CHAPTER V.

DISEASES OF THE LACHRYMAL PASSAGES.

Displacement and obstructions of the puncta and canaliculi-Inflammation of the sac-Obstruction of the nasal duct-Defective secretion of lachrymal glandEpiphora-Lachrymal cysts and fistula.

TIONS IN

THE

in health.

DISPLACEMENT AND OBSTRUCTIONS OF THE PUNCTA. OBSTRUCIn the healthy eye, the lachrymal puncta are in contact with the eyeball, and cannot therefore be seen PUNCTA. unless the eyelids are everted. When the eye is closed, the puncta are situated in the lacus lachrymalis, so Position of that the tears, whether the person is sleeping or waking, can always drain away through them into the canaliculi, lachrymal sac, nasal duct, and so down into the nose. (Fig. 18.)

Any cause which displaces the puncta, or which obstructs the passage of the tears into the nares, gives rise to an accumulation of the lachrymal se

FIG. 18.

Effects of obstruction;

tion,

cretion in the lacus lachrymalis, which in time over- lachrymaflows, and running down the cheek, causes the patient considerable inconvenience.

Not only is lachrymation thus induced, but a tear is left constantly hanging in front of the cornea, and by interfering with the rays of light in their passage to the eye, renders it necessary for the patient to be perpetually wiping it before he can see clearly; and

Conjunctivitis.

Causes; inflamma

tion,

eversion,

inversion.

Diagnosis

over the

sac,

lastly, the prolonged contact of the tears with the surface of the eye gives rise to chronic conjunctivitis and its consequences.

The most common cause of obstruction to the exit of the tears is inflammation of the lining membrane of the lachrymal passages, producing a stricture in some part of their course. The same effect, however, is brought about if the puncta are prevented from maintaining their normal position, either by the margin of the lids becoming thickened, as in tinea, or from an hypertrophied state of the conjunctiva. Obviously, the same effect will follow ectropium, however induced. On the other hand, it not unfrequently happens that the puncta are too much inverted, when, as in old age, the eye becomes deep sunk into the orbit.

Obstruction of the lachrymal puncta may be either partial or complete—that is, one or both the puncta may be closed, giving rise to symptoms such as I have above described.

I mentioned in the first chapter, that if, in the by pressure healthy eye, pressure were made over the lachrymal sac, a drop of fluid might be observed to ooze out through the lachrymal puncta. Should one or both of them, however, be occluded, it necessarily follows that no fluid can be made to regurgitate through the obstructed orifice. Under these circumstances also we shall find it impossible to pass a probe into the canaliculus. There can, therefore, be no difficulty whatever in arriving at an accurate diagnosis in a case of this kind; and the line of treatment to be followed is no less simple, our efforts being directed to restore the communication between the eye and the nares.

and use of a probe.

Treatment.

closure,

Treatment.-Even in cases of congenital deficiency of the puncta, the normal situation of the opening may generally be detected, a small spot or depression near the inner extremity of the palpebral margin indicating its position; and it by no means follows that because In complete the puncta are closed, the canaliculi are also occluded; so that, in some instances, all that is necessary is, simply to cut through the membrane closing the passage into the canaliculus, and keep it open by passing a probe through the passage daily, till the edges of the incision have cicatrized; after which there is but little chance of their growing together, and again obstructing the passage of the tears into the canaliculus.

The lid in which the punctum to be operated on is situated (whether upper or lower) having been everted,

a sharp-pointed instrument is to be run through the pierce the obstruction in the direction of the canaliculus, the membrane. punctum being laid freely open. If a full-sized lachrymal probe can then be passed through the canaliculus into the lachrymal sac, there will be no necessity for any further treatment, beyond the insertion of the Pass a instrument through the incision every day for four or probe daily. five days, to prevent its edges from uniting.

Supposing we cannot make out the seat of the punctum, it is well to cut across the line of direction of the canaliculus, and then pass a grooved lachrymal director along this canal into the lachrymal sac, slit up the canaliculus throughout its length, and thus leave a free passage for the tears into the sac.

It by no means follows, however, that the puncta are Partial obalways either completely occluded, or else of their nor- structions, mal calibre; they may be obstructed to any extent between these two extremes, being so far contracted that it is impossible for the lachrymal secretion to find its way through them, in sufficient quantities to keep the corner of the eye free from an accumulation of tears. Under these circumstances, a very fine probe Similarly may be passed through the punctum, and under the treated." guidance of the instrument its inner and upper wall may be incised, and subsequently kept dilated as above described.

OF THE

Permanent.

