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Aids in Restoring Patency in Obstructions of the Lacrimal Drainage System*
bACRYOCYSTÔRHINOSTOMY tern via the fistula is accomplished easily without undue resistance. Splitting of the nasolacrimal punctum occurred in one case, with migration of the wire within the skin of the lid two mm. from the punctum. Fol lowing removal of the wire there was no visible scar and no interference with over-all drainage. There was no permanent dilatation or eversion of the lacrimal punctum. A further modification of this technique is contemplated in which dilatation to only a No. 6 or No. 7 Bowman probe size will be performed and the drill bit or Kirschner wire will be inserted directly into the canal iculus rather than through the hollow needle. The wire will be inserted through the fistula within a hollow needle of considerable small-
977
er bore, thus reducing the chance of split ting the rim of the punctum. SUMMARY
A technique of dacryocystorhinostomy is presented in which a fistula is made by drill or Kirschner wire through a dilated punc tum rather than through an external skin excision. Maintenance of the fistula is ini tially accomplished by the use of a wire splint. Eye Section, Valley Forge General Hospital. ACKNOWLEDGMENT
I wish to thank Dr. Harold G. Scheie for his suggestions in the refinement of this technique.
REFERENCES
1. Abrahamson, I. A., Sr., and Abrahamson, I. A., Jr.: Dacryocystorhinostomy with wire fistulization. Am. J. Ophth., 48:769-774 (Dec.) 1959. 2. Fasanella, R. M.: Management of Complications in Eye Surgery. Philadelphia, Saunders, 1957, p. 111. 3. Bonaccolto, G.: Dacryocystorhinostomy with polyethylene tubing: A simplified technic. J. Internat. Coll. Surg., 28:789-796, 1957.
AIDS IN R E S T O R I N G P A T E N C Y IN O B S T R U C T I O N S O F LACRTMAL D R A I N A G E S Y S T E M * E V E R E T T R. V E I R S ,
THE
M.D.
Temhlc, Texas Stenosis of a freshly severed canaliculus following its repair, closure of a freshly recanalized common punctum, or stenosis of the anastomosis following an external dacryocystorhinostomy are frustrating to both the surgeon and the patient. M a n y cor rective aids have been used in the treatment of these conditions, including wicks of su ture, plastics (polyethylene tubing or sheet ing) and other material. M a n y of these are difficult to insert, and most of them are annoying to the patient and, all too often, prove ineffective. * From the Department of Ophthalmology of the Scott and White Clinic.
F R E S H L Y SEVERED CANALICULUS
Previously, I 1 reported the use of canalicular rodst in the repair of a freshly severed canaliculus (fig. 1 ) . In 1962, in a personal communication, to be quoted, Dr. Guillermo Pico, 2 of Puerto Rico, reported sucess with the use of these rods in eight out of nine cases of repair of freshly severed canaliculi, stating that in the one failure the canaliculus was severed close to the lacrimal sac. The results in the first nine cases of lacerated inferior canaliculus which I have repaired since 111175-33, American Cyanamid Company, Surgi cal Products Division, Danbury, Connecticut, and X-0398, Ethicon, Incorporated, Somerville, New Jer sey.
978
EVERETT R. VEIRS
over a year ago when you sent to me the firs rods for experimental use have been as follows: eight cases have perfect results with patent in ferior canaliculus and no lacrimation. One of these cases has a small fistula in the conjunctival side of the canaliculus but it is serving as an additional punctum. One case, which was a failure, has a slanting cut of the inferior canaliculus extending from near the outer punctum up to close to the inner punctum. Apparently there was not good approximation of the tissues so that the mucosal lining of the canaliculus could heal border to border, and, after the rod was removed six weeks after the surgery, scar tissue formed in that area near the middle of the canaliculus and obliterated it. This experi ence has shown to us the need of accurate suturing of the cut canaliculus and tissues around it after the rod has been inserted in the segments of the canaliculus. I have left the rod in place for six weeks be cause I feel that enough time is needed for strong, complete healing of the mucosa of the cut canal iculus and adjacent lacerated tissues without fibrotic retraction that may reopen or obliterate the repaired canaliculus. The 10 mm. rod is good enough for most cases but the 12 mm. size is needed for those cases in which there is a slanting cut that extends up to the inner punctum or lacrimal sac or when a vertical cut occurs in the canaliculus near the sac.
