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The Lacrimal Apparatus
T H E LACRIMAL APPARATUS. J O H N A. MCCAW, M. D., O P H . D. DENVER, COLORADO. This section reviews the literature from January, 1917, to July, 1918. matter will be found in the section of Injuries. EXTIRPATION
OF
THE
LACRIMAL
GLANDS.—The abundant and continuous epiphora following removal of the lacrimal drainage channels depends, Calderaro thinks, in a majority of cases upon hypersecretion of the lacrimal glands. This disturbance ceases with removal of the orbital lacrimal gland and more surely with the removal of the palpebral portion. After the removal of the orbital gland there is a period from 2 to 6 days during which the conjunctiva is either not at all or scantily lubricated; subsequently this condition improves and the moistening becomes sufficient to keep the conjunctiva normal. Following the removal of the palpebral gland there is abrupt disappearance of the lacrimal secretion. When the conjunctiva is normal its condition of lubrication improves little by little until it is restored to physiologic limits, there being established a vicarious hypersecretion of the subconjunctival glands. In old chronic trachoma there are always changes in the subconjunctival lacrimal glands; which may _in large part atrophy and disappear, in which case removal of the orbital or the palpebral gland may expose the eye to unhappy results from xerosis and conjunctival atrophy. Petit for the extirpation of the palpebral portion of a gland everts the upper lid, and with a curved needle passes the thread thru the tarsal conjunctiva about the posterior margin of the tarsus close to the external canthus. This thread is made into a loop by which the position of the parts is easily controlled by the left hand, which can still be used to hold the forceps for the ablation of the gland.
Some related
LACRIMAL DRAINAGE.—After careful and exhaustive study of the mechanism of the drainage of tears with special reference to the results of modern tear sac operations, Frieberg is of the opinion that there is some hindrance to the regurgitation of tears especially at the sac end of the canaliculi. There seems to be no absolute evidence that there is any sphincter action around the puncta. The theories that explain the exit of tears can be classified in two groups. The flow is dependent upon the movement of the lids or it is not. In the latter group there are three theories : Tears flow into the nose by siphon action, by capillary attraction, or by aspiration from the nose. None of these mechanisms account for the known facts. The movement of the lids can act by compressing or dilating the sac or by squeezing the canaliculi. After West's and Toti's operations the tears pass normally into the sac, so we are bound to conclude that even if we admit some alteration in the shape of the sac, the canaliculi .alone are able to drive the tears into the nose. There is no proof that blinking either dilates or compresses the sac. The canaliculi, normally are held open by the elastic fibers that surround them, and by the tonus of the surrounding muscular fibers. During lid closure they are compressed against the caruncle and the fluid they contain is forced into the nose. The author, after a West operation, succeeded in proving that fluid is expressed during lid closure. He made a funnel of rubber which he attached to a U tube. The funnel was pressed against the nasal opening made in the operation, and then each time the lid
THE LACRIMAL APPARATUS
160
closed the fluid rose in the U tube till it stood several millimeters above the level of the eye. ABSCESS OF CANALICULUS. — Tooker
reported an interesting case of localized suppuration of a canaliculus. A man aged 88, complained of a painful swelling in the upper lid of the right eye at the angle of the nose. Examination revealed the presence of chronic trachoma in the lids of both eyes; and in the upper lid of the right eye an abscess of the canaliculus, with drainage neither into the lacrimal sac nor the conjunctival sac. The swelling was about the size of a bean, and on being opened a cheesy purulent liquid escaped. H e thinks that the canaliculus became occluded at both narrowed orifices, externally and internally, following an extension of the trachomatous processes from the conjunctiva. The occluded passage then probably became infected and an abscess resulted. LACRIMAL
STENOSIS
IN
INFANTS.—
Roy in his article on lacrimal stenosis in infants and its treatment, defines this condition, as those cases which present excessive tearing in the conjunctival sac, or flowing out upon the cheek, and some catarrh of the palpebral conjunctiva. He gives the following groups: (1) Stenosis due to congenital malformations, as absence of the puncta, or closed with a membrane. (2) Stenosis due to spasmodic contraction in some portion of the passages. (3) Stenosis the result of a catarrhal thickening of the mucous membrane at some point in the lacrimal passages. Treatment can be summed up as follows : Expression of the contents of the sac, mild antiseptic in the eye, treatment of nasal conditions, occasionally probing and washing out the tear passages. Most of these cases get well without any treatment. Roy asked Knapp, Gruening, Cheatham, Burnett, Alt, de Schweinitz and Theobald if they had ever seen a case of spasmodic stenosis; all replied in the negative. Green thinks that infantile dacryocystitis, in the majority of cases, is the result of blockage of the lower end of
the nasal duct by fetal remains, and considers the rational treatment is to probe the canal, after expression and lavage have failed. He also thought a flexible probe might be an advantage. Curdy thought that since the pneumococcus is the microorganism infecting the closed passage, there is danger to the cornea in waiting too long, before resorting to the probe. INFECTION OF THE LACRIMAL CANAL.