STRICTURE OF THE CANALICULUS may be permanent STRICTURE or spasmodic. A permanent stricture, whether partial CANAL. or complete, will give rise to the same symptoms as occlusion of the puncta, and for the most part it arises from a similar cause-namely, chronic inflammation of Causes. the mucous membrane. A foreign body, as, for instance, a cilium or calcareous concretion, occasionally closes the canal.

The existence of a stricture of the canaliculus is determined by passing a probe through the punctum, when its further passage towards the sac will be prevented by the obstruction.

probes.

Particular care should always be taken in exploring Caution in the canaliculus; a probe roughly thrust through it using may, by wounding the mucous membrane, induce a permanent stricture, even in cases where the obstruction is entirely of a spasmodic character, or arising

Spasmodic stricture:

Treatment.

If recent, delay interference.

In old cases operate at once.

1. If incomplete.

Open the

canal on a director.

Pass a

merely from a congested state of the mucous membrane.

Spasmodic stricture of the canaliculus always occurs either at the inner or outer opening of the canal, and the watery eye accompanying it may be of an intermittent character, depending on relaxation at one time and spasm at another of the constrictor muscle. There is never the same resistance to the passage of an instrument through the canaliculus as in instances of permanent stricture.

Treatment.-Unless the obstruction is of some standing, attempts should hardly be made to pass an instrument, as the stricture may arise simply from congestion of the lining membrane of the canal, and astringents will cure it; whereas the injudicious use of a probe, by wounding the mucous membrane, may cause a permanent obstruction. On the other hand, if the patient has complained of symptoms of occlusion of the lachrymal passage for some two or three months, it is better, under any circumstances, to operate at Old-standing cases of obstruction, from whatever cause they arise, seldom improve under local applications, and the sooner the canaliculus is laid open the better.

once.

1. If the stricture is not complete, a fine grooved director may be passed through it into the lachrymal sac, and an assistant having everted and drawn the lids outwards, a knife must be run along the groove, so as to lay the punctum and canaliculus freely open from end to end. The edges of the incision should subsequently be prevented from uniting, by passing a probe through the wound into the sac every day for a probe daily. week, after which the channel will remain permanently open, and the lachrymal secretion pass through it into the sac. Care must be taken in this operation to turn the groove of the director inwards, or towards the eye, so that the incision will be in apposition with the eyeball; otherwise the tears will not be able to find their way into the canal from the surface of the lacus lachrymalis.

Mr. Bowman's operation.

Mr. Bowman describes the above operation as follows:*"The patient sits in a chair, and leans his head against the chest of the surgeon, who stands

* Ophthalmic Hospital Reports, vol. i. p. 15.

behind and bends over him. For dividing, for example, Slitting the the left lower punctum, the ring finger of the left hand canal. is placed on the skin over the lower edge of the orbit, and fixes it there, while tightening or relaxing the lower canal by a sliding movement of the skin upon the bone, the punctum being at the same time everted. The right hand now inserts No. 1 probe while the canal is relaxed, and then places the probe between the index finger and thumb of the left hand, which holds it in the canal, and further everts the punctum by turning the probe downwards on the cheek, while the ring finger stretches and fixes the canal by a sliding movement of the skin outwards, towards the malar bone. A fine, sharp-pointed knife, held in the right hand, now slits up the canal on the everted conjunctival aspect, from the punctum, as far as the caruncle, and the probe is raised on its point out of the canal, to make sure that the edge of the punctum has not escaped division. Care should be taken not to slope this little incision obliquely through the tissues it severs, as there is then a broader surface exposed, and greater chance of union by the first intention. To avoid this, it is in all cases desirable to pass a probe across the line of incision, on each of the few ensuing days, to break through adhesions if they form."

ett's modi

Mr. Critchett recommends that, in some cases, a Mr. Critchsmall portion of the posterior lip of the wound, near fication. the caruncle, should be taken up with forceps, and removed with scissors, particularly if there is much thickening of the lower lid.* By this proceeding the edges of the incision being separated, there will be no necessity for the use of the probe to keep them apart.

This operation may often be resorted to with advantage when the puncta are everted, as in ectropium, the incision being directed well inwards, so as to be in contact with the eyeball, in order that the lachrymal secretion may drain away through it into the sac.

ture.

2. Supposing, however, that the stricture is both 2. In comcomplete and permanent, so that we cannot pass even plete stricthe finest director along the canaliculus into the sac, it is evident that we must endeavour to effect another passage for the tears, from the lacus lachrymalis into the sac, behind the tendo palpebrarum.+ The sac.

*Ophthalmic Hospital Reports, vol. i. p. 103. "Maladies des Yeux," par M. Wecker, tom. i.

p. 786.