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ARTICLE
Year : 1964  |  Volume : 12  |  Issue : 1  |  Page : 23-26

Roentgenologic evaluation of inefficiency of the lacrimal passages


M. G. M. Medical College & M. Y. Hospital, Indore, India

Date of Web Publication13-Feb-2008

Correspondence Address:
Mohanlal Agarwal
M. G. M. Medical College & M. Y. Hospital, Indore
India
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Source of Support: None, Conflict of Interest: None


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How to cite this article:
Agarwal M. Roentgenologic evaluation of inefficiency of the lacrimal passages. Indian J Ophthalmol 1964;12:23-6

How to cite this URL:
Agarwal M. Roentgenologic evaluation of inefficiency of the lacrimal passages. Indian J Ophthalmol [serial online] 1964 [cited 2020 Jan 25];12:23-6. Available from: http://www.ijo.in/text.asp?1964/12/1/23/39068

By a routine use of x-Rays in the study of the lacrimal drainage system we wish to call attention to a condi­tion of inefficiency (as against obstruc­tion) of the lacrimal passages, which we have already described in a pre­vious communication (Agarwal-1961). The cases presented here are selected from a series of cases seen during the last three years, at the ophthalmic Department, M. Y. Hospital, Indore.

Neo-hydriol 'fluid' was used as a con­trast medium, following the same pro­cedure in injection and radiographic technique, as in my previous communi­cation. [2]

In order to interpret the changes in the lacrimal passages as seen in dacrycystograms it is essential to keep in mind the anatomy and the structure of the lacrimal fossa and the lacrimal passages. The lacrimal fossa is wider and unbounded above and anteriorly, while below it is bounded by the hammulus of the lacrimal bone and tapers in the narrow osseous naso­lacrimal canal. The lacrimal sac is lodged in this spacious fossa. The membranous wall of the sac consists of fibro-elastic tissue. Thus there is suffi­cient room for the lacrimal sac to dilate, much more in its upper part. Normally the lumen of the sac is merely a cleft, but if need arises it can hold 0.2 cc. of fluid easily. The naso­lacrimal duct is surrounded by a rich plexus of veins. Engorgement of this plexus is in itself sufficient to interfere with drainage into the duct.

With this preamble, let us consider a group of patients, who complain of tearing off and on, with periods of normalcy in between, which becomes a constant nuissance later, with a visible swelling over the lacriminal sac. In many of these, it can be demonstrated that on applying pressure, most of the fluid passes down the nose while a little of it regurgitates in the con­junctival sac.

Let us review the sequence of events and the manner in which the lacrimal sac has been acting during this period.

There are patients who develop partial block of the naso-lacrimal duct, which is due to edema of the mucous membrane lining the canal, the most common cause being engorgement of the rich venous plexus surrounding the naso-lacrimal duct, which may result from various factors. The partial block hampers the lacrimal- drainage. Un­drained tears overflow over the cheeks producing embarrassing epiphora. The lacrimal secretion tends to collect in lacrimal sac which dilates, being com­posed of fibro-elastic tissue and with room for expansion in the spacious lacrimal fossa. The dilatation of the sac, depends on the capacity of the fossa and on the duration and degree of the block. If the block is relieved early, by itself or by treatment, the sac assumes normal shape and tone. Such episodes may be frequent, each leaving its imprint on the sac, which dilates and loses tone progressively with each attack.

The following case reports clearly demonstrate the functional inefficiency of the lacrimal drainage system.

Case No. l : [Figure - 1]A & B

Patient had epiphora for 3 months with periods of normalcy in between. Syringing showed patency of the system. Dacryocystogram revealed the lacrimal sac and the duct in its whole course [Figure - 1]A. Presence of dye in the nasal fossa, confirmed patency. [Figure - 1]B shows clearly dilatation of the sac in its upper part and anter­iorly.

