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Applications of cautery to the mucosa and muscle at the base of the lacrimal papillae can result in retraction of the walls of the punctum, reestablishing patency. A relationship may exist between the cause of stenosis of the lacrimal papillae and stenosis at other juncture points in the lacrimal excretory system.
A chemiluminescent material (Cyalume) was injected into the lacrimal excretory passages of eight normal monkeys (16 eyes). Patency was established by almost instantaneous observation of a yellowish-green glow in the nose and pharynx. No toxic effects of the chemical were noted in any of the monkeys.
By means of postmortem dacryocystograms and photomicrographs of histological slides, the topography and morphology of the lacrimal passages in premature and mature newborn infants are demonstrated. Because of the bends in the course of the lower tear duct, a percentage of probings will fail to effect satisfactory perforation of Hasner's membrane. In most cases the soft texture of this membrane requires no more than syringing under pressure using a hollow probe.
A series of 132 children with congenital nasolacrimal system obstruction was prospectively randomized into three groups to determine the effectiveness of different modes of nonsurgical treatment. Massaging the nasolacrimal sac in a manner that increased hydrostatic pressure and ruptured the membranous obstruction was more effective (with a high degree of statistical significance) than simple massage or no massage at all. Of those children requiring nasolacrimal probing, a high success rate was found with simple obstructions in the nasolacrimal duct. Failure of probing was more common in canalicular obstructions or generally narrow nasolacrimal ducts. Silicone intubation of the nasolacrimal system is an effective way of treating cases not cured by probing.
Previously, the standard procedure in the treatment of patients having had unsuccessful lacrimal surgery has been Jones tube bypass, regardless of the anatomic site of obstruction. However, many of these patients may be treated by a reconstructive approach, namely, the canaliculodacryocystorhinostomy operation. Dacryocystography is helpful in determining which of these patients are amenable to this treatment modality. Success rates are encouraging and eliminate the necessity of a permanent prosthesis and long-term follow-up.
A rigid endoscope was used to directly examine, measure, and photograph the intranasal ostium created by an external dacryocystorhinostomy (DCR). This technique was used to examine 19 patients who underwent 22 standard external DCRs. All patients had clinically successful results, documented by a positive Jone I dye test following surgery. The dimension of the bony opening created at surgery was measured and averaged 11.84 mm in diameter. The average diameter of the healed intranasal ostium was only 1.80 mm. No statistically valid correlation between the size of the bony opening and the final size of the healed intranasal ostium could be established. Thus, a large surgical anastomosis did not necessarily result in a large healed intranasal ostium. Excellent functional results were obtained even when the intranasal ostium was quite small. Other indications for the use of this technique are discussed.
In the 42 patients (84 eyes) in this study, 32 eyes had dacryocystorhinostomy (DCR), 15 had Jones' tube insertions, and the remaining 37 were considered controls. All patients were studied using nuclear scanning with computer interfacing quantitative lacrimal scintillography to determine the effects of blinking, respiration, and gravity on their functioning. Tears flowed through DCR openings faster than through the systems of normal patients. Patients with Jones' tubes demonstrated slower flow than in normal patients. The effect of respiration on tear flow was minimal, but blinking and lid function were important. Patients with eyelid laxity may show decreased flow even if the DCR and Jones' tubes are functional.
Fifteen patients with symptoms of nasolacrimal duct obstruction were evaluated with B-scan and standardized A-scan ultrasonography. Results were correlated with findings on routine clinical tests of lacrimal drainage function, and echographic findings were confirmed at surgery in all cases. Ten normal lacrimal systems were also examined. In all patients the lacrimal sac and duct were easily visualized as an echolucent defect bounded by the bony lacrimal crests. Abnormal dilatation, diverticuli, and inflammatory exudates were readily detected. Surgically created dacryocystorhinostomy ostia were imaged on both A- and B-scans, as were obstructing membranes seen before surgical revision. Physiologic lacrimal pump failure could not be evaluated, and the exact site of obstruction could not be determined.