—Such infection in war ophthalmology is the subject of a paper by Grelault. Infection of the lacrimal canal, he thinks constitutes a danger to the vitality of the eye in wounds of the latter. Infection may be said to exist whenever the drainage of the lacrimal duct is imperfect. The signs of imperfect drainage are: (1) When by pressure of the sac there is an exudate of mucus, or a muco-purulent or purulent fluid from the puncta. (2) The presence of a swelling, a liquid tumor on the inner side and below the internal commissure. This dilation shows that the walls have lost their elasticity and that the sac is incapable of emptying itself. (3) Investigation of the patency of the lacrimal canals by an injection made thru one of the lacrimal points. (4) Investigation of the physiologic capillary permeability. This should be done by the aid of a weak collyrium of argyrol or methylene blue. The patient blows his nose to clear the middle meatus of mucus. Each nostril is occluded with a plug of cotton. The subject's head is slightly inclined forward to prevent the passage of the fluid into the rear cavities. In presence of normal permeability the colored liquid stains the upper surface of the. cotton. In a subject who presents none of these signs, the lacrimal canals may safely be regarded as healthy. Therapeutic Conclusions: (1) Radical cure by extirpation or igneous destruction except when men are at the front, this constitutes prophylaxis in view of subsequent wound of the eye. (7"fl be
continued)
OF
THE
LACRIMAL
GLANDS.—The abundant and continuous epiphora following removal of the lacrimal drainage channels depends, Calderaro thinks, in a majority of cases upon hypersecretion of the lacrimal glands. This disturbance ceases with removal of the orbital lacrimal gland and more surely with the removal of the palpebral portion. After the removal of the orbital gland there is a period from 2 to 6 days during which the conjunctiva is either not at all or scantily lubricated; subsequently this condition improves and the moistening becomes sufficient to keep the conjunctiva normal. Following the removal of the palpebral gland there is abrupt disappearance of the lacrimal secretion. When the conjunctiva is normal its condition of lubrication improves little by little until it is restored to physiologic limits, there being established a vicarious hypersecretion of the subconjunctival glands. In old chronic trachoma there are always changes in the subconjunctival lacrimal glands; which may _in large part atrophy and disappear, in which case removal of the orbital or the palpebral gland may expose the eye to unhappy results from xerosis and conjunctival atrophy. Petit for the extirpation of the palpebral portion of a gland everts the upper lid, and with a curved needle passes the thread thru the tarsal conjunctiva about the posterior margin of the tarsus close to the external canthus. This thread is made into a loop by which the position of the parts is easily controlled by the left hand, which can still be used to hold the forceps for the ablation of the gland.
