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Conjunctivodacryocystorhinostomy

LESTER T. JONES, M.D.

S
URGERY IS INDICATED IN THE FOLLOWING CASES IN b. Secondary dye test. If the result of the primary dye test is
which disturbing epiphora exists because of canalic- negative, the dye is washed from the conjunctival sac, the
ular failure: patient’s head is tipped forward far enough for fluid to run
out from the anterior nares into a white basin. One cubic
1. Congenital absence, traumatic destruction or com- centimeter of normal saline is injected by a lacrimal can-
plete closure of both canaliculi in one eye. nula that has been inserted as far as the internal common
2. Closures of two or more mm of the nasal ends of the punctum. If the fluid comes out of the nose stained with
canaliculi. the dye, it is a positive test.
3. Cases with patent ducts in which the primary and A positive secondary dye test proves that there is no
secondary dye tests (see later) are both negative after obstruction at the punctum nor in the canaliculus and
all conservative treatment has failed. that the lacrimal pump is functioning as far as the tear
4. Following a dacryocystorhinostomy in which the sac which fills with the dye. The partial obstruction is in
canaliculi are patent but nonfunctioning. the nasolacrimal duct. If there is no dye in the fluid from
5. Cases with a permanent paralysis of the lacrimal pump. the nose, it is a negative test.
A negative secondary dye test proves that no dye has
reached the tear sac; the primary cause of the epiphora
DIAGNOSIS lies in the canaliculi.
Inspection must also rule out inverted, everted or
THE PRESENCE OF A TOTAL OBSTRUCTION CAN BE ESTAB- phimotic puncta, canalicular foreign bodies and neoplasms,
lished easily by irrigation and probing. A congenital allergic edema and inflammations of the ducts as being the
absence of the canaliculi usually can be assumed to be pre- cause of the epiphora. Epiphora due to lacrimal hypersecre-
sent if neither punctum can be found and there is a history of tion is never an indication for surgery on the lacrimal
epiphora since birth. At the time of operation, when the sac excretory mechanism.
is opened, this can be checked further by retrograde probing.
The canaliculus test1 also is of value. When normal saline
solution comes out through the upper canaliculus, after be-
ing injected into the lower, the test is positive, indicating
that the ducts are patent at least as far as their union
SURGICAL PROCEDURES
with each other or the lacrimal sac. EPIPHORA DUE TO DESTRUCTION OF THE LATERAL HALVES
The dye tests2 are of no value in complete obstructions of the canaliculi usually can be cured by an intermarginal
but are indispensable in the differential diagnosis of partial slitting of the patent medial parts.3 A closure of 2.0 mm or
obstructions. They tell one whether the epiphora is due to less of the nasal ends of the canaliculi often can be reopened.
the malfunction of the canaliculi or the nasolacrimal duct Both of these procedures have been reported previously.2
or to hypersecretion. Where the canaliculi are absent or cannot be restored to
a. Primary dye test. One drop of 1% fluorescein solution is normal function, a substitute for the lacrimal pump must
instilled in the conjunctival sac. A small cotton-tipped be found. Such a substitute is a tube that possesses capillary
applicator, moistened with a mixture of 1:1,000 epineph- attraction combined with a negative pressure exerted at its
rine and 5% cocaine solution, is introduced into the inferior nasal end. This latter factor is furnished by the negative pres-
meatus of the nose at intervals from one to five minutes. If sure phase, in the nose, of inspired air. A glass tube, and often
the cotton comes out stained with the dye it is a positive test. an epithelial-lined tube, will furnish the capillary attraction.
A positive primary dye test proves that there is no In my experience, there are only three acceptable types
obstruction in the lacrimal passages and that the epiphora of surgery for canalicular failure: (1) conjunctivodacryocys-
is due to hypersecretion. If, after three to five minutes, there tostomy, (2) conjunctivodacryocystorhinostomy and (3)
is no dye on the cotton, it is a negative test. conjunctivorhinostomy. Many doctors prefer the term
‘‘laco’’ for ‘‘conjunctivo.’’ The term, conjunctivorhinos-
Portland, Oregon. tomy, is used in cases in which the tear sac is absent and

