|Year : 1979 | Volume
| Issue : 3 | Page : 41-48
A study on lacrimal insufficiency
Department of Ophthalmology, S.P. Medical College, Bikaner, India
S P Mathur
Department of Ophthalmology, S.P. Medical College, Bikaner
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Mathur S P. A study on lacrimal insufficiency. Indian J Ophthalmol 1979;27:41-8
Lacrimal insufficiency is described as a condition when epiphora is present inspite of the fact that there is normal lacrimal secretion and patent lacrimal passage.
The lacrimal portion of orbicularis oculii muscle surrounds the lacrimal sac. It exercises a pumping action on the sac, so that when contracted, the contents of the sac are pushed into the nose, while during relaxation the fluid from the lacus lacrimalis is sucked in. It is supposed that when the orbicularis oculii muscle gets weak, the pumping action gets weak, lacrimal conduction becomes poorer. and this results in epiphora.
The aim of the present work is:
1. To measure the strength of the orbicularis oculii muscle in normal and in cases of lacrimal insufficiency by devising a suitable instrument.
2. To make the orbicularis oculii muscle stronger by suitable stimulation, and to find its effect on epiphora and lacrimal insufficiency.
3. To measure the amount of fluid conducted through the sac in normal and in cases of lacrimal insufficiency.
The cases of lacrimal insufficiency were diagnosed when they showed normal lacrimal secretion as tested by Schirmer's test, and prolonged Jone's test time so that the dye in the conjunctiva took a longer time to appear into the nose.
The study was divided into various parts depending upon the approach planned.
| Material and method|| |
The strength of orbicularis oculii was estimated in milligram weight needed to pull the lower lid away from its contact with the conjunctiva.
An aluminium foil pan was stitched to the skin of the centre of the lower lid, [Figure - 1]. Increasing weights were put to find out when the lower lid margin was just away from the eye ball. Weights were gradually reduced till the lowcr lid margin was just in contact with the eye ball. A mean of the two readings in milligrams was taken as a measure of strength of the orbicularis oculii.
The muscle was made stronger by stimulating with faradic current. It resulted in mild twitchings. The current was so adjusted that there was no spasm or pain. Each stimulation lasted for about 5 minutes, and such 8 to 10 sittings were given, depending upon relief from epiphora. After this the orbicularis strength was again measured as before, and difference in weights used was recorded.
Average strength of orbicularis oculii in:
10 normal cases = 870 mg.
18 cases of lacrimal insufficiency - 536 mg.
After faradic current stimulation = 868 mg.
Epiphora disappeared in every case after stimulation. In 5 cases epiphora reappeared after 6 to 8 months, which again disappeared after another course of faradic current stimulation.
In order to measure strength of the orbicularis oculii muscle an instrument was devised and named as Orbiculo-myometer No. I [Figure - 2]. It was an eye speculum with a spring between the two limbs. The spring got compressed when limbs got closer. A pointer was attached to one limb, and a scale to the other. The deflections were calibrated against standard weights in grams [Figure - 3].
Orbiculo-myometer No. 1 was applied in the anaesthetised conjunctiva and following was recorded:
1. Initial reading of the pointer on the scale [Figure - 4].
2. Patient was asked to squeeze both the eyes to the maximum, and deflection of the pointer on the scale was noted.
3. The patient was asked to continue squeezing, till there was fatigue of the muscle and the pointer reached the initial reading [Figure - 5]. The fatigue time was noted.
A Strength of orbicularis oculii.
Normal persons examined-200
Males 100 Females 100
Average power of orbicularis oculii was:
Males-173 Gms. Females-157 Gms.
Age-20 to 40 years 172 Gms.
Above 40 years 158 Gms.
Right eye-179 Gms. Left eye-151 Gms.
All above 40 years of age.
Average strength of orbicularis:
Sex R.E. L. E.
Males 127 Gm. 113 Gm.
Females 123 Gm. 105 Gm.
Average reduction in orbicularis strength in patients with lacrimal insufficiency:
Sex R.E. L. E.
Males 50. Gm. 44. Gm.
Females 37 Gm. 35 Gm.
Stimulation of orbicularis oculii with faradic current.
