient looks down; grasp lashes; press cotton bud on upper tarsal fold; fold lid over the bud.
• Allows examination of tarsal conjunctiva, papillae, follicles.

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Diseases of the Eyelid

Inflammatory Conditions

Lid Malpositions

Eyelid Neoplasms

Other Notable Conditions

• Dermatochalasis: Redundant, baggy eyelid skin due to aging; may cause superior visual field loss
• Blepharospasm: Involuntary forceful contraction of orbicularis oculi; treated with botulinum toxin (Botox)
• Xanthelasma: Yellow lipid plaques on medial eyelid skin; associated with hyperlipidaemia
• Herpes Zoster Ophthalmicus: Involvement of tip of nose (Hutchinson sign) indicates nasociliary nerve involvement and high risk of ocular complications; treat with systemic aciclovir

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Q3. Examination of Conjunctiva & Diseases of Conjunctiva

Examination of the Conjunctiva

• Palpebral conjunctiva: Lines the inner surface of upper and lower lids; firmly attached to tarsal plates; vertically oriented blood vessels
• Fornical conjunctiva: Loose and redundant; forms upper and lower fornices
• Bulbar conjunctiva: Covers anterior sclera; continuous with corneal epithelium at the limbus; contains palisades of Vogt (corneal stem cell reservoir)
• Plica semilunaris: Nasal fold; medial to which lies the caruncle (modified cutaneous tissue)

1. Inspect bulbar conjunctiva: Look for injection (hyperaemia), chemosis (oedema), haemorrhage, follicles, papillae, symblepharon, pterygium, pinguecula
2. Inspect lower palpebral conjunctiva: Pull down lower lid; look for follicles, papillae, discharge, foreign body
3. Evert upper eyelid: Inspect upper tarsal conjunctiva - follicles (e.g., viral, chlamydia) vs. papillae (e.g., allergic, GPC)
4. Classify discharge: Watery (viral), mucoid (allergic), mucopurulent (bacterial), purulent (gonococcal)
5. Staining: Rose Bengal or lissamine green highlights devitalized epithelium; fluorescein shows corneal epithelial defects
6. Conjunctival swab/scraping: For culture and cytology (intracytoplasmic inclusions in chlamydial infection; multinucleate giant cells in viral)

• Follicles: Lymphoid aggregates (no central vessels); seen in viral/chlamydial conjunctivitis; lower fornix predominantly
• Papillae: Vascular tufts with fibrous septa (central vessels); seen in bacterial, allergic, GPC; cobblestone papillae in vernal keratoconjunctivitis
• Chemosis: Conjunctival oedema; seen in severe allergic or bacterial conjunctivitis
• Symblepharon: Adhesion between palpebral and bulbar conjunctiva; seen in cicatricial pemphigoid, Stevens-Johnson syndrome

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Diseases of the Conjunctiva

1. Conjunctivitis (Classification)

2. Cicatricial Conditions

• Ocular Cicatricial Pemphigoid: Autoimmune; progressive scarring; symblepharon, forniceal shortening, dry eye, corneal opacification. Treatment: systemic dapsone, azathioprine, or mycophenolate mofetil
• Stevens-Johnson Syndrome / Toxic Epidermal Necrolysis: Drug-induced (sulfonamides, anticonvulsants); bilateral acute conjunctivitis progressing to severe scarring, symblepharon, corneal opacification. Conjunctival membranes form acutely
• Trachoma: Leading infectious cause of blindness; caused by Chlamydia trachomatis serovars A-C; transmitted by flies and direct contact

3. Degenerative Conditions

4. Subconjunctival Haemorrhage

• Bright red, flat, well-demarcated bleed beneath the bulbar conjunctiva
• Causes: straining, coughing, Valsalva, trauma, anticoagulants, hypertension
• Usually resolves in 1-2 weeks without treatment; investigate BP and coagulation if recurrent

5. Tumours of the Conjunctiva

• Squamous cell carcinoma / CIN (Ocular Surface Squamous Neoplasia): Most common conjunctival malignancy; at limbus; associated with HPV and UV exposure
• Melanoma: From PAM (Primary Acquired Melanosis) with atypia; aggressive; poor prognosis
• Lymphoma: Usually MALT type; pink "salmon patch" appearance
• Kaposi Sarcoma: In HIV/AIDS patients

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