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One-Sided Epiphora*
444
NOTES, CASES, INSTRUMENTS
longer is there the feeling of suffocation due to the hot humid atmosphere beneath the drapes. These patients now are quieter, more relaxed, and comfortable. The results are, of course, of the utmost importance to the ophthalmic surgeon in intraocular surgery. The apparatus adds to the comfort of any patient who is undergoing surgery un der local anesthesia, necessitating the use of drapes over the face. The apparatus is easy and inexpensive and can be made by any machine shop. The coil through which the tubing passes has an ad justable point so that the apparatus can be adjusted to fit any patient. The open end of the suction tubing should be used, as the addition of any sort of nozzle or tip which narrows the orifice, produces a noise which may be annoying to both patient and surgeon.
surgery about the eyelids. Tantalum foil was folded into four or six thicknesses and su tures were found to pass easily through either thickness when the foil was held with a forceps (fig. 1). It was found not to buckle when the sutures were tied and there was no tissue reaction.
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TANTALUM F O I L PEGS* EARL MAXWELL, COL., (MC)
U.S.A.F.
San Francisco, California About two years ago, after observing how little tissue reaction there was to tantalum, it was decided to try it as pegs in plastic
Fig. 2 (Maxwell). Tantalum pegs used in tarsorrhaphy. Since the initial trial, it has been used ex tensively and found to be more satisfactory than any other substance in tarsorrhaphy (fig. 2), Blaskovicz's ptosis operation, lid repair, reconstruction of the orbit, and other plastic procedures requiring tension sutures to be tied over pegs. It has several advantages —among them: it is nonirritating, secretions do not adhere to the material, it is easily handled, and may be quickly trimmed to any desired size or shape.
ONE-SIDED E P I P H O R A * SAM ENGEL,
M.D.
San Francisco, California Fig. 1 (Maxwell). The suture is being passed through the tantalum peg. * From the Letterman General Hospital.
Not so rarely a patient is seen who com plains of one-sided epiphora. After exclu* From the Department of Ophthalmology, Stan ford University Medical School.
445
NOTES, CASES, INSTRUMENTS sion of an irritating foreign body, distichiasis, conjunctivitis, or superficial keratitis, the tear passage is examined. In many cases, however, it can be washed through easily, to ward the nose, and the watering of the eye is not explained by a blockage of the tear duct or the tear sac. The nose and the sinuses may be without any pathologic finding to ex plain the disturbance, and X-ray examination of the tear passage—after lipiodine injection —may show no anomalous configuration. In practice, a number of such cases of one-sided epiphora will then receive repeated irrigations of the sac or the patients will be treated for allergy. One of our patients re ported that tincture of belladonna was pre scribed, 40 drops to be taken by mouth three times daily. When this medication had no effect, removal of the tear gland was sug gested. When the lower tear point is examined in these cases, it seems in good position at the first glance, but at closer inspection the point may be seen everted to a minute degree, when compared with the tear point of the other side where it appears in closer apposition to the conjunctiva bulbi. Stallard1 says, that epiphora may be "due to a small, spastically closed, lower punctum," in which case he recommends the "three-snip operation." I do not think that the tonus of the sphincter, or at least not the tonus of the sphincter alone, is the cause of the tearing, and for the following reason: Occasionally cutting of the sphincter alone gives relief, but the cut has then to be made toward the conjunctiva tarsi, while cutting of the sphincter in any direction should relieve the spasm of an overactive ring muscle. In most cases, cutting of the sphincter, even toward the tarsus, is not sufficient, as the healing conjunctiva again blocks the com munication of the tear duct with the conjunctival lacrimal lake. I then have had a good result with Hoffmann's excision,2 a procedure which corresponds to Stallard's three-snip operation.
