Anatomy-The lachrymal glands is lodged in a fossa at the outer and upper part of the orbit and close to its anterior margin. It is separated into two portions by a septum of connective tissue, the larger part of the glands being about twenty mm. in length and ten to twelve in breadth. It is a compound tubulo-racemose gland like the serous salivary. The excretory ducts, some ten to fourteen in number, run from portions of the gland to the upper and outer part of the superior fornix of the conjunctiva. The secretion of the lachrymal gland is faintly alkaline, containing about 1.25 per cent. of sodium chloride and 5 per cent of albumin. It serves to moisten the anterior surface of the eye, and passes off through the puncta, canaliculi, lachrymal sac, and nasal duct, into the inferior meatus of the nose (Fig 42 ). The puncta are the two minute openings of the canaliculi, on the free margin and about six mm. from the inner angle of the lids.
The canaliculi, both upper and lower, extend from the puncta to the lachrymal sac, just before reaching which they unite. The upper canaliculus is slightly smaller than the lower, and first ascends, then turns downward and inward. The lower canaliculus first descends, then runs horizontally to the sac. The lachrymal sac is the upper dilated portion of the nasal duct. It is located in a groove formed by the lachrymal and superior maxillary bones: its upper end is closed and rounded. The nasal duct extends from the lachrymal sac to the inferior meatus of the nose. The bony canal is lined with a fibrous membrane, and this, in turn, by cylindric epithelium like that of the nostrils. It is highly vascular and thrown into folds at two or three points. The total length of the sac and duct is about one inch. Its direction is downward, backward and slightly inward. The tears are forced into the excretory passage by muscular action, aided by a kind of suction caused by the muscular fibres of the puncta and canaliculi.
Dacryoadenitis.-Inflammation and abscess of the lachrymal glands are extremely rare. In the acute form the symptoms are, great swelling and redness of the upper lid at its outer angle. The globe may be displaced downward and inward by the swelling. The pain is severe and increased by touch. The conjunctiva is inflamed and may be chemosed. The inflammation may terminate by resolution, or run into the chronic form, in which all the acute symptoms are less severe, merely a considerable swelling remaining. Dacryoadenitis is generally cause by injury, and this fact, together with its symptoms, makes it very difficult to diagnose from periostitis of the orbit or abscess of the lid.
TREATMENT-When in the early stage, before there is a formation of pus, ice will often cut short an attack which might otherwise go on to suppuration. As soon, however, as there is evidence of suppuration, we should resort to hot fomentations in order to promote suppuration, and, when well established, a free incision should be made through the conjunctiva, if possible. The most useful remedies are Aconite Apis, Hepar, Rhus and Silicea. For indications see dacryocystitis phlegmonosa, page 139.
Hypertrophy of the Lachrymal Gland is very rare. It is a circumscribed, nodular tumor of gradual growth and has been known to occur in children and infants. If it increases sufficiently to cause interference with the movements of the eyeball it should be removed.
Tumors of the Lachrymal Glands, such as fibroids, sarcomatas, adenomas, hydatid cysts and cancers have all been recorded. They require extirpation of the gland.
Anomalies of the Puncta and Canaliculi-Eversion of the puncta is frequently found in blepharitis and conjunctivitis, causing epiphora, or watering of the eye, and will often result in ectropium from the irritation of the tears flowing over the lid.
The same result will occur from a narrowing or stoppage of the canaliculus, from wounds of the lid involving the canaliculus, or foreign bodies in the canaliculi blocking the passage of the tears. Obstruction of the canaliculus can be relieved by slitting up the canal with the canaliculus knife (Fig 43), a narrow-bladed, probe-pointed knife, which is to be entered into the puncta vertically, the handle then brought to a horizontal position, when the knife is pushed directly inward until it reaches the inner wall (the lid being kept taut with the thumb of the other hand), the knife is then brought to the vertical position, cutting through the whole length of the canaliculus. The edge of the knife should be kept toward the conjunctiva during its passage, so as to divide the canaliculus close to the muco-cutaneous junction. It is better, where possible, to preserve the physiological suction action of the canaliculus by only slitting it up for two or three mm.from the punctum and dilating the remainder of the canal with probes.
Strictura Ductus Lachrymalis-Stricture of the nasal duct is the most common affection of the lachrymal apparatus.
