Colored nasolacrimal test. Study of the patency of the lacrimal ducts, canalicular test. 14. study of tear production Probing of the nasolacrimal duct
N.N. Arestova
Dacryocystitis is one of the most common inflammatory diseases eyes in children, accounting for 7 to 14% of ophthalmopathologies in childhood, and develop especially often in newborns. The frequency of dacryocystitis in newborns is, according to various authors, 1-4% of all newborns (Beklemisheva M.G., 1973; Cherkunov B.F., 2001; Brzhesky V.V. et al., 2005). Untreated dacryocystitis in a timely manner leads to the need for complex repeated surgical operations and is often difficult to treat, leading to constant lacrimation, which further limits the choice of profession.
Definition
Dacryocystitis of newborns- inflammation of the lacrimal sac, caused by congenital narrowing or obstruction of the lacrimal ducts, clinically manifested in the form of first catarrhal and then purulent inflammatory process (purulent, mucopurulent or mucous dacryocystitis) (Fig. 1, 2, see color insert).
Etiology and pathogenesis
The main cause of dacryocystitis in newborns is obstruction of the nasolacrimal duct, caused by the presence of an embryonic gelatinous plug of mucus and dead embryonic cells or an embryonic rudimentary membrane that did not have time to resolve before birth (underdeveloped, imperforate).
the Hasner valve, which was formed at birth), closing the exit from the nasolacrimal duct into the nasal cavity (Cherkunov B.F., 2001; Chinenov I.M., 2002; Somov E.E., 2005; Kanski D., 2006; Saydasheva E.N. et al., 2006; Taylor D., 1997; Fanaroff A.A., Martin R.J., 2000).
Normally, the exit from the nasolacrimal duct is closed until the 8th month of gestation. In 35% of newborns, the outlet of the nasolacrimal duct is closed by the embryonic membrane, incompetence of the lacrimal ducts varying degrees detected in almost 10% of newborns (Krasnov M.M., Beloglazov V.G., 1989; Cherkunov B.F., 2001). In the first days or weeks after the birth of a child, the patency of the lacrimal ducts usually recovers on their own with the release of the plug or rupture of the film of the nasolacrimal duct. If the lumen of the nasolacrimal duct does not clear on its own, dacryocystitis of the newborn develops. The contents of the lacrimal sac (mucus, detritus of embryonic, epithelial cells) is a favorable environment for the development of the inflammatory process.
Other causes of obstruction of the lacrimal ducts in newborns may be their congenital pathology or the consequences of birth trauma. Among them, the most common are narrowings of the bony nasolacrimal canal or the membranous nasolacrimal duct, especially at the junction of the lacrimal sac with the nasolacrimal duct; diverticula and folds of the lacrimal sac, abnormal exit of the nasolacrimal duct into the nasal cavity: a narrow, tortuous exit, often covered by the nasal mucosa or exit by several excretory canaliculi. Less common is agenesis of the nasolacrimal duct with dysostosis. upper jaw(Beloglazov V.G., 1980, 2002; Cherkunov B.F., 2001; Grobmann T., Putz R., 1972; Goldbere A., Hurwitz J.J., 1979).
Anatomical features of the structure of the nasal cavity in newborns (small height of the nasal cavity, narrow nasal passages, frequent curvature of the nasal septum, virtually no volume of the lower nasal passage due to the relatively thick inferior nasal concha, touching the bottom of the nasal cavity and covering the lower nasal passage) contribute to the incompetence of the lacrimal passages. ways. In addition, half of the children have inflammation of the mucous membrane and abnormalities of the nasal cavity.
The rhinogenic factor can be concomitant, worsening the prognosis of treatment, or be the main cause of incurable epiphora (lacrimation) (Beloglazov V.G., 1980; 2002; Cherkunov B.F., 2001).
There is practically no lacrimation in newborns due to underdevelopment of the lacrimal gland. The newborn's eye is moisturized
secretion of the mucous glands of the conjunctiva. Normal tear production in 90% of children is formed by the 2-3rd month of a child’s life.
The main factors that ensure normal lacrimal drainage in a child are capillarity of the lacrimal openings (suction of fluid into them), negative pressure in the lacrimal system (due to contraction and relaxation of the orbicularis oculi muscle and Horner’s muscle), contraction of the lacrimal sac, the gravity of the tear, and the presence folds of the mucous membrane of the lacrimal ducts, playing the role of hydraulic valves (Malinovsky G.F., Motorny V.V., 2000; Cherkunov B.F., 2001). The absence of pathology in the nasal cavity and the preservation of nasal breathing are important in ensuring normal tear drainage (Beloglazov V.G., 1980 and 2002).
Clinical picture
The main clinical signs of dacryocystitis in a newborn are purulent, mucous or mucopurulent discharge in the conjunctival cavity of one or more often both eyes in the first days or weeks of life. Conjunctival hyperemia, lacrimation, and less often lacrimation are possible (Kovalevsky E.I., 1969; Avetisov E.S. et al., 1987).
The cardinal sign of the disease is the release of mucus or pus from the lacrimal openings (usually the lower ones) when pressing on the area of the lacrimal sac - compressing it (Fig. 3). However, with pronounced congenital or post-inflammatory stenosis, fusion tear ducts or against the background of drug treatment, this symptom may be absent. Lacrimation and lacrimation are usually detected somewhat later, as tear production increases with age. With careful care and preventive treatment of the child's eyes with disinfectant solutions, discharge from the eyes and lacrimation, especially in premature infants, may appear much later - in the second or third month of life (Avetisov E.S. et al., 1987; Cherkunov B.F., 2001; Saidasheva E.I. et al., 2006).
Often, in the first days of life, a congenital malformation of the lacrimal sac is detected - dacryocystocele - hydrocele of the lacrimal sac (Fig. 4, see color insert) (Harris G.I. et al., 1982; Taylor D., 1997; Taylor D., Hoyt K. , 2007). This prominent formation in the area of the sac does not pulsate, the skin over it has a bluish-purple tint due to tissue stretching; when an infection develops in the cavity of the lacrimal sac, the yellow contents of the sac are visible through the skin.
DIAGNOSTICS
When analyzing complaints, it is necessary to find out the presence and duration of discharge from the eyes, lacrimation or lacrimation, the dynamics of complaints; find out how the child was treated, at what age and for how long. It is necessary to record in detail which local medications have already been used, what effect or adverse reactions were observed from the conjunctiva and skin of the eyelids. Be sure to ask the child’s mother to demonstrate the technique of lacrimal sac massage she performs on herself and on the child.
Physical examination
State Research lacrimal organs start with an external examination: assess the presence of lacrimation or lacrimation in calm state child, position of the eyelids, costal edge of the eyelids, eyelash growth. In newborns, especially when chubby cheeks, Mongoloid type of face, narrow palpebral fissure or epicanthus, a fold of the lower eyelid is often observed, which is accompanied by lacrimation and trichiasis - the eyelashes are turned towards the eyeball and injure the cornea. In such cases, surgical treatment is usually not required. early age, but active keratoprotective treatment is necessary to prevent keratitis and corneal opacities (taufon 4% 3 times a day, corneregel 2 times a day).
The presence and characteristics of lacrimal openings are determined.
Often in children, one or all of the lacrimal openings are absent or covered with germinal film. For better visualization of lacrimal openings, 1-2 drops of a 2-3% collargol solution should be installed into the conjunctival sac.
The lacrimal sac is compressed (Fig. 3, see color insert) to assess the nature and amount of discharge from the lacrimal openings and the lacrimal sac. The nature of the discharge (mucous, mucopurulent or purulent) will presumably allow us to judge the type infectious agent
. Voluminous yellow pus is characteristic of a staphylococcal infection, copious mucopurulent discharge, sometimes with a greenish tint, can be with a gonorrheal infection, liquid yellowish pus or mucus - with a chlamydial infection. Scanty, viscous discharge against a background of intermittent lacrimation or very
is often a manifestation of an allergic reaction to previously used topical antibiotics.
