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Home , Epiphora (medicine), Lacrimal lake, Lacrimal nerve, Nasolacrimal duct

: Diagnosis and treatment

FRANK J. DITTRICH, D.O. Mount Clemens, Michigan

levator palpebrae superioris muscle. The lar- ger, almond-shaped orbital lobe has from two Tearing is a necessary protective function to five ducts which traverse the smaller, pal- in which about 1 ml. of fluid is secreted pebral part of the . This is by each eye every day and carried away situated just above the lateral part of the through the nasolacrimal ducts. There upper fornix and can be seen through the are several causes for the overflow of when the upper lid is everted. onto the cheeks, but the most common Small ducts from the palpebral portion join is obstruction of the puncta lacrimalia those from the orbital portion to open by from in newborn infants in whom the membranes 10 to 12 small orifices just anterior to the la- have not disappeared. In elderly persons, teral part of the upper fornix, about 4 or 5 on the other hand, often is due mm. above the superior border of the upper to atrophy of the orbicularis oculi and palpebarum. Because the ducts from the loss of elasticity of the skin. Other orbital lobe pass through the palpebral lobe, causes include fungal infection, often the removal of that lobe prevents tears from unilateral, and traumatic laceration of reaching the eye. a canaliculus. Diagnostic and therapeutic In addition to the principal gland are the measures for epiphora are described and glands of Krause and Wolf ring, which are their indications are considered. accessory lacrimal glands located between the fornix and the upper border of the tarsus of each . The blood supply to the lacrimal gland comes from the , a branch of the oph- thalmic artery. A corresponding vein drains The Dictionary of Visual Science has defined behind the superior and inferior ophthalmic epiphora as "an overflow of tears onto the veins. The lymphatic drainage is to the pre- cheek caused by excessive lacrimation, by ob- auricular lymph nodes via the conjunctival struction of the lacrimal ducts, or by ectro- lymphatic vessels. pion." This paper will deal with the detection The innervation of the lacrimal gland con- and management of this lacrimal malfunction sists of sensory input via the lacrimal nerve after a brief review of the normal anatomy and branches of the ophthalmic division of the tri- function of the lacrimal apparatus. geminal nerve. The motor output is via the parasympathetic fibers of the greater super- Anatomy ficial petrosal nerve and the pterygopalatine A distant relative of the salivary gland, the ganglion. Sympathetic fibers to the lacrimal lacrimal gland is a tubuloracemose structure gland arise from the superior cervical gang- derived from ectoderm. It rests above and la- lion. (Paralysis of the sympathetic nerves teral to the eyeball in a bony fossa just under causes an increase in tears, while paralysis of the roof of the superior outer portion of the the facial nerve causes suppression of tears.) bony . It weighs about 0.78 gram and There is also a hypothalamic-limbic lobe cor- measures 20 by 12 by 5 mm. It is partially tical regulation of tearing, manifested by emo- divided by the expanding aponeurosis of the tional or psychic .