These rods are easily inserted, seem to be nonirritating, and cannot slip out of the canaliculus because they are anchored with 4-0 silk to the skin surface of the lid adja cent to the punctum. (A curved needle is threaded onto the free end of the silk so that a firm bite can be taken and the knot tied securely so that it will not come loose prematurely.) If the proximal cut end of a freshly severed canaliculus cannot be easily located soon after its injury, postponement of re pair for 48 hours makes repair simpler, for the cut edges of the canaliculus then stand out pearly white in color, bleeding is mini mal and final healing is just as satisfactory. If unusual difficulty is encountered, the "pigtail" spiral probe designed by Worst 3 may be used to locate the proximal severed end of the canaliculus. STENOSIS OF THE COMMON PUNCTUM
Stenosis of the common punctum is not unusual and has resisted satisfactory treat
ment. In a paper published in January, 1962, I 4 reported the use of polyethylene tubing in the repair of stenosis of the common punc tum ; however, I have discontinued this pro cedure. Polyethylene tubing is irritating and is less effective than the canalicular rod. U S E OF CANALICULAR RODS
Often, a stenosis of the common punctum can be opened by forcing a probe, with varying degrees of pressure, through the stenotic area into the lacrimal sac after the area has been infiltrated with procaine or lidocaine hydrochloride (Xylocaine). In such instances, the probe is forced through the stenosed common punctum, preferably by way of the lower canaliculus; however, occasionally the opening can be established only through the upper canaliculus. The patency of the drainage system should then be tested with saline lavage. If the drainage system is patent, the canalicular rod is in serted so that it lies entirely within the canaliculus (either upper or lower) except for its distal end, which projects into the lacrimal sac for a distance of one or two mm. The 4-0 silk projects through the punc tum and is anchored to the lid adjacent to the punctum, as shown in Figure 1. The canalicular rod may often be left in position from four to six weeks, or longer, with little or no discomfort. Most patients get some tear drainage into the nose even while the canalicular rod is in position. This is in dicated by less epiphora as well as by the appearance of fluorescein in the nose after instillation into the conjunctival sac. OPERATIVE TECHNIQUES
If the stenosis of the common punctum cannot be opened with moderate force or if there is also obstruction at another point, such as the nasolacrimal duct, a more ex tensive procedure must be carried out. A skin incision similar to that used in an ex ternal dacryocystorhinostomy is made ex cept that it begins about four mm. superiorly and three mm. medially to the inner canthus.
OBSTRUCTION OF LACRIMAL SYSTEM This incision is carried downward 25 to 35 mm. The medial canthal ligament is cut and the lacrimal sac retracted laterally. A verti cal incision is made through the medial wall of the lacrimal sac. Several methods, then are used to re-establish the drainage chan nel. Beard5 passes a probe into the canaliculus until there is tenting of the common punc tum into the lacrimal sac. An incision is made with a No. 11 Bard-Parker knife in the direction of the probe until the tip of the probe is reached. The excessive tissue about the tip of the probe is excised. Two 6-0 chromic catgut sutures are placed for anas tomosis of the sac and the canalicular mucosa, much in the fashion of Arruga's" operation. Jones 7 feels that "primary" stenosis of the common punctum occurs much more commonly than stenosis that follows dacryocystitis, trauma, or mucosal obstruction. He has found that in cases of primary stenosis a dense fibrous tissue appears to strangle the common punctum as it passes through the posterior part of the medial palpebral
Fig. 1 (Veirs). Canalicular rod lying within the freshly severed canaliculus, bridging the cut ends. A bite has been taken in the skin and tarsus near the punctum (after a curved needle has been threaded onto the free end of the 4-0 silk that is swaged to one end of the rod) and a knot tied securely to anchor the rod in position.
