User:Hom Bahadur Gurung/sandbox

Lacrimal syringing and probing in adults

Lacrimal syringing is a diagnostic procedure to find out the patency of lacrimal system.common indication for lacrimal syringing is 1. To diagnose if the lacrimal system is patent or not in epiphora. 2. to delineate the site of obstruction. contraindication 1. acute dacryocystitis 2. acute lacrimal system comprises of lacrimal papilla(an elevation in the medial lid margin), lacrimal punctum, vertical canaliculus , ampulla , horizontal canalaiculus , common canalaiculus, lacrimal sac ( fundus, body and neck) and nasolacrimal duct. The punctum is in contact with the tear lake(lacus lacrimalis) and the nasolacrimal duct opens in the in ferior meatus of nasal cavity.

For the procedure, patient is informed of the procedure and laid supine on bed. Topical anaesthetics usually 4% lidocaine or proparacaine is instilled in the eye.lower lid is gently pulled down to expose the lower punctum and dilated using nettleship dilator. Normal punctal diameter is 0.2-0.3mm. Three ml syringe is filled with normal saline and fitted with blunt tipped lacrimal 19-27 G cannula or visco cannula. It is cannulated 2 mm vertically than shifted horizontally till hard or soft resistance is felt. It is withdrawn a little and fluid is gently forced in. If the patient tastes salty fluid in his throat the lacrimal system is patent and functioning in pressure condition. If there is regurgitation of fluid,The results are interpreted in three heads 1. what comes out?( clear fluid or mucoid fluid or pus)2. from where it regurgitates?( same punctum or opposite punctum)3. time taken for regurgitation?(immediate or delayed)

If there is regurgitation of clear fluid from same punctum, there is proximal canalicular obstruction.If there is regurgitation of clear fluid from the opposite punctum there may be obstruction is common canaliculus or nasolacrimal duct.if there is mucoid or pus, it is more likely to be nasolacrimal obstruction since the space in common canaliculus is not enough for pus formation. If the regurgitation is immediate the regurgitation is more likely to be in common canaliculus, if it is delayed it is more likely to be nasolacrimal duct obstruction. The site of obstruction can be conformed by probing with bowmans probe. Bowmans probe is made of stainless steel and comes in different sizes from 0000 to 8.If the probe hits the bone i.e. hard touch then the obstruction is at the nasolacrimal duct. if the probe hits soft tissue only, it suggests canalicular block. the length of probe that can be inserted also suggests the site of block. complication of syringing 1. punctal trauma- punctal tear or laceration.( may convert the distal obstruction i.e. NLDO to proximal obstruction i.e. punctal stenosis)2. canalicular injury - inadverent perforation may cause bleeding and scarring leading to canalaicular stenosis 3. false passage - injection into the tissue may cause swelling Soiberman U, Kakizaki H, Selva D, Leibovitch I. Punctal stenosis: definition, diagnosis, and treatment. Clin Ophthalmol. 2012;6:1011-8. doi: 10.2147/OPTH.S31904. Epub 2012 Jul 3. PMID: 22848141; PMCID: PMC3402122./ref>