The amount of discharge released from the lacrimal sac during its compression allows us to indirectly judge the size of the lacrimal sac and suggest the presence of dilatation of the lacrimal sac without radiographic examination. The presence of skin hyperemia, tissue infiltration, fluctuation in the area of the lacrimal sac indicate acute inflammation
lacrimal sac. Edema, diffuse hyperemia of the skin or swelling in the area of the lacrimal sac may be a sign of the inflammatory process extending beyond the sac.
After squeezing out the contents from the lacrimal sac and cleaning the child’s nasal cavity, color tests are performed: canalicular and nasal (Avetisov E.S. et al., 1987; Somov E.E., Brzhesky V.V., 1994).
Canalicular (tear suction) test carried out to check the suction function of the lacrimal openings, tubules and sac.
Instill 2-3 drops of 3% collargol into the conjunctival cavity. The disappearance of paint from the conjunctival cavity no later than 5 minutes indicates the normal function of the lacrimal openings, tubules, and sac (positive tubular test). Retention of paint in the conjunctival cavity for up to 10 minutes after instillation indicates a functional failure of the lacrimal ducts, more often accompanied by complaints of lacrimation or lacrimation in wind or cold (slow canalicular test). If the paint remains in the conjunctival cavity for more than 10 minutes, there is an obstruction to the outflow of tears from the lacrimal openings or tubules (negative tubular test).
Nasal test(Vesta nasolacrimal test) is intended to determine the degree of patency of the entire lacrimal drainage system.
After instilling 2-3 drops of 3% collargol into the conjunctival cavity, the appearance of collargol staining at the end of a cotton swab inserted into the child’s lower nasal passage (to a depth of 2 cm from the entrance to the nose) no later than 5 minutes indicates normal patency of the entire lacrimal drainage system (nasal test is positive). The appearance of paint in the nasal cavity after 6-10 minutes reveals a slowdown in the active patency of the entire lacrimal drainage system (nasal test is slowed down) - it is necessary to check the passive
patency by washing the lacrimal ducts or radiographic contrast study. The appearance of paint in the nasal cavity later than 10 minutes or its absence diagnoses a complete violation of the active patency of the entire lacrimal drainage system - it is necessary to clarify the level and nature of the lesion with an X-ray contrast study.
When performing color tests on a newborn, the child lies on his back, usually screams and his mouth is open, so it is more convenient to observe the appearance of paint (collargol) not in the nose, but on back wall pharynx - the so-called “tear-nasopharyngeal test in infants.” The interpretation of the results of the lacrimal-nasopharyngeal test is identical to the nasal test - the appearance of paint on the back wall of the pharynx no later than 5 minutes indicates normal patency of the entire lacrimal drainage system (the lacrimal-nasopharyngeal test is positive).
If the nasal or nasopharyngeal test is slow or the presence of a rhinogenic factor is suspected, a “double Vesta test” is performed - the test is repeated after introducing a tampon with a 0.1% solution of adrenaline into the lower nasal passage. If, after adrenalization of the mucous membrane of the lower nasal passage, color in the nose appears no later than 5 minutes after instillation of collargol (the double Vesta test is positive), the presence of a rhinogenic cause of lacrimation is diagnosed, requiring treatment by an ENT specialist.
Laboratory research
In parallel with the elimination of the identified congenital obstruction of the lacrimal ducts, microbiological examination smears, scrapings and cultures of discharge from the conjunctiva of the eyelids.
Instrumental studies
Passive patency of the lacrimal ducts is determined by probing and/or washing them.
is performed using one method - both diagnostic and therapeutic purpose: using conical Sichel probes, the lower or upper lacrimal punctum is used (Fig. 5, see color insert) and the lacrimal canaliculus is probed (Fig. 6, see color insert); then with a cylindrical Bowman probe? 1-2 or a soft probe - a cannula with a sealed end and a side
The hole is used to probe the lacrimal sac and the nasolacrimal canal (more precisely, the duct) (Fig. 7, see color insert). Probing of the lacrimal ducts is completed by mandatory rinsing. For immediate probing and washing of the lacrimal ducts, hollow cannula probes are used, connected by a tube to a syringe or placed on the tip of the syringe (Bobrova N.F., Verba S.A., 1996).
Rinsing the lacrimal ducts carried out through the upper or lower lacrimal openings using a cannula and syringe (Fig. 8, 9, see color insert). With normal patency of the lacrimal ducts, the washing liquid (solution of nitrofural (furacillin 1:5000), picloxidine (Vitabact), chloramphenicol (chloramphenicol 0.25%, etc.) freely passes into the nasopharynx.
Complications of probing
and washing the lacrimal ducts
Probing and washing the lacrimal ducts in newborns has its own characteristics. Reliable immobilization of the child with rigid fixation of the head and torso is important due to possible subluxation of the child’s cervical vertebrae during the procedure. Due to the possible entry of lavage fluid into the respiratory tract, resuscitation and anesthesia support is advisable, especially for premature, weakened newborns. Cases of respiratory arrest and death have been described when probing the lacrimal ducts and washing them in newborns.
Among the complications of probing the lacrimal ducts are the following:
Rupture of the inflamed wall of the lacrimal canaliculus when the probe is sharply turned from a horizontal to a vertical position;
Rupture of the wall of the lacrimal sac with penetration of the probe between the wall of the nasolacrimal duct and the bone wall of the nasolacrimal canal or into soft fabrics along the anterior surface of the upper jaw, followed by sinusitis, phlegmon of the lacrimal sac, orbit, thrombophlebitis and even meningoencephalitis;
Damage to the wall of the bone canal with penetration of the probe into the maxillary sinus;
Damage to the lacrimal bone with penetration into the nasal cavity, ethmoiditis, etc.;
Cases of probe fracture have been described that required surgical removal of the fragment.
Significant nosebleeds during probing are rare, but small ones are inevitable and are a sign of restoration of the patency of the lacrimal ducts, since they are more often caused by rupture of the vascularized film or minor damage to the mucosa at the exit of the nasolacrimal duct. The manipulation itself was previously called “bloody probing.”
To prevent complications in newborns, it is necessary to strive for an atraumatic technique for probing and washing the lacrimal ducts: use special thin probes and cannulas, do not allow high pressure of the washing liquid, lubricate the probes and cannulas with ointment and do not force their advancement, given the presence of complex system folds, valves, flaps along the lacrimal ducts.
The decisive link in the future normal functioning of the lacrimal ducts and the quality of active tear production in a child - maintaining the elasticity of the lacrimal canaliculi - is largely determined by the quality of their first probing in newborns.
Atony of the lacrimal canaliculi after traumatic probing with thick probes leads to incurable painful lacrimation and lacrimation in the future.
X-ray examination with contrast of the lacrimal ducts makes it possible to clarify the level and degree of disruption of their patency.
Dacryocystoradiography is performed in occipitofrontal and bitemporal projections after the cannula of the contrast agent iodolipol (0.5 ml) is introduced through the lacrimal canaliculus (usually the lower one) into the lacrimal sac.
In particularly complex cases of combined congenital anomalies, computed tomography of the head with contrast dacryocystoradiography (contrast-omnipaque) is useful, allowing one to obtain unique information about the relationship of the lacrimal sac with surrounding tissues and identify frequent congenital developmental anomalies - fistulas, scars, diverticula, atresia of the tubules, sac, lacrimal -nasal duct, canal, sinuses, etc.
X-ray examination can be performed on the child while he or she is asleep or under anesthesia. However, in newborns with dacryocystitis, X-ray examination should have very limited indications - only cases of ineffective probing or combined congenital anomalies.
Indications for consultation with other specialists Rhinological examination
Considering anatomical features the structure of the nasal cavity and its paranasal sinuses in newborns (see above for more details), their inflammation and pathology in almost half of newborns, endoscopy of the nasal cavity should be considered a mandatory study in children with neonatal dacryocystitis.
Thus, when probing, it is important to take into account different variants of the structure of the nose: concave and flattened shape of the nose, low and wide bridge of the nose (Grigorieva V.I., 1968), possible cleft palate, etc. Rhinological examination not only allows us to identify various pathological changes in the nasal cavity , but also to choose the optimal algorithm for subsequent treatment of dacryocystitis in newborns, congenital obstruction of the lacrimal ducts, and increase its effectiveness.