xxxvi © 2018 ELSEVIER INC. ALL RIGHTS RESERVED. 0002-9394/$36.00

https://doi.org/10.1016/j.ajo.2018.02.004
in cases in which the sac has been obliterated by a dacryo-
cystorhinostomy or dacryocystectomy. Except in congen-
ital cases, a tear sac is usually present.
A fourth method is mentioned only to be condemned
and that is removal of the lacrimal gland or cutting of its
ducts or efferent nerve supply. Where such successful
methods are at hand to repair the excretory system, it seems
folly to impair the secretory system and thereby risk
creating a much more disabling condition—a dry eye.

1. CONJUNCTIVODACRYOCYSTOSTOMY
THE USUAL CUTANEOUS APPROACH IS MADE TO THE TEAR
sac and the fundus of the sac is mobilized.4 A stab incision
is then made through the lacus area to the lacrimal fossa,
beginning 2.0 mm posterior to the commissure. This inci-
sion is extended laterally, between the converging heads
of the lower pretarsal muscle, nearly to the conjunctival
side of the tarsus. The fundus is then opened and pulled
into this opening (Figure 1) and sutured to its conjunctival
margins.
I have done 25 cases by this method. There are several
drawbacks. It is often difficult to dissect out the fundus FIGURE 1. (JONES). Conjunctivodacryocystostomy. The
and mobilize it adequately. The new ostium will almost al- fundus of the sac (a) has been mobilized and opened at the
ways close unless held open by a tube with a collar on its top, to be sutured to the conjunctival margins of the stab incision
upper end. The tube is poorly tolerated as the movement into the lacrimal fossa. The deep head of the lower pretarsal
of the lids is at right angles to the direction of the tube muscle is seen on the posterior side of the incision.
(Figure 2). Even if the ostium is kept from closing, drainage
into the nose is unpredictable. Transplanting the fundus
destroys the pumping effect of the preseptal muscles.

2. CONJUNCTIVODACRYOCYSTORHIN-
OSTOMY AND
CONJUNCTIVORHINOSTOMY
THESE TWO PROCEDURES SHOULD BE DESCRIBED TOGETHER
as the technique is identical in nearly every detail. In the
absence of a sac, instead of suturing the nasal mucosal flaps
to the tear sac flaps, the former are sutured to the lacrimal
fascia instead.
a. Transplantation of the sac. This is done in the same way
as the conjunctivodacryocystostomy already described, as
far as the transplantation of the fundus is concerned. The
bone of the medial wall of the lacrimal fossa is then FIGURE 2. (JONES). Conjunctivodacryocystostomy with
removed; the lower end of the sac is severed from the naso- persistent epiphora. A glass tube was installed, but the medial
lacrimal duct and transplanted upward and sutured to the movement of the lids would lift the collar above the level of
margins of an opening made in the nasal mucosa. This is the lacus.
a long and arduous procedure and about half of the patients
will have to wear a tube to keep the passage from closing or
to relieve the epiphora. Sometimes the opening is too large b. Mucous membrane flaps. Conjunctival and nasal
or its final position changes to a less functional place mucosal flaps (Figure 4) have been advocated especially
(Figure 3) . in cases without a tear sac. These all have the same