Strength of current-1.5 to 4 ma, just sufficient to cause twitchings but not pain.
Frequency-10 twitchings per minute for three minutes 6 to 10 sittings depending upon the response.
Place-near lateral canthus.[Table - 1][Table - 2][Table - 3][Table - 4]
The Jone's test time was reduced by 40% after faradic current stimulation of orbicularis oculii in cases of lacrimal insufficiency.
Comments- It is possible to measure the strength of orbicularis oculii muscle with orbiculo-myometer no. 1. The instrument proved to be rather crude as small changes could not be measured.
The study compared the normal with the patients suffering from lacrimal insufficiency in strength of the orbicularis oculii, the fatigue time of the orbicularis, and the Jone's test time.
It is also possible to treat the cases of lacrimal insufficiency by stimulation of the orbicularis oculii with suitable strength of faradic current. The strength of the muscle increased, fatigue time prolonged, and Jone's test time reduced after the treatment.
It is evident that the method of study described above is purely subjective, and needed a lot of patient's co-operation, which was frequently lacking.
An objective method was planned. It was presumed that to a fixed amount of current, a weak muscle will contract less as compared to a strong muscle. Again, the same amount of contraction of a muscle can be brought about by a weak current in a strong muscle, and strong current in a weak muscle.
The study was conducted by designing a more delicate orbiculo-myometer No. 3. In order to measure the orbicularis strength, it was stimulated with a known galvani- current sufficient to give the same amount of contraction. The strength of the galvanic current was recorded before and after treatment in cases of lacrimal insufficiency. In order to make the orbicularis muscle stronger it was exercised by sinusoidal current, and effect on lacrimal insufficiency noted.
Orbiculo-myometer No. 3
1. The spring used in the eye speculum worked against the action of the orbicularis muscle [Figure - 6].
2. The joint of the speculum was fitted with a ball bearing so that the movements were friction free.
3. The movements of the instrument were magnified by attaching a longer pointer and a finer acale.
Facial nerve was blocked on the side of examination to eliminate voluntary control over the orbicularis muscle.
Orbiculo-myometer No. 3 was applied in the anaes*hetised conjunctiva [Figure - 7]. The orbicularis muscle was stimulated by galvanic current strong enough to deflect the myometer pointer by 5° at break. This was recorded. The procedure was totally painless.
For exercising the orbicularis an A.C. step down transformer was used with an out put of I M.A. and 9 Volts, for 5 minutes at each sitting for 8 to 10 days, over the skin near lateral canthus and the lower lid. This resulted in disappearence of epiphora. The procedure for the measurement of the strength of the orbicularis was repeated and record was made of the amount of current sufficient to give 5° contraction of the muscle on the myometer.
Observation[Table - 5]
Jone's test time and current used for 5° contraction of the orbicularis muscle were more in cases of lacrimal insufficiency as compared to the control group. This was very much remarkable in those cases who were given facial block for cataract extraction by O'Brain method.
After stimulation of the orbicularis oculii muscle, all these cases showed improvement in Jone's test time, electrical potential, and the epiphora disappeared.
A more sensitive orbiculo-myometer no. 4 was devised [Figure - 8]. The principle was the same as in the previous one, that the joint of the speculum was fitted with ball bearing, and the spring expanded with the contraction of orbicularis. One limb of the speculum was fixed to the chin rest, while to the other a mirror was attached. A light source was placed at one meter distance. The reflected light from the mirror was received on the wall at one meter distance which was caliberated in centimeter scale. By this we were able to magnify the slightest contraction of the orbicularis.
For measuring the strength of the orbicularis muscle and also to stimulate it subsequently, an A.C. step down transformer was used from the mains, with an output of 7.9 volts and 10 M.A.
Facial nerve was blocked on the side under study. Orbiculo-myometer no. 4, was applied in the anaesthetised conjunctiva [Figure - 9]. The chin was placed on the chin rest. The light was adjusted so that reflection from the mirror of the myometer was seen over the scale on the wall [Figure - 10]. The terminals of the transformer were placed over the skin near the lateral canthus and the lower lid [Figure - 11]. As the current was switched on, the twitchings of the orbicularis muscle squeezed the myometer, and changed the position of the mirror. The light deflection on the wall was recorded in centimeters.