Pediatric examination
A child with neonatal dacryocystitis needs clinical analysis blood and examination by a pediatrician to assess the child’s somatic condition and exclude ARVI, allergies, concomitant diseases. There are known cases of meningoencephalitis and sepsis after probing the lacrimal ducts in a child with purulent dacryocystitis against the background of severe leukocytosis and hyperthermia.
The goal of treatment is to restore the physiological patency of the lacrimal ducts, relieve the inflammatory process in the lacrimal sac, and sanitize the entire lacrimal drainage system as a whole.
Non-drug treatment
Treatment of dacryocystitis in a newborn should, perhaps, be earlier, more gentle, and should begin with massage of the lacrimal sac, the technique of which must be taught to the child’s parents not only theoretically, but also practically, demonstrating the massage technique on the child and inviting the mother to show the acquired skills on the child.
Correctly performed massage of the lacrimal sac leads to full recovery a child without surgical manipulation in 1/3 of children under 2 months of age, in 1/5 of children aged 2-4 months, and only in 1/10 of children over 4 months of age (Brzhessky V.V., 2005).
The purpose of the massage is to use downward jerky movements to create differences in hydrostatic pressure in the lacrimal system, which can remove the gelatinous plug or break the rudimentary film that closes the exit from the nasolacrimal duct to the nose.
Technique for massaging the lacrimal sac (Fig. 10, see color insert).
A push-like downward digital massage of the lacrimal sac is performed as follows.
After washing your hands, you must index finger right hand make 5-10 jerky movements from top to bottom, strictly in the vertical direction. Strive, pressing soft tissues to the nasal bones along with the lacrimal sac and the mouth of the lacrimal canaliculi (blocking reflux through the lacrimal openings), to push the contents of the sac downwards into the nasolacrimal duct.
Often, parents copy the movements of a doctor who performs compression of the lacrimal sac to assess its contents, regarding this upward movement as a massage of the lacrimal sac. It is strictly forbidden to allow parents to squeeze out pus from the lacrimal sac. The retrograde movement of pus causes inflammation of the lacrimal canaliculi. Circular, spiral, and other movements are also unacceptable, since repeated “rubbing” of purulent contents into the walls of the sac can lead to its stretching, deformation, and even rupture.
The massaging movement should begin by feeling the internal commissure of the eyelids (a dense horizontal cord under the skin at the inner corner of the eye), placing the pad of the index finger of the right hand strictly above the commissure (the arch of the lacrimal sac protrudes 3-4 mm above the internal ligament of the eyelids) and finish with a downward jerk-like movement - 1 cm below this commissure.
Massage should be performed 5-6 times a day - before each feeding of the baby. After massaging the lacrimal sac, apply the prescribed disinfectants. eye drops. To prevent skin irritation, it is necessary to eye drops remove with damp sterile cotton wool from the skin of the eyelids. It is necessary to explain to the child’s mother that it is inadmissible to drop breast milk, tea, etc. into the child’s eyes.
Massage of the lacrimal sac is strictly contraindicated and should be stopped at the first sign of inflammation beyond the lacrimal sac - edema, skin hyperemia or swelling in the area of the lacrimal sac.
Drug treatment
Massage of the lacrimal sac is combined with disinfectant and antibacterial therapy.
Microbiological examination of conjunctival discharge, discharge from the lacrimal sac of children with dacryocystitis of the newborn reveals in more than 95% of children pathogenic staphylococci(often hemolytic, golden), sensitive to chloramphenicol, gentamicin, less often - streptococcus (Allen, 1996) and even Pseudomonas aeruginosa. Usually, before receiving the results laboratory research, identification of flora (separated from the conjunctiva of the eyelids) and its sensitivity to antibiotics, it is recommended to begin treatment for washing the eyes of newborns with the use of minimally toxic, non-allergenic disinfectants.
In recent years, Vitabact (0.05% picloxidine), approved by WHO for use in newborns, has become a modern drug for the treatment of anterior eye infections in children. The wide spectrum of antibacterial action of this drug is comparable to antibiotics and covers Staphylococcus aureus, Streptococcus pneumoniae, Neisseria, Escherichiae coli, Acinetobacter baumannii, Haemophilus influenzae, Klebsiella oxytoca, inhibition Chlamydia trachomatis. The advantage of this antiseptic is also the absence of cross-sensitivity with antibiotics, the absence allergic reactions in children and low cost.
The use of drugs such as 20% sodium sulfacyl solution is undesirable due to crystal formation, which impedes the outflow of tear fluid (Pilman N.I., 1967; Saidasheva E.I. and co-
Local antibiotics (chloramphenicol 0.25%, Tobrex 0.3%, gentamicin 0.3%) should be prescribed strictly in accordance with the results of sensitivity studies to them. Contraindicated for newborns local application ciprofloxacin (cipromed, ciprofloxacin, etc.). In case of an allergic reaction, additional lecrolin is prescribed.
Surgery
If correctly performed downward massage of the lacrimal sac within 1-2 weeks does not lead to recovery, it is necessary to probing of the lacrimal ducts, It is better when the child is between 1 and 3 months old.
Probing of the lacrimal ducts is both a diagnostic procedure that allows you to assess their patency, and a therapeutic one, since it eliminates obstruction of the lacrimal ducts, breaking the embryonic plug or film, restoring the patency of the lacrimal drainage system (the probing technique is described above in the section instrumental studies(see Fig. 5). Bougienage of the inferior lacrimal punctum; rice. 6. Probing of the lower lacrimal canaliculus; rice. 7. Probing of the nasolacrimal canal).
Most ophthalmologists carry out primary probing using the classical method - through the lower lacrimal punctum, and during repeated probing and rinsing, sparing the lower lacrimal canaliculus, as the most important in the act of lacrimal drainage - through the superior lacrimal punctum. For more than half of children, a single probing is sufficient, 1/4 of children require double probing, and 1/10 require multiple probing.
According to the American Academy of Ophthalmology (1992), treatment of dacryocystitis by probing is effective in 90% of children under the age of 9 months, especially when carried out in the early stages.
The effectiveness of descending probing of the lacrimal ducts with their washing (sometimes repeated) in children 1-3 one month old is 92-98.1% in cases where the cause of obstruction of the lacrimal ducts is the closure of the nasolacrimal duct by an embryonic plug or film. Probing of the lacrimal ducts may be ineffective if their obstruction is due to other reasons (pathology of the lacrimal sac, aplasia of the bony nasolacrimal duct, pathology of the nose, surrounding tissues, etc.).
With late primary probing, the effectiveness of treatment decreases in children over 1 year of age to 74.1%, and with repeated probing due to relapses of dacryocystitis in children under 1 year of age - to 75.3%, in children 1-2 years of age - to 65.1% (Brzhesky V.V. et al., 2005).
However, in children over 1 year of age, treatment of dacryocystitis should begin with probing.
For children over 2 months it is possible endonasal retrograde sounding(Krasnov M.M., Beloglazov V.G., 1989; Beloglazov V.G.,
2002), the effectiveness of which in children under 1.5 years of age reaches 94.6%, although traditional external downward probing is still more generally accepted. In children over 1.5 years old, endonasal sounding is useless due to obliteration of the entire nasolacrimal duct by this age (Cherkunov B.F., 2001). More often, the retrograde sounding method is used when there is no effect from the external method or in case of pathology of the nasal cavity.
In general, probing is a fairly safe procedure, but, like any surgical procedure, it is not without the risk of possible complications, so probing should be carried out not at home, but in an outpatient operating room, using special care and delicacy. Taking into account the anatomical variants of the structure and age characteristics lacrimal ducts and nose in children, their probing should be carried out by an experienced doctor who has sufficient skills in performing this intervention.
Rinsing of the lacrimal ducts is carried out immediately after probing (Fig. 8, 9, see color insert). The washing technique is described above in the section Instrumental studies.