979
Fig. 2 (Veirs). A probe is being passed through the lower canaliculus. The dotted line shows the area of the nasolacrimal anastomosis that closed following an external dacryocystorhinostomy.
ligament. His procedure consists of dissect ing out the common punctum and a little of the adjacent upper and lower canaliculi, re moving any of the strangling fibrous tissue, and anastomosing the common punctum to the sac with four silk sutures. He then per forms a rhinostomy, as this tends to keep the two canalicular flaps apart. He passes a fine nylon tube from the upper punctum through the anastomosis of the canaliculus
Fig. 3 (Veirs). The probe has been forced from the lacrimal sac into the nose through the area of the previously closed anastomosis.
980
EVERETT R. VEIRS
Fig. 4 (Veirs). One strand of 4-0 silk suture has been looped around a folded Dermalene suture wick and
Suture material that is flexible and nonirritating, such as Dermalene or Mersilene, may easily be inserted so that it extends through the anastomotic area of the common punctum and out through the canaliculus. It is then anchored into position by threading a curved needle onto the end of the silk that projects through the punctum and anchor ing it to the skin near the punctum, as shown in Figure 6. This suture material may consist of a single strand of No. 2 Dermalene or of strands of Dermalene folded over and held with 4-0 silk, as shown in Figures 4, 5, and 6. This suture material should be lubricated with an antibiotic oint ment before its insertion. This type of wick may be worn for days or weeks with little or no discomfort. If the drainage channel is completely blocked with large strands of the suture material, epiphora will obviously exist while the suture is in place. If much irritation exists while the wick is in place, antibiotic drops may be helpful. P R E V E N T I O N OF CLOSURE FOLLOWING
to the sac and out through the nose, and passes the other end of this tube through the lower canaliculus. This tube is left in position seven to 14 days.
Fig. 5 (Veirs). The wick of suture material has been pulled through the re-established anastomo sis. One end of the 4-0 silk projects through the lower punctum, and a needle is threaded onto it.
DACRYOCYSTORHINOSTOMY
M a n y factors may contribute to the clo sure of the anastomosis following an ex ternal dacryocystorhinostomy, among which are the following: ( 1 ) a large anastomosis
Fig. 6 (Veirs). A substantial bite has been taken in the skin and tarsus adjacent to the lower punctum in order to anchor the wick into the proper position. The wick may be left in position for several weeks.
OBSTRUCTION OF LACRIMAL SYSTEM is not possible if the lacrimal sac is small; (2) a previously injured lacrimal sac may be difficult to anastomose because of dis placed tissues, its small size, and scarring; (3) pathologic nasal conditions may exist; (4) the operation may have been poorly performed. In order to prevent closure, three or four strands of No. 2 Dermalene that has been thoroughly lubricated with antibiotic oint ment may be doubled over and tied with 4-0 silk. The free end of the silk is then drawn through the canaliculus (the lower, usually) and the Dermalene wick pulled into the lacrimal sac. The free end of the Dermalene extends into the nose, and the free end of the silk is anchored to the lower lid after a curved needle is threaded and a bite taken adjacent to the punctum (fig. 5). If the Dermalene wick is not pulled into the canaliculus, tear drainage is good during the two weeks or so that the wick is left in place. Often, after a period of a week or so, the wick of suture that extends into the nose pulls loose, especially if there are several strands, and the patient blows it out of his nose. If this does not happen within 10 to 14 days, the knot that is tied near the punc tum may be cut and the wick grasped in the nose and pulled out. This procedure is es pecially useful when only a remnant of the lacrimal sac is present and an anastomosis is attempted (Amiga's 6 procedure). RE-ESTABLISHING THE ANASTOMOSIS FOLLOWING ITS CLOSURE
