CHAPTER X

OPERATIONS UPON THE LACHRYMAL APPARATUS

Operations upon the lachrymal apparatus are divided into--

I. Operations upon the lachrymal canals. II. Operations upon the lachrymal gland.

The majority of operations are undertaken for the relief of obstruction to some portion of the canal which leads from the conjunctival sac to the nose, obstruction to which causes an overflow of tears (epiphora)--a condition which must be distinguished from hypersecretion (lachrymation).

The obstruction may occur in any part of the canal, that is to say, in the puncta, canaliculi, lachrymal sac or duct; and it is most important to determine the cause and position of the obstruction in every case before undertaking an operation for its relief. Hence it need hardly be said that the nose should be carefully examined in every case unless the cause is obvious. The operations are divided into two classes:--

1. Those which are undertaken for the relief of the obstruction.

2. Those which are undertaken for the obliteration of the canals.

Except under exceptional circumstances, the latter operations are only undertaken when a cure cannot be brought about by the former.

The presence of a septic focus, such as a distended lachrymal sac, apart from the irritation and increased lachrymal secretion caused thereby, is a source of grave danger to the eye if not relieved, as it is a frequent cause of serpiginous corneal ulceration.

OPERATIONS FOR THE RELIEF OF LACHRYMAL OBSTRUCTION

DILATATION OF THE CANALICULUS

=Indications.= (i) Contraction of the puncta following marginal blepharitis, especially when associated with ectropion.

(ii) Preparatory to syringing or probing.

(iii) To dilate a stricture of the canaliculus.

=Instruments.= Nettleship’s canaliculus dilator (Fig. 163).

=Operation.= The operation is performed under adrenalin and cocaine, a little solid cocaine being rubbed in over the canaliculus.

The lid is slightly everted and put on the stretch by pulling it downwards and outwards with the thumb. The depression caused by the punctum is seen on the top of a small elevation. The point of the dilator is entered vertically into the punctum and then turned parallel with the lid margin and passed onwards with a steady pressure. At the same time it should be rotated between the finger and thumb, until the inner bony wall of the lachrymal sac is felt. The only difficulty which may be experienced is in entering the dilator into the punctum, owing to the small size of the latter. For this reason the fine point of Nettleship’s dilator is more suitable than the form modified by Lang. Even Nettleship’s dilator is too large in a few cases, and here a large sharp-pointed pin is sometimes of use in defining the punctum before using Nettleship’s dilator.

SLITTING THE CANALICULUS

=Indications.= To enlarge the punctum and direct the entrance to the canaliculus inwards. This is especially desirable before ectropion operations and for the removal of concretions (leptothrix) from the duct. In former days the canaliculus used to be slit with the idea of passing very large probes down the lachrymal duct; this has now been abandoned, since slitting the canaliculus throughout its whole length, as is required for this treatment, does away with the capillary attraction.

=Instruments.= Dilator, canaliculus knife (Fig. 164), straight iris forceps, sharp-pointed scissors.

=Operation.= It is usually performed on the lower canaliculus. The eye is cocainized as in the previous operation and the patient is made to look up.

_First step._ The canaliculus is first dilated. The knife is inserted for a short distance with the handle parallel to the lid margin. The lower lid being held on the stretch by the thumb, the handle of the knife is raised towards the brow, thus dividing the canaliculus. The blade of the knife should be directed upwards and slightly backwards.

_Second step._ As the lips of the wound are liable to reunite, it is better to remove the posterior lip of the groove. This is performed by seizing the latter with forceps and dividing it with scissors. The entrance to the canaliculus should be kept open by means of the dilator passed twice a week for a month.

SYRINGING THE LACHRYMAL DUCT

=Indications.= (i) To test whether the lachrymal canals are patent.

(ii) By constantly cleansing the sac and washing away all purulent discharge the mucous membrane may regain a more healthy condition, and so an obstruction due to an alteration in the mucous lining may be relieved. In cases with a purulent discharge a small quantity of protargol (10% solution) may be left in the sac after syringing.

(iii) The injection of adrenalin and cocaine into the sac before its excision.