To wash the lacrimal ducts for therapeutic purposes, use the same local antibacterial agents, as for instillations (Vitabact, chloramphenicol 0.25%, Tobrex 0.3%, gentami-
The opinion of ophthalmologists on the advisability of attempting to restore the patency of the lacrimal ducts by repeatedly washing them before probing (Panfilov N.I., Pilman N.I., 1967; Kovalevsky E.I., 1969; Avetisov E.S. et al., 1987; Chinenov I.M., 2002), has been changing in recent years. Many authors note that an attempt to carry out primary lavage of the lacrimal ducts in case of dacryocystitis in newborns in order to break through the embryonic plug or film with a stream of liquid under pressure often leads to rupture of the altered inflamed wall of the lacrimal canaliculus or lacrimal sac with inflammation of the surrounding tissues. Therefore, if massage of the lacrimal sac in newborns with dacryocystitis is ineffective, it is advisable to first probe the lacrimal ducts, with guaranteed restoration of their patency and subsequent rinsing to sanitize them (Brzhesky V.V. et al., 2005; Saidasheva E.I. et al.
Further management of the patient
In the future, persistent long-term drug treatment (from 1 to 3 months) is necessary to completely stop the signs of the inflammatory process in the lacrimal sac and prevent relapses of inflammation, which are not uncommon in children. For this purpose, in addition to instilling eye drops, if necessary, repeated rinsing of the nasolacrimal ducts with antibiotic solutions or combination drugs(Garazon, Tobradex).
Typically, a 1-2 month old child recovers after a single probing with rinsing of the lacrimal ducts. For a 2-3 month old child, 1 probing and 2-3 rinses at intervals of 7-10 days are sufficient. In children who presented late, over the age of 4-6 months, with highly pathogenic microflora, concomitant pathology of the nasopharynx, combined congenital anomalies, etc., it is necessary to carry out long-term treatment of the lacrimal sac - repeated courses of sounding, bougienage and therapeutic lavages of the lacrimal ducts with individual selection of medications in depending on the microbiological flora detected during examination of the contents of the child’s lacrimal sac.
Only timely probing of the lacrimal ducts, restoration of their patency and complete sanitation of the lacrimal sac by repeated therapeutic rinsing will avoid post-inflammatory cicatricial deformities, phlegmon of the lacrimal sac and the need for more radical surgical treatment.
If multiple probing and courses of therapeutic lavage of the lacrimal ducts are unsuccessful in children 5-7 years of age without ectasia of the lacrimal sac outside the period of exacerbation of dacryocystitis, intubation of the lacrimal ducts is possible. Moreover, elastic tubes passed through the lacrimal ducts from the tubules or retrogradely from the nose must be left for a long time - from 3-4 months to 2 years! (Chinenov I.M., 2002; Belogla-
call V.G., 2002).
If the treatment is ineffective, children over 5 years of age and older (with sufficient formation of the facial skeleton and nasal bones) are indicated for complex radical surgery - dacryocystorhinostomy- restoration of the anastomosis between the lacrimal sac and the nasal cavity with trepanation of the nasal bones (trephine and cutter, ultrasound knife, holmium laser, etc.), often performed externally
approach (up to 70%), less often - endonasal. Some ophthalmologists perform endonasal dacryocystotomy for children from 2-3 years of age (Beloglazov V.G., 2002; Chinenov I.M., 2002).
Endonasal operations have undoubted advantages: they are highly effective, low-traumatic, cosmetic (without skin incisions), less disrupt the physiology of the lacrimal drainage system, are able to eliminate anatomical and pathological rhinogenic factors, but require special training specialists, training ophthalmologists in rhinoscopy skills, ENT training, as well as special equipment.
Indications for hospitalization
Treatment is usually carried out on an outpatient basis; only if repeated probing and lavage of the lacrimal ducts are ineffective, inpatient treatment is indicated - a course of therapeutic bougienages with lavage of the lacrimal ducts, selection of medications based on the results of antibiograms for children 1-5 years old, or dacryocystorhinostomy for children 5-7 years of age.
Treatment of dacryocystitis in a newborn requires a differentiated individual approach, taking into account the age of the child, the clinical form of dacryocystitis, duration of the disease, the nature of the process, possible complications, previous treatment and its effectiveness, the presence of congenital anomalies of the maxillofacial region, rhinogenic factor, etc.
Complications
Untimely and inadequate treatment of dacryocystitis in newborns threatens the development of corneal ulcers with the risk of vision loss.
The main serious complications of dacryocystitis in newborns are caused by the inflammatory process extending beyond the lacrimal sac: acute purulent peridacryocystitis, abscess and phlegmon of the lacrimal sac (or phlegmonous dacryocystitis). Purulent infection from the lacrimal sac can spread into the orbital tissue (orbital phlegmon) and the cranial cavity, causing thrombosis of the cavernous sinus, meningitis, sepsis with hematogenous foci of purulent infection (Averbukh S.L. et al., 1971; Beloglazov V.G., 1980 and 2002 ).
These inflammatory complications often arise due to late contact with an ophthalmologist, improper technique of lacrimal massage
bag, untimely and incomplete treatment. Most often, exacerbations of purulent inflammation recur against the background of a chronic course, so phlegmonous dacryocystitis can be observed at any age (Fig. 11, see color insert).
In recent years, the frequency of phlegmon of the lacrimal sac has increased significantly as a complication of purulent dacryocystitis in newborns (up to 5-7% of all congenital dacryocystitis), even in the first days of life (Katorgina O.A., Gritsyuk S.N., 1972; Cherkunov B.F., 2001).
Phlegmonous dacryocystitis is characterized by a violently expressed inflammatory reaction in the area of the lacrimal sac: severe skin hyperemia, swelling, dense painful infiltration of surrounding tissues, swelling of the eyelids, cheeks with partial or complete closure of the palpebral fissure. Later, the dense infiltrate softens, the abscess opens through the skin - an external fistula (fistula) of the lacrimal sac is formed (Fig. 12, see color insert), which often heals, but can recur with the formation of granulations. Less commonly, the abscess opens into the nasal cavity - an intranasal fistula of the lacrimal sac is formed.
Usually, phlegmon of the lacrimal sac is accompanied by a deterioration in the child’s general condition and intoxication: the temperature rises sharply, blood leukocytosis, and increased ESR are noted. The general condition of the child can be severe, even septic, therefore, if an abscess or phlegmon of the lacrimal sac is suspected, urgent inpatient treatment in a children's clinic is required.
Treatment - antibiotics wide range actions parenterally. If there is a fluctuation in the area of the lacrimal sac, the abscess is opened (an incision under the internal ligament of the eyelids). In recent years, more active probing tactics have been adopted for phlegmon of the lacrimal sac. It is advisable, against the background of improvement in the general condition, without allowing the spontaneous opening of the abscess, to carry out early probing with washing of the lacrimal ducts with antibiotics (taking into account the risk of the washing liquid getting outside the bag). Before this, you can suction the pus through a hollow probe (Cherkunov B.F., 2001). Delicate implementation of these manipulations, restoring the patency of the lacrimal drainage system and sanitizing it, usually quickly stops the inflammatory process (Katorgina O.A., Gritsyuk S.N., 1972).
Late detection, untimely and inadequate treatment of dacryocystitis in newborns, despite the restoration of patency of the lacrimal ducts, leads to chronic dacryocystitis, adhesions in the nasolacrimal canal, dilatation, ectasia and atony
lacrimal sac with the development of functional incompetence of the lacrimal ducts, painful constant or periodic lacrimation and often has a poor prognosis. Therefore, probing with thick probes should be avoided, and if repeated probings or courses of therapeutic lavage of the lacrimal ducts are necessary, they should be carried out through the upper rather than the lower lacrimal punctum (Cherkunov B.F., 2001).
For chronic dacryocystitis, treatment tactics depend on the nature pathological changes lacrimal ducts, identified by X-ray examination with contrasting lacrimal ducts. The main method of treatment is dacryocystorhinostomy, which is performed both externally and endonasally.
Prevention
To prevent complications of dacryocystitis in newborns, early detection of the disease is necessary. Often, dacryocystitis of a newborn is treated for several months as “purulent conjunctivitis of the newborn.” Prolonged local use of antibiotics, especially highly toxic ones, which lead to temporary improvement but do not eliminate the cause of the disease, is unacceptable.
Timely detection of dacryocystitis in newborns entirely depends on the qualifications of neonatologists and pediatricians, who must be able to diagnose dacryocystitis and urgently refer the child for treatment to an ophthalmic surgeon.