TECHNIQUE
The lower canaliculus is slit two to three mm. with a canalicular knife (Weber), a right-angled incision with scissors is made toward the conjunctiva at the site of the punctum, and the so-formed small triangle of the posterior canalicular wall is excised. The wound is controlled for several days so that the communication of the canaliculus with the conjunctival sac is kept open. Following is a short history of five cases in which the above-described method re lieved a one-sided epiphora which had caused some patients to suffer for more than a year. These cases were seen among our patients in the last two and one-half years. Although slitting of the tear duct should be avoided if possible, it was indicated in these cases and benefited the patients. CASE REPORTS
Case 1. Mrs. E. R., aged 59 years, was seen first for left-sided epiphora in October, 1946. The left lower tear point was very nar row and could be dilated only with difficulty; the left tear passage washed through easily toward the nose. Injection of lipiodol in the tear sac showed normal configuration of the canal and sac. Since the epiphora continued with slight fluctuations, on January 23, 1947, the lower tear point was split toward the conjunctiva. The next day tearing stopped entirely and there has been no more epiphora since (No vember, 1949). Case 2. Mr. L. B., aged 66 years, had had tearing in the right eye for eight months. The right tear sac washed through easily. On October 30, 1948, the right lower tear point was slit. Since tearing continued, on November 9, 1948, a Hoffmann's excision was done. There have been no more com plaints about tearing. Case 3. Mr. I. S., aged 71 years, had had tearing of the right eye for three weeks. The tear sac was easily irrigated. The right lower tear point appeared farther away from
446
NOTES, CASES, INSTRUMENTS
the conjunctiva bulbi than the left tear point. On May 29, 1948, slitting of right lower tear point was followed by Hoffmann's excision. There has been no tearing since. Case 4. Mrs. M. F. V., aged 72 years, had had tearing of left eye for one year. On June 28, 1948, Hoffmann's excision was done with good results for 10 days, after which there was no tearing but the eye felt wet. The triangular opening had narrowed markedly, so the excision was slightly enlarged. Since then there had been no more tearing, "not even in strong wind." Case 5. Miss M. K., aged 38 years, had had right epiphora for one year, treated by an oculist with tincture of belladonna. Later removal of the right tear gland was recom mended. She was sent to an ear and nose specialist who gave her tablets for an allergic condition.
When she was seen on October 8,1949, the right tear sac washed through easily. The right lower point turned slightly outward as compared to the left point. The right lower tear point was slit toward the conjunctiva. The patient had relief for only two days, al though the incision was opened again. There fore, on October 8, 1949, a Hoffmann's exci sion was done with the result that tearing has been relieved since. SUMMARY
In one-sided epiphora without an apparent cause, a minute outward position of the lower tear point, compared to the position of the point in the other eye, should be looked for and, if present, a Hoffmann's excision of the posterior wall of the lower canaliculus may relieve the epiphora. 350 Post Street (8).
REFERENCES
1. Stallard, H. B.: Eye Surgery, Baltimore, William & Wilkins, 1946. 2. von Hoffmann: Keilformige Excision: eine Verbesserung der Bowmanschen Schlitzung. Inter national Ophthalmological Congress, Luzern, 1904.
FLUORESCEIN PAPER* A SIMPLE MEANS OF INSURING THE USE OF STERILE FLUORESCEIN SAMUEL J. KIMURA,
M.D.
San Francisco, California
The susceptibility of fluorescein solution to bacterial contamination, particularly with Pseudomonas aeruginosa, prompted an effort to develop an equally stable preparation of the drug whose sterility could be relied upon. Even the use of preservatives, such as quarternary ammonium chloride (1:8,000) and sterilization by autoclave, fail to eliminate the danger of contamination and solutions must be replaced frequently to be considered safe. Unfortunately it is common office practice to use a dropper bottle of fluorescein indefi* From the Division of Ophthalmology, Francis I. Proctor Laboratory for Research in Ophthalmology, University of California Medical School.
nitely and to discard it only after an infection has been traced to it. In view of the disastrous nature of the pyocyaneus hypopyon ulcer which may fol low the use of a contaminated fluorescein solution, a trial with fluorescein paper is recommended on the basis of the following experience at the University of California Eye Clinic: For the past two years fluorescein-impregnated paper has been substituted satisfac torily for fluorescein solution in this clinic. It has proved to be easy to make, easy to keep sterile, and thoroughly stable (fig. 1— A, B, a n d C ) . METHOD OF PREPARATION
Bibulous filter paper (Braun-Knecht-Heimann #28510, San Francisco) was found to be the best paper available for the prepara tion of fluorescein paper but any fine-grade filter paper can be used. One-half inch of
NOTES, CASES, INSTRUMENTS
longer is there the feeling of suffocation due to the hot humid atmosphere beneath the drapes. These patients now are quieter, more relaxed, and comfortable. The results are, of course, of the utmost importance to the ophthalmic surgeon in intraocular surgery. The apparatus adds to the comfort of any patient who is undergoing surgery un der local anesthesia, necessitating the use of drapes over the face. The apparatus is easy and inexpensive and can be made by any machine shop. The coil through which the tubing passes has an ad justable point so that the apparatus can be adjusted to fit any patient. The open end of the suction tubing should be used, as the addition of any sort of nozzle or tip which narrows the orifice, produces a noise which may be annoying to both patient and surgeon.
