CONDITION GUIDELINES

Dacryocystitis

Dacryocystitis is an acute or chronic inflammation of the lacrimal sac (Figure 7.3). It is a rare condition but is more common than dacryoad- enitis. It is usually unilateral and is associated with obstruction to the lacrimal drainage system.

Causes Acute

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Most causes of acute dacryocystitis are unknown;

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Following chronic dacryocystitis;

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Causative organisms include – Staphylococci, Streptococci and pneumococci.

Chronic

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Following trauma to the lacrimal system;

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Following chronic conjunctivitis, e.g. trachoma.

Figure 7.3 Dacrocystitis. From James, Chew and Bron (2007) Lecture Notes: Ophthalmology, Blackwell Publishing, reproduced with

permission.

Infant

Failure of canalisation of lacrimal ducts following birth.

Signs

Adult acute and infant:

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Pain;

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Red, tender swelling over the lacrimal sac;

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Pus regurgitating through the punctum;

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Conjunctivitis;

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Watering eye (epiphora), which may cause visual disturbance.

Chronic:

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There may be swelling over the lacrimal sac, which can be recurrent.

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Pus may emerge from the punctum when pressure is applied to the

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sac.Epiphora may be present, which may cause visual disturbance.

Patient’s needs Acute

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Relief of pain, which can be severe, with appropriate analgesia; warm compresses can effect some relief of pain. Measure pain and the effect of analgesia using an appropriate pain-assessment tool.

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Lid hygiene can be used to address the problem of discharge and watering eye.

Chronic

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Relief of watering eye due to blockage of drainage channels;

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Diagnosis and treatment of obstruction.

Infant

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Relief of pain;

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Lid hygiene to address the problem of discharge and watering

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eye;Admission to hospital for probing of ducts if initial treatment fails.

Nursing action Acute adult

1 Apply/instruct the patient how to apply warm compress to the in- flamed area (clean face cloths rinsed under a warm tap can provide some relief).

2 Give/instruct him to take the prescribed analgesia and antibiotics, e.g. amoxicillin 250 mg three times a day for 7–10 days.

3 Clean/instruct him how to clean the eye if sticky and instil pre- scribed antibiotic drops or apply ointment, usually chloramphenicol or Fucithalmic.

Chronic adult

1 Perform lacrimal sac washout to detect area of blockage. Note: this is never carried out on a patient with an acute infection of the sac as the inflamed walls are easy to perforate.

2 Prepare patient for dacryocystogram. This is an X-ray using radio- opaque dye, which is introduced into the lacrimal drainage system to show up any blockage. Warn the patient that it is an uncomfortable procedure and that he should be accompanied home following this test as he may feel unwell.

3 Admit and prepare the patient for surgery to correct the block- age. Dacryocystorhinostomy (DCR) is performed to open up a new drainage channel into the nasal cavity. This may be performed using an endoscope or a more traditional external approach through the skin. Sometimes a tube is left in situ (DCR and tubes) for 3–6 months to maintain the patency of the new drainage channels. These tubes should not interfere with the cornea unless they extrude.

Post-operative care

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Pain should be managed effectively, ideally using a pain-assessment tool to plot the severity of the pain and the degree of relief obtained following the administration of analgesia.

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In the immediate post-operative period, the patient must be mon- itored carefully for any epistaxis (nosebleed). Blood loss from this can be catastrophic. The haemorrhage may be overt or could be via the back of the throat. For this reason, pulse, blood pressure and res- piratory rate should be monitored and, where used, an early warning score recorded. Where appropriate, urgent medical assistance must be obtained.

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A pressure dressing will remain in place until the dressing the morn- ing after surgery. This should be observed for signs of haemorrhage.

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In the case of endoscopic DCR, a nasal pack will be in situ. This too must be observed for haemorrhage. It usually is removed the next

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day.Standard DCR:

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Clean the eye and suture line.

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Instil antibiotic drops; occasionally antibiotic cream is prescribed to be applied to the suture line. The surgeon may recommend that this is gently massaged in to reduce scarring.

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Remove sutures 5–7 days post-operatively (usually in outpatient department).

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Instruct the patient not to blow his nose vigorously as this could cause bleeding and will dislodge the tubing.

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If a tube is present, it will be removed in the outpatient depart- ment. The procedure is relatively painless and does not warrant surgery.

Infant

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Instruct the parent/guardian to instil topical antibiotic drops, e.g. G.

chloramphenicol.

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Instruct the parent/guardian to massage over the lacrimal sac area to remove the accumulated mucus, which may lead to a patent duct.

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Admitting the child to hospital should be considered if these methods fail to open the canaliculus.

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A thorough pre-operative assessment as well as review by the anaes- thetist should be completed. Parental or legal guardian’s consent must be obtained.

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Probing of the tear ducts will be done under general anaesthetic.

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Give standard pre-operative care prior to probing of the ducts.

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Give post-operative care, including analgesia: instil antibiotic drops.