Management of obstructions in the lacrimal drainage system would be greatly aided by improvements in the ability to visualize the blockages. We describe a new method of observation using miniature fiberoptics to view the entire lacrimal excretory system. We employed flexible endoscopes of fiberoptic bundles with outside diameters of from 0.5 to 0.7 mm. These endoscopes were inserted through the puncta and canaliculi. Sixteen patients were examined. A range of pathologic conditions were found, including slightly stenosed passages and severely destroyed canalicular mucosal lining. Our results indicate that this technique is feasible and useful in the diagnosis of lacrimal excretory disease.
PURPOSE: To develop a protocol for treatment of injuries to the puncta and canaliculi associated with eyelid burns. METHODS: We retrospectively reviewed the records of seven patients who required treatment of punctal and canalicular stenosis caused by burns to the medial eyelids. RESULTS: Seven patients were treated within 5 days of injury: one by punctal dilation and six by surgical debridement, punctoplasty or canaliculoplasty, and silicone intubation. All remained free of epiphora. CONCLUSIONS: Early evaluation and treatment of punctal and canalicular burn injuries are beneficial. If the puncta are only slightly stenotic, close observation with serial lacrimal testing and punctal dilation is recommended. If the puncta and lateral canaliculi are severely stenotic or obliterated, surgical débridement and punctoplasty or canaliculoplasty followed by placement of a silicone stent effectively prevents permanent lacrimal stenosis and epiphora.
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A synopsis of the embryonic development of the eye, the ear, and the olfactory organ and taste buds is presented. The eye is discussed in terms of the sensory and nonsensory protions of the eyeball and of such associated structures as the extrinsic eye muscles, eyelids, conjuctiva, and lacrimal apparatus. The embryology of the internal, middle, and external ear is reviewed, as well as positional changes of both the eye and ear relative to other sturctures of the head and neck. Various congenital defects affecting the eye and ear are also discussed.
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This investigation describes the normal function of the lacrimal drainage system of the eye. The intent of the presentation is to illustrate by clinical examples and pertinent literature, those alterations of normal function occurring from obstruction, trauma, or neoplasm. Sixty-nine patients with lacrimal dysfunction are included; 19 are offered in detail to illustrate principles of surgical management. It is not within the scope of this discussion to examine any condition which may cause primary hyperlacrimation or hypolacrimation, but to discuss: 1. the role of trauma as a cause of lacrimal drainage dysfunction. 2. the role of surgery in the prevention of lacrimal dysfunction, and 3. the role of surgery in the restoration of function. Among 18 patients with non-traumatic obstruction treated by silicone stenting, previous multiple dilatations treatment was associated with a higher rate of failure than in those patients not previously treated by multiple dilatations. Forty percent of 96 patients with facial fractures of the medial orbit had obstructive nasolacrimal symptoms; 79% of the 96 patients' symptoms cleared spontaneously; 15% required treatment. No incidence of significant iatrogenic trauma (requiring surgical treatment) was found in reviewing 1292 cases of rhinoplasty, rhinoseptoplasty, blepharoplasty, or sinus surgery. Normal function and physiology are reviewed. From the experiences of 69 patients emerge clinically proven methods of surgical management of lacrimal system obstruction. These methods are defined and then compared and contrasted to traditional methods and concepts. When there is disagreement or no consensus, alternate theories are discussed in attempting to explain those clinical conditions which seem to defy accepted principles. This presentation includes cases which have been managed by surgeons other than the author and who have been trained in fields other than otolaryngology. The cases offered in detail have been managed by the author.
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Digital subtraction macrodacryocystography (DSMD) has proved to be the best imaging method for diagnosing situations of stenosis of the lacrimal system. The examination is performed with a computer-controlled X-ray unit with a C-arc coupled to an image intensifier TV system with a fluoroscopic control. All the findings were recorded on videotape thus allowing good dynamic flow documentation and contributing to improved scientific analysis.
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Ocular side effects of systemic fluorouracil include excessive lacrimation, due to punctal and canalicular stenosis and fibrosis. Obstruction of the tear ducts after systemic therapy with fluorouracil is more frequent than is assumed. Five patients with breast cancer and punctal or canalicular stenosis are presented. Although complaints of epiphora usually resolve two weeks after cessation of systemic therapy, local antibiotics and steroids may be indicated. In patients with persisting complaints, and patients treated with fluorouracil for a prolonged period of time, prophylactic intubation of the tear ducts with silastic tubes has been advocated. (Conjunctivo)dacryocystorhinostomy may be unavoidable.