surgery about the eyelids. Tantalum foil was folded into four or six thicknesses and su tures were found to pass easily through either thickness when the foil was held with a forceps (fig. 1). It was found not to buckle when the sutures were tied and there was no tissue reaction.
* .">• -
<**HT
"*j5sr>
TANTALUM F O I L PEGS* EARL MAXWELL, COL., (MC)
U.S.A.F.
San Francisco, California About two years ago, after observing how little tissue reaction there was to tantalum, it was decided to try it as pegs in plastic
Fig. 2 (Maxwell). Tantalum pegs used in tarsorrhaphy. Since the initial trial, it has been used ex tensively and found to be more satisfactory than any other substance in tarsorrhaphy (fig. 2), Blaskovicz's ptosis operation, lid repair, reconstruction of the orbit, and other plastic procedures requiring tension sutures to be tied over pegs. It has several advantages —among them: it is nonirritating, secretions do not adhere to the material, it is easily handled, and may be quickly trimmed to any desired size or shape.
ONE-SIDED E P I P H O R A * SAM ENGEL,
M.D.
San Francisco, California Fig. 1 (Maxwell). The suture is being passed through the tantalum peg. * From the Letterman General Hospital.
Not so rarely a patient is seen who com plains of one-sided epiphora. After exclu* From the Department of Ophthalmology, Stan ford University Medical School.
445
NOTES, CASES, INSTRUMENTS sion of an irritating foreign body, distichiasis, conjunctivitis, or superficial keratitis, the tear passage is examined. In many cases, however, it can be washed through easily, to ward the nose, and the watering of the eye is not explained by a blockage of the tear duct or the tear sac. The nose and the sinuses may be without any pathologic finding to ex plain the disturbance, and X-ray examination of the tear passage—after lipiodine injection —may show no anomalous configuration. In practice, a number of such cases of one-sided epiphora will then receive repeated irrigations of the sac or the patients will be treated for allergy. One of our patients re ported that tincture of belladonna was pre scribed, 40 drops to be taken by mouth three times daily. When this medication had no effect, removal of the tear gland was sug gested. When the lower tear point is examined in these cases, it seems in good position at the first glance, but at closer inspection the point may be seen everted to a minute degree, when compared with the tear point of the other side where it appears in closer apposition to the conjunctiva bulbi. Stallard1 says, that epiphora may be "due to a small, spastically closed, lower punctum," in which case he recommends the "three-snip operation." I do not think that the tonus of the sphincter, or at least not the tonus of the sphincter alone, is the cause of the tearing, and for the following reason: Occasionally cutting of the sphincter alone gives relief, but the cut has then to be made toward the conjunctiva tarsi, while cutting of the sphincter in any direction should relieve the spasm of an overactive ring muscle. In most cases, cutting of the sphincter, even toward the tarsus, is not sufficient, as the healing conjunctiva again blocks the com munication of the tear duct with the conjunctival lacrimal lake. I then have had a good result with Hoffmann's excision,2 a procedure which corresponds to Stallard's three-snip operation.