VOL. 187 CONJUNCTIVODACRYOCYSTORHINOSTOMY xxxvii

FIGURE 3. (JONES). Conjunctivodacryocystorhinostomy
with transplantation of the lower end of the tear sac through
an opening in the nasal mucosa. The opening is too large and
has migrated medially.
FIGURE 4. (JONES). Conjunctivorhinostomy. The nasal mu-
cosa has been cut and elevated from the bone. The lower end of
the flap (a) has been rolled upward to make an epithelial-lined
difficulties that are found in transplantation of the sac,
tube. The insert shows the tube rotated into the incision into
although most of them can be salvaged by installing a the conjunctival sac, where it is sutured in place.
tube, as will be described later.
c. Epithelial transplants. This is, perhaps, the ideal proced-
ure. But it takes more skill than the average ophthalmic
surgeon may feel that he possesses. The epithelium is su-
injection is also placed above the canthus in the region
tured around polyethylene tubing, 3.0 mm in diameter,
of the dorsalis nasi artery. The region around the anterior
epithelial side in. A very thin graft of buccal mucosa works
end of the middle turbinate is packed with gauze saturated
quite well. With good care, about half of these cases will
with a mixture of 10% cocaine solution and 1:1,000
succeed and almost all that close can be salvaged with a
epinephrine solution.
tube.
The operation is begun not sooner than 15 minutes after
the injection is made. The operator should stand at the side
of the patient (Figure 5) as it will enable him to do the sur-
TECHNIQUE OF OPERATION gery without cutting the medial palpebral tendon. Another
advantage is that he can look up under the ligament and
THE FOLLOWING TECHNIQUE WAS FIRST REPORTED IN I960.5 tell when enough bone has been removed to clear the
It is offered as the most successful treatment in all cases of area for the new passage into the nose.
nonfunctioning canaliculi, with or without a tear sac. I The skin incision is made 11 mm medial to the medial
have now done 125 of these operations and, of the ones I commissure (Figure 6), beginning slightly above the level
have been able to follow personally, have had no failures. of the tendon and extending downward and slightly out-
However, no ophthalmologist should attempt this proced- ward 30 mm. The knife should not cut deeper than the sub-
ure unless he is willing to observe the intranasal end of the cutaneous fascia. A self-retaining spring type retractor is
tube and ostium, at nearly every postoperative visit or, in inserted and the remaining strands of fascia are cut with
lieu of this, to work closely with a rhinologist. scissors.
A preliminary nasal inspection must be made to rule out With two Freer elevators, the angular vein is located as it
a deviated septum, an enlarged anterior end of a middle crosses the medial palpebral tendon. The vein is pressed to
turbinate, polyps or anything that might impinge on the the medial side with one elevator, while the other begins
end of the tube or impair the airway. If nasal surgery is the separation of muscle and periosteum exactly beneath
necessary, it should be done as a preliminary procedure, the point where the tendon attaches to the bone. With
although it can be done at the same time as the lacrimal pressure against the bone, the elevator is carried downward
surgery. and outward parallel to the muscle fibers, until the region of
As good hemostasis is a most important factor; every the spine of the anterior lacrimal crest is reached (Figure 7).
adult patient is urged to have a local anesthetic. The oper- This should make the periosteal division about 5.0 mm
ating table is tilted foot downward about 20 degrees. An medial to and below the margin of the anterior lacrimal
infiltration consisting of 2% novocaine, with 10 drops of crest.
1:1,000 epinephrine to the ounce, is made in the tissue The periosteum should be elevated from the bone on
beneath the medial canthus. A small amount is injected both sides of this incision. The elevator is then passed back-
lateral to the sac, posterior to the septum orbitale. One ward between the periosteum and bone of the lacrimal

xxxviii AMERICAN JOURNAL OF OPHTHALMOLOGY MARCH 2018

FIGURE 5. (JONES). The operator stands at the side of the pa-
tient so he has better visibility of the bony wall of the lacrimal
fossa and fundus of the sac. The foot of the table is tipped down-
ward 15 degrees to lessen bleeding.
FIGURE 7. (JONES). The bone should be removed from
5.0 mm anterior to the anterior lacrimal crest (E) back to (but
not including) the posterior lacrimal crest (B). (C) Attachment
of medial palpebral ligament. (A) Frontal process of maxilla. (D)
Lacrimomaxillary suture. (F) Spine of anterior lacrimal crest

of 10% cocaine solution and 1:1,000 epinephrine solution.