For stimulating and strengthening the orbicularis oculii muscle, the same step down transformer was used. The terminals were placed at the same place and current was switched on. The twitchings in the muscle were noted. This was continued for 5 minutes at a time for each eye, everyday for 10 days. As the epiphora disappeared, orbicularis muscle strength was measured once again in centimeter deflection of the light reflected from myometer mirror.
Jone's test time
Control cases-6 minutes.
Cases with lacrimal insufficiency-12 minutes.
After orbicularis stimulation-5.5 minutes.
Contraction of the orbicularis measured as deflection on the scale
Control cases-14 cm.
Cases with lacrimal insufficiency- 8 cm.
After orbicularis stimulation-16 cm.
It is evident that orbiculo-myometer no. 4 is probably the most sensitive instrument to measure the strength of orbicularis oculii muscle.
The step down transformer used is a very simple, effective, and cheap method to exercise orbicularis muscle and make it stronger in the treatment of lacrimal insufficiency.
Quantitative measurement of the lacrimal drainage was planned in normal and in cases of lacrimal insufficiency and this was co-related with the strength of orbicularis oculii muscle.
Measurement of lacrimal drainage.
A graduated 1 ml. pippette was attached to a lacrimal cannula by a rubber tubing [Figure - 12]. 0.2 ml. of normal saline was sucked in. The upper punctum was blocked, and the cannula was put into the lower canaliculus. The level of fluid in the pippette was kept at the eye level while the patient was in recumbent position [Figure - 13].
The patient was asked to blink 10 times in 1 minute. Some of the fluid from the pippette got sucked into the sac, and there was change in the level of the fluid in the pippette, which was recorded. The procedure was repeated 4 times, and mean of the 4 readings was recorded as the amount of fluid conducted through the passage by lacrimal pump mechanism.
Measurement of orbicularis strength [Figure - 14] and its stimulation [Figure 15] was done the same way as in part IV, with orbiculo-myometer no. 4, and the step down transformer.[Table - 6][Table - 7]
| Observations|| |
Lacrimal secretion, as examined by Schirmer's test, showed reduction by 12%, after the orbicularis strength was restored to normal, in cases of lacrimal insufficiency, after electrical stimulation.
Weakness of orbicularis oculii is possibly the only factor responsible for poor lacrimal pump mechanism resulting in lacrimal insufficiency. It is because of anatomical distribution of lacrimal portion of the muscle.
Lacrimal secretion is greater in cases of lacrimal insufficiency probably because of reflex irritation produced by the presence of large amount of stagnated fluid in the conjunctiva, lacrimal sac, and over the skin of the lids. This secretion was normalised as soon as the lacrimal pump was restored to its normal strength by orbicularis stimulation.
| Summary|| |
- An attempt is made to measure the strength of orbicularis oculii muscle, and the lacrimal pump, by self designed orbiculomyometers in normal and in patients suffering from lacrimal insufficiency.
- The strength of the orbicularis oculii and the lacrimal pump, was restored to normal in cases of lacrimal insufficiency by electrical stimulation. This resulted in some reduction of lacrimal secretion as well.
- Quantitative estimation of the amount of fluid conducted through the lacrimal pump mechanism is done.
| Acknowledgements|| |
It gives me pleasure to acknowledge the help received from Dr. L.K. Kothari, Dr. Saket Bhatnagar, Dr. S.C. Bhargava, Dr. Lokesh Kumar Sharma, and Dr. Lata Paliwal.
| References|| |
Jones and Linn,. 1969, Amer. Jour.Ophthal., 67,
Jones, 1962, Trans. Amer. Acad. Ophthal„ 66,
Jones., 1969, Amer. Jour. Ophthal., 62,
[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6], [Figure - 7], [Figure - 8], [Figure - 9], [Figure - 10], [Figure - 11], [Figure - 12], [Figure - 13], [Figure - 14]
[Table - 1], [Table - 2], [Table - 3], [Table - 4], [Table - 5], [Table - 6], [Table - 7]