מערכת הדמעות פועלת כמערכת מאוזנת: הדמעות מיוצרות בבלוטת הדמעות, מתפזרות על פני העין בזמן מצמוץ, ומתנקזות דרך פתחים זעירים בעפעפיים אל שק הדמעות ומשם לחלל האף. כאשר קיימת חסימה לאורך המסלול הזה, הדמעות אינן מתנקזות כראוי – ונוצר מצב של דמעת מתמשכת.
מתי לחשוד בחסימה בדרכי הדמעות?
לא כל דמעת מעידה על חסימה. עם זאת, ישנם מצבים שבהם עולה חשד משמעותי יותר לבעיה במערכת הניקוז:
- דמעת מתמשכת לאורך זמן
- דמעת שאינה סימטרית, ובולטת יותר בעין אחת
- הפרשה רירית או מוגלתית נלווית
- זיהומים חוזרים באזור שק הדמעות
- דלקות עיניים חוזרות, בעיקר כאשר הן חד־צדדיות
- מצב שבו נוסו טיפולים שונים וטיפות ללא הטבה משמעותית
במקרים שבהם בוצעה שטיפת דרכי הדמעות והודגמה זרימה לא תקינה – החשד לחסימה מתחזק עוד יותר.
חשוב להדגיש כי חסימה יכולה להופיע גם במצבים אחרים, ולעיתים התמונה הקלינית מורכבת יותר. לכן, האבחון מחייב בדיקה יסודית ולא הסתמכות על סימפטום בודד.
לא כל דמעת נובעת מחסימה מלאה
בפועל, התמונה הקלינית אינה תמיד חד־משמעית. לעיתים הדמעת נובעת ממצרף גורמים: גירוי עיני או יובש הגורמים לייצור מוגבר של דמעות, לצד הפרעה במערכת הניקוז. במקרים אחרים מדובר בחסימה חלקית בלבד, או בהפרעה תפקודית הקשורה לעפעפיים עצמם – כגון רפיון של העפעף או מנח לא תקין הפוגע ביכולת הניקוז.
במצבים אלה, האבחון מחייב התייחסות לכלל המרכיבים – הן לייצור הדמעות והן למנגנון הניקוז והעפעפיים – כדי להתאים טיפול מדויק ולא אחיד.
שטיפה אינה פתרון
שטיפת דרכי הדמעות משמשת כלי אבחנתי חשוב, ולעיתים עשויה להקל באופן זמני. אולם כאשר קיימת חסימה משמעותית או מלאה, השטיפה אינה פותרת את מקור הבעיה, אלא לכל היותר מדגימה אותה.
במצבים אלה נשקל טיפול כירורגי שמטרתו יצירת מעבר ניקוז חדש בין שק הדמעות לחלל האף – הליך המכונה ניתוח מעקף דרכי דמעות (DCR).
ניתוח מעקף דרכי דמעות – בגישה אנדוסקופית משולבת
כאשר קיימת חסימה משמעותית, ניתן לבצע ניתוח מעקף דרכי דמעות (DCR) בגישה אנדוסקופית דרך חלל האף. בגישה זו נוצר מעבר ניקוז חדש בין שק הדמעות לחלל האף, ללא חתך עור חיצוני.
ההליך מתבצע באמצעות ציוד אנדוסקופי עדין המאפשר ראייה ישירה של האנטומיה הפנימית. בניתוחים בגישה זו, שיתוף פעולה עם רינולוג – מומחה לניתוחים אנדוסקופיים של מעברי האף והסינוסים – מאפשר עבודה מדויקת באזור האפי ויצירת מעבר ניקוז יציב בסביבה אנטומית מורכבת.
סיכום
דמעת כרונית אינה אבחנה אלא סימפטום, ולעיתים קרובות מקור הבעיה שונה מכפי שנדמה בתחילה. ההבחנה בין ייצור יתר של דמעות לבין הפרעה במערכת הניקוז, ובין חסימה מלאה לבין הפרעה תפקודית עדינה יותר, היא שלב מרכזי בקביעת הטיפול הנכון.
מערכת הדמעות היא חלק בלתי נפרד מאזור העיניים, ולכן האבחון מחייב ראייה כוללת של מבנה העפעפיים, מנגנון הניקוז ובריאות פני העין. כאשר מזהים במדויק את מקור הבעיה, ניתן להציע פתרון ממוקד ויעיל – תפקודי ומבוסס אנטומית.
ד"ר ינון שפירא הוא רופא עיניים מומחה לאוקולופלסטיקה, דרכי דמעות וארובת העין.
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