Some related
LACRIMAL DRAINAGE.—After careful and exhaustive study of the mechanism of the drainage of tears with special reference to the results of modern tear sac operations, Frieberg is of the opinion that there is some hindrance to the regurgitation of tears especially at the sac end of the canaliculi. There seems to be no absolute evidence that there is any sphincter action around the puncta. The theories that explain the exit of tears can be classified in two groups. The flow is dependent upon the movement of the lids or it is not. In the latter group there are three theories : Tears flow into the nose by siphon action, by capillary attraction, or by aspiration from the nose. None of these mechanisms account for the known facts. The movement of the lids can act by compressing or dilating the sac or by squeezing the canaliculi. After West's and Toti's operations the tears pass normally into the sac, so we are bound to conclude that even if we admit some alteration in the shape of the sac, the canaliculi .alone are able to drive the tears into the nose. There is no proof that blinking either dilates or compresses the sac. The canaliculi, normally are held open by the elastic fibers that surround them, and by the tonus of the surrounding muscular fibers. During lid closure they are compressed against the caruncle and the fluid they contain is forced into the nose. The author, after a West operation, succeeded in proving that fluid is expressed during lid closure. He made a funnel of rubber which he attached to a U tube. The funnel was pressed against the nasal opening made in the operation, and then each time the lid
THE LACRIMAL APPARATUS
160
closed the fluid rose in the U tube till it stood several millimeters above the level of the eye. ABSCESS OF CANALICULUS. — Tooker
reported an interesting case of localized suppuration of a canaliculus. A man aged 88, complained of a painful swelling in the upper lid of the right eye at the angle of the nose. Examination revealed the presence of chronic trachoma in the lids of both eyes; and in the upper lid of the right eye an abscess of the canaliculus, with drainage neither into the lacrimal sac nor the conjunctival sac. The swelling was about the size of a bean, and on being opened a cheesy purulent liquid escaped. H e thinks that the canaliculus became occluded at both narrowed orifices, externally and internally, following an extension of the trachomatous processes from the conjunctiva. The occluded passage then probably became infected and an abscess resulted. LACRIMAL
STENOSIS
IN
INFANTS.—
Roy in his article on lacrimal stenosis in infants and its treatment, defines this condition, as those cases which present excessive tearing in the conjunctival sac, or flowing out upon the cheek, and some catarrh of the palpebral conjunctiva. He gives the following groups: (1) Stenosis due to congenital malformations, as absence of the puncta, or closed with a membrane. (2) Stenosis due to spasmodic contraction in some portion of the passages. (3) Stenosis the result of a catarrhal thickening of the mucous membrane at some point in the lacrimal passages. Treatment can be summed up as follows : Expression of the contents of the sac, mild antiseptic in the eye, treatment of nasal conditions, occasionally probing and washing out the tear passages. Most of these cases get well without any treatment. Roy asked Knapp, Gruening, Cheatham, Burnett, Alt, de Schweinitz and Theobald if they had ever seen a case of spasmodic stenosis; all replied in the negative. Green thinks that infantile dacryocystitis, in the majority of cases, is the result of blockage of the lower end of
the nasal duct by fetal remains, and considers the rational treatment is to probe the canal, after expression and lavage have failed. He also thought a flexible probe might be an advantage. Curdy thought that since the pneumococcus is the microorganism infecting the closed passage, there is danger to the cornea in waiting too long, before resorting to the probe. INFECTION OF THE LACRIMAL CANAL.
—Such infection in war ophthalmology is the subject of a paper by Grelault. Infection of the lacrimal canal, he thinks constitutes a danger to the vitality of the eye in wounds of the latter. Infection may be said to exist whenever the drainage of the lacrimal duct is imperfect. The signs of imperfect drainage are: (1) When by pressure of the sac there is an exudate of mucus, or a muco-purulent or purulent fluid from the puncta. (2) The presence of a swelling, a liquid tumor on the inner side and below the internal commissure. This dilation shows that the walls have lost their elasticity and that the sac is incapable of emptying itself. (3) Investigation of the patency of the lacrimal canals by an injection made thru one of the lacrimal points. (4) Investigation of the physiologic capillary permeability. This should be done by the aid of a weak collyrium of argyrol or methylene blue. The patient blows his nose to clear the middle meatus of mucus. Each nostril is occluded with a plug of cotton. The subject's head is slightly inclined forward to prevent the passage of the fluid into the rear cavities. In presence of normal permeability the colored liquid stains the upper surface of the. cotton. In a subject who presents none of these signs, the lacrimal canals may safely be regarded as healthy. Therapeutic Conclusions: (1) Radical cure by extirpation or igneous destruction except when men are at the front, this constitutes prophylaxis in view of subsequent wound of the eye. (7"fl be
continued)