755/111 Journal AOA/vol. 73. May 1974 Epiphora

The tears produced by the lacrimal gland during embryonic life, and in 2 percent of in- serve their purpose and are carried away by fants it fails to disappear shortly after birth. the lacrimal drainage system.2 A flowing tear This causes epiphoric symptoms. Rupture of on its way to the nasal exit first encounters this membrane usually can be felt during prob- the puncta. These are rounded or oval aper- ing of the region in a young infant. tures that sit atop a slight elevation, the lac- rimal papilla. The papillae are paler than the Physiology rest of the lid margins, and this aids in their Contrary to popular belief, newborn babies identification. The puncta are about 0.3 mm. do secrete tears. Close inspection of the con- in diameter. The upper one is about 6 mm. junctivae of newborn infants will show them from the medial , the lower one about to be moist, and they rarely suffer from con- 6.5 mm. from the medial canthus. Both puncta ditions due to a hypolacrimation. Apt and point slightly backward into the . Cullen• found that more than 80 percent of In about 30 percent of newborn infants the newborn infants secreted adequate amounts puncta are closed.3 In persons at the other of tears when they were crying, and 96 per- end of the age scale, the lacrimal papillae are cent had normal tearing when they cried. prominent because of atrophy of the orbicu- These percentages are similar to those of nor- laris oculi muscle. Weakness of this muscle mal adults. plus loss of elasticity of skin leads to senile As might be expected, a tear is a heterogen- ectropion, a frequent cause of epiphora. ous fluid closely resembling plasma; its osmotic By action of the capillaries and the lacrimal composition is equivalent to 0.9 percent sodium pump,4 which will be explained shortly, tears chloride, and its pH is the same as that of pass through the puncta into the vertical ca- blood, 7.35. Tears contain similar elements naliculus, which is about 2 mm. in length, to those of blood, that is, protein, sugar, urea, with a lumen that soon widens to form an and sodium chloride. In fact, investigators in ampulla. From here the tears travel in a me- Boston,® using the modified Schirmer test with dial direction along the horizontal canaliculus Clinistix, were able to correlate the amount for from 8 to 10 mm. to reach the common of glucose in tears with the amount in blood canaliculus, also termed the sinus of Maier. in the hypoglycemic state. The average glu- This common channel pierces the lacrimal cose concentration in tears of normal subjects fascia to enter the 2.5 mm. below was found to be from 1.0 to 7.2 mg./100 ml. its apex. Although the apex of the lacrimal In a study of 200 diabetic patients, 119 of sac lies above the medial palpebral ligament whom had blood sugar levels above 160 mg./ (actually a tendon joining muscle to bone), the 100 mI.,7 85 percent had enough glucose in common canaliculus enters the sac beneath this their tears to yield a positive Clinistix reaction. important landmark. The most important ana- Tears contain the bacteriostatic enzyme tomic relation of the lacrimal sac is to the lysozyme, which was first described in 1922 anterior ethmoid air cells, which lie just medial by the discoverer of penicillin, Sir Alexander to the lacrimal sac. Fleming. Lysozyme protects the eye by hydro- The is a downward con- lyzing the beta 1-4 linkage of the mucopolypep- tinuation of the lacrimal sac. It averages about tide substance found in the cell wall of po- 15 mm. in length and slants back and slightly tentially harmful bacteria,8 and damage occurs laterally. Lateral to the nasolacrimal duct lies when the amount of lysozyme in the tears is the maxillary sinus. The nasolacrimal duct low. The lysozyme content was found to be empties into the inferior meatus beneath the low or absent in industrial workers and cit- inferior turbinate about 10 mm. posterior to izens working or living in smog-polluted at- its anterior tip. At this terminus of the lac- mosphere. The lysozyme content is diminished rimal apparatus is the most common cause of also in patients suffering from keratoconj unc- epiphora in infants. A thin membrane closes tivitis sicca or Sjogrens syndrome, and in the intranasal end of the nasolacrimal duct those at both ends of the age scale (Table 1).