Early detection of dacryocystitis in a newborn and seeking qualified help is a real prevention of chronicity and relapse of inflammation, incurable incompetence of the lacrimal ducts due to late treatment and a decisive factor in increasing the effectiveness of treatment.
Bibliography
1. Avetisov E.S., Kovalevsky E.I., Khvatova A.V. Anomalies and diseases of the lacrimal apparatus: A guide to pediatric ophthalmology. - M.: Medicine, 1987. - P. 294-300.
2. Beloglazov V.G. Endonasal methods of surgical treatment of lacrimal duct obstruction: Guidelines. - M., 1980. - 23 p.
3. Beloglazov V.G. Lacrimal organs. Eye diseases: Textbook / Ed. V.G. Kopaeva. - M.: Medicine, 2002. - P. 168-179.
4. Bobrova N.F., Verba S.A. Modification of closed probing for congenital obstruction of the nasolacrimal ducts // Ophthalm. magazine - 1996. - ? 1. - pp. 60-62.
5. Brzhesky V.V., Chistyakova M.N., Diskalenko O.V., Ukhanova L.B., Antanovich L.A. Tactics for the treatment of lacrimal duct stenosis in children // Contemporary issues pediatric ophthalmology. Mat. scientific-practical
conf. - St. Petersburg, 2005. - pp. 75-76.
6. Kanski D. Lacrimal drainage system: Clinical ophthalmology: a systematic approach. Per. from English - M.: Logosphere, 2006. -
7. Katorgina O.A., Gritsyuk S.N. Early active conservative treatment of phlegmonous dacryocystitis in children // Ophthalm. magazine - 1972. - ? 7. - pp. 512-514.
8. Krasnov M.M., Beloglazov V.G. Diagnostic issues and therapeutic tactics for congenital dacryocystitis // Ophthalm. magazine - 1989. - ? 3. - pp. 146-150.
9. Malinovsky G.F., Motorny V.V. Practical guide for the treatment of diseases of the lacrimal organs. - Minsk: Belarusian Science, 2000. - 192 p.
10. Saydasheva E.I., Somov E.E., Fomina N.V. Infectious diseases: Selected lectures on neonatal ophthalmology. - St. Petersburg: Publishing house "Nestor-History", 2006. - P. 188-201.
11. Somov E.E., Brzhesky V.V. A tear. Physiology. Research methods. Clinic. - St. Petersburg: Nauka, 1994. - 156 p.
12. Somov E.E. Pathology of the lacrimal apparatus of the eye: Clinical ophthalmology. - M.: Med. press-inform, 2005. - pp. 176-188.
13. Taylor D., Hoyt K. Lacrimal organs. Pediatric ophthalmology. Per.
25-01-2014, 01:11
Description
External examination and palpation of the lacrimal gland, tubules and lacrimal sac
As with diseases of many other departments human body, in case of pathology of the lacrimal apparatus, external examination is the main method of examining the patient. The lacrimal gland is normally accessible to inspection and palpation only to a very small extent, with the upper eyelid inverted and dislocated. In case of its diseases, examination, if not the gland itself, covering its eyelids, and most importantly palpation, brings a lot of data. The external one provides significantly greater opportunities when examining all parts of the lacrimal drainage apparatus, i.e. grooves, lacrimal duct, lacrimal lake, lacrimal caruncle and semilunar ligament of lacrimal openings, lacrimal canaliculi, lacrimal sac. When examining, you can use a Garcher's magnifying glass or a simple magnifying glass. Palpation of the lacrimal canaliculi and lacrimal sac, gentle at first, should be followed by forced palpation, trying to squeeze out the contents of the sac and canaliculi, if present.
External examination is supplemented by some special tests. Special attention deserve:
- Schirmer tests,
- capillary test,
- tubular and nasal tests,
- probing the lacrimal canaliculi,
- probing of the nasolacrimal duct,
- washing the lacrimal ducts,
- contrast and radiography of the lacrimal ducts.
The intended purpose of Schirmer tests, No. 1 and No. 2 comes down to trying to find out with their help the functional status of the lacrimal gland - whether there is hypofunction of the gland and what the condition is! its reactive secretion. The intended purpose of all other tests is topical diagnosis of the level of damage to the lacrimal tract, if any.
Schirmer test No. 1
is carried out as follows. The lower eyelids of both eyes are folded 0,5 cm long ends of narrow strips of filter or litmus paper 3,5 and width 0,5 cm. The other ends of the strips remain hanging freely over the eyelids. Gradually the strips are wetted from the ends placed behind the eyelids. Through 5 min the length of the wetted part of the strips is measured. If not wetted 1,5 cm length of the paper strip, we can assume that there is no hypofunction of the lacrimal gland on the side being examined.
Schirmer test No. 2
serves to resolve the issue of the state of the reflex system of the tear-producing apparatus. After unilateral local anesthesia of the conjunct and the valvular sac, the end of a strip of filter paper is placed behind the edge of the eyelid. Then mechanical irritation of the nasal mucosa in the area of the middle concha is performed. By the length of time the filter paper becomes wet, one can judge whether the state of the reflex system is satisfactory or unsatisfactory.
Stream sample or capillary sample.
A drop of dye is placed into the conjunctival sac ( 1 % solution of flirescein or 3% solution of collargol). Through 10-15 sec pay attention to the tear stream: if it looks like a hair capillary, then it is not changed (Fig. 92).
However, the expansion of the stream, indicating pathology, may be so insignificant that it is not detected even by staining. In such cases, a comparison of the colored tear ducts on both sides is very revealing. If the capillary test does not reveal expansion of the stream, then the lacrimal drainage apparatus is functioning properly and lacrimation is caused by some other reason, for example, conjunctivitis. At in good condition of the lacrimal drainage apparatus, while the eye moves in all directions, the colored hair capillary remains unchanged. In cases of pathology, when the patient looks up, the tear stream becomes wider. This symptom occurs in people of all ages and is associated with muscle atony Riolapa - a consequence of pulling back the lower eyelid when wiping away tears.
The capillary test very early reveals functional disorders in the lacrimal drainage system (even before pathological atopic changes become clearly expressed).
Pokhisov evaluates the capillary test using a three-point system:
- it is normal when the tear stream looks like a hair capillary;
- the sample is indicated by a + sign when the tear duct is slightly dilated;
- the test is designated ++ when the tear stream is sharply expanded.
- The greatest advantage of the capillary test is that it is objective and allows one to judge how well-founded the patient’s complaints are.
Tubular and nasal tests
These tests are performed simultaneously and serve to determine the patency of the lacrimal canaliculi and nasolacrimal canal.
Into the conjunctival sac three times with an interval of 1-2 minutes let in the dye ( 1% - solution of fluorescent or 3% solution of collargol). If after one and a half to two minutes the solution disappears from the conjunctival sac, it means that fluid is being absorbed normally from the lacrimal lake - the ability of the tubules is preserved, and the reason lies somewhere further in the lacrimal ducts. In addition, in these cases, when pressing on the lacrimal canaliculi into the conjunctival sac, drops of the dye solution come out through the points.
If the dye remains in the conjunctival sac for more than two to five minutes and does not appear from the dots when pressing on the area of the lacrimal sac, the tubular test should be considered negative. However, experience shows that even under normal conditions, a tubular test can sometimes be negative. Thus, the diagnostic value of this test for lacrimation is low.
At the same time, a nasal test is performed to determine the narrowing in the nasolacrimal canal. The subject is asked to blow his nose or a tampon is inserted into the nose under the lower concha, alternately on each side. The appearance of paint in the nose after five minutes indicates good patency of the tear ducts. If there is no color in the nose or it appears later, then there is no patency or it is difficult.
It should be noted that even with normal conditions Collargol does not always appear in the nasal cavity within five minutes. This is explained by the fact that, in addition to pathological conditions,9 in the lacrimal ducts, other factors also influence their patency. In particular, individual characteristics the structure of the nasolacrimal canal, excessive development of the Ashner valve, etc., may cause a delay in the appearance of paint in the nose, which, however, does not at all indicate a narrowing of the canal. Therefore, the nasal test cannot be considered reliable.
