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Lacrimal Drainage Function
LACRIMAL DRAINAGE F U N C T I O N 1. T H E JONES FLUORESCEIN TEST ROBERT J. ZAPPIA, M.D.,
AND B E N J A M I N MILDER,
M.D.
St. Louis, Missouri
Over the years, the clinician has had at his disposal many methods of evaluating the function of the lacrimal apparatus. The fact that these tests have not been subjected to careful evaluative study has not diminished the enthusiasm for their use. One of the most widely used tests for this purpose is the flu orescein test as described by Lester Jones 1 in 1961. The Jones test has several attractions for the busy ophthalmologist. It is simple, atraumatic, consumes little time, and requires no sophisticated equipment. Most important, it is an objective test and the results can be ob served and interpreted directly. The test, as described by Jones 2 is per formed in the following manner: One drop of 1% fluorescein is instilled in the conjunctival sac. The dye is recovered in the nose by means of a cotton-tipped applicator within one to five minutes. If no dye appears in the nose, a "secondary dye test" is performed; the lacrimal system is flushed with clear sa line and the fluid emanating from the nose is checked for fluorescein staining. From Jones' interpretation of the primary and secondary tests, he draws specific conclusions about mal function and its localization. It is the pur pose of this paper to evaluate the primary and secondary Jones tests of lacrimal drain age function. MATERIALS AND METHODS
Jones' tests were performed on 155 pa tients in this series, examining a total of 308 lacrimal systems. One-half of the population was derived from the clinic and approxi mately one-half from an office practice. A From the Jewish Hospital of St. Louis and the Department of Ophthalmology, Washington Uni versity School of Medicine, St. Louis, Missouri. Reprint requests to Robert J. Zappia, M.D., The Beaver Medical Clinic, 2 West Fern Avenue, Redlands, California 92373.
history was taken from each patient concern ing the presence or absence of pertinent ocu lar disease or lacrimal dysfunction. The pa tients were examined externally for relaxa tion of the eyelids, puncta eversion, and ex ternal disease. Slit lamp examinations were performed. A Schirmer test was performed using litmus paper placed in the lower culde-sac at the junction of the middle and outer thirds of the lower eyelids. The degree of wetting at the end of five minutes was measured in millimeters and recorded. Our replication of the Jones test was per formed as follows : The patients were seated in an ophthalmic chair with the head back against the headrest. The nose was sprayed with 4% cocaine. One drop of 2 % fluores cein solution was instilled in each conjunctival sac from an Alcon 2-ml Drop-tainer. This drop measures 0.12 to 0.14 ml. At one minute, two minutes, and five minutes after instillation of the dye, a cotton-tipped nasal applicator was introduced into the nose un der the inferior turbinate. The applicator was then moved posteriorly across the floor of the nose and removed. An indirect oph thalmoscope was used for illumination. If the cotton swab had any amount of fluores cein staining at one, two, or five minutes, the test was considered a positive primary Jones test and indicative of normal tear excretion. If after five minutes no dye had been recovered, the remaining fluorescein was flushed from the conjunctival sac with clear irrigant until the washings appeared free of dye. Anesthesia of the puncta and eye was effected with 0.5% proparacaine HC1 (Ophthaine) drops followed by cotton pled gets moistened with the same anesthetic agent and placed between the puncta for a period of two minutes. The puncta were then di lated with a punctum dilator. A lacrimal cannula was introduced and, with the head tilted 154
155
LACRIMAL DRAINAGE FUNCTION
VOL. 74. NO. 1
TABLE 1 AGE RANGE
No. Patients (Age in years)
Sex Males Females
11-20
21-30
31-10
41-50
51-60
61-70
Over 70
2 16
0 14
0 12
9 18
17 48
12 52
28 80
forward over the emesis basin, clear irrigant was flushed through the lacrimal system. If the irrigant emerged from the nose stained with fluorescein, this was considered a posi tive secondary Jones test. If the irrigant came through clear, this secondary test was considered negative. RESULTS
When we separate our 200 normal tests into patients who were bilaterally normal and those with unilateral lacrimal disease, we find 169 eyes in the first group and 31 uni laterally normal eyes in the second group. In the group of 169 normal eyes, we find the Jones test was positive in 8 1 % within five minutes and 19% had a positive secondary Jones test. In the 31 that were unilaterally normal, only 58% positive primary Jones tests were found and 42% positive secon dary tests were found (Fig. 2 ) . This dramatic difference between the uni laterally and bilaterally normal supports the impression that lacrimal excretory abnor malities, whether congenital or acquired, tend to be bilateral. This tendency for bilaterality has been pointed up in the literature for many years, and the differences elicited