756/112 The normal person secretes about 1 ml. of TABLE 1. AVERAGE LYSOZYME CONTENT OF TEARS OF tears from each eye per day, and the principal PERSONS OF VARIOUS AGES.° function of tears is to keep the eye moist and mcg./ml. constantly to flush away noxious particles. Infant, 15 days to 1 year 850 Jones9 divided the secretory system between Child, 1-10 years 2,000 basic and reflex secretors. Three sets of glands Adult, 10-40 years 1,750 comprise the basic secretors, and these contri- Adult past 80 years 800 bute to the composition of the tear film, which consists of three layers. The first or innermost layer of tear film is made up of mucin secreted by the goblet cells the circuit, a flood of tears occurs in an at- of the conjunctivae, the glands of Henle found tempt to wash away the irritating stimulus. in the inner third of the upper and lower tar- Reflex secretion can be divided into periph- sus, and finally the mucin-secreting glands of eral sensory, retinal and central sensory, and Manz in the circumcorneal ring of limbal con- psychogenic. Peripheral sensory reflex lacri- junctivae. mation occurs via the route just described Second is the middle or lacrimal layer, which whenever there is an irritating stimulus to comes from the accessory lacrimal glands of the conjunctiva, , , , Krause, of which there are about 40 in the and those structures innervated by the affer- upper fornix and six in the lower. The acces- ent sensory fibers of the fifth cranial nerve. sory lacrimal glands of Wolfring also contri- Retinal stimulation of reflex lacrimation bute to the middle layer of tear film, and there occurs whenever is present or may be secretions from an occasional acces- whenever intense light enters the eye. sory lacrimal gland found in the caruncle or Psychogenic reflex lacrimation deserves plica semilunaris. special consideration. Darwin" stated that The third or outermost layer, perhaps the crying was acquired after man branched off most important, consists of oil secretions aris- from the common progenitor of genus Homo ing from the meibomian glands, of which there and the nonsweeping anthropomorphic apes. are about 25 in the upper tarsus and 20 in the Of all the vertebrates and primates, man alone lower tarsus. The glands of Zeis at the palpe- possesses the psychogenic type of reflex lac- bral margins and the glands of Moll at the rimation. roots of the cilia also contribute. The oily layer According to Sadoff, 11 psychogenic crying has a twofold function. It prevents evapora- has much significance in folklore and myth- tion of the tear film and maintains the integ- ology. After expulsion from the Garden of rity of the tear film strip, to prevent spillage Eden, Adam was said to have shed such a of tears onto the cheeks. volume of tears that "all beasts and birds The tear film in its entirety protects the satisfied their thirst therewith." In ancient eye and lubricates eye movement, and yet it times, it was believed that the more tears were must remain optically clear. shed during human sacrifice for crops, the Reflex tear secretion occurs from the prin- more rain would fall. Weeping has not always cipal lacrimal gland, both orbital and palpe- been considered beneficial, however. In old bral lobes. Reflex irritation follows the affer- Brittany, it was believed that a dead child ent fibers of the fifth cranial nerve to the has to carry water uphill in a little bucket superior salivatory nucleus, the site of the and that the tears of the mother increase its parasympathetic fibers for lacrimation. Effer- weight." ent impulses then pass via the geniculate Psychologically, crying seems to function as ganglion to the sphenopalatine nerves to the a symbolic act of washing away pain and of the maxillary division of grief from the body. Ovid stated: "It is a re- the seventh cranial nerve and thence to the lief to weep; grief is satisfied and carried off lacrimal nerve and gland. With completion of by tears." Psychogenic crying is only one

