DISEASES OF THE LACHRYMAL SAC.*
BY
A. E. Iles, O.B.E., M.B., F.R.C.S.,
Ophthalmic Surgeon, Bristol General Hospital;
Surgeon, Bristol Eye Hospital.
In dealing with the treatment of these conditions I
propose to devote my time chiefly to the methods of
treatment of stenosis and inflammation of the lachrymal
passages, passing quickly over those of congenital or
traumatic origin.
1. Congenital.?The most frequent cause is
obstruction at the lower end owing to a mass of
epithelial cells situate at the nasal opening. This results
in the formation in most cases of a mucocele. Treatment
consists either (1) of Crigler's method, which by means
of pressure occlusion of the canaliculi forces the
contents of the sac down the canal and breaks down
the obstruction, or if this does not suffice, then
(2) the passage of a probe under an anaesthetic
will ensure a cure, especially if the probe be rotated
so as to completely open the lower end of the
canal.
2. Traumatic.?(a) Those due to wounds of the
* A Paper read before the Bristol Medieo-Chirugical Society on
Wednesday, February 13th, 1935.
152 Mr. A. E. Iles
lid. When the canaliculus has been torn across this calls
for very careful approximation of the wound with a
probe passed into the punctum through both segments
of the canaliculus. (b) Laceration of the sac due to
severe contusions of the face, where the firmly adherent
fascia which overlies the sac is torn. These accidents
give rise to those symptoms of surgical emphysema
where the eye bulges forwards on the nose being
blown, due to air being forced up the lachrymal
passages from the nose. Treatment consists of pressure
over the sac.
Stenosis of Parts or the Lachrymal Passages.
Before dealing with stenosis and inflammation of
the sac it may be just as well to go through the sequence
of events which takes place in these cases.
First of all there is a slight obstruction which is
intermittent, giving rise to occasional watering. As
this obstruction becomes more definite the epiphora
becomes more constant. Eventually stasis occurs, with
the result that owing to irritation by decomposition
the sac wall becomes inflamed, so that a chronic
dacryocystitis with enlargement and loss of elasticity
of the sac wall supervenes. Then if one presses over
the sac regurgitation in the early stages of glairy
fluid and latterly mucopus through the punctum
takes place. As the lower end of the canal is continuous
with the nasal mucosa, diseases of the nasal
mucous membrane are very prone to infect the canal.
In some cases this leads on to an acute dacryocystitis
owing to infection of the surrounding tissues caused
by a slight break in the sac lining.
Diseases of the Lachrymal Sac 153
(a) The Canaliculus.?In these cases it is advisable
to dilate the passages rather than have recourse to
canaliculus slitting, which is deleterious in case an
operation such as Toti is required, as it has been found
that these operations have a much more successful
result if the valve-like action of the punctum is
intact.
How does stricture occur, and is it frequent ?
In my experience there are many more cases in women
than men, partly owing to the fact that the nasal
canal in woman is narrower. It is more common than
is supposed, and this is supported by Sandermann,
who examined canaliculi and lachrymal canals in the
cadaver. He found 80 per cent, had normal canaliculi,
but in only 31 per cent, were the lachrymal passages
really .normal, forty cases being male and three
female.
The first symptom is usually intermittent watering
of the eyes in cold winds, frequently due to
a slight obstruction. If this obstruction be allowed
to persist stasis occurs, and then the stricture gets
tighter and tighter. In early cases of obstruction my
practice has always been, first of all, to pass a syringe
into the canaliculus, and then endeavour to pass fluid
into, the nose. This should pass freely, and one can
roughly measure the amount of obstruction by the
force necessary for fluid to pass. Elschnig introduced
a syringe in 1926 by which one was able to measure
"the amount of pressure required. Syringing in early
cases may be sufficient by itself to bring about a cure.
If fluid does not pass I then, after cocainization,
endeavour to pass a probe through the canal. In
154 Mr. A. E. Iles
these cases gentleness in manipulation is required, and
if one allows the probe to rest with gentle pressure
against the stricture frequently after a short interval
the probe will be felt to pass on. This is aided by oil
and adrenalin.
Lipoidol in localizing the stricture is also useful,
as it should in a normal canal pass through in eight
minutes, and X-ray will show the site of the stricture
and also will show whether there are any diverticula
present which would contraindicate the use of a
probe.
X-ray examination of the region is helpful in that
it may show up an aberrant cell. I had one of my own
cases which illustrated this. On a West operation being
performed, the rhinologist, Mr. Wright, found that
he was in an accessory ethmoidal cell, and this had to
be traversed before the sac was found.