Probing of tear ducts
After anesthetizing the conjunctiva with a few drops 0,5-1 % - but a conical probe is inserted into the canaliculus through the lacrimal punctum, first vertically, then it is transferred to horizontal position and is brought to the lateral bone wall of the nose. After removing the conical probe, an ordinary zone of larger or smaller caliber is introduced. If a stricture is detected in the tubule, it is immediately dissected with a probe. Thus, this manipulation is not only diagnostic, but also an effective therapeutic measure for strictures, foreign bodies in lacrimal canaliculi and other diseases.
After probing, it is necessary to drip a solution of some antiseptic used in ophthalmic practice into the conjunctival sac. Pokhnsov recommends letting it into the conjunctival sac after such an intervention 1-2 drops 1 % - solution of lapis and 5% xeroform ointment, and bury it at home 3% -we are a solution of collargol or 30% - solution of albucid.
Probing of the nasolacrimal duct
This manipulation is also carried out for both diagnostic and therapeutic purposes, as it allows not only to determine! the presence of narrowings and curvatures of the nasolacrimal canal, but in some cases it makes it possible to restore its normal patency.
Probing can be done either from top to bottom, i.e., through one of the lacrimal openings (usually through the lower one), or from bottom to top, from the side of the nasal passage (endonasally, or retrograde).
Probing consists of three points:
- insertion of the probe vertically through the lacrimal opening into the vertical surface of the lacrimal canaliculus;
- transferring the probe to a horizontal position and moving it along the canaliculus up to the nasal wall;
- moving the probe back into a vertical position and advancing it into the lacrimal sac and nasolacrimal canal.
Ophthalmologists probe primarily through the lacrimal openings with conical and then Bowman probes of varying thicknesses. Previously, the lacrimal canaliculi were split during probing, as they were not given any importance in the lacrimal drainage mechanism.
Golovin et al. (1923) used it for probing to force the expansion of the nasolacrimal canal.
Odintsov, Strakhov, Tikhomirov, Kolen and many others, attaching great importance to the lacrimal canaliculi in the mechanism of lacrimal drainage, spare them in every possible way. They first dilate the lacrimal canaliculi with conical probes and then probe them with thin Bowman probes.
Before probing, local anesthesia is administered by multiple installations into the conjunctival sac 0,5% -th dicaip solution. It is recommended to lubricate the probe with oil before insertion.
When probing, it is necessary to take into account the topographic structure of the entire lacrimal canal. You can’t rush, you need to insert it carefully, especially if there is an obstacle in the canal.
If probing fails, it should be postponed. Considering that the probing operation is sometimes very painful, in addition to dikaip installations, we can recommend infiltration for particularly sensitive patients 2% solution of novocaine with 3-4 drops of adrenaline under the lacrimal sac area. It is also necessary that the probes be polished, smooth, and without bending. They should be sterilized first.
If the probing technique and technique are incorrect or if probing is rough, complications may occur. Thus, rough penetration of the probe in the horizontal direction can lead to damage to the lacrimal bone and the probe entering the nasal cavity. It is also possible for the wall of the lacrimal canal to rupture with the formation of a passage. There were even cases of bone wall fracture and the end of the probe getting into the maxillary cavity.
Other complications are also dangerous: nose bleed, phlegmon of the lacrimal sac, which developed as a result of the formation of a false passage, phlegmon of the orbit with inflammation of the optic nerve. The literature reports meningitis and orbital thrombophlebitis. Improper insertion of the probe can cause swelling and tissue swelling; after two or three days they usually disappear without a trace. It is dangerous to rinse the lacrimal ducts after probing if you are not sure of the correct placement of the probe. If there is a suspicion of a false passage (a feeling of bare bone and the appearance of two or three drops of blood from the lacrimal punctum after removing the probe), it is necessary to immediately perform an active massage of the lacrimal sac area from the bottom up towards the lacrimal punctum, thus freeing the canal from blood (so that prevent the formation of a hematoma) and apply a tight, damp bandage for one or two days. Sulfonamides are given internally. For a week after this, you should not probe through the lacrimal openings, you should be content with only endonasal probing.
Retrograde probing does not replace probing through the lacrimal tubules, but only complements it. It is an auxiliary intervention used in cases where probing from above is not effective enough,
The widespread opinion among ophthalmologists about the difficulty of mastering the retrograde sounding technique is unfounded. Thus, Arlt wrote in 1856 that it is easy to acquire the skill of retrograde insertion of a probe into the nasolacrimal canal. Pokhisov recommends the widespread use of retrograde probing as an independent intervention and as an auxiliary measure when probing through the lacrimal openings. He conducts it in both adults and children, even newborns.
Washing the tear ducts
Rinsing of the lacrimal ducts is done through the lower lacrimal punctum, and if the lower lacrimal canaliculus is narrowed, through the upper punctum. Anesthesia is required in advance - two or three times instillation into the conjunctival sac 0,5 - 1 % -n solution of dicaine, which is used to simultaneously extinguish the lacrimal opening. For rinsing, use a two-gram syringe, an Anel syringe or an injection needle with a blunt and rounded end. Washing for diagnostic purposes is performed 0,1 % solution of rivanol or saline solution. The lacrimal punctum and canaliculus are pre-expanded with a conical probe. The needle is advanced along the lacrimal canaliculus, drawn outward and downward, while the head of the patient is tilted. Then the needle is slightly pulled back and the syringe is emptied by pressing on the plunger.
If the patency is normal, the flushing fluid flows out in copious streams. Slow fluid flow indicates a narrowing of the canal. With complete obstruction, fluid does not flow out of the nose, but flows out in a thin stream from the upper or lower lacrimal duct. When probing, it is necessary to take into account the topographic diatom of the lacrimal canal.
Probing is difficult in case of abnormal development of the lacrimal canal, atresin of the lacrimal punctum, cicatricial changes in the nasolacrimal canal, narrowing of the lacrimal punctum and canaliculus of a spastic nature.
The following complications of probing are possible: nosebleeds, swelling in the lower eyelid, phlegmon of the lacrimal sac, which developed as a result of the formation of a false passage, phlegmon of the orbit with inflammation of the optic nerve.
X-ray examination of the lacrimal ducts
If you inject the lacrimal ducts with a control mass that blocks X-rays, then it will fill all the smallest bends of the lacrimal sac, nasolacrimal canal and lacrimal canaliculi, forming an exact cast of them. Photographs taken in two mutually perpendicular planes will give a completely accurate and clear image of the cast, and with it an image of the lacrimal ducts themselves. Such images not only allow you to see the exact location and nature of the stenosis, but also indicate the topography of the pathological area, but also the size and degree of disorders,
In this regard, radiography of the lacrimal ducts is the most accurate method for determining the location of obstacles that cause their complete or partial obstruction.
The method of radiography of the lacrimal ducts was first used by Ewing in 1909. He injected the lacrimal ducts with a mast emulsion of bismuth nitrate and took photographs in the lateral position. Regardless of Ewing, the contrast method has been used since 1911 by Aubert, who developed a detailed methodology and detailed instructions on the diagnostic use of this method. However, in those years the contrasting method did not become widespread, and the works of these authors were forgotten. In 1914, he independently rediscovered this method, re-developing its technical and clinical aspects and, through persistent polarization, achieved its introduction into clinical practice.
Oxide on liquid paraffin, barium sulfate, podulyatrin, torotrost, podipin, sublipol can be used as a contrast mass.
The technique for injecting a contrast mass is as follows: after local linthesis (Sol. dicaini 0,5-1,0% ) with a conical probe, the lacrimal canaliculus is expanded and the lacrimal ducts are washed with some solution. Then, using a syringe, a contrast mass is very slowly injected through the lower lacrimal canaliculus into the lacrimal ducts until the patient feels its presence in the nose. In total, at least 0,3-0.4 ml. After this, the patient is quickly placed on the table and two x-ray- lateral and anteroposterior. If the nasolacrimal duct is passable, then the injected mass comes out on its own through 1-2 hours. Sometimes the release of the mass must be facilitated by a light massage or rinsing. In case of complete obstruction, the contrast mass is delayed for several days.