Reoperation with insertion of suture wicks offers the best chance for re-establishing an anastomosis after its closure following an external dacryocystorhinostomy. The fol lowing procedure is reasonably effective. A No. 3 or No. 4 Bowman probe is passed into the lacrimal sac through the lower canaliculus (fig. 2). While it is being pressed tightly toward the nose, the probe is elevated to a nearly vertical position. It is then forced into the nose through the area of the old anastomosis. The probe can be manipulated
981
so that the nasal opening is enlarged (fig. 3). This is done by side-to-side movement of the probe and by substitution of a No. 2 Bowman probe, which can be grasped with a hemostat within the nose, and rotating it to make the opening as large as possible. A No. 1 Bowman probe is then passed into the nose through the new channel. This probe is grasped with a hemostat and pulled toward the naris. A 4-0 silk is tied around the nasal tip of this probe with just one knot. Usually, the probe can be pulled out through the punctum with the silk attached. This procedure is easily repeated if the silk slips off. Another method is to thread one end of the suture through a No. 3 Bowman lacri mal probe that has a hole near its tip. The nasal end of the 4-0 silk is looped around three or four strands of folded Dermalene that has been lubricated with antibiotic oint ment and tied (fig. 4). This wick of Derma lene is pulled up into the lacrimal sac through the newly opened anastomosis, and the punctal end of the silk is anchored se curely near the punctum (figs. 5 and 6). Care should be exercised that the wick is pulled into the re-established opening into the lacrimal sac but not so tightly as to close the common punctum. If much infection is present, antibiotics should be given for at least a few days fol lowing the procedure. This wick should be left in position four to six weeks. If it is not securely anchored at the punctum, however, the wick will pull the knot loose and come out of the nose prematurely.* CONCLUSIONS
1. Canalicular rods to restore the patency of freshly severed canaliculi are easy to in sert, cause little if any irritation, and are effective. * Instead of using suture material as a wick to help maintain anastomosis, I now use folded strands of polyethylene sheeting (two or three mm. in width) through which a 4-0 silk suture is passed to serve as an anchor.
EVERETT R. VEIRS
982
2. Canalicular rods may be effective in restoring the patency in the milder cases of stenosis of the common punctum. 3. The inserting and anchoring of wicks made of suture material is an effective
method for maintaining patency following other operations for obstructions of the lacrimal drainage system. Scott and White Clinic.
REFERENCES
1. Veirs, E. R. : Malleable rods for immediate repair of the traumatically severed lacrimal canaliculus. Tr. Am. Acad. Ophth., Mar.-Apr., 1962. 2. Pico, G. : Personal communication. 3. Worst, J. C. F.: Method for reconstructing torn lacrimal canaliculus. Am. J. Ophth., 53:520-522 (Mar.) 1962. 4. Veirs, E. R. : Treatment of frequent disorders of the lacrimal drainage system. Am. J. Ophth, 53:39-43 (Jan.) 1962. 5. Beard, C. : Personal communication. 6. Arruga, H.: Surgical treatment of lacrimation. Arch. Ophth., 19:9-21 (Jan.) 1938. 7. Jones, B. R.: Tr. Ophth. Soc. U. Kingdom, 80:343, 1960.
ORBITAL F R A C T U R E S * R E P O R T O F S I X CASES W I T H OCULAR COMPLICATIONS
W. L. ERDBRINK, CMDR. (MC) U.S.N. AND V. L. S M I T H / M.D. Pensacola, Florida R. W. WALKER, CMDR. (MC) U.S.N. Oakland, California AND
C. E. GOSSETT, LT. COMDR. (MC) U.S.N. New York Facial trauma and bony orbital injuries are common. Early recognition and defini tive management are essential in order to minimize distressing sequelae.1"3 Presented here are six case reports illustrating various orbital and facial fractures with ocular com plications of the injuries. C A S E REPORTS CASE 1
G. E. M., a 21-year-old Caucasian, U.S. Coast Guard seaman, sustained left facial injuries on August 6, 1961, in an automobile accident. He had * From the Ophthalmology Department, U. S. Naval School of Aviation Medicine (Dr. Erdbrink and Gossett), and the Otolaryngology Service, U. S. Naval Hospital (Dr. Walker), U. S. Naval Avia tion Medical Center, Naval Air Station, Pensacola, Florida. t Ophthalmology consultant.