It has three values: it is hemostatic, supplements the anes-
thesia and protects the sac from possible trauma during
removal of the bone.
The spring retractor is exchanged for one with longer
teeth which will reach the periosteum and give better
deep exposure. The bone of the anterior lacrimal crest
and wall of the lacrimal fossa is removed with chisel,
trephine or dental burr, being careful not to injure the nasal
mucoperiosteum. After careful separation of the soft tissue
from the bony margins, the opening is enlarged with a flat-
nosed Kerason punch. The area most important to remove
FIGURE 6. (JONES). The incision is begun 11 mm medial to is just in front of the posterior lacrimal crest and under the
the medial commissure and 3.0 mm above the level of the medial medial palpebral tendon (Figures 8 and 9). The tendon
palpebral tendon. It is extended downward and slightly outward should never be cut as it is a most important guide for
for 30 mm. placing the tube later.
The last bone to remove is the medial half of the nasola-
crimal canal. The nasal mucoperiosteum is separated first
from the canal down to the inferior turbinate. A flat chisel
fossa, keeping as close as possible to the level of the lower is used to separate the anterior attachment of the canal
margin of the tendon. The contents of the lacrimal fossa from the maxilla. The posterior attachment is so thin
are then freed from the bone back to but not beyond the that it usually breaks when the anterior attachment is sev-
posterior lacrimal crest. The separation is also carried ered. The bone is then mobilized and removed with a
downward as far as possible into the nasolacrimal canal. straight hemostat. A good rule in all tear-sac surgery is
A dental-pellet sponge (used by neurosurgeons in most never to have a bony margin nearer than 5.0 mm to the in-
hospitals) is then inserted. This consists of a small pellet ternal common punctum.
of cotton to which the nurse has attached a short length The tear sac is now opened with a pointed Bard-Parker
of black threat. It is dipped into a mixture of equal parts blade slightly posterior to the center of its medial wall

VOL. 187 CONJUNCTIVODACRYOCYSTORHINOSTOMY xxxix

FIGURE 8. (JONES). Illustration showing incomplete removal FIGURE 9. (JONES). Illustration showing complete removal
of bone (a) from beneath the medial palpebral tendon (b). of bone from beneath the medial palpebral tendon.

(Figure 10). As soon as the wall is perforated, one blade of a is then passed along the flat side of the knife into the nose.
small curved iris scissors is inserted into the sac and the The tube is turned so that its point lies between the flat side
incision is extended from the top of the fundus to the bot- of the knife and the probe and then is pushed through the
tom of the nasolacrimal duct. A similar incision is made in new passage. If this technique is not followed, the tube
the nasal mucoperiosteum adjacent and parallel to the one often is difficult to insert, due to its nasal end catching in
in the tear sac (Figure 11). The posterior flaps of the tear sac fascial bands. A 6-0 black silk suture on a cutting needle
and nasal mucosa are sutured together with two 4-0 plain is passed through the collar of the tube and out through
catgut sutures on an atraumatic, one-fourth inch, half- the adjoining skin of the commissure and tied. If the nasal
circle needle. end of the tube touches the septum, it is cut shorter.
The caruncle is next excised, being careful not to remove Two or more sutures are now placed in the anterior tear
any of the adjacent conjunctival tissue with it. A 23-gauge sac and nasal mucosal flaps. The periosteum is similarly
hypodermic needle, 30-mm long, is bent into a curve so closed and the skin united with a running mattress suture
that the point of the needle is on the inside of the curve. of 6-0 black silk. In the absence of the tear sac, the nasal
The needle should be held with the concavity of the curve flaps are sutured just posterior and anterior to the point
facing anteriorly. The point is then inserted in the lacus where the guide needle emerges. It is necessary for the
exactly 2.0-mm posterior to the cutaneous margin of the tube to have ‘‘soft-tissue’’ suspension, that is, free move-
canthal angle. It is then pushed in a direction that will ment without contact with rigid structures during blinking.
cause its point to emerge just posterior to the anterior The dacryocystorhinostomy may be done by any other
tear sac flap and slightly below the level of the palpebral method. The foregoing description is given primarily
fissure (Figure 11). Several attempts may be necessary to because it furnishes the new passage with a little more
get the point to emerge in exactly the right place. It must epithelization at its nasal end. It is the Ohm6 procedure
be anterior to the body of the ethmoid and middle turbi- with occasional crosshatching of the anterior nasal flap as
nate, whose anterior end should be resected if it interferes described by Dupuy-Dutemps,7 when necessary to suture
with the tip of the needle. the anterior flaps together.
A cataract knife of medium width is then inserted into The polyethylene tube may be left in until the postoper-
the sac, following the guide needle. The needle is then ative swelling subsides. However, a pyrex glass tube may be
removed and the knife (Figure 12) enlarges the passage su- substituted at almost any time. The glass tubes recommen-
periorly and inferiorly just enough to allow insertion of a ded are 2.0 mm in outside diameter with a rounded 4.0-mm
No. 240 polyethylene tube. Do not remove the knife until collar and a 2.25-mm enlargement at the nasal end
the tube is in place, as will be described later. (Figure 13). They are custom made* and vary from 10 to
The tube should have a collar at least 4.0-mm wide. It
should be about 18-mm long and have a bevelled end. It
is threaded, collar first, over a No. 1 lacrimal probe, which Gunther Weiss, 2025 S.W. Briggs Court, Beaverton, Oregon.