Typically, the contrast mass is administered through the lower canaliculus. In cases of atresia of the inferior lacrimal punctum, the contrast mass can be injected through the superior lacrimal punctum.
Radiography of the lacrimal ducts has great scientific, theoretical and clinical and practical significance. This method makes it possible to study in situ the normal shape of the lacrimal duct with all the variations in its direction, bends, calibers, changes in the lumen at different levels, as well as its relationship to the surrounding sinuses, to the nasal cavity itself, etc.
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What is dacryocystitis?
Dacryocystitis- inflammation of the lacrimal sac. This bag is located near the inner corner of the eye in the so-called lacrimal fossa. Tear fluid passes through the nasolacrimal duct into the nasal cavity. If the outflow of tear fluid from the lacrimal sac is disrupted, pathogenic bacteria accumulate in it, which causes inflammation.Dacryocystitis can develop in both adults and children (including newborns).
There are acute and chronic forms of dacryocystitis.
Signs of dacryocystitis are:
- unilateral lesion (usually);
- pronounced, persistent lacrimation;
- swelling, redness and tenderness in the inner corner of the eye;
- discharge from the affected eye.
Causes
The immediate cause of dacryocystitis is obstruction of the nasolacrimal canal or blockage of one or both lacrimal openings, through which tears enter the nasolacrimal canal. The causes of obstruction of the nasolacrimal duct can be:- congenital anomaly or underdevelopment of the lacrimal ducts; congenital stenosis (narrowing) of the lacrimal ducts;
- trauma (including fracture of the upper jaw);
- inflammatory and infectious diseases of the eye and their consequences;
- rhinitis (runny nose); syphilitic lesion of the nose;
- inflammatory processes V maxillary sinus, in the bones surrounding the lacrimal sac;
- blepharitis (purulent inflammation of the eyelids);
- inflammation of the lacrimal gland;
- tuberculosis of the lacrimal sac;
Dacryocystitis in adults (chronic dacryocystitis)
Dacryocystitis in adults occurs in a chronic form of the disease. It can develop at any age, young or mature. Dacryocystitis occurs 7 times more often in women than in men. There are several clinical forms dacryocystitis:
- stenosing dacryocystitis;
- catarrhal dacryocystitis;
- phlegmon (suppuration) of the lacrimal sac;
- empyema (purulent lesion) of the lacrimal ducts.
The chronic form of dacryocystitis is manifested by swelling of the lacrimal sac and chronic lacrimation or suppuration. Often, there is a simultaneous manifestation of conjunctivitis (inflammation of the mucous membrane of the eyelids) and blepharitis (inflammation of the edges of the eyelids).
When you press on the area of the lacrimal sac (at the inner corner of the eye), purulent or mucopurulent fluid drains from the lacrimal openings. The eyelids are swollen. A nasal test or Vesta test with collargol or fluorescein is negative (the cotton swab in the nasal cavity is not stained). During diagnostic lavage, fluid does not enter the nasal cavity. With partial patency of the nasolacrimal canal, the mucopurulent contents of the lacrimal sac can be released into the nasal cavity.
At long term chronic dacryocystitis, the lacrimal sac can stretch to the size of a cherry and even to the size walnut. The mucous membrane of a stretched sac may atrophy and stop secreting pus and mucus. In this case, a somewhat viscous, transparent liquid accumulates in the cavity of the sac - hydrocele of the lacrimal sac develops. If left untreated, dacryocystitis can lead to complications (infection of the cornea, ulceration and subsequent visual impairment, including blindness).
The acute form of dacryocystitis in adults is most often a complication of chronic dacryocystitis. It manifests itself in the form of phlegmon or an abscess (ulcer) of the tissue surrounding the lacrimal sac. Very rarely, the acute form of dacryocystitis occurs primarily. In these cases, the inflammation on the fiber passes from the nasal mucosa or paranasal sinuses.
Clinical manifestations acute form Dacryocystitis is characterized by bright redness of the skin and pronounced painful swelling of the corresponding side of the nose and cheeks. The eyelids are swollen. The palpebral fissure is significantly narrowed or completely closed.
The resulting abscess may spontaneously open. As a result, the process may stop completely, or a fistula may remain with prolonged discharge of pus through it.
Dacryocystitis in adults requires mandatory consultation with an ophthalmologist and subsequent treatment. There is no self-healing of dacryocystitis in adults.
Dacryocystitis in children
IN childhood Dacryocystitis occurs quite often. They constitute, according to statistics, 7-14% of all eye diseases in children. There are primary dacryocystitis (in newborns) and secondary dacryocystitis (in children over 1 year old). This division of dacryocystitis is due to the fact that they differ in the reasons for their development and in the principles of treatment.
Based on age, dacryocystitis is divided into dacryocystitis of premature babies, newborns, infants, preschool and school-age children.
Dacryocystitis of newborns (primary dacryocystitis)
Dacryocystitis in newborns is caused by underdevelopment or abnormal development of the lacrimal ducts, when the nasolacrimal canal is partially or completely absent. In some cases, damage to the lacrimal ducts can occur when forceps are used during childbirth.Dacryocystitis of newborns is also called congenital dacryocystitis. It occurs in 5-7% of newborn babies and usually responds well to treatment. The disease manifests itself already in the first weeks of life, and sometimes even in the maternity hospital.
During the prenatal period of fetal development, a special gelatin plug or film is formed in the lower part of the nasolacrimal canal, which prevents the entry of amniotic fluid into the lungs (the channel is connected to the nasal cavity). At the first cry of a newborn baby, this film breaks through, and the nasolacrimal canal opens for tears. Sometimes the film breaks through a little later, during the first 2 weeks of life.
If the film does not break through, then the nasolacrimal canal becomes impassable for tears. If the baby's eyes are wet all the time, this may indicate an obstruction of the lacrimal ducts (partial or complete). Newborns cry without tears.
If tears appear (in one or both eyes), this may be the first manifestation of dacryocystitis. Tears stagnate and spill through the lower eyelid. Bacteria multiply well in stagnant tears. Inflammation of the canal develops, and then the lacrimal sac.
Much less frequently, dacryocystitis in newborns develops as a result of an abnormality in the structure of the nose or lacrimal ducts. Dacryocystitis in newborns due to infections is also rare.
Manifestations of dacryocystitis in newborns are mucous or mucopurulent discharge in the conjunctival cavity, mild redness of the conjunctiva and lacrimation - the main sign of the disease. After a night's sleep, “sourness” of the eye, especially one, can also be a symptom of dacryocystitis.
Sometimes these manifestations are regarded as conjunctivitis. But with conjunctivitis, both eyes are affected, and with dacryocystitis, as a rule, the lesion is one-sided. It is simple to distinguish dacryocystitis from conjunctivitis: when pressing on the area of the lacrimal sac, mucopurulent fluid is released from the lacrimal openings during dacryocystitis. The Vesta test (see section “diagnosis of dacryocystitis”) and diagnostic lavage of the lacrimal ducts will also help in diagnosing dacryocystitis.
You should not start treatment on your own; you should consult an ophthalmologist for advice. In the case of neonatal dacryocystitis, it is very important to start treatment as early as possible. This is a guarantee of cure. Chances of recovery will be significantly reduced if treatment is delayed or improper treatment. This may lead to the progression of the disease to chronic form or to severe complications(phlegmon of the lacrimal sac and the formation of a fistula of the lacrimal sac or phlegmon of the orbit).
Secondary dacryocystitis
The development of secondary dacryocystitis may be due to the following reasons:- improper treatment of primary dacryocystitis;
- descending inflammatory processes of the lacrimal sac from the conjunctival cavity or lacrimal canaliculi;
- inflammatory process in the nasal cavity and paranasal sinuses nose (sinusitis);
- injuries leading to compression or damage to the bony nasolacrimal canal;
- pathological processes in soft and bone tissues near the lacrimal ducts.
Inflammation of the lacrimal ducts can be caused by staphylococci, gonococci, E. coli and other pathogens. In order to determine the pathogen, a bacteriological examination is carried out.
Nasal test is negative; During diagnostic lavage, fluid also does not enter the nasal cavity. During diagnostic probing, the probe passes only to the bony part of the nasolacrimal canal.