This test was performed on a total of 308 lacrimal systems. Of these, 200 were consid ered normal by history and by physical ex amination. The remaining 108 lacrimal sys tems were considered abnormal according to a history suggestive of lacrimal disease or actual abnormal examination findings. The age range was from 14 to 85 years (Table 1)· To determine if the skills involved in the Jones test are a factor in the results ob tained, our normal patients were divided into a first group of 99 eyes and a subsequent JONES JONES JONES 2 2 2 group of 101 eyes. In the first group, 8 1 % 19* 25% 22 % of the primary Jones tests were positive 80 within the first five minutes. In 19%, no Ö dye was recovered until the secondary Jones f» JONES JONES JONES 0 60 test was performed (Fig. 1). 1 1 1 75 % 78% «1% In the subsequent group, 75% of the Jones tests were positive within five minutes. 40 In 25%, no dye was recovered until the sec | ondary Jones test was performed (Fig. 1). Combining the statistics for both groups, ^ 20we find that the primary Jones test is posi tive in 78% within five minutes and 22% 0 were positive by subsequent irrigation (posi ieries 1 Series 2 Series 1&2 tive secondary Jones test). There thus ap Fig. 1 (Zappia and Milder). Percent of posi peared to be no significant learning factor tive and secondary Jones tests in two sérier of between the two groups. normal eyes.
1
AMERICAN JOURNAL OF OPHTHALMOLOGY
156
JULY, 1972
not be prejudged to be either normal or ab normal ; 53 were excluded because of abnor mal physical findings. 42% 80 Of the 55 who were abnormal by history alone, 40% (22 eyes) had a positive primary Jones test, 49% (27 eyes) had a positive sec 60ondary Jones test and 1 1 % (six eyes) were positive for neither. Fifty-three eyes were JONES JONES noted to have abnormal examinations; of 1 1 40 81% 58« these, 10% (five eyes) had a positive pri mary Jones test, 49% (26 eyes) had a posi tive secondary Jones test, and 4 1 % (22 20 eyes) were negative for both tests (Table 2 ) . Analysis of the group that was abnormal by history is difficult because we are dealing Uni lateral Bilatera with a mixture of normals and abnormals in-. Fig. 2 (Zappia and Milder). Percent of positive sofar as lacrimal function is concerned. primary and secondary Jones tests in bilaterally The results in the group that was abnor normal patients and unilaterally normal patients. mal by examination show that the secondary Jones test is not a test of lacrimal function by the primary Jones test appear to support because the percentage of positive tests did its validity as a means of appraising lacrimal not differ from the group that was abnormal function. by history alone. On the other hand, the per There were 108 lacrimal systems excluded centage of positive primary Jones tests from the normal series because of (1) a his showed a dramatic drop when comparing the tory suggestive of lacrimal disease or of results in subjects abnormal by history with some form of ocular disease which could in results in those abnormal on examination fluence lacrimal function, or (2) abnormal (Table 3 ) . Of five judged abnormal by examination findings. These findings could examination, there were two cases of postop include gross epiphora, chronic dacryocysti- erative dacryocystorhinostomy, and one case tis, everted or stenosed puncta, malposition of postoperative repair of ectropion, one of the eyelid margins, conjunctivitis, or ker- subject had a conjunctival discharge, and the atitis. We separated those cases which were fifth had small tight puncta. The positive abnormal by history but not by examination primary Jones tests in the first three indicate from those in which we obtained definite ab success in the surgery, while the positive pri normal examination findings. Of the 108 lac mary Jones test in the patient with conjunc rimal systems, 55 were excluded from the tival discharge probably indicated that this in normal series because of history and could no way impaired lacrimal function. We con100
JONES 2 19X
JONES 2
s
TABLE 2 AVERAGE SCHIRMER TEST RESULTS FOR DIFFERENT AGE GROUPS
No. Patients (Age in years)
Test Schirmer results (in mm)
11-20
21-30
31-40
41-50
51-60
61-70
Over 70
19
20
18
13
13
10
9
LACRIMAL DRAINAGE FUNCTION
VOL. 74, NO. 1
157
number of lower Schirmer tests. If we now plot the Schirmer tests versus the group that had negative primary Jones tests and posi tive secondary Jones tests, we find a dramatic change, with one-third of the tests having Schirmer tests of 4 mm or less, and 60% have Schirmer tests below 9 mm (Fig. 6).