Case Nos. 2, 3, 4 & 5

Each had epiphora off and on of between 1 and 4 years duration. All had a visible lacrimal swelling. All of them could empty the contents of the sac on pressure, in the nose. Dacry­ocystograms [Figure - 2],[Figure - 3]A, B, [Figure - 4]A, B,[Figure - 5]A, B reveal in each case the dilatation of the sac, vertically and antero-posteriorly, maximum in its upper part and anteriorly, while in the lower part, the sac tapers to end in the duct, thus assuming more or less an appearance of a pear.


  Site of Obstruction Top


According to Wolff, (1954) the site of obstruction is at the sac-duct junc­tion, there being slight angulation. Schaeffer [3] (1920) states that lumen of the duct is frequently irregular and tortuous, predisposing to stasis and consequent stricture. Duke Elder (1952) considers that there may be constriction at the top or in the middle of the duct. Fuch states that engorge­ment of rich venous plexus around the canal is in itself sufficient to cause obstruction.

In the present series of cases of functional block, it is quite obvious from the study of the dacryocystograms that the lower end of the sac is tapering in a narrow naso-lacrimal duct, indi­cating that the dye has crossed the sac­duct junction, the site of obstruction being in the duct.

[Figure - 2],[Figure - 3]A and B, show tapering end of the sac. Dye has crossed sac­duct junction.

[Figure - 4]A,[Figure - 5]A & B show the dye in the canal reaching approximately the middle point of the canal.


  Comments Top


In this study, it has been found that epiphora can result from an in­efficiency of the lacrimal sac, to drain the fluid, though the lacrimal passage­way is patent, as shown by dacryocys­tograms. The dye seems to have cross­ed the sac-duct junction, showing the naso-lacrimal duct in its whole course or more usually its upper portion, in­dicating that the site of obstruction (partial) is in the duct.

The partial obstruction of the duct does not allow the proper drainage of the fluid. The lacrimal sac dilates to hold the unexpelled fluid. This is seen even in an early case of partial obstruc­tion [Figure - 1]. In the later stages, the sac assumes a typical pear shape i.e. dilation in the upper part, gradually tapering into the lower part.

It is suggested that a subject who complains of epiphora should be sub­jected to radiography. In an early case, an attempt to relieve the partial obstruction of the naso-lacrimal duct and check its further recurrence, shall keep the drainage system patent. As the remissions are common, by the time the patient makes up his mind to consult an ophthalmic surgeon, the symptom is relieved. It is only in the late stage, when the sac has lost its tone, epiphora becomes a constant nuissance. Few of them, discover that by pressure at the lacrimal area, the sac contents can be emptied, thus relieving them of epiphora for a few hours. They, therefore, never bother to seek the advice of an ophthalmic surgeon till an absolute block results.

At this stage, dacryocystorhinostomy is an ideal operation for treatment.[4]


  Summary Top


In simple epiphora the obstruction to the outflow of tears is partial and within the duct.

Dacryocystography helps to diagnose such an early case and determine the site and degree of obstruction.


  Acknowledgement Top


I am extremely thankful to the Department of Radiology, M. Y. Hospital. Indore, for the help and co-operation and to Prof. B. K. Dhir, for his valuah.e guidance and suggestions.

 
  References Top

1.
Duke Elder (1952) Text Book of Ophthalmology Vol. 1 & Vol. V. Henry Kimpton London.  Back to cited text no. 1
    
2.
Mohanlal Agarwal (1961) Amer. J. Ophth. 52: 245-51.  Back to cited text no. 2
    
3.
Schaeffer, J. P. (1920) The nose, Paran­asal sinuses, Nasolacrimal passage ways and Olfactory organs in Man, Blakis­ton's, Philadelphia.  Back to cited text no. 3
    
4.
Wolff, E. (1954) The Anatomy of the Eye & Orbit, Lewis, London.  Back to cited text no. 4
    


    Figures

  [Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5]



 

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