=Operation.= The eye is cocainized and the patient made to look up. The punctum is everted by pulling down the lower lid. The canaliculus is then dilated. The nozzle of the lachrymal syringe (Fig. 165) should be passed until it is felt to impinge on the bony outer wall of the sac. Withdraw the syringe slightly and apply gentle pressure to the piston. The fluid will either regurgitate through the upper canaliculus or, if the duct be patent, pass down into the nose and so into the throat.

=Complications.= If too forcible syringing be used extravasation of the fluid may take place. This is accompanied by pain and swelling in the lachrymal region. It usually subsides under hot fomentations, but suppuration and even cellulitis of the orbit have been known to occur.

PROBING THE LACHRYMAL DUCT

=Indications.= (i) In cases of congenital lachrymal obstruction due to débris blocking the duct.

(ii) When syringing has failed to bring about a cure, a probe may be passed once or twice to see if dilatation causes any improvement. It is especially useful in children.

(iii) As a preliminary to the insertion of styles.

Various forms of probes are employed, those of Bowman being in general use. Too fine a probe should not be used, otherwise a false passage is liable to be made.

=Operation.= This is performed under adrenalin and cocaine, which should be injected into the lachrymal sac.

The lower punctum is dilated and the probe passed parallel to the lid margin until it is felt to impinge upon the lachrymal bone. Keeping the point applied to the bone, the handle of the probe is rotated upwards through rather more than a quarter of a circle and passed by a gentle pressure downwards and slightly outwards into the duct, keeping the point of the probe close to the bone the whole way. The direction of the probe after entering the duct should be downwards, outwards, and backwards in the direction of the first molar tooth on the same side. The backward direction of the duct is much more marked in young children than in adults.

=Complications.= A false passage may be made into the antrum of Highmore. If such an accident should occur, no further attempt should be made to pass a probe for a few days until the wound has healed.

THE INSERTION OF STYLES

A few surgeons still insert styles into the lachrymal duct with the idea of continuous dilatation. The hollow styles used by Bickerton are the ones most frequently employed.

=Instruments= for dilating, slitting the canaliculus, probing, and styles. Also Stilling’s knife.

=Operation.= A general anæsthetic is desirable.

_First step._ The canaliculus is dilated and slit up, the posterior lip being removed (see p. 29).

_Second step._ The duct is dilated by probing (_vide supra_) or enlarged by passing Stilling’s knife down it.

_Third step._ A style is passed down the dilated duct. The lower end of the style should rest upon the floor of the nose, otherwise there is a tendency for the style to slip into the duct and disappear. Care should be taken that the upper end does not rub on the globe. Styles should generally be left in position from three to six months. A style should at first be made of lead wire and moulded until a suitable pattern is obtained, from which a hollow gold style can be made subsequently.

=Complications.= 1. _Dacrocystitis_ may follow the insertion of a style, which should then be removed until the inflammation has subsided.

2. _The style may slip down the duct._ If this should occur an attempt should be made to grasp it through the slit canaliculus. The lower end may present in the nose and the style can then be withdrawn with forceps. Occasionally styles lodge in the antrum of Highmore, in which case they must be removed after localization by the X-rays through an opening from the mouth above the canine tooth.

OPERATIONS FOR THE OBLITERATION OF THE CANALS

When syringing and probing have failed to relieve the lachrymal obstruction, one of the following operations for the obliteration of the lachrymal passages may be employed.

OBLITERATION OF THE CANALICULI

=Indications.= In cases of lachrymal obstruction in which an immediate operation upon the globe is required.

=Operation.= Under cocaine. Fine sutures armed with a small curved needle are passed beneath both the upper and lower can[al]iculus and tied so as to include them in the ligature. Permanent obliteration may be caused by the destruction of the lining membrane with the actual cautery.

EXCISION OF THE LACHRYMAL SAC

=Indications.= (i) For mucocele in cases of lachrymal obstruction which have failed to yield to other treatment.

(ii) In all cases of tuberculous disease of the sac.

(iii) For a recurrent lachrymal abscess after subsidence of the acute inflammation.

(iv) For hypopyon ulcer associated with lachrymal obstruction.

(v) Before operation on the globe in cases of lachrymal obstruction.

(vi) For lachrymal fistula.

=Instruments.= Small scalpel, forceps, Muller’s speculum (Fig. 166), Axenfeld’s retractor (Fig. 167), straight scissors, horsehair sutures.