96r 80-
I S 16
4
JO
14
J5 19
20 24
25+
SCHIRMER TEST VALUES
Fig. 3 (Zappia and Milder). The distribution of Schirmer test values in all eyes. sidered the last patient to be the only one who represented a false-positive test. In order to determine the influence of the Schirmer test on the Jones test, Schirmer tests, using litmus paper, were performed on 305 normal and abnormal eyes. The average Schirmer tests results for the different age groups appear in Table 2. If we plot the spread of Schirmer tests in millimeters for the total number of eyes, we find a curve that peaks at 10-14 milimeters (Fig. 3 ) . If we now plot the Schirmer tests versus the Jones tests that were positive at one min ute, we find a similarly-shaped curve except for a smaller number of lower Schirmer tests—i.e., those with 0-4 mm of secretion (Fig. 4 ) . If we plot the Schirmer tests against the Jones tests that were positive at two minutes and at five minutes, we find the shape of the curve has changed. We now have no peak at 10-40 mm and note a progressive increase in the number of lower Schirmer tests (Fig. 5). The longer the delay before the primary Jones test becomes positive, the greater the
£ D J5 20 9 14 19 24 SCHIRMER TEST VALUES
25*
Fig. 4 (Zappia and Milder). Distribution of Schirmer test values in eyes with a positive Jones test at one minute. 48r 4032-Jonts 1 test positif in 2 minutes -Jones 1 test Positivs in S minutes
HJ 24
S_ 9
10 14
15 19
20 24
25*
SCHIRMER TEST VALUES
Fig. S (Zappia and Milder). Distribution of Schirmer test values in eyes with positive Jones tests at two and five minutes.
AMERICAN JOURNAL OF OPHTHALMOLOGY
158 48 r
£ 4
_5_ 10 15 20 9 14 19 24 SCHIRMER TEST VALUES
25+
Fig. 6 (Zappia and Milder). Distribution of Schirmer test values in eyes with negative Jones 1 and positive Jones 2 tests. These data show that the more rapid ap pearance of fluorescein in the nose tends to be associated with the higher Schirmer test values. CONCLUSIONS
The primary Jones test, if positive, must be accepted as a valid indication of a nor mally-functioning excretory system. It de tects only 77% of normal, subjects, however, and therefore, it is not highly reliable. A negative primary Jones test does not neces sarily indicate pathology. In the unilaterally normal patients, the percentage of positive primary Jones tests drops to 58%, and the percentage of positive secondary Jones tests rises to 42%. Compar ison of the percentage of positive tests be tween subjects in this group and those hav ing two normal eyes emphasizes the potential for lacrimal abnormalities in the normal eye of those unilaterally normal. In this series, no normal patient had a negative primary and negative secondary Jones test. This combination was found only in patients having a history or findings of lacrimal system disease.