SYMPTOMS- The chief characteristic symptom of stricture is the overflow of tears, which is increased on exposure to cold wind or bright light. There is also often noticed a dryness of the nostril on the same side as the stricture. Usually on making pressure with the finger over the sac we can press out from the puncta a few drops of clear viscid secretion. We may also find a slight conjunctivitis present.
CAUSES-It is usually due to the extension of a nasal catarrh. Injury or periostitis of the nasal bones, carious teeth, or pressure from tumors in that vicinity may cause it. Its treatment will be found under dacryocystitis.
Dacryocystitis Catarrhalis- Catarrhal inflammation of the lachrymal sac is generally the result of a stricture associated with it. The catarrhal inflammation, on the other hand, may be the cause of the stricture, as the swelling of the mucous membrane will in itself cause a damming up of the secretions. The retention of the tears, from obstruction, causes a gradual distension of the sac-a swelling at the inner angle of the eye. By making firm pressure on this swelling the mucus can be pressed either out of the canaliculus; or it no stricture remaining, down through the nasal duct into the nose. The contents of the swelling may be either clear and transparent or mixed with pus. This disease usually develops very slowly, with simply the history of having had a watery eye for a long while previous to noticing any swelling of the sac, and oftentimes they will notice a dryness of the corresponding nostril. The swelling is usually free from pain or sensitiveness to touch.
TREATMENT-Since lachrymal diseases are frequently dependent upon nasal catarrh, treatment must be directed to this affection.
As in nearly all cases of blennorrhoea of the sac, a more or less firm stricture of the lachrymal duct is present, this will require our special attention. If the stricture is due to inflammatory swelling of the mucous membrane, the knife is rarely necessary. Bony strictures are to be regarded as incurable. The cutting of the stricture is only necessary in those rare cases that will not yield to probing and electrolysis.
If the stricture in the nasal duct is so firm as to not yield to the probe, the best operation to divide the stricture is that of Stillings, who, after slitting the canaliculus (as already described), introduces into the lachrymal sac a triangular shaped knife (Fig.44) in the same way as a probe, and then forces it down two or three times in succession, the blade being turned in a different direction at each passage.
Blood issuing from the nostrils is proof that the passage has been opened. Care should be taken for a day or two after the operation to see that the canaliculus does not close, and, commencing on the second day after the operation, the duct should be probed every two or three days until it remains permanently opened.
A passage sufficient to admit of a Bowman probe, from No.5 to 8 (varying in different cases), should be secured (Fig. 45). The use of larger probes has been recommended, but in my experience they have not proved as satisfactory. If there is very little catarrhal inflammation, especially in children, it is not always necessary to probe after Stillings’s operation. A far better method than operating, when it can be carried out, is that of gradual dilation of the strictures by using larger and larger probes. Commencing with No. o or oo, the canaliculus and duct can be gradually distended so as to admit of a No.4 or 5 Bowman probe without even slitting the canaliculus. In many cases the dilatation to simply a No.1 probe has been sufficient to result in a cure, and in some cases it seems to be better than to dilate to a larger size. Rarely, where the punctum is occluded, it will be necessary to slightly nick it with the point of the knife so as to admit of the smallest-sized probe. The advantages of this method seems to lay in the fact that we do not destroy the function of the parts and that the normal suction action of the canal is retained. This plan, of course, is not practical in very firm or bony strictures. Marked benefit has also been observed from electrolysis, and there is no doubt it should be more extensively employed. My plan has been to insert a probe the usual way until it comes in contact with stricture, then attaching the probe to the negative pole of a battery, apply the positive to the temple, and make gentle pressure as the stricture yields. Usually four or five treatments will be sufficient to keep the passage permanently opened.
Professor of Ophthalmology in the College of the New York Ophthalmic Hospital; Surgeon to the New York Ophthalmic Hospital. Visiting Oculist to the Laura Franklin Free Hospital for Children; Ex-President American Homoeopathic Ophthalmological, Otological and Laryngological Society. First Vice-President American Institute of Homoeopathy : President Homoeopathic Medical Society of the State of New York ; Editor Homoeopathic Eye. Ear and Throat Journal : Associate Editor. Department of Ophthalmology, North American Journal of Homoeopathy, etc.