|Year : 1960 | Volume
| Issue : 3 | Page : 60-63
Physio-therapy in inefficiency of lacrimal passages
Department of Ophthalmology, P. B. M. Group of Hospitals, Bikaner, Rajasthan, India
|Date of Web Publication||5-May-2008|
S P Mathur
Department of Ophthalmology, P. B. M. Group of Hospitals, Bikaner, Rajasthan
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Mathur S P. Physio-therapy in inefficiency of lacrimal passages. Indian J Ophthalmol 1960;8:60-3
A failure of conduction of tears in absence of organic obstruction of drainage passages constitutes a condition of inefficiency. (Duke-Elder, 1950). Weeping is known to occur either due to (1) an excessive secretion of tears, called lacrimation, or (2) an inadequacy or blocking of the passages, called epiphora. As a general rule lacrimation tends to be less constant than epiphora and is not excited by the same stimuli. Also lacrimation tends frequently to come inexplicably in crisis, or on such stimuli as bright light or an accommodative effort. The surest guide, however, in differentiating lacrimation from epiphora is a measurement of the amount of fluid secreted, a rough idea of which could be had by Schirmer's blotting paper test.
Inefficiency of lacrimal passage is diagnosed by persistent weeping in absence of disease and can be demonstrated by the failure or delay of a coloured fluid to find its way from the conjunctival sac to the nose even though the passages themselves may be patent and can be syringed through freely.
The fault could be traced to: (1) the lacrimal puncta, which although anatomically correct, may not oppose the globe because of entropion or ectropion or slight laxity or atony of the lower lid as one finds in old age, or (2) inefficiency of the valve of Hasner at the lower end of the nasolacrimal duct may occur resulting in admittance of air into the naso-lacrimal duct from the nose - a condition called ocular whistling, thus causing obstruction to the lacrimal passage, or (3) due to a functional or mechanical atony of the orbicularis muscle.
It is a common experience that a large majority of cases of lacrimal passage inefficiency fall in the senile age group. For no apparent cause, they are usually given a prolonged treatment by astringent drops or mild antiseptic lotions in the hope to relieve come chronic irritation by trachoma granules or a hidden focus of infection causing reflex lacrimation. Looking into the physiology of conduction of tears is is well established that the orbicularis muscle plays an important part on account of its anatomical layout. A minor degree of its weakness in association with senile general atony is frequently overlooked, which, as a matter of tact is an important cause of epiphora at this age. The present work was aimed at strengthening this muscle by means of faradic current. This has ultimately proved to be of value because no suitable treatment is yet known to relieve this condition.
| Material and Method|| |
Patients over the age of 50 years with baggy lids, generalised flabbyness, and weak constitution, who complained of constant epiphora were taken for this study. Schirmer's test was performed in order to execute excessive lacrimation. Lacrimal passage was syringed in order to exclude any organic obstruction or stricture. The efficiency of conduction of the lacrimal passage was tested by putting argyrol drops into the conjunctival sac. Those cases who had normal lacrimal secretion and patent passage, but took longer time for the argyrol to pass through, were labelled as cases of lacrimal - passage inefficiency. A careful examination of the position of puncta, particularly the lower one, was made. Those cases who gave history of ocular whistling were excluded. Finally, examination of the nose was done to exclude the presence of obstruction, neoplasm, atrophy, infection and reflex irritability.
A simple, though rough method of estimating the tone of orbicularis muscle was devised as follows :
A square pan of the size of 1cm. x 1cm. was stitched to the skin of centre of the lower lid margin. The head of the patient was bowed forward so that the pan suspended freely without touching the cheek. Increasing weights were put over the pan just sufficient to pull the central part of the lid margin away from the eye ball. Again, the weights were gradually reduced to let the lid margin fall back on the eye ball with a normal blinking reflex. The mean of these two readings including the weight of the pan, was taken to denote the tone of the orbicularis muscle in milligrams.