JULY, 1972
The secondary Jones test indicates that the upper excretory system (eyelid margin, puncta, and canaliculi) is functioning since fluorescein enters the canaliculus and sac. The recovery of fluorescein in the nose indi cates that the lower system is patent. The data derived in this study indicate that one cannot make an unequivocal diagnosis of partial obstruction from a positive secondary Jones test, since 22.5% of our normal series had negative primary Jones tests and posi tive secondary Jones tests. In dealing with subjects with a known ab normality, 49% had a positive secondary Jones test, and in dealing with patients who were abnormal by history alone, 49% also had positive secondary Jones tests. The fact that both of these groups had identical per centages of positive secondary Jones tests would indicate that the secondary Jones test is not a measure of physiologic lacrimal function, but rather of patency, as deter mined by flushing fluid through the excre tory system. In patients having known lacrimal abnor malities, false-positive Jones tests are very uncommon (one out of 53 eyes in this group), again suggesting that a positive pri mary test is a valid indication of normal function, but no conclusions can be drawn from a negative test. The results of the Jones test were found to be reproducible, indicating that the skill TABLE 3 JONES TEST RESULTS IN ABNORMAL SUBJECTS
Test Jones 1 positive: One minute Two minutes Five minutes
Totals
Abnormal History 7 7 8
22(40%)
Jones 2 positive 27(49%) Jones 1 and 2 negative 6 (11%) Totals
55
Abnormal Examination 1 0 4
5(9.5%) 26(49%) 22 (41.5%) 53
LA'CRIMAL DRAINAGE FUNCTION
VOL. 74. NO. 1
gained from repetition of administering the test is not a significant factor. In order to interpret and evaluate the Jones test, the physician must know the rate of tear secretion. When the Jones test was positive within one minute, the average Schirmer test was 14 mm ; at two minutes, 10.5 mm ; and at five minutes, 10.5 mm. The average Schirmer test was less than 10 mm in the group in which the primary Jones test was negative and the secondary Jones test was positive. These data indicate that in patients having lower Schirmer values positive pri mary Jones tests may be delayed or negative. SUMMARY
When the ability of the primary and sec ondary Jones tests to evaluate lacrimal func tion was assessed, it was found that in nor mal individuals the primary Jones test was positive in 78% and the secondary Jones test was positive in 22%. Analysis of individuals with known lacrimal abnormalities showed
159
that the secondary Jones test was an indica tion of patency of the system as determined by mechanical flushing, rather than partial obstruction. The Schirmer test was performed by plac ing litmus paper in the lower cul-de-sac at the junction of the middle and outer thirds of the lower eyelids. The degree of wetting at the end of five minutes was measured in millimeters. Schirmer tests were performed in 305 normal and abnormal eyes in order to determine its influence on the Jones test. Analysis of the data indicates that in patients having lower Schirmer values, the positive primary Jones test may be delayed or nega tive. REFERENCES
1. Jones, L. T. : An anatomical approach to prob lems of the eyelids and lacrimal apparatus. Arch. Ophth. 66:111, 1961. : The cure of epiphora due to canalicular disorders, trauma and surgical failures on the lacri mal passage, Tr. Am. Acad. Ophth. Otolarvng. 66 : 506, 1962.
AND B E N J A M I N MILDER,
M.D.
St. Louis, Missouri
Over the years, the clinician has had at his disposal many methods of evaluating the function of the lacrimal apparatus. The fact that these tests have not been subjected to careful evaluative study has not diminished the enthusiasm for their use. One of the most widely used tests for this purpose is the flu orescein test as described by Lester Jones 1 in 1961. The Jones test has several attractions for the busy ophthalmologist. It is simple, atraumatic, consumes little time, and requires no sophisticated equipment. Most important, it is an objective test and the results can be ob served and interpreted directly. The test, as described by Jones 2 is per formed in the following manner: One drop of 1% fluorescein is instilled in the conjunctival sac. The dye is recovered in the nose by means of a cotton-tipped applicator within one to five minutes. If no dye appears in the nose, a "secondary dye test" is performed; the lacrimal system is flushed with clear sa line and the fluid emanating from the nose is checked for fluorescein staining. From Jones' interpretation of the primary and secondary tests, he draws specific conclusions about mal function and its localization. It is the pur pose of this paper to evaluate the primary and secondary Jones tests of lacrimal drain age function. MATERIALS AND METHODS
Jones' tests were performed on 155 pa tients in this series, examining a total of 308 lacrimal systems. One-half of the population was derived from the clinic and approxi mately one-half from an office practice. A From the Jewish Hospital of St. Louis and the Department of Ophthalmology, Washington Uni versity School of Medicine, St. Louis, Missouri. Reprint requests to Robert J. Zappia, M.D., The Beaver Medical Clinic, 2 West Fern Avenue, Redlands, California 92373.