Journal AOA /vol. 73, May 1979 757/113 Epiphora

aspect of a general bodily reaction in which The epiphora patient typically will complain the whole glandular system is affected so that of tears overflowing the lower lid to run the secretions of fluid are increased. That the down the side of the cheek. A young mother principal secretion associated with emotional might note this manifestation in her infant grief is from the lacrimal glands may be ex- in association with purulent matter in the plained by the idea that the ego resides pri- corner of the eye, particularly in the morning. marily in the face, so that weeping is most ap- Mucopus often can be expressed from the propriate in the facial area." puncta by digital pressure on the lacrimal The psychogenic crying center appears to sac. be in the hypothalamic and/or limbic lobes of When the patient presents himself for ex- the cerebrum. Its efferent pathway is via the amination, the physician must determine parasympathetic fibers of the facial nerve, as whether there is obstruction of the excretory stated before. mechanism, an increase in reflex lacrimation, So much for tears themselves. With regard or a decrease in basic secretion with pseudo- to tear drainage, ordinarily about 50 percent epiphora. Epiphora must be distinguished of tears are lost via evaporation. The rest from excessive lacrimation due to any irrita- drain through the nose. Most of the tears tion of the fifth nerve, for example, from from the lacrimal gland empty into the upper corneal abrasion, ulcer, a foreign body irri- cul-de-sac. A few empty into the lower, near tant, infection, photophobia, psychic stress, the outer canthus. The tear film arranges it- neoplasm, or stimulation with a drug (pilo- self into a strip along the margins of the carpine). A complete history must be taken, upper and lower lids. The puncta are in con- and a thorough examination of the lacrimal tact with this strip of film and the medial mechanism must be done. Orbital trauma can lacrimal lake. interrupt the drainage mechanism. Disturb- Blinking is the major force for movement ance in nasal architecture, such as fracture of tears to the region of the lacrimal lake. A or deviation of the nasal septum, should be thin film of tears is spread over the eye by looked for. An ectropion is a possible cause in blinking. Responsible for blinking is the or- the elderly. Close examination may reveal mal- bicularis oculi muscle, which has its origin position of the puncta. Agenesis or atresia medially, so that its contraction causes a me- may be noted. dial excursion of the lids. The lids contract It has been shown recently12 that in glau- from the side to the center. Tears get into the coma patients using topical epinephrine, epi- puncta partly by capillary action and partly phora has developed as a result of blockage through shortening and widening of the ca- of the lacrimal drainage system by dark mel- naliculi during contraction of the orbicularis. anin casts, since melanin is one of the by- The orbicularis oculi and the pars lacrimalis products of oxidation of epinephrine. (Horners muscle) of the orbicularis indirect- A logical sequence of simple tests is now ly attach to the lacrimal sac via the medial performed that will either localize the site palpebral ligament and sac fascia, respectively. of the obstruction or point to hypersecretion. When the orbicularis contracts and relaxes The first diagnostic step is the primary dye during blinking, the sac is dilated and relaxed test, in which a Flurostrip is placed in the like a fireplace bellows and sucks the tears into eye as the dye source and a small cotton-tipped the sac. Thus it serves as a lacrimal pump. As wire applicator is placed in the inferior meatus the sac relaxes, its elasticity, aided slightly next to the orifice of the nasolacrimal duct. If by gravity, causes expulsion of tears down into the cotton is stained with dye, the test is posi- the nasolacrimal duct and into the nose. tive, meaning that the drainage system is patent and functioning. If the patient has Diagnosis true epiphora and this test is positive, the It has been stated that one careful observa- cause is hypersecretion. If the cotton tip does tion is worth a thousand alibis. not stain, the test is negative, suggesting an