xl AMERICAN JOURNAL OF OPHTHALMOLOGY MARCH 2018

FIGURE 10. (JONES). A vertical incision is made in the
medial wall of the tear sac from the fundus to as far into the
nasolacrimal duct as possible. The incision should be between
the anterior two thirds and posterior one third of the sac wall.

FIGURE 12. (JONES). The needle has been withdrawn and

the passage enlarged by knife above and below. The insert shows
the tube in position.

not get obstructed with secretions as easily as the plastic

tube (Figure 14). Following parotid duct transplantation,
a tube with a slightly larger diameter might be adequate.
Due to the invasion of fibroblasts, the new passage will
contract down about the tube within a few minutes in
the early postoperative stage. But in the later stages,
contraction becomes greatly diminished, the tube becomes
loose and is often blown out or lost. This usually occurs
about 18 to 24 months after the surgery. The patient
must be taught not to blow his nose, or to hold his finger
over the tube if he does.

FIGURE 11. (JONES). Illustration showing the guide needle

in position entering the nasal cavity just posterior to the anterior
tear-sac flap. The Graefe knife is being inserted along the guide MODIFICATION OF TECHNIQUE
needle. The posterior tear sac and the nasal mucosal flaps have
been sutured together. A MODIFICATION OF THE METHOD JUST DESCRIBED IS USED
in cases that have had previous dacryocystorhinostomies
which have failed and in which part or all of one or both
16 mm in length. Some are made with a bevel and no canaliculi are still present. The purpose is to use all of the
enlargement at the nasal end, but these are more easily remaining epithelium of the canaliculi, that is medial to
lost. If the mouth of the tube lies at a poor angle in the lacus the commissure, to line the new passage. Any patent part
and does not drain well, a slight angle to the tube may be of of the canaliculi lateral to the commissure is bypassed, as
value. After a month or two, a tube with a 3.0-mm collar is a slit canaliculus is moderately disfiguring and the move-
substituted for the 4.0-mm one. ment of that part of the lid against the collar of the tube
The glass tube has the advantage of being less irritating often causes the epithelium to become swollen and cause
to the tissues. It possesses capillary attraction and does discomfort.

VOL. 187 CONJUNCTIVODACRYOCYSTORHINOSTOMY xli

 FIGURE 15. (JONES). Dilator inserted to stretch the passage
while the glass tube is being exchanged or cleaned.

FIGURE 13. (JONES). The pyrex glass tubes with bevelled

ends and 2.5-mm enlarged ends. The collars are either 4.0 mm point of the needle must emerge in the nose far enough
or 3.0 mm in diameter. The double-ended dilator is inserted in anteriorly to be free of the ethmoid body and middle turbi-
the passage whenever the tube is changed or taken out for clean- nate. Only where the bone of the lacrimal fossa has been
ing.
inadequately removed at the original operation, will a
skin incision have to be made to remove more bone.
Postoperative care. Most of these cases will require very
little postoperative care, but some will challenge the inge-
nuity of the surgeon. In my experience, every case can be
saved as long as the nasal airway is patent.