history was taken from each patient concern ing the presence or absence of pertinent ocu lar disease or lacrimal dysfunction. The pa tients were examined externally for relaxa tion of the eyelids, puncta eversion, and ex ternal disease. Slit lamp examinations were performed. A Schirmer test was performed using litmus paper placed in the lower culde-sac at the junction of the middle and outer thirds of the lower eyelids. The degree of wetting at the end of five minutes was measured in millimeters and recorded. Our replication of the Jones test was per formed as follows : The patients were seated in an ophthalmic chair with the head back against the headrest. The nose was sprayed with 4% cocaine. One drop of 2 % fluores cein solution was instilled in each conjunctival sac from an Alcon 2-ml Drop-tainer. This drop measures 0.12 to 0.14 ml. At one minute, two minutes, and five minutes after instillation of the dye, a cotton-tipped nasal applicator was introduced into the nose un der the inferior turbinate. The applicator was then moved posteriorly across the floor of the nose and removed. An indirect oph thalmoscope was used for illumination. If the cotton swab had any amount of fluores cein staining at one, two, or five minutes, the test was considered a positive primary Jones test and indicative of normal tear excretion. If after five minutes no dye had been recovered, the remaining fluorescein was flushed from the conjunctival sac with clear irrigant until the washings appeared free of dye. Anesthesia of the puncta and eye was effected with 0.5% proparacaine HC1 (Ophthaine) drops followed by cotton pled gets moistened with the same anesthetic agent and placed between the puncta for a period of two minutes. The puncta were then di lated with a punctum dilator. A lacrimal cannula was introduced and, with the head tilted 154
155
LACRIMAL DRAINAGE FUNCTION
VOL. 74. NO. 1
TABLE 1 AGE RANGE
No. Patients (Age in years)
Sex Males Females
11-20
21-30
31-10
41-50
51-60
61-70
Over 70
2 16
0 14
0 12
9 18
17 48
12 52
28 80
forward over the emesis basin, clear irrigant was flushed through the lacrimal system. If the irrigant emerged from the nose stained with fluorescein, this was considered a posi tive secondary Jones test. If the irrigant came through clear, this secondary test was considered negative. RESULTS
When we separate our 200 normal tests into patients who were bilaterally normal and those with unilateral lacrimal disease, we find 169 eyes in the first group and 31 uni laterally normal eyes in the second group. In the group of 169 normal eyes, we find the Jones test was positive in 8 1 % within five minutes and 19% had a positive secondary Jones test. In the 31 that were unilaterally normal, only 58% positive primary Jones tests were found and 42% positive secon dary tests were found (Fig. 2 ) . This dramatic difference between the uni laterally and bilaterally normal supports the impression that lacrimal excretory abnor malities, whether congenital or acquired, tend to be bilateral. This tendency for bilaterality has been pointed up in the literature for many years, and the differences elicited
This test was performed on a total of 308 lacrimal systems. Of these, 200 were consid ered normal by history and by physical ex amination. The remaining 108 lacrimal sys tems were considered abnormal according to a history suggestive of lacrimal disease or actual abnormal examination findings. The age range was from 14 to 85 years (Table 1)· To determine if the skills involved in the Jones test are a factor in the results ob tained, our normal patients were divided into a first group of 99 eyes and a subsequent JONES JONES JONES 2 2 2 group of 101 eyes. In the first group, 8 1 % 19* 25% 22 % of the primary Jones tests were positive 80 within the first five minutes. In 19%, no Ö dye was recovered until the secondary Jones f» JONES JONES JONES 0 60 test was performed (Fig. 1). 1 1 1 75 % 78% «1% In the subsequent group, 75% of the Jones tests were positive within five minutes. 40 In 25%, no dye was recovered until the sec | ondary Jones test was performed (Fig. 1). Combining the statistics for both groups, ^ 20we find that the primary Jones test is posi tive in 78% within five minutes and 22% 0 were positive by subsequent irrigation (posi ieries 1 Series 2 Series 1&2 tive secondary Jones test). There thus ap Fig. 1 (Zappia and Milder). Percent of posi peared to be no significant learning factor tive and secondary Jones tests in two sérier of between the two groups. normal eyes.