758/114 obstruction, and the secondary dye test" is basic secretion. If there is 10 mm. or more done. With the patients head tipped forward of wetting, the basic secretors are functioning and down over a white basin, saline solution normally. is introduced via a lacrimal cannula passed Less than 10 mm. of wetting shows a de- as far as the sinus of Maier, and the system crease in the basic secretions and pseudoepi- is flushed. If no fluid at all comes out of the phora. The mechanism by which a lack of nose, there is total obstruction of the nasolac- basic secretions causes the symptom of epi- rimal duct. If dye-stained fluid comes out, there phora calls for explanation. The lack of basic is partial obstruction of the nasolacrimal duct. secretions causes the eye to be dry and irri- This indicates that the lacrimal pump is work- table, and this triggers the reflex secretors ing but there is partial obstruction of the through the afferent nerves of the conjunc- nasolacrimal duct. Paralysis of the orbicularis tiva." This is best treated with artificial tears oculi may be present." If the irrigant passes to alleviate the dryness. from the nose unstained, the test is negative, If it is demonstrated by the foregoing tests indicating that the dye never entered the sac, that the action of both the basic and the reflex and therefore that the obstruction lies in the secretors is diminished, a final test is done canaliculi or puncta. to determine whether there is a "fatigue block" If any of the aforementioned tests shows of reflex lacrimation. This is called the Schir- complete obstruction, the canaliculus test is mer No. 2 test. The technique is similar to the done. In this test clear saline solution is in- basic secretion test except that a cotton-tipped jected into one canaliculus. If there is reflux applicator is placed at the anterior tip of the through the opposite punctum, the test is middle turbinate. This will cause marked irri- positive, indicating that both canaliculi are tation of the fifth nerve and copious reflex patent to the sinus of Maier. If no fluid re- tearing if there is a fatigue block for con- turns, the problem is in one of the canaliculi, junctival stimuli. If no reflex tearing is pro- and each should be tested individually. duced, complete failure of the reflex secretors If epiphora still exists in the presence of a is present." patent lacrimal excretory system, the secretory Finally, with Sinografin, a nontoxic, non- mechanism must be evaluated by the Schirmer irritating, and readily absorbable radiopaque tests." dye, dacryocystography may be performed to The Schirmer No. 1 test" is performed with get a total visual outline of the lacrimal ex- Whatman No. 41 filter paper 35 by 5 mm. cretory system. In a case of obstructive epi- A 5-mm. flap is made at one end to lie next to phora if there is persistent tearing for reasons the conjunctiva. Normal secretion causes about other than nasolacrimal obstruction, the dac- 15 mm. of wetting in 5 minutes. The first 10 ryocystogram will reveal patency and will mm. of wetting is produced by the basic secre- show that surgery or repeated probing of the tors. Wetting beyond 10 mm. is produced by nasolacrimal duct is unnecessary. The only reflex secretion from conjunctival irritation contraindication to dacryocystography is acute by the filter paper. The effects of temperature infection in or around the eye. and humidity on the results" should be taken into account. Treatment If there is only a small amount of wetting Treatment only of conditions that cause ob- or if deficient secretion is suspected, the basic structive epiphora, that is, conditions causing secretion test" is done. In this test one or two a loss of normal lacrimal excretory drainage, drops of a topical anesthetic is instilled into will be considered here. the eye. After about 2 minutes, excess mois- First of all, the treatment must eliminate ture is blotted away and a fresh filter paper the abnormality. It is futile to try to treat the strip is inserted as in the Schirmer No. 1 test. lacrimal system if paralysis of the seventh Because the anesthetic has blocked any reflex nerve or an injury damaging the motor power secretion, wetting in this case represents true of the muscles of the lacrimal pump is the