COMPLICATIONS
A. THE TUBE MAY COME OUT. SEE THE PATIENT AS SOON AS
possible. During the first few weeks, simply dilate the pas-
sage with a curved Ziegler punctum dilator and a Ziegler
FIGURE 14. (JONES). Appearance of tube in normal position. No. 12 probe (made by Sklar). The dilator shown in
Figure 13 is also excellent for this.* The pyrex tube,
threaded over a No. 1 Bowman probe, can then easily be
reinserted.
The caruncle is first excised. The end of a Bowman No. 1 If the tube has been out too long and the passage has
probe is bent at a slight angle and passed into the canalic- closed, inject about 0.5 cc of 2% novocaine with adrenaline
ulus as far as the lacus area. Here the duct is tented forward solution above and below the medial canthus and cocainize
and buttonholed with pointed scissors. Where the duct is the nasal mucosa in front of the middle turbinate. Install
patent into the nose, a knob-ended canaliculus knife is the tube by repassing the guide needle under intranasal in-
inserted through the new opening, the duct is slit and the spection etc., as previously described. This can be done as
tube installed. If both canaliculi are patent, both are slit an office procedure.
and a single passage is created between them. If the nasal b. Infection with or without granulation tissue. This is usu-
ends are obliterated, the patent parts are slit and a guide ally due to the formation of a rough, hard, scalelike coating
needle is pushed through the obstructed area which is on the outside of the tube. A mucopurulent discharge is
then slit with a Graefe knife. usually seen whenever the outside of the tube gets this de-
In this same group of postoperative failures without us- posit. Pressure from the collar of the tube against the upper
able canalicular epithelium, the caruncle is removed and
the guide needle is inserted as previously described, under Made by Custom Tool Co., 5305 NE. 47th Avenue, Portland, Oregon,
intranasal inspection. This latter is necessary because the 97218.

xlii AMERICAN JOURNAL OF OPHTHALMOLOGY MARCH 2018

lid and conjunctiva may also cause it. In one or two cases it the use of the tube and use the dilator just often enough to
has developed at the nasal end of the tube. keep the passage from contracting. One patient has solved
The cure is simple—the tube is removed and cleaned and the problem by working up to the point where she can take
replaced after the granulation tissue has been excised. the tube out in the morning and reinsert it at night.
c. The tube becomes obstructed. This usually denotes a The question has been raised as to whether this opera-
conjunctival or nasal allergy or infection. The patient or tion is justified for the relief of epiphora alone, for only in
one of his family is given a wire (such as the stylet which an occasional traumatic case is there an infection medial
comes with 30-mm long hypodermic needles) and taught to the canaliculi. Certainly, no patient with a minor hand-
how to pass it through the tube to open it. Mucous accumu- icap from epiphora should be encouraged to have the sur-
lations around the nasal end may be removed with forceps. gery. Elderly patients with the pseudo-epiphora of
The patient is taught to use a daily nasal douche of normal beginning decrease in function of the basic lacrimal glands
saline, or ‘‘squirt’’ normal saline through with a medicine (mucin-secreting conjunctival goblet cells, accessory
dropper. lacrimal glands of Kraus and Wolfring, and oil producing
d. The collar of the tube becomes partially or completely glands) should not have the surgery. The condition can
submerged. This is usually found in patients who habitually be diagnosed by instilling one or two drops of a local anes-
press on the tube or have a narrow canthal angle and do an thetic into the conjunctival sac of both eyes and, after wait-
abnormal amount of squeezing. The tissue over the collar ing a minute or two and drying the eye, taking a Schirmer
should be cocainized and a Bowman No. 1 probe passed test, the result of which is lower than normal.
through the tube (this can usually be done even though Patients who are truly handicapped by epiphora are,
the collar is completely submerged). The nasal mucosa is however, most grateful for their relief. Children who feel
then cocainized and the tube is pushed back out along socially rejected because of their tearing eye make remark-
the probe with a small ring curette or spatula. If this fails, able adjustments. The wife of a 35- year-old patient wrote,
novocaine is injected around the collar and the constrict- ‘‘This is the first time in three years that I have seen my hus-
ing ring of tissue is cut with a pointed Bard-Parker blade band without a piece of Kleenex in his hand.’’ A doctor’s
or small pointed scissors. The intranasal procedure is wife told me she had to wipe her eye every six minutes dur-
then repeated. ing every waking hour, before the operation. A Texas
e. The tube may drain poorly after several months. As the physician whose ducts had been ruined by one or more
scar tissue at the medial canthus begins to relax, the tube ‘‘3-snip’’ operations on all four canaliculi, wrote, ‘‘I
sinks deeper into the nose and often rides against the nasal wouldn’t take a fortune for my glass tube. I had about
septum. Whenever the surgeon can see that the tube is pro- decided to give up my surgery as it was almost impossible
truding more than 2.0 mm into the nose, it should be taken to see what I was doing through the tears.’’
out and exchanged for a shorter one.