=Operation.= Hæmorrhage is the most troublesome part of this operation; it is best controlled by injecting adrenalin (made from the dried gland, ʒj, and ℥j of water) and cocaine, 10%, into the sac a quarter of an hour before operating. Swabs on the end of a glass rod dipped in adrenalin and cocaine may also be used during the operation. A general anæsthetic is desirable, but many surgeons perform the operation under local anæsthesia, produced by injecting 5% cocaine with 1 in 1,000 adrenalin into the tissue surrounding the sac; but the latter plan has the disadvantage that the mixture may cause severe toxic effects, and the patient usually experiences some pain while the upper portion of the incision is being made and the lower end of the sac is being divided.

_First step._ The internal tarsal ligament is first defined by putting the lids on the stretch. An incision should be made, 15 millimetres in length (5 millimetres of which should fall above the tarsal ligament), backwards and inwards directly over the lachrymal sac. Muller’s retractor is then inserted to retract the wound laterally, the hooks being made to engage the margins of the incision by means of forceps. The superficial fascia and the fibres of the orbicularis muscle are then divided. The internal tarsal ligament in the upper part of the wound, together with the glistening deep fascia, is exposed and divided carefully so as not to injure the lachrymal sac, which is found directly beneath it (Fig. 168).

_Second step._ With scissors the sac-wall is then separated from the deep fascia which encloses it, first externally and then internally, the canaliculi being divided. Axenfeld’s retractor is then inserted in the longitudinal axis of the wound (Fig. 167). The middle of the sac is grasped with forceps and pulled forward, and the top of the sac is defined and detached. This is frequently difficult owing to the troublesome hæmorrhage which often occurs. The sac is pulled well forward, and the posterior wall is separated, the neck of the sac being divided as far down the duct as possible by means of scissors. A large probe is passed down the duct into the nose. Some surgeons remove the periosteum of the lachrymal bone as well as the sac, which is unnecessary. The wound is closed by three sutures, the middle one including the divided ends of the internal tarsal ligament. A firm dressing should be applied so as to keep the walls of the cavity in contact. In tuberculous cases it is desirable to curette the lower end of the duct after removal of the sac. The stitches are removed on the seventh day.

=Complications.= These may be immediate or remote.

=Immediate.= 1. _Inability to find the sac._ This may happen to a beginner, and is generally due to the fact that the dissection is carried too much inwards towards the nose. It should not occur if the guides to the sac carefully borne in mind, namely, the internal tarsal ligament and, on the inner side, the lachrymal crest, which can easily be felt with the finger or forceps in the wound.

2. _Opening the conjunctival sac._ This may take place when dividing the canaliculi. It is more likely to occur if the deep fascia has been imperfectly divided before carrying out the dissection to the inner side. As a rule the opening heals readily.

3. _Opening of the orbit_, due to the division of the fascia attached to the posterior lip of the lachrymal groove. It is recognized by the fact that orbital fat presents in the wound, and for this reason it makes the operation more difficult. It is most likely to happen when the lower end of the sac is being divided. It lays the orbit open to the possibility of septic infection. The internal rectus has been divided, no doubt due to the fact that the fascia, which passes from the outer surface of this muscle, is attached to the posterior lip of the lachrymal groove, and the muscle has been thereby pulled up into the wound; with ordinary caution such an accident is impossible.

4. _Injuries to the cornea._ Corneal abrasions by the clumsy insertion of retractors may lead to severe corneal ulceration.

=Remote.= 1. _Epiphora._ Normally the lachrymal secretion is largely removed from the conjunctival sac by a process of evaporation. It is only when the hypersecretion of tears takes place that the lachrymal apparatus is called much into use. As a rule, patients who have had the lachrymal sac excised do not complain of epiphora, except in a cold wind. Occasionally this epiphora may be so troublesome that removal of the palpebral portion of the lachrymal gland is desirable for its relief. There is no fear of the conjunctival sac becoming dry after this operation, since there are numerous accessory lachrymal glands (glands of Waldeyer and Krause) opening on to the superior fornix.

2. _A sinus._ The wound may break down and a sinus may form at the site of the incision. These cases are nearly always of tuberculous origin and not infrequently have underlying bone trouble. They can usually be made to heal by the use of iodoform and scraping.