an extensive, repaired left facial laceration which extended from the left lateral orbital margin down the left cheek and to below the chin. The left lids were edematous and ecchymotic with a moderate left ptosis and left enophthalmos. The left malar eminence was grossly flattened and the mouth opening was markedly restricted. The vision was 20/20 in each eye. There was poor abduction, O.S., with diplopia in the three fields of left gaze. Ex amination revealed palpable fractures of the left zygoma and maxilla. Stereo-Waters X-ray views showed a marked separation of the left zygomatico-frontal and maxillary suture lines; the body of the left zygoma was fractured and separated from the inferior and lateral orbital walls, the zygomatic arch was fractured and separated from the body of the zygoma ; there was extensive com minution of the anterior lateral wall of the left antrum. On August 10, under general anesthesia, the previously sutured skin lacerations were re-opened and the wounds palpated. The left lateral orbital wall had multiple displaced fragments of bone into the temporal fossa. With molding and re-
977
er bore, thus reducing the chance of split ting the rim of the punctum. SUMMARY
A technique of dacryocystorhinostomy is presented in which a fistula is made by drill or Kirschner wire through a dilated punc tum rather than through an external skin excision. Maintenance of the fistula is ini tially accomplished by the use of a wire splint. Eye Section, Valley Forge General Hospital. ACKNOWLEDGMENT
I wish to thank Dr. Harold G. Scheie for his suggestions in the refinement of this technique.
REFERENCES
1. Abrahamson, I. A., Sr., and Abrahamson, I. A., Jr.: Dacryocystorhinostomy with wire fistulization. Am. J. Ophth., 48:769-774 (Dec.) 1959. 2. Fasanella, R. M.: Management of Complications in Eye Surgery. Philadelphia, Saunders, 1957, p. 111. 3. Bonaccolto, G.: Dacryocystorhinostomy with polyethylene tubing: A simplified technic. J. Internat. Coll. Surg., 28:789-796, 1957.
AIDS IN R E S T O R I N G P A T E N C Y IN O B S T R U C T I O N S O F LACRTMAL D R A I N A G E S Y S T E M * E V E R E T T R. V E I R S ,
THE
M.D.
Temhlc, Texas Stenosis of a freshly severed canaliculus following its repair, closure of a freshly recanalized common punctum, or stenosis of the anastomosis following an external dacryocystorhinostomy are frustrating to both the surgeon and the patient. M a n y cor rective aids have been used in the treatment of these conditions, including wicks of su ture, plastics (polyethylene tubing or sheet ing) and other material. M a n y of these are difficult to insert, and most of them are annoying to the patient and, all too often, prove ineffective. * From the Department of Ophthalmology of the Scott and White Clinic.
F R E S H L Y SEVERED CANALICULUS
Previously, I 1 reported the use of canalicular rodst in the repair of a freshly severed canaliculus (fig. 1 ) . In 1962, in a personal communication, to be quoted, Dr. Guillermo Pico, 2 of Puerto Rico, reported sucess with the use of these rods in eight out of nine cases of repair of freshly severed canaliculi, stating that in the one failure the canaliculus was severed close to the lacrimal sac. The results in the first nine cases of lacerated inferior canaliculus which I have repaired since 111175-33, American Cyanamid Company, Surgi cal Products Division, Danbury, Connecticut, and X-0398, Ethicon, Incorporated, Somerville, New Jer sey.
978
EVERETT R. VEIRS
over a year ago when you sent to me the firs rods for experimental use have been as follows: eight cases have perfect results with patent in ferior canaliculus and no lacrimation. One of these cases has a small fistula in the conjunctival side of the canaliculus but it is serving as an additional punctum. One case, which was a failure, has a slanting cut of the inferior canaliculus extending from near the outer punctum up to close to the inner punctum. Apparently there was not good approximation of the tissues so that the mucosal lining of the canaliculus could heal border to border, and, after the rod was removed six weeks after the surgery, scar tissue formed in that area near the middle of the canaliculus and obliterated it. This experi ence has shown to us the need of accurate suturing of the cut canaliculus and tissues around it after the rod has been inserted in the segments of the canaliculus. I have left the rod in place for six weeks be cause I feel that enough time is needed for strong, complete healing of the mucosa of the cut canal iculus and adjacent lacerated tissues without fibrotic retraction that may reopen or obliterate the repaired canaliculus. The 10 mm. rod is good enough for most cases but the 12 mm. size is needed for those cases in which there is a slanting cut that extends up to the inner punctum or lacrimal sac or when a vertical cut occurs in the canaliculus near the sac.