SUMMARY
COMMENT
IN EVERY CASE OF DISTURBING EPIPHORA DUE TO A PERMA-
THE QUESTION THAT IS MOST FREQUENTLY ASKED IS ‘‘HOW nent failure of the canaliculi, a new passage should be
long will the patient have to wear the tube?’’ This seems to created through which the tears can be propelled. A glass
depend on how long it takes the new passage to epithelize tube or an epithelial-lined passage, possessing capillary
and when the fibroblasts in its walls will cease to contract. attraction combined with the negative pressure phase of
Cases in which canalicular epithelium helps line the pas- tidal respiration in the nose, is a satisfactory substitute for
sage do the best. One 65-year-old patient was able to the lacrimal pump.
discard her tube after about two months. In almost all cases Various methods of creating such a passage are discussed
the tube will begin to get looser after about one year. This is and my experience with a conjunctivodacryocystorhinos-
a sign that the fibroblastic contraction is diminishing. tomy is given. In this procedure a pyrex glass tube is used
The patient can buy the dilator shown in Figure 13 and until the new passage is completely epithelized and ceases
be taught how to use it (Figure 15). He or one of his family, to constrict.
begins by learning to take the pyrex tube out and immedi- 624 Medical Arts Building (5).
ately reinserting it. He then learns to take the tube out,
wait a few minutes and then put the dilator in for a white,
always replacing the tube after withdrawing the dilator.
REFERENCES
Each day the interval of time between taking the tube
out and putting the dilator in, is increased until he can 1. Waldapfel, R.: Clinicopathologic studies of obstructions of the
take the tube out in the morning and insert the dilator in tear passages. Tr. Pacific Coast Oto- Ophth. Soc., 34:289,
the evening. From that time on the patient can discontinue 1953.

VOL. 187 CONJUNCTIVODACRYOCYSTORHINOSTOMY xliii

2. Jones, L. T.: The cure of epiphora due to canalicular disorders, 5. An anatomic approach to problems of the eyelids and lacrimal
trauma, and surgical failures on the lacrimal passages. Tr. Am. apparatus. Arch. Ophth., 66: 111–124 (July) 1961.
Acad. Ophth., 66:511 (July-Aug.) 1962. 6. Ohm, J.: Geschichtliche Bemerkung zur Verbesserung der
3. Tr. Am. Acad. Ophth., 66:514, 523 (July-Aug.) 1962. Totischen Operation. Klin. Monatsbl. Augenh., 77:825–832,
4. Epiphora: Its relation to the anatomic structures and surgery of 1926.
the medial canthal region. Tr. Pacific Coast Oto-Ophth. Soc., 7. Dupuy-Dutemps, and Bourguet: Plastic operation for chronic
37:59, 1956. dacryocystitis. Bull. Acad. Nat Med., 1921, p. 293.

xliv AMERICAN JOURNAL OF OPHTHALMOLOGY MARCH 2018