3. _Recurrence of the mucocele or lachrymal abscess._ Occasionally the mucocele may re-form, or an abscess result after removal of the sac. This is due either to a piece of sac-wall being left behind, or to the relining of the cavity with epithelium from the cut end of the duct. It is particularly liable to occur in cases of a tuberculous nature. Firm pressure with the dressings after the operation is the best method of preventing the cavity relining with epithelium. If the condition has arisen, the pseudo-sac should be excised.

OPENING A LACHRYMAL ABSCESS

=Indications.= Lachrymal abscess is due to an inflammation around the sac-wall through which infection of the cellular tissue has taken place. The abscess should not be opened until pus is present, as even considerable swelling and œdema will often subside without suppuration; this is usually about the end of the third day. Further, if the opening be made too soon, the inflammation takes considerably longer to subside.

=Instruments.= Beer’s knife, forceps, and probe.

=Operation.= Usually performed under gas. An incision is made over the lachrymal sac and is carried downwards and inwards to the bone by a single puncture of the knife. The pus is evacuated, and the cavity stuffed with gauze, which should be changed daily for the first three days. Hot fomentations should be applied. As soon as the swelling has subsided, the lachrymal obstruction should be treated by one of the methods previously described.

OPERATIONS UPON THE LACHRYMAL GLAND

REMOVAL OF THE PALPEBRAL PORTION

=Indications.= For obstinate epiphora after removal of the lachrymal sac.

=Instruments.= Fixation forceps (two pairs), two sharp hooks, strabismus scissors, suture.

=Operation.= Usually performed under adrenalin and cocaine.

_First step._ The upper lid is doubly everted. The eversion is best carried out by holding the singly everted lid between forceps and then re-everting it; the forceps are then given to an assistant to hold. With a syringe a few drops of 5% cocaine are injected through the conjunctiva into the area to be operated upon.

_Second step._ The gland is seen beneath the conjunctiva at the outer part of the upper fornix, seized with forceps, and drawn forwards. A horizontal incision is made with scissors through the conjunctiva, which is dissected backwards. The edges of the wound are then held apart by means of sharp hooks (Fig. 170).

_Third step._ The gland, which is seen as a nodule, is drawn forward with forceps. By means of the scissors the gland is separated from its attachments along its whole length, starting on the inner side, the wound being subsequently closed with a few points of catgut suture.

REMOVAL OF THE ORBITAL PORTION

=Indications.= It is usually undertaken for tumours (endotheliomata, &c.) and retention cysts.

=Instruments.= Knife, artery and dissecting forceps, retractors, ligatures.

=Operation.= Performed under a general anæsthetic.

_First step._ An incision, three inches long, is made through the skin immediately below the outer third of the orbital margin. The underlying orbicularis palpebrarum is divided, and the orbital fascia covering the gland is defined and incised.

_Second step._ The gland is first separated from the periosteum of the depression in the bone in which it lies, and is drawn forward and carefully dissected out from the lid. The wound is then closed with sutures.

=An abscess in the lachrymal gland= should be opened by an incision similar to, but not so long as that in the above operation.

OPERATIONS UPON THE ORBIT

EXPLORATION OF THE ORBIT (KRÖNLEIN’S METHOD)

In this operation the bony outer wall of the orbit is divided above and below, and turned outwards so as to expose the orbital contents without interfering with the globe; the bony wall, being kept attached to the overlying tissue, can be replaced subsequently without fear of necrosis.

=Indications.= The operation is performed in cases of a suspected tumour of the orbit, which, if small and non-malignant, can be removed, the eye being left _in situ_. If doubt exists as to the nature of the tumour a piece can be removed and examined microscopically, either at the time of the operation or later. It is especially suitable for tumours of the optic nerve and for orbital cysts behind the globe.

=Instruments.= Scalpel, dissecting forceps, artery forceps, scissors, periosteum detacher, chisel and hammer, or preferably, a motor rotary saw, and retractors.

=Operation.= Performed under a general anæsthetic.

_First step._ A slightly curved incision with the convexity forwards is made so as to expose the outer margin of the orbit and carried down to the bone. The periosteum is separated from the inner surface of the outer wall of the orbit by means of a periosteum detacher and divided horizontally, the finger is inserted, and the orbit explored. If a small tumour or cyst be found it can sometimes be shelled out through this incision without enlarging the wound further.