TECHNIQUE
The lower canaliculus is slit two to three mm. with a canalicular knife (Weber), a right-angled incision with scissors is made toward the conjunctiva at the site of the punctum, and the so-formed small triangle of the posterior canalicular wall is excised. The wound is controlled for several days so that the communication of the canaliculus with the conjunctival sac is kept open. Following is a short history of five cases in which the above-described method re lieved a one-sided epiphora which had caused some patients to suffer for more than a year. These cases were seen among our patients in the last two and one-half years. Although slitting of the tear duct should be avoided if possible, it was indicated in these cases and benefited the patients. CASE REPORTS
Case 1. Mrs. E. R., aged 59 years, was seen first for left-sided epiphora in October, 1946. The left lower tear point was very nar row and could be dilated only with difficulty; the left tear passage washed through easily toward the nose. Injection of lipiodol in the tear sac showed normal configuration of the canal and sac. Since the epiphora continued with slight fluctuations, on January 23, 1947, the lower tear point was split toward the conjunctiva. The next day tearing stopped entirely and there has been no more epiphora since (No vember, 1949). Case 2. Mr. L. B., aged 66 years, had had tearing in the right eye for eight months. The right tear sac washed through easily. On October 30, 1948, the right lower tear point was slit. Since tearing continued, on November 9, 1948, a Hoffmann's excision was done. There have been no more com plaints about tearing. Case 3. Mr. I. S., aged 71 years, had had tearing of the right eye for three weeks. The tear sac was easily irrigated. The right lower tear point appeared farther away from
446
NOTES, CASES, INSTRUMENTS
the conjunctiva bulbi than the left tear point. On May 29, 1948, slitting of right lower tear point was followed by Hoffmann's excision. There has been no tearing since. Case 4. Mrs. M. F. V., aged 72 years, had had tearing of left eye for one year. On June 28, 1948, Hoffmann's excision was done with good results for 10 days, after which there was no tearing but the eye felt wet. The triangular opening had narrowed markedly, so the excision was slightly enlarged. Since then there had been no more tearing, "not even in strong wind." Case 5. Miss M. K., aged 38 years, had had right epiphora for one year, treated by an oculist with tincture of belladonna. Later removal of the right tear gland was recom mended. She was sent to an ear and nose specialist who gave her tablets for an allergic condition.
When she was seen on October 8,1949, the right tear sac washed through easily. The right lower point turned slightly outward as compared to the left point. The right lower tear point was slit toward the conjunctiva. The patient had relief for only two days, al though the incision was opened again. There fore, on October 8, 1949, a Hoffmann's exci sion was done with the result that tearing has been relieved since. SUMMARY
In one-sided epiphora without an apparent cause, a minute outward position of the lower tear point, compared to the position of the point in the other eye, should be looked for and, if present, a Hoffmann's excision of the posterior wall of the lower canaliculus may relieve the epiphora. 350 Post Street (8).
REFERENCES
1. Stallard, H. B.: Eye Surgery, Baltimore, William & Wilkins, 1946. 2. von Hoffmann: Keilformige Excision: eine Verbesserung der Bowmanschen Schlitzung. Inter national Ophthalmological Congress, Luzern, 1904.
FLUORESCEIN PAPER* A SIMPLE MEANS OF INSURING THE USE OF STERILE FLUORESCEIN SAMUEL J. KIMURA,
M.D.
San Francisco, California
The susceptibility of fluorescein solution to bacterial contamination, particularly with Pseudomonas aeruginosa, prompted an effort to develop an equally stable preparation of the drug whose sterility could be relied upon. Even the use of preservatives, such as quarternary ammonium chloride (1:8,000) and sterilization by autoclave, fail to eliminate the danger of contamination and solutions must be replaced frequently to be considered safe. Unfortunately it is common office practice to use a dropper bottle of fluorescein indefi* From the Division of Ophthalmology, Francis I. Proctor Laboratory for Research in Ophthalmology, University of California Medical School.
nitely and to discard it only after an infection has been traced to it. In view of the disastrous nature of the pyocyaneus hypopyon ulcer which may fol low the use of a contaminated fluorescein solution, a trial with fluorescein paper is recommended on the basis of the following experience at the University of California Eye Clinic: For the past two years fluorescein-impregnated paper has been substituted satisfac torily for fluorescein solution in this clinic. It has proved to be easy to make, easy to keep sterile, and thoroughly stable (fig. 1— A, B, a n d C ) . METHOD OF PREPARATION
Bibulous filter paper (Braun-Knecht-Heimann #28510, San Francisco) was found to be the best paper available for the prepara tion of fluorescein paper but any fine-grade filter paper can be used. One-half inch of