|Year : 1981 | Volume
| Issue : 3 | Page : 235-237
Management of intractable epiphora
Department of Ophthalmology, Dr. Ram Manohar Lohia Hospital, New Delhi, India
N C Singhal
Department of Ophthalmology, Dr. Ram Manohar Lohia Hospital, New Delhi
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Singhal N C. Management of intractable epiphora. Indian J Ophthalmol 1981;29:235-7
Watering of eyes may be due to two causes : (i) excessive secretion of tears (Lacrimation) (2) blocking of lacrimal passages (Epiphora). Whether it is epiphora or lacrimation, disability to the sufferer is the same, management of the former would be in reducing the excessive formation of tears, improving the lacrimal drainage system in the latter case. In this paper word epiphora will be used to denote both for the sake of brevity.
The reserets of partial dacryoadenectomy will be described in resistant case of epiora.
| Materials and methods|| |
Before performing the operation of partial adenectomy it is necessary to determine that the basic secretions are intact. Qualitatively it is determined by noting that the conjunctiva is healthy. Quantitatively it is determined by performing Schirmer test No. 1, 2, 3 and basic secretion test. Thus we can find the contribution made by the lacrimal glands. If the basic secretion shows less than 10 mm of wetting, partial adenectomy should not be done. Apparently, if the conjunctiva appears healthy, there is no reason for the test to show less than 10 mm of wetting. Since the success was good, it encouraged me to manage other causes of intractable epiphora.
For causes No. I to 3, before performing the operation, patient should be given long acting antiallergic tablet such as 'Forestal' one daily at bed time for 2 to 3 weeks along with betnesol-N/decadron drops every three hours for 2 weeks. I have seen some patients report good improvement with this treatment and do not consider operation necessary. They also show improvement in Schirmer test. If after some interval they have recurrence of symptoms, medicines can be repeated. Such courses can be repeated number of times as long as the patient remains satisfied which is the prime object of management. When the medical treatment fails, then the operation can be done. Obviously this treatment is of no use in crocodile tears. Rationale of this treatment is that to some extent epiphora is caused or maintained by subclinical inflammation and infection and allergy. Both the medicines are antiallergic and anti-inflammatory.
The operation of removal of palpebral lobe of lacrimal gland is done under local aneasthesia and is well described in surgical text books. The orbital lobe is put out of action by the destruction of its different ductules which pass through the palpebral lobe. At first state only the prolapsed part of the gland is removed and in majority of cases this is sufficient. Occassionally watering to some extent may still be there after the operation when the operation can be repeated and more of the gland is removed.
| Observations|| |
For the last 6 years, me have done this operation in conditions as shown in the [Table - 1].
In one case of atresia of cannaliculus aged 28, since he still had watering of eyes after the operation, a repeated operation 7 months after the first one was done with good result. In him the Schirmer test before the first operation showed 45 mm of wetting and after the operation it was 25 mm and after the second operation it was 14 mm. In all other cases initially the Schirmer test showed 35 to 60 mm of wetting and after the operation it was varying from 13 mm to 18 mm. The greatest benefit subjectively was in cases of paradoxical gustatory lacrimal reflex.
| Discussion|| |
Epiphora due to causes like congenital sac block, chronic dacryocystitis and lid disorders is easily managed. Difficulty arises in the following causes :
1. After dacryocystectomy
2. Failed dacryocystorhinostomy
3. Atresia of punctum or cannaliculus
4. Paradoxical gustatory lacrimal reflex (crocodile tears)
5. Other causes of lacrimation such as
a) Disease of lacrimal gland
b) Reflex trigeminal irritation
c) Irritation of facial nerve
d) Symptomatic lacrimation as in tabes, thyrotoxicosis and during certain stages of central nervous diseases especially of cortical areas, thalamus, hypothalamus and cervical sympathetic ganglion.
For cause No. 1, the only operation practised is conjunctivorhinostomy. For causes No. 2 & 3 conjunctivodacryocystostomy or conjunctivodacryocystorhinostomy are the cconventional operations. All these operations are difficult and time consuming and ordinarily are not within the practice of majority of eye surgeons and the failure rate is high.
| Summary|| |
Epiphora is a serious disability socially, mentally and physically to the sufferer, though it appears a minor disability to a doctor. If it cannot be managed by medical or any con
ventional operation, simple procedure of removal of palpebral lobe of lacrimal gland is suggested and the apprehension of development of keratoconjunctivitis sicca need not be feared.
In cause No. 4, the only treatment is cutting of either the greater superficial petrosal nerve or of tpmpanic plexus for which the patient has to be handed over to a neurosurgeon. This is a potentially dangerous operation. In majority of the conditions under cause No. 5, epiphora is for a temporary period and amenable to treatment with control of the main disease.
When epiphora cannot be managed by any of the above mentioned procedures and medicines, the latest and even the old literature states "the best advice to give any patient especially the young ones is to live with the annoyance because the amount of tears secreted usually diminish with age although the improvement may not occur before middle age or later".
Faced with the above situations, I have performed the operation of partial dacryoadenectomy which is well described in surgical text books but hardly practised due to fear of development of keratoconjunctivitis sicca. In this paper the object is to dispel this fear regarding this simple and highly successful operation. I first performed this operation with remarkable result in cases of crocodile tears. Since the success was good, it encouraged me to manage other causes of intractable epiphora.
| References|| |
Euke Elder, S. 1952, Text book of Ophthalmology Vol. V, Henry Kimpton London.
Jones, L.T., 1966, Amer. J. Ophthalmol., 62: 47.
Veirs, Everett R., 1971, The Lacrimal System, Proceedings of First International Symposium, C.V. Mosby company.
[Table - 1]