These rods are easily inserted, seem to be nonirritating, and cannot slip out of the canaliculus because they are anchored with 4-0 silk to the skin surface of the lid adja cent to the punctum. (A curved needle is threaded onto the free end of the silk so that a firm bite can be taken and the knot tied securely so that it will not come loose prematurely.) If the proximal cut end of a freshly severed canaliculus cannot be easily located soon after its injury, postponement of re pair for 48 hours makes repair simpler, for the cut edges of the canaliculus then stand out pearly white in color, bleeding is mini mal and final healing is just as satisfactory. If unusual difficulty is encountered, the "pigtail" spiral probe designed by Worst 3 may be used to locate the proximal severed end of the canaliculus. STENOSIS OF THE COMMON PUNCTUM
Stenosis of the common punctum is not unusual and has resisted satisfactory treat
ment. In a paper published in January, 1962, I 4 reported the use of polyethylene tubing in the repair of stenosis of the common punc tum ; however, I have discontinued this pro cedure. Polyethylene tubing is irritating and is less effective than the canalicular rod. U S E OF CANALICULAR RODS
Often, a stenosis of the common punctum can be opened by forcing a probe, with varying degrees of pressure, through the stenotic area into the lacrimal sac after the area has been infiltrated with procaine or lidocaine hydrochloride (Xylocaine). In such instances, the probe is forced through the stenosed common punctum, preferably by way of the lower canaliculus; however, occasionally the opening can be established only through the upper canaliculus. The patency of the drainage system should then be tested with saline lavage. If the drainage system is patent, the canalicular rod is in serted so that it lies entirely within the canaliculus (either upper or lower) except for its distal end, which projects into the lacrimal sac for a distance of one or two mm. The 4-0 silk projects through the punc tum and is anchored to the lid adjacent to the punctum, as shown in Figure 1. The canalicular rod may often be left in position from four to six weeks, or longer, with little or no discomfort. Most patients get some tear drainage into the nose even while the canalicular rod is in position. This is in dicated by less epiphora as well as by the appearance of fluorescein in the nose after instillation into the conjunctival sac. OPERATIVE TECHNIQUES
If the stenosis of the common punctum cannot be opened with moderate force or if there is also obstruction at another point, such as the nasolacrimal duct, a more ex tensive procedure must be carried out. A skin incision similar to that used in an ex ternal dacryocystorhinostomy is made ex cept that it begins about four mm. superiorly and three mm. medially to the inner canthus.
OBSTRUCTION OF LACRIMAL SYSTEM This incision is carried downward 25 to 35 mm. The medial canthal ligament is cut and the lacrimal sac retracted laterally. A verti cal incision is made through the medial wall of the lacrimal sac. Several methods, then are used to re-establish the drainage chan nel. Beard5 passes a probe into the canaliculus until there is tenting of the common punc tum into the lacrimal sac. An incision is made with a No. 11 Bard-Parker knife in the direction of the probe until the tip of the probe is reached. The excessive tissue about the tip of the probe is excised. Two 6-0 chromic catgut sutures are placed for anas tomosis of the sac and the canalicular mucosa, much in the fashion of Arruga's" operation. Jones 7 feels that "primary" stenosis of the common punctum occurs much more commonly than stenosis that follows dacryocystitis, trauma, or mucosal obstruction. He has found that in cases of primary stenosis a dense fibrous tissue appears to strangle the common punctum as it passes through the posterior part of the medial palpebral
Fig. 1 (Veirs). Canalicular rod lying within the freshly severed canaliculus, bridging the cut ends. A bite has been taken in the skin and tarsus near the punctum (after a curved needle has been threaded onto the free end of the 4-0 silk that is swaged to one end of the rod) and a knot tied securely to anchor the rod in position.
979
Fig. 2 (Veirs). A probe is being passed through the lower canaliculus. The dotted line shows the area of the nasolacrimal anastomosis that closed following an external dacryocystorhinostomy.
ligament. His procedure consists of dissect ing out the common punctum and a little of the adjacent upper and lower canaliculi, re moving any of the strangling fibrous tissue, and anastomosing the common punctum to the sac with four silk sutures. He then per forms a rhinostomy, as this tends to keep the two canalicular flaps apart. He passes a fine nylon tube from the upper punctum through the anastomosis of the canaliculus
Fig. 3 (Veirs). The probe has been forced from the lacrimal sac into the nose through the area of the previously closed anastomosis.