_Second step._ The eye and orbital contents are carefully protected with a large flat retractor. The bone is first divided above, by means of either a chisel or a saw. The upper incision should pass through the base of the external angular process of the frontal bone, and run backwards and slightly downwards to the posterior end of the spheno-maxillary fissure. The lower incision should run directly backwards from the lower orbital margin into the spheno-maxillary fissure. The triangular wedge of bone attached by its outer surface to the soft tissues in the temporal fossa is then forced outwards. In doing this care must be taken not to fracture the orbital wall anteriorly, otherwise the space to work in will be much reduced.

_Third step._ Consists in the removal of the tumour. Care must be taken to displace the external rectus to one side so as to avoid injury to it as much as possible. If the case should be one of an optic nerve tumour, for which the operation is most frequently performed, the optic nerve is divided close behind the globe. The tumour is freed from the surrounding ciliary nerves and the ophthalmic artery and brought up into the wound as much as possible. The optic nerve is then divided at the apex of the orbit and the tumour removed. The wound in the periosteum of the outer wall of the orbit is closed with a catgut suture, the bone, together with the soft parts, replaced in position and the skin wound closed by sutures. A drainage tube should be inserted for at least twenty-four hours.

=Complications.= 1. _Proptosis._ The operation is liable to be followed by great proptosis as the result of hæmorrhage into the orbit. If the optic nerve has been removed, the globe may be dislocated forwards between the lids and come in contact with the dressings.

2. _Corneal ulceration._ As the cornea is frequently anæsthetic from division of the ciliary nerves, ulceration is very liable to follow. It is, therefore, desirable in many cases to stitch the lids together after closing the skin wound.

3. _Defective outward movement in the globe_ is of frequent occurrence, owing either to injury of the external rectus or the sixth nerve, or to involvement of them in the scar tissue. Stitching the periosteum together obviates the latter to a certain extent.

4. As the wound cicatrizes a certain amount of _enophthalmos_ is very liable to result.

EVISCERATION OF THE ORBIT

=Indications.= This operation is usually performed for some form of new growth originating either in the eye or the orbit.

=Operation.= This may be modified (1) according to the _position_ of the growth. In severe cases of rodent ulcer and sarcomatous growths, which involve the lids, it is desirable that the lids should be removed with the tumour; but in cases of tumour of the optic nerve, or disease situated far back in the orbit, and not involving the lids or conjunctiva, these structures may be retained, since a much better socket is thus obtained. (2) The _nature_ of the growth. In simple tumours, such as nævi and some cases of arterio-venous aneurism which have failed to yield to other treatment, the incomplete method, in which the lids are retained, is all that is necessary, but in malignant cases they should be removed.

_The Complete Method._ An incision down to the bone is first made, completely encircling the orbital margin and including any growth that may be involving the skin. The periosteum is then separated completely, as near to the optic foramen as possible. Care must be taken in dealing with the periosteum over the lachrymal bone, as the bone is liable to be fractured and an opening made into the nose if undue force be used. The apex of the cone formed by the periosteum is divided, as far back as possible, with curved scissors, and the whole orbital contents are removed. The wound is packed with gauze, and skin-grafting is subsequently performed when the bone has become covered with granulations; this usually occurs about the end of the second week.

_The Incomplete Method._ The globe is first enucleated and the outer canthus divided. The lids are well retracted and an incision is carried down to the bone along the orbital margins. The periosteum is then stripped up from the walls of the orbit and the apex of the cone divided as far back as possible, as in the previous operation. The conjunctiva and outer canthus are then united with sutures. As a rule, skin-grafting is not necessary after this operation.

OPENING AN ORBITAL ABSCESS

Orbital abscesses should be incised where they point. In the upper lid care should be taken not to divide the levator palpebræ muscle; the incision should be placed well to one side. In making an incision over the inner side of the orbit care should be taken not to detach the pulley of the superior oblique. The cause of the abscess should be ascertained if possible. Suppuration in the ethmoidal sinuses coming through from the nose is the commonest cause, and should be treated appropriately (see Section V).

SECTION III

OPERATIONS UPON THE EAR

BY HUNTER F. TOD, M.A., M.D. (Cantab.), F.R.C.S. (Eng.) Aural Surgeon to the London Hospital