1
AMERICAN JOURNAL OF OPHTHALMOLOGY
156
JULY, 1972
not be prejudged to be either normal or ab normal ; 53 were excluded because of abnor mal physical findings. 42% 80 Of the 55 who were abnormal by history alone, 40% (22 eyes) had a positive primary Jones test, 49% (27 eyes) had a positive sec 60ondary Jones test and 1 1 % (six eyes) were positive for neither. Fifty-three eyes were JONES JONES noted to have abnormal examinations; of 1 1 40 81% 58« these, 10% (five eyes) had a positive pri mary Jones test, 49% (26 eyes) had a posi tive secondary Jones test, and 4 1 % (22 20 eyes) were negative for both tests (Table 2 ) . Analysis of the group that was abnormal by history is difficult because we are dealing Uni lateral Bilatera with a mixture of normals and abnormals in-. Fig. 2 (Zappia and Milder). Percent of positive sofar as lacrimal function is concerned. primary and secondary Jones tests in bilaterally The results in the group that was abnor normal patients and unilaterally normal patients. mal by examination show that the secondary Jones test is not a test of lacrimal function by the primary Jones test appear to support because the percentage of positive tests did its validity as a means of appraising lacrimal not differ from the group that was abnormal function. by history alone. On the other hand, the per There were 108 lacrimal systems excluded centage of positive primary Jones tests from the normal series because of (1) a his showed a dramatic drop when comparing the tory suggestive of lacrimal disease or of results in subjects abnormal by history with some form of ocular disease which could in results in those abnormal on examination fluence lacrimal function, or (2) abnormal (Table 3 ) . Of five judged abnormal by examination findings. These findings could examination, there were two cases of postop include gross epiphora, chronic dacryocysti- erative dacryocystorhinostomy, and one case tis, everted or stenosed puncta, malposition of postoperative repair of ectropion, one of the eyelid margins, conjunctivitis, or ker- subject had a conjunctival discharge, and the atitis. We separated those cases which were fifth had small tight puncta. The positive abnormal by history but not by examination primary Jones tests in the first three indicate from those in which we obtained definite ab success in the surgery, while the positive pri normal examination findings. Of the 108 lac mary Jones test in the patient with conjunc rimal systems, 55 were excluded from the tival discharge probably indicated that this in normal series because of history and could no way impaired lacrimal function. We con100
JONES 2 19X
JONES 2
s
TABLE 2 AVERAGE SCHIRMER TEST RESULTS FOR DIFFERENT AGE GROUPS
No. Patients (Age in years)
Test Schirmer results (in mm)
11-20
21-30
31-40
41-50
51-60
61-70
Over 70
19
20
18
13
13
10
9
LACRIMAL DRAINAGE FUNCTION
VOL. 74, NO. 1
157
number of lower Schirmer tests. If we now plot the Schirmer tests versus the group that had negative primary Jones tests and posi tive secondary Jones tests, we find a dramatic change, with one-third of the tests having Schirmer tests of 4 mm or less, and 60% have Schirmer tests below 9 mm (Fig. 6).
96r 80-
I S 16
4
JO
14
J5 19
20 24
25+
SCHIRMER TEST VALUES
Fig. 3 (Zappia and Milder). The distribution of Schirmer test values in all eyes. sidered the last patient to be the only one who represented a false-positive test. In order to determine the influence of the Schirmer test on the Jones test, Schirmer tests, using litmus paper, were performed on 305 normal and abnormal eyes. The average Schirmer tests results for the different age groups appear in Table 2. If we plot the spread of Schirmer tests in millimeters for the total number of eyes, we find a curve that peaks at 10-14 milimeters (Fig. 3 ) . If we now plot the Schirmer tests versus the Jones tests that were positive at one min ute, we find a similarly-shaped curve except for a smaller number of lower Schirmer tests—i.e., those with 0-4 mm of secretion (Fig. 4 ) . If we plot the Schirmer tests against the Jones tests that were positive at two minutes and at five minutes, we find the shape of the curve has changed. We now have no peak at 10-40 mm and note a progressive increase in the number of lower Schirmer tests (Fig. 5). The longer the delay before the primary Jones test becomes positive, the greater the
£ D J5 20 9 14 19 24 SCHIRMER TEST VALUES
25*
Fig. 4 (Zappia and Milder). Distribution of Schirmer test values in eyes with a positive Jones test at one minute. 48r 4032-Jonts 1 test positif in 2 minutes -Jones 1 test Positivs in S minutes
HJ 24
S_ 9
10 14
15 19
20 24
25*
SCHIRMER TEST VALUES
Fig. S (Zappia and Milder). Distribution of Schirmer test values in eyes with positive Jones tests at two and five minutes.