980
EVERETT R. VEIRS
Fig. 4 (Veirs). One strand of 4-0 silk suture has been looped around a folded Dermalene suture wick and
Suture material that is flexible and nonirritating, such as Dermalene or Mersilene, may easily be inserted so that it extends through the anastomotic area of the common punctum and out through the canaliculus. It is then anchored into position by threading a curved needle onto the end of the silk that projects through the punctum and anchor ing it to the skin near the punctum, as shown in Figure 6. This suture material may consist of a single strand of No. 2 Dermalene or of strands of Dermalene folded over and held with 4-0 silk, as shown in Figures 4, 5, and 6. This suture material should be lubricated with an antibiotic oint ment before its insertion. This type of wick may be worn for days or weeks with little or no discomfort. If the drainage channel is completely blocked with large strands of the suture material, epiphora will obviously exist while the suture is in place. If much irritation exists while the wick is in place, antibiotic drops may be helpful. P R E V E N T I O N OF CLOSURE FOLLOWING
to the sac and out through the nose, and passes the other end of this tube through the lower canaliculus. This tube is left in position seven to 14 days.
Fig. 5 (Veirs). The wick of suture material has been pulled through the re-established anastomo sis. One end of the 4-0 silk projects through the lower punctum, and a needle is threaded onto it.
DACRYOCYSTORHINOSTOMY
M a n y factors may contribute to the clo sure of the anastomosis following an ex ternal dacryocystorhinostomy, among which are the following: ( 1 ) a large anastomosis
Fig. 6 (Veirs). A substantial bite has been taken in the skin and tarsus adjacent to the lower punctum in order to anchor the wick into the proper position. The wick may be left in position for several weeks.
OBSTRUCTION OF LACRIMAL SYSTEM is not possible if the lacrimal sac is small; (2) a previously injured lacrimal sac may be difficult to anastomose because of dis placed tissues, its small size, and scarring; (3) pathologic nasal conditions may exist; (4) the operation may have been poorly performed. In order to prevent closure, three or four strands of No. 2 Dermalene that has been thoroughly lubricated with antibiotic oint ment may be doubled over and tied with 4-0 silk. The free end of the silk is then drawn through the canaliculus (the lower, usually) and the Dermalene wick pulled into the lacrimal sac. The free end of the Dermalene extends into the nose, and the free end of the silk is anchored to the lower lid after a curved needle is threaded and a bite taken adjacent to the punctum (fig. 5). If the Dermalene wick is not pulled into the canaliculus, tear drainage is good during the two weeks or so that the wick is left in place. Often, after a period of a week or so, the wick of suture that extends into the nose pulls loose, especially if there are several strands, and the patient blows it out of his nose. If this does not happen within 10 to 14 days, the knot that is tied near the punc tum may be cut and the wick grasped in the nose and pulled out. This procedure is es pecially useful when only a remnant of the lacrimal sac is present and an anastomosis is attempted (Amiga's 6 procedure). RE-ESTABLISHING THE ANASTOMOSIS FOLLOWING ITS CLOSURE
Reoperation with insertion of suture wicks offers the best chance for re-establishing an anastomosis after its closure following an external dacryocystorhinostomy. The fol lowing procedure is reasonably effective. A No. 3 or No. 4 Bowman probe is passed into the lacrimal sac through the lower canaliculus (fig. 2). While it is being pressed tightly toward the nose, the probe is elevated to a nearly vertical position. It is then forced into the nose through the area of the old anastomosis. The probe can be manipulated
981
so that the nasal opening is enlarged (fig. 3). This is done by side-to-side movement of the probe and by substitution of a No. 2 Bowman probe, which can be grasped with a hemostat within the nose, and rotating it to make the opening as large as possible. A No. 1 Bowman probe is then passed into the nose through the new channel. This probe is grasped with a hemostat and pulled toward the naris. A 4-0 silk is tied around the nasal tip of this probe with just one knot. Usually, the probe can be pulled out through the punctum with the silk attached. This procedure is easily repeated if the silk slips off. Another method is to thread one end of the suture through a No. 3 Bowman lacri mal probe that has a hole near its tip. The nasal end of the 4-0 silk is looped around three or four strands of folded Dermalene that has been lubricated with antibiotic oint ment and tied (fig. 4). This wick of Derma lene is pulled up into the lacrimal sac through the newly opened anastomosis, and the punctal end of the silk is anchored se curely near the punctum (figs. 5 and 6). Care should be exercised that the wick is pulled into the re-established opening into the lacrimal sac but not so tightly as to close the common punctum. If much infection is present, antibiotics should be given for at least a few days fol lowing the procedure. This wick should be left in position four to six weeks. If it is not securely anchored at the punctum, however, the wick will pull the knot loose and come out of the nose prematurely.* CONCLUSIONS
1. Canalicular rods to restore the patency of freshly severed canaliculi are easy to in sert, cause little if any irritation, and are effective. * Instead of using suture material as a wick to help maintain anastomosis, I now use folded strands of polyethylene sheeting (two or three mm. in width) through which a 4-0 silk suture is passed to serve as an anchor.