Journal AOA/vol. 73, May 1974 759/115 Epiphora

cause of the epiphora. Simple examination pebral conjunctiva just lateral to the punctum may reveal the problem. Foreign bodies such have been advocated. The Kuhnt-Szymanowski as cilia, parasites, or polyps may cause the blepharoplasty may be necessary for severe epiphora. Roentgen radiation, radium, or senile ectropion.18 thermal burns may destroy the drainage sys- Traumatic lacerations of the canaliculi re- tem. The copious use of eye cosmetics, some quire meticulous and delicate repair, which of which are easily contaminated, has been should be done immediately. A Worst "pig- known to plug the puncta. The use of topical tail" probe is passed via the upper punctum epinephrine may cause blockage. Strictures and out at the distal part of the severed following infection or trauma may be ob- canaliculus." A knotted nylon thread is passed served. through 0.5-mm. polyethylene tubing and at- The fungus Streptothrix is the most com- tached to the notch at the end of the probe. mon cause of unilateral canaliculitis. Women Withdrawal of the probe causes the plastic usually are affected, and the lower canaliculus tube to follow. The other end of the tube is usually is involved. Treatment consists of re- introduced through the proximal part of the moval of the concretions by massage or cu- canaliculus via the inferior punctum. The ends rettage. Irrigation with 7 percent tincture of the cut canaliculus are anastomosed with of iodine or a penicillin solution may be used." 6-0 chromic catgut. The tubing may be re- A stenotic punctum is treated by repeated moved in about 2 weeks. Malleable rods also dilation or cautery with 5 percent silver ni- have been used." trate of any epithelium that obstructs the usually causes obstruction of orifice. If stenosis of a punctum is refractory the nasolacrimal duct, which may or may not to repeated dilation, Jones 13 recommended a be accompanied with canalicular obstruction. "one-snip" procedure in which a 2-mm. verti- During the acute phase, cultures and antibiotic cal incision is made through the entire con- sensitivity testing should be done on any se- junctival wall of the vertical part of the ca- cretions. The appropriate antibiotic then naliculus. The "two-snip" and "three-snip" should be administered. Hot packs may bring operations are now considered by many physi- some relief. A stab incision into the infected cians to be too destructive. lacrimal sac with a No. 11 blade will bring Ectropion has many causes. The most com- prompt relief, but there is some danger that a mon type is senile or atonic ectropion. Chronic persistent fistula may develop. Except in the often is seen in association with very young, probing rarely results in perma- it. Spastic ectropion generally is seen in per- nent cure. is needed sons with enlarged eyeballs, as in retrobulbar for permanent relief. inflammation. The paralytic type of ectropion The classic method of dacryocystorhinosto- is seen in patients with paralysis of the facial my is the Dupuy-Dutemps operation, a mod- nerve. Cicatricial ectropion is observed after ification of Totis dacryocystorhinostomy. burns, trauma, conjunctivitis, , and Keith reported successful temporary intu- eczema and frequently occurs in persons of bation of the excretory system with silicone fair complexion who have had prolonged ex- rubber tubing without open operation as well posure to light. as in conjunction with dacryocystorhinostomy. Treatment of ectropion consists of such Goto22 advocated a new surgical technique, general measures as eradication of conjuncti- dacryocystoethmoidostomy, with anastomosis vitis, blepharitis, or retrobulbar inflammation. of the lacrimal sac to the ethmoid sinus. Gentle massage of the lower lid may help. Spe- Epiphora due to obstruction of the nasolac- cific measures include the debatable "three- rimal duct most often is caused by persistence snip" operation, excision, and cauterization of the distal membrane in the early postnatal of an enlarged caruncle, which may be done by months. Ffooks3 stated that the cause appears mechanically everting the lower lid. Four- to to be infection of the lacrimal excretory ducts six-point cautery punctures through the pal- shortly after birth. This interferes with the