AMERICAN JOURNAL OF OPHTHALMOLOGY
158 48 r
£ 4
_5_ 10 15 20 9 14 19 24 SCHIRMER TEST VALUES
25+
Fig. 6 (Zappia and Milder). Distribution of Schirmer test values in eyes with negative Jones 1 and positive Jones 2 tests. These data show that the more rapid ap pearance of fluorescein in the nose tends to be associated with the higher Schirmer test values. CONCLUSIONS
The primary Jones test, if positive, must be accepted as a valid indication of a nor mally-functioning excretory system. It de tects only 77% of normal, subjects, however, and therefore, it is not highly reliable. A negative primary Jones test does not neces sarily indicate pathology. In the unilaterally normal patients, the percentage of positive primary Jones tests drops to 58%, and the percentage of positive secondary Jones tests rises to 42%. Compar ison of the percentage of positive tests be tween subjects in this group and those hav ing two normal eyes emphasizes the potential for lacrimal abnormalities in the normal eye of those unilaterally normal. In this series, no normal patient had a negative primary and negative secondary Jones test. This combination was found only in patients having a history or findings of lacrimal system disease.
JULY, 1972
The secondary Jones test indicates that the upper excretory system (eyelid margin, puncta, and canaliculi) is functioning since fluorescein enters the canaliculus and sac. The recovery of fluorescein in the nose indi cates that the lower system is patent. The data derived in this study indicate that one cannot make an unequivocal diagnosis of partial obstruction from a positive secondary Jones test, since 22.5% of our normal series had negative primary Jones tests and posi tive secondary Jones tests. In dealing with subjects with a known ab normality, 49% had a positive secondary Jones test, and in dealing with patients who were abnormal by history alone, 49% also had positive secondary Jones tests. The fact that both of these groups had identical per centages of positive secondary Jones tests would indicate that the secondary Jones test is not a measure of physiologic lacrimal function, but rather of patency, as deter mined by flushing fluid through the excre tory system. In patients having known lacrimal abnor malities, false-positive Jones tests are very uncommon (one out of 53 eyes in this group), again suggesting that a positive pri mary test is a valid indication of normal function, but no conclusions can be drawn from a negative test. The results of the Jones test were found to be reproducible, indicating that the skill TABLE 3 JONES TEST RESULTS IN ABNORMAL SUBJECTS
Test Jones 1 positive: One minute Two minutes Five minutes
Totals
Abnormal History 7 7 8
22(40%)
Jones 2 positive 27(49%) Jones 1 and 2 negative 6 (11%) Totals
55
Abnormal Examination 1 0 4
5(9.5%) 26(49%) 22 (41.5%) 53
LA'CRIMAL DRAINAGE FUNCTION
VOL. 74. NO. 1
gained from repetition of administering the test is not a significant factor. In order to interpret and evaluate the Jones test, the physician must know the rate of tear secretion. When the Jones test was positive within one minute, the average Schirmer test was 14 mm ; at two minutes, 10.5 mm ; and at five minutes, 10.5 mm. The average Schirmer test was less than 10 mm in the group in which the primary Jones test was negative and the secondary Jones test was positive. These data indicate that in patients having lower Schirmer values positive pri mary Jones tests may be delayed or negative. SUMMARY
When the ability of the primary and sec ondary Jones tests to evaluate lacrimal func tion was assessed, it was found that in nor mal individuals the primary Jones test was positive in 78% and the secondary Jones test was positive in 22%. Analysis of individuals with known lacrimal abnormalities showed
159
that the secondary Jones test was an indica tion of patency of the system as determined by mechanical flushing, rather than partial obstruction. The Schirmer test was performed by plac ing litmus paper in the lower cul-de-sac at the junction of the middle and outer thirds of the lower eyelids. The degree of wetting at the end of five minutes was measured in millimeters. Schirmer tests were performed in 305 normal and abnormal eyes in order to determine its influence on the Jones test. Analysis of the data indicates that in patients having lower Schirmer values, the positive primary Jones test may be delayed or nega tive. REFERENCES
1. Jones, L. T. : An anatomical approach to prob lems of the eyelids and lacrimal apparatus. Arch. Ophth. 66:111, 1961. : The cure of epiphora due to canalicular disorders, trauma and surgical failures on the lacri mal passage, Tr. Am. Acad. Ophth. Otolarvng. 66 : 506, 1962.