EVERETT R. VEIRS
982
2. Canalicular rods may be effective in restoring the patency in the milder cases of stenosis of the common punctum. 3. The inserting and anchoring of wicks made of suture material is an effective
method for maintaining patency following other operations for obstructions of the lacrimal drainage system. Scott and White Clinic.
REFERENCES
1. Veirs, E. R. : Malleable rods for immediate repair of the traumatically severed lacrimal canaliculus. Tr. Am. Acad. Ophth., Mar.-Apr., 1962. 2. Pico, G. : Personal communication. 3. Worst, J. C. F.: Method for reconstructing torn lacrimal canaliculus. Am. J. Ophth., 53:520-522 (Mar.) 1962. 4. Veirs, E. R. : Treatment of frequent disorders of the lacrimal drainage system. Am. J. Ophth, 53:39-43 (Jan.) 1962. 5. Beard, C. : Personal communication. 6. Arruga, H.: Surgical treatment of lacrimation. Arch. Ophth., 19:9-21 (Jan.) 1938. 7. Jones, B. R.: Tr. Ophth. Soc. U. Kingdom, 80:343, 1960.
ORBITAL F R A C T U R E S * R E P O R T O F S I X CASES W I T H OCULAR COMPLICATIONS
W. L. ERDBRINK, CMDR. (MC) U.S.N. AND V. L. S M I T H / M.D. Pensacola, Florida R. W. WALKER, CMDR. (MC) U.S.N. Oakland, California AND
C. E. GOSSETT, LT. COMDR. (MC) U.S.N. New York Facial trauma and bony orbital injuries are common. Early recognition and defini tive management are essential in order to minimize distressing sequelae.1"3 Presented here are six case reports illustrating various orbital and facial fractures with ocular com plications of the injuries. C A S E REPORTS CASE 1
G. E. M., a 21-year-old Caucasian, U.S. Coast Guard seaman, sustained left facial injuries on August 6, 1961, in an automobile accident. He had * From the Ophthalmology Department, U. S. Naval School of Aviation Medicine (Dr. Erdbrink and Gossett), and the Otolaryngology Service, U. S. Naval Hospital (Dr. Walker), U. S. Naval Avia tion Medical Center, Naval Air Station, Pensacola, Florida. t Ophthalmology consultant.
an extensive, repaired left facial laceration which extended from the left lateral orbital margin down the left cheek and to below the chin. The left lids were edematous and ecchymotic with a moderate left ptosis and left enophthalmos. The left malar eminence was grossly flattened and the mouth opening was markedly restricted. The vision was 20/20 in each eye. There was poor abduction, O.S., with diplopia in the three fields of left gaze. Ex amination revealed palpable fractures of the left zygoma and maxilla. Stereo-Waters X-ray views showed a marked separation of the left zygomatico-frontal and maxillary suture lines; the body of the left zygoma was fractured and separated from the inferior and lateral orbital walls, the zygomatic arch was fractured and separated from the body of the zygoma ; there was extensive com minution of the anterior lateral wall of the left antrum. On August 10, under general anesthesia, the previously sutured skin lacerations were re-opened and the wounds palpated. The left lateral orbital wall had multiple displaced fragments of bone into the temporal fossa. With molding and re-