760/116 natural disappearance of the terminal mem- 4. Jones, L.T.: Symposium. The lacrimal apparatus: practical fundamentals of anatomy and physiology. Trans Am Acad brane of the nasolacrimal duct, Hasners valve, Ophthalmol Otolaryngol 62:669-78, Sep-Oct 68 5. Apt. L.. and Cullen. B.F.: Newborns do secrete tears. JAMA in the nose. It is advisable to remove any mu- 189:951-8. 21 Sep 64 cus or debris from the infants eyes at the 6. Gasset, A.R., et al.: Tear glucose detection of hyperglycemia. time the head is delivered, to lessen the chance Am J Ophthalmol 66:414-20, Mar 68 7. Lewis, J.G., and Stephens, P.J.: Tear glucose in diabetics. of infection. Br J Ophthalmol 42:764-8, Dec 68 8. Bonavida. B., and Sapse, A.T.: Human tear lysozyme Quan- Often a mother will bring an infant of from titative determination with standard Schirmer strips. Am J 2 to 6 months to the physician because of epi- Ophthalmol 66:70-6, Jul 68 9. Jones, L.T.: The lacrimal secretory system and its treatment. phora and mucoid drainage from an irritated Am J Ophthalmol 62:47-60, Jul 66 eye. Mucopus may be expressed from the punc- 10. Darwin. C.: Expression of the emotions. Appleton, New York, 1873. cited by Sadoffu ta after pressure is applied to the lacrimal 11. Sadoff, R.L.: On the nature of crying and weeping. Psy- sac. The secretions should be cultured and chiatr Q 40:490-608, Jul 66 12. Spaeth, G.L.: Nasolacrimal duct obstruction caused by therapy discussed with the parents. topical epinephrine. Arch Ophthalmol 77:356-7, Ma y 67 Conservative measures include antibiotic 13. Jones. L.T.: The cure of epiphora due to canalicular disorders. trauma and surgical failures on the lacrimal passages. Trans Am and/or antiseptic ophthalmic medication and Aced Ophthalmol Otolaryngol 66:606-24, Jul-Aug 62 instruction of the parents to massage the lac- 14. Moiel, R.H., and Waltz, T.A.: Testape tear test. Quantitative measurement of lacrimation. South Med J 60:593, 598. Jun 67 rimal sac with a digital rolling motion from 15. Jones, L.T., and Linn, M.L.: The diagnosis of the causes of above downward several times a day. epiphora. Am J Ophthalmol 67:751-4, May 69 16. Williamson, J.. and Allison, M.: Effect of temperature and When this is not curative, the parents are humidity in the Schirmer tear test. Br J Ophthalmol 61:596-8, advised that one or more probings is needed.23 Sep 67 17. Fedukowicz, H.B.: External infections of the eye. Bacterial, If the infant is small and sufficient help is viral, and mycotic. Appleton-Century-Crofts, New York, 1968 18. HervouEt, F.. and Tessier, P.: Ectropion senile et cicatriciel. available, this can be done in the office, a sheet In Plastic and reconstructive surgery of the eye and adnexa, by being used for mummification of the infant R.C. Troutman, J.M. Converse, and B. Smith. Butterworth, Washington, 1962 while an assistant holds the head still. 19. Sexton, E.R.: , lacrimal apparatus, and conjunctiva. For older infants, a light general anesthetic Arch Ophthalmol 81:281-99, Feb 69 20. Veirs, E.R.: Malleable rode for immediate repair of the such as cyclopropane or fluothane may be giv- traumatically severed lacrimal canaliculus. Trans Am Acad en. The lower lid is everted slightly, and the Ophthalmol Otolaryngol 66:263-4, Mar-Apr 62 21. Keith, C.G.: Intubation of the lacrimal passages. Am J vertical arm of the canaliculus is dilated with Ophthalmol 65:70-4, Jan 68 22. Goto, T.: Dacryocystoethmoidostomy. Am J Ophthalmol a punctum dilator so that a No. 1 or No. 0 66:68-9, Jan 68 Bowman probe, with the end well lubricated, 23. Mirecki, R.: Causes of failures in probing the nasolacrimal duct in infants and children and ways of avoiding them. J can enter the vertical portion for about 2 mm. Pediatr Ophthalmol 6:171-6, Aug 68 The probe is then moved horizontally until the Amdur, J.: Excision of palpebral lacrimal gland for epiphora. tip touches the nasal bone. It is then raised Arch Ophthalmol 71:71-2, Jan 64 Burns, R.P.: Eyelids, lacrimal apparatus, and conjunctiva. Arch toward the vertical position and directed Ophthalmol 79:211-25, Feb 68 slightly back, about 15 degrees, and pushed downward into the nose. At this point one or (Submitted for publication in June 1972. Updating, as necessary, more popping sounds may be noted as the has been done by the author.) obstructing membranes are perforated. The system is then irrigated as a test for patency, but only after the infant is allowed to awaken almost completely from the anesthetic to per- mit return of the normal swallowing and gag reflexes. Dr. Dittrich is chairman of the EENT Department at Green Cross General Hospital, Cuyahoga Falls, Ohio. This paper was written during a residency in the BENT De- partment at Mt. Clemens (Michigan) General Hospital of which D.R. Gibbings, D.O.. and B.L. Larlee, D.O., were 1. Schapero, M.. Cline, D., and Hofstetter, H.W.: Dictionary t.o-chairmen at that time. of visual science. Ed. 2. Chilton Book Co., Philadelphia, 1968 Dr. Dittrich, 1900 23rd St., Cuyahoga Falls, Ohio 44223. 2. Veirs, E.R.: The lacrimal system. Clinical application. Grune and Stratton. New York, 1965 L nooks, 0.0.: Dacryocystitio in infancy. Br J Ophthalmol 46:422-84, Jul 62

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