Passage of an electric current to facilitate probing
has been tried and stated to be of service, but I have
had no experience of this. Forcible probing has been
carried out by the use of large probes, and success has
been claimed for this; but I feel that the large amount
of bruising and, occasionally, even fracture of the
bone which may result makes a trial of this method
inadvisable.
I have frequently found that if probing is started
sufficiently early in the course of the trouble it will
result in a cure. In some cases even after a long
history repeated probing will materially benefit the
patient and allay the epiphora.
(b) Slitting of the Canaliculus used to be practised
most extensively, but in my opinion it should be
Diseases of the Lachrymal Sac 155
reserved for those cases when the puncta are displaced
by ectropion, and thus a lake is made for the tears
before they can get to the punctum.
Chronic Dacryocystitis.
There are two methods of dealing with this :?
1. Conservative.?If a chronic dacryocystitis be
present then first of all it is essential to try and clean
the sac. Methods which have been applied are injections
of silver nitrate in J per cent, solution. This is only
advisable when free entry without force can be made
into the sac, one of which consists of injecting the
fluid through a hollow probe.
2. Operative.?In my own practice, if there is a
chronic dacryocystitis without much secretion and
there is a mucocele formed so that without undue
force one is unable to express the fluid up or down, I
generally aspirate the sac directly through the skin by
a hypodermic needle, and then inject into the sac a
small quantity of 1 per cent, mercurochrome.
A solution of tincture of iodine has also been used
in this way with beneficial results. I myself have
bad quite a number of successful cases, the most
striking being a pregnant woman of eight months,
who had a very large mucocele. I aspirated and left
mercurochrome in the sac, with the result that when
I saw her some months after there was no sign of
obstruction and no palpable sac.
I have had an equal number of failures ; but in view
of the successes I am convinced that this is worth
trying, in that you do no harm, you may cure, and you
do not diminish the prospect of a cure by operative
156 Mr. A. E. Iles
measures if necessary later. This method is useful if
you are dealing with a severe ulcer of the cornea, in
that it cleans up the sac temporarily.
Those cases of chronic dacryocystitis which do not
respond to conservative treatment divide themselves
into three groups :?
1. Those with obstructed canaliculi.
2. (a) Those with free canaliculi and with no
matting around due to a previous dacryocystitis ;
(b) as in (a) but with considerable matting.
In the first group excision of the sac will probably
give the best results, as with dacryocystorhinostomy
a good passage from the puncta is required. If possible
I always prefer restoration of the original channel,
or provision of an equally efficacious alternative
one, rather than excision of the sac, which should be
confined to those matted sacs where it is very difficult
to identify the walls.
Excision of the sac is very greatly favoured by many
surgeons, and it entails a deeper dissection and
disturbance of parts than the modified Toti operation,
which does not necessitate the cutting across of the
internal palpebral ligament, which is necessary in
excision in order to get to the dome of the sac.
Since I am of the opinion that this disease in the
majority of cases has primarily a nasal origin?some
observers make it 78 per cent.?I make it my practice
to have these cases seen by a rhinologist to report on
the nasal condition.
By means of dacryocystorhinostomy a new opening
is made into the nose, which in the majority of instances
has proved successful. The disappearance of stasis
Diseases of the Lachrymal Sac 157
is a great factor in clearing up the condition, and
the conjunctival sac rapidly becomes sterile.
Acute Dacryocystitis.
The acute form only supervenes on the chronic. The
patient usually comes with a tense red swelling over
the site of the sac, induration having extended beyond
the sac owing to a loss of continuity in its walls.
As a rule these conditions are best treated by
incision and cleaning up of the sac cavity, but there is
so much matting present that excision of the diseased
sac becomes advisable later on. Therefore early
recognition and treatment of a chronic dacryocystitis
should prevent this occurrence.
Summary.
Early recognition of lachrymal obstruction and
treatment by gentle probing or syringing should bring
about a cure.
When definite obstruction is present with a
chronic dacryocystitis then restoration of the original
channel or formation of an alternative one should
be procured.
With considerable matting of the surrounding
tissues and impermeable canaliculi extirpation of the
sac should be performed. It has been said that a
good extirpation of the sac is better than a poor
dacryocystorhinostomy; but the converse is equally
true, and the constant epiphora of one of my
friends brings this home to me every time I see
him.
I feel I cannot do better than conclude by quoting
158 Diseases of the Lachrymal Sac
Professor Meller, himself an exponent of excision,
who ends by saying, " The aim of the treatment
of chronic dacryocystitis must be the same ideal
which we try to attain in the treatment of all diseases
?restoration of the normal anatomic and physiological
conditions, that is, in this particular case restoration
of the mucus membrane of the sac and duct to a normal
condition, and restoration of the normal avenues of
conveyance so that they become permeable again."


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