The orbicularis oculi muscle was then subjected to stimulation with faradic current. One of the terminals was applied about 2cm. outside the lateral canthus, while the other one was kept under the head. The intensity of the current was regulated to just make the muscle twitch. A stronger current brought about a painful spasmodic contraction which did not serve any useful purpose. The muscle was stimulated for five minutes at a time and six to eight such sittings were given depending upon the severity of the case. After this course subjective improvement and argyrol disappearence time were noted, and the tone of the orbicularis oculi was again measured for comparison.
| Observations|| |
Forty three cases have been treated on these lines, complete investigations and follow-up could be done only in eleven, the details of which are given in the table. In general, the patients felt very much relieved of epiphora even after 3 or 4 stimulations, after which many of them discontinued the treatment. But in most of the cases the complaints gradually returned after 8 to 10 months, and faradic stimulations had to be repeated with equally satisfactory results. Cases No. 3, 7, q and ro in the table showed a little eversion of the lower punctum, which did not dip into the lacus lacrimalis. After faradic stimulations the punctum went to its normal physiological position, the time of disappearance of argyrol drops from the conjunctival sac reduced to nearly half, and the tone of orbicularis muscle was increased by 350 mgm. on an average, in everycase.
| Discussion|| |
Various operations have been devised from time to time to treat this annoying disability. Slitting of puncturn and canaliculus when the punctum looks upward had been advocated by Bowman (1857), Critchett (1858) and v. Hoffmann (1904). Haiti (1930) preferred to remove the posterior wall of the punctum by a specially designed punch forceps. Duke-Elder (1950) considered it ideal to slit open the posterior wall of the punctum and canaliculus, converting them into a free open unobstructed groove, which dips into the lacus. The three snip operation has also been suggested (Viers, 1958). For atonic epiphora due to an atonic sac, almost the only way of treatment is to establish a wide nasal anastomosis so that aspiration and gravitation of tears may replace the normal pumping action.
The vital part played by the orbicularis oculi muscle in the conduction of the lacrimal fluid is on account of its anatomical relations to the lacrimal passages. It forms into a sphincter at the punctum, winds spirally round the canaliculus, and goes to attach itself to the medial palpebral ligament and the anterior lacrimal crest. When it contracts, as during the blinking reflex, the punctum gets constricted, and the canaliculus shortened to push the tears into the sac. The sac shows an active dilatation, while the naso-lacrimal duct is pressed to squeeze out its contents into the nose. Once the muscle relaxes the process is reversed, so that the punctum and canaliculus receive more of fluid from the lacus lacrimalis, and the sac constricts to push its contents into the naso-lacrimal duct which is now dilated.
Evidently therefore, the best physiological treatment of this condition, in which the normal pumping action goes weak, will be to strengthen the orbicularis muscle. In old age there is general atony and wasting of muscles all over and so also of the orbicularis oculi. Response to faradic current stimulation to this muscle has given gratifying results inasmuch as it has been able to re-establish the normal pumping action. Although this had to be repeated after 8 to 10 months, yet the simplicity of this procedure is of great consideration in comparison to the usual operative and post-operative complications associated with other types of treatment.
| Summary|| |
Cases of lacrimal inefficiency at the senile age have been treated with faradic current stimulations to the orbicularis oculi muscle with gratifying results. It was noted that as the muscle went stronger, the disappearance time of argyrol drops from the conjunctiva reduced considerably, and the symptoms were completely relieved. This paper may be considered as a preliminary report. A wider use of this procedure under more scientific controls may give it a final place in the treatment of lacrimal inefficiency.
| Acknowledgements|| |
I would like to express my gratitude to Dr. S. C. Mehta, F.R.C.S. Principal Medical and Health Officer, Bikaner, for his permission to present this paper, I am very much thankful to Dr. S. N. Cooper, Dr. J. P. Udawat, Dr. R. K. Sharma and Dr. J. N. Razdan for their help during the work and preparation of this paper.
| References|| |
Bowman, 1857, R. L. O. H. Rep., 1,10, 88.
Critchett, 1858, R. L. O. H. Rep., 1,103.
Duke-Elder, 1950, Text Book of Ophth. Vol. 5, P. 5287 Henry Kimpton, London.
v. Hoffmann A. F., 1904, Psy. Nervenkr., XXXIX, 389.
Haitz. 1930, Klin. Monats. Aug., LXXXV, 541.
Viers, E. R., 1958, Tr. Ani. Acad. Ophth. 62,
[Figure - 1]
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