Complications

Following acute dacryocystitis, fistula formation may develop. DCR is not always successful in curing the watering eye.

CONDITION GUIDELINE

Epiphora

Epiphora is watering of the eye (increased lacrimation).

Causes

Causes of Epiphora include:

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Acute or chronic dacryocystitis;

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Ectropion;

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A small, tight or absent punctum;

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Increased secretion of tears due to reflex stimulation of the lacrimal gland, e.g. by wind, smoke, onions, or a foreign body in the eye;

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Allergy, e.g. hay fever.

Patient’s needs

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Explanation of the condition, its cause and prognosis;

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Dilation of a small or tight punctum;

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Removal of causative agent of increased stimulation;

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Treatment of hay fever.

Nursing action

1 A careful history should be carried out of the presenting complaint, systematic examination of the eyelids, conjunctiva and the cornea.

2 If a foreign body is present, remove this appropriately.

3 If the cause is a small or tight punctum, this needs to be dilated regularly over a period of several months. This is usually performed every week or so using for example, a Nettleships dilator, holding it in place in the punctum for 5 minutes.

4 Prepare patient and equipment for a one, two or three-snip opera- tion, which will be carried out if the dilation fails. During this proce- dure, performed under local anaesthetic, snips are made behind the punctum to release the muscle around the punctum.

5 Prescribe topical antihistamine drops such as Lodoxamide 0.1%.

CONDITION GUIDELINE

Dry eye syndrome (keratoconjunctivitis sicca)

Dryness of the eye results from any disease associated with deficiency of any of the layers of the tear film as well as lid or corneal surface abnormalities. Its name (dry eyes) appears to imply a non-significant condition. This is not the case. In addition to being very uncomfortable, it has the potential to be sight-threatening.

Causes

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Lacrimal gland failure;

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Oil deficiency;

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Exposure: proptosis, facial palsy;

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Hot, dry climate/environment;

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Lid damage;

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Blepharitis;

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Meibomianitis;

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Aqueous deficiency;

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Sj¨ogren’s syndrome (arthritis, dry eye, achlorhydria);

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Removal/absence of glands;

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Trachoma;

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Chronic dacryoadenitis;

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Drugs: beta-blockers, diuretics;

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Old age;

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Menopause;

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Mucin deficiency;

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Chemical burns;

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Chronic conjunctivitis;

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Antihistamines;

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Stevens-Johnson syndrome;

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Xerophthalmia;

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Other causes: deficient blinking; corneal scarring.

Signs

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Usually a normal-looking eye;

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Damaged epithelial, corneal and conjunctival cells stain with fluores- cein drops;

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Breaks in the tear film are seen when stained with G. fluorescein.

The normal tear break-up time is usually over ten seconds.

Patient’s needs

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An adequate explanation of the condition;

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Recognition that it causes ocular disturbance;

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Advice that this is a chronic condition and treatment is about reliev- ing symptoms or preventing symptoms occurring;

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Relief of symptoms that include:

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Gritty feeling;

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Itching;

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Burning sensation;

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Inability to produce tears;

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Pain around and in the eye;

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Sometimes a red eye;

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Difficulty in opening eyes on waking and moving lids;

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Excessive watering eye (if the outer oil layer of the tear film is deficient, tears will spill over the lower lid margin);

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Investigation and treatment of underlying cause, if possible;

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Treatment with replacement tears.

Nursing action

1 Perform tear production test.

2 Instruct the patient to use the prescribed artificial tears, e.g.

hypromellose. These drops can usually be used as often as the pa- tient requires, keeping the eye feeling comfortable, and will probably need long-term use.

3 Cautery to the punctum or insertion of punctal plugs may be em- ployed to prevent what little tears are produced from draining into the punctum.

Complications

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Chronic conjunctivitis due to loss of the protective function of the tear film and lysozyme;

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Corneal scarring and vascularisation;

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Corneal ulceration, thinning and perforation;

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Eventual loss of the eye through recurrent infections.

REFLECTIVE ACTIVITY

Consider a patient that you have seen recently with a condition affect- ing the lacrimal system or tear film:

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What were the presenting signs and symptoms?

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Was there any associated systemic disease or diseases?

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What tests and investigations were carried out and why?

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How did you arrive at a diagnosis?

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What was the treatment plan?

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Outline the care and management of the patient.

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If there were any challenges in caring for the patient, what were they?

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Was any other member of the multidisciplinary team involved in the care and what was their input?

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Utilising a recognised health-promotion framework, how would you explain the condition and treatment to the patient in order to ensure that the he or she adheres to the treatment?

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What was the clinical outcome?

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What local or national policies; guidelines or protocols influenced the care and management of this patient?

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On reflection, would you have done anything differently and, if so, what?

Your completed case study can be used to contribute to your con- tinuing professional development portfolio for Registration and your Knowledge and Skills Framework or appraisal review.

Chapter 8