Evaluation of Tear Drainage

Conjunctival fluorescein dye test: Normal tear drainage can be demonstrated by having the patient blow his or her nose into a facial tissue following application of a 2% fluorescein sodium solution to the inferior fornix.

Probing and irrigation: These examination methods are used to locate stenoses. After application of a topical anesthetic, a conical probe is used to dilate the punctum. Then the lower lacrimal system is flushed with a physiologic saline solution introduced through a blunt cannula (Figs. 3.5 a and b). If the passage is unobstructed, the solution will drain freely into the nose.

H Canalicular stenosis will result in reflux through the irrigated punctum. If the stenosis is deeper, reflux will occurthrough the opposite punctum (Fig. 3.6).

A probe can be used to determine the site of the stricture, and possibly to eliminate obstructions (Fig. 3.7).

Radiographic contrast studies: Radiographic contrast medium is instilled in the same manner as the saline solution. These studies demonstrate the shape, position, and size of the passage and possible obstructions to drainage.

Digital substraction dacryocystography: These studies demonstrate only the contrast medium and image the lower lacrimal system without superimposed bony structures. They are particularly useful as preoperative diagnostic studies (Fig. 3.8).

Lacrimal endoscopy: Fine endoscopes now permit direct visualization of the mucous membrane of the lower lacrimal system. Until recently, endoscopic examination of the lower lacrimal system was not a routine procedure.

Irrigation of the lower lacrimal system under topical anesthesia.

Figs. 3.5a and b First the punctum is dilated by rotating a conical probe. Then the lacrimal passage is flushed with a physiologic saline solution. The examiner should be particularly alert to good drainage or possible reflux.

Tear Lacrimal Drainage System

Localizing an obstruction by irrigating the lower lacrimal system. -

Fig. 3.6 The lower lacrimal system should be irrigated with care by an experienced ophthalmologist. Failure to locate the passage will inflate the eyelid and provide no diagnostic information.

Stenosis Lacrimal Punctum
Stenosis of the inferior canaliculus

Stenosis of the inferior common punctum

56 3 Lacrimal System Opening a stenosis of the lower lacrimal system with a probe.

Lacrimal Drainage System

Figs. 3.7 a-c After application of a topical anesthetic, the probe is carefully introduced into the lower lacrimal system. The puncta are dilated and then the valve of Hasner is opened (a and b). A dye solution can then be introduced to verify patency of the lower lacrimal system (c). In infants six months or older, the procedure is best performed under short-acting general anesthesia.

— Radiographic image of the lower lacrimal system. -

Fig. 3.8 Digital

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