With a long course of secondary dacryocystitis, ectasia (stretching) of the lacrimal sac cavity may occur; in this case, a protrusion will appear at the inner corner of the eye.
The use of Albucid in pediatrics is undesirable: firstly, it causes a pronounced burning sensation when instilled, and secondly, it is characterized by crystallization and compaction of the embryonic film.
If several drugs are prescribed, the interval between instillations should be at least 15 minutes.
Massage of the lacrimal sac
As soon as parents notice manifestations of dacryocystitis, it is necessary to contact an ophthalmologist, because without a doctor it will not be possible to cope with this disease. An examination by a pediatrician and an ENT doctor is also scheduled. You should not hesitate to see a doctor, because... after 2-3 months, the gelatin film will turn into cellular tissue, and conservative treatment will become impossible. True, some doctors admit the possibility conservative treatment until the child is six months old.
Massage of the lacrimal sac plays a significant role in the treatment of dacryocystitis. But if there is the slightest sign of inflammation, massage cannot be performed due to the danger of pus getting into the tissue surrounding the lacrimal sac and the development of phlegmon.
The doctor must clearly show how to properly massage. Before starting the procedure, the mother should thoroughly wash and treat her hands with a special antiseptic solution or wear sterile gloves.
Before the massage, you should carefully squeeze out the contents of the lacrimal sac, clean the eyes of pus by rinsing with a solution of furatsilin. And only after this you can start the massage. It is best to massage immediately before feeding. The procedure is carried out at least 5 times a day (in the first 2 weeks up to 10 times a day).
The massage is carried out with the index finger: Gently press the area of the lacrimal sac 5 times, moving from top to bottom, and at the same time try to break through the gelatin film with sharp pushes.
If the massage is performed correctly, pus will be released from the canal. You can remove pus with a cotton ball dipped in freshly brewed broth. medicinal herb(chamomile, calendula, tea, etc.) or in a furatsilin solution at room temperature.
Purulent discharge can also be removed by rinsing the eyes using a pipette for rinsing. After removing the pus remedy washed off with warm boiled water. After the massage, antibacterial eye drops prescribed by your doctor should be placed in the eye.
During conservative treatment, you should visit your doctor 2 times a week.
After 2 weeks, the ophthalmologist will evaluate the effectiveness of the manipulations performed and, if necessary, adjust the treatment. Massage is effective only in the first months of a baby’s life. According to statistics, complete cure dacryocystitis in infants under three months of age – 60%; at the age of 3-6 months – only 10%; from 6 to 12 months – not higher than 2%. If the tear flow is not restored, the doctor will select other treatment methods. A specially trained physician may proceed to irrigate the tear ducts with a sterile saline solution containing an antibiotic. Before rinsing, an anesthetic is instilled into the eye - a 0.25% solution of dicaine.
Surgical methods of treatment
Probing the tear duct
Doctors' opinions regarding the timing of probing the tear ducts vary. Supporters conservative methods treatment, it is believed that probing should be carried out no earlier than 4-6 months if there is no effect from massage. But there are also supporters early use probing – if there is no effect from conservative treatment within 1-2 weeks.If massage does not give the desired effect in the first 2-3 months of the baby’s life, the ophthalmologist may prescribe probing of the tear ducts. This procedure is performed on an outpatient basis by a pediatric ophthalmologist. Under local anesthesia, a probe is inserted through the lacrimal opening into the nasolacrimal canal. A rigid probe allows you to break through the remaining film and expand the canal to ensure normal outflow of tears.
During probing, the child does not feel pain; the procedure is completed within a few minutes. How younger age baby, the less he feels discomfort from probing. In 30% of cases, probing has to be repeated after a few days. It is possible to restore tear drainage using probing in 90% of cases and above. To prevent inflammation after probing, the child is prescribed antibacterial drops in the eye.
Bougienage of the tear duct
Bougienage is a fairly common method of treatment, more gentle than surgery. It consists of introducing a special probe into the tubules - a bougie, which will physically remove the obstacle and push apart and expand the narrowed walls of the nasolacrimal canal.The bougie is inserted through the lacrimal opening. The procedure is not painful, but there may be discomfort when carrying it out. Sometimes used intravenous anesthesia. The procedure is completed within a few minutes. Sometimes several bougienages are required at intervals of several days.
In some cases, bougienage is performed with the introduction of synthetic elastic threads or hollow tubes.
Surgical treatment
Treatment depends on the patient's age, the form of dacryocystitis and its cause. Surgical treatment of dacryocystitis is indicated:- in the absence of effect from the treatment of primary dacryocystitis; with severe anomalies in the development of the lacrimal ducts;
- Treatment of secondary dacryocystitis, chronic dacryocystitis and its complications is carried out only surgically.
For primary dacryocystitis (in newborns), a less traumatic operation is used - laser dacryocystorhinostomy.
Surgical treatment of secondary dacryocystitis in children and chronic dacryocystitis in adults is carried out only surgically. In adults and children over 3 years old, dacryocystorhinostomy is performed - an artificial nasolacrimal canal is created connecting the eye cavity with the nasal cavity. Removal of the lacrimal sac in adults with dacryocystitis is carried out in exceptional cases.
Before the operation, it is recommended to apply pressure to the area of the lacrimal sac 2 times a day; to remove purulent discharge, thoroughly wash the eyes with running water and instill anti-inflammatory antibacterial drops (20% sodium sulfacyl solution, 0.25% chloramphenicol solution, 0.5% gentamicin solution, 0.25% zinc sulfate solution with boric acid) 2-3 times a day.
There are two types of operational access: external and endonasal (through the nose). The advantage of the endonasal approach is that the operation is less traumatic and there is no scar on the face after surgery. The purpose of the operation is to create a wide opening between the nasal cavity and the lacrimal sac.
The operation is performed under local anesthesia with the patient in a sitting position. As a result of surgical treatment with endonasal access, complete cure for chronic dacryocystitis is achieved in 98% of cases.
With dacryocystitis of newborns surgical treatment carried out when conservative treatment is ineffective. Before surgery, sufficient antibacterial therapy is carried out to prevent infectious complications. Infectious complications pose a risk of brain abscess, because With venous blood an infection from the nasolacrimal duct area can enter the brain and cause the development purulent inflammation brain or brain abscess formation. During the operation under general anesthesia normal communication between the nasal cavity and the conjunctival cavity is restored.
For dacryocystitis, the cause of which is a congenital anomaly or a deviated nasal septum, surgical treatment is carried out at the age of 5-6 years.
Treatment with folk remedies
Many adult patients and mothers of sick children begin to treat dacryocystitis on their own, folk remedies. Sometimes such treatment unforgivably takes too long, which leads to a protracted course of the disease or the development of complications.Washing the eyes with herbal decoctions and using eye drops can only temporarily reduce or eliminate the manifestations of the disease, but does not affect the cause of dacryocystitis. After some time, the symptoms of the disease reappear.
Folk remedies and methods of treating dacryocystitis can be used, but after consulting with an ophthalmologist:
- Compresses based on infusions of chamomile, mint, dill.
- Lotions: sachets with tea leaves should be briefly placed in hot water, let them cool slightly and apply them to your eyes, covering them with a towel on top.
- Lotions or drops of Kalanchoe juice
Spontaneous cure
Most of all, mothers are afraid of probing the nasolacrimal canals, as one of the methods of treating dacryocystitis. But not every dacryocystitis requires canal probing. In 80% of children with dacryocystitis, the embryonic gelatin film itself ruptures at 2-3 weeks of the baby’s life, i.e. self-healing occurs. Massaging the nasolacrimal canal will only help and speed up the rupture of the film.When detecting dacryocystitis in a newborn, ophthalmologists first of all suggest expectant management. Although ophthalmologists have different opinions about the waiting period: some suggest waiting up to 3 months, and some – up to 6 months of age. By this time, self-healing of congenital dacryocystitis may occur - as the nasolacrimal canal gradually matures, the gelatinous film covering the opening of the canal may rupture. Other ophthalmologists consider early probing of the lacrimal canal to be successful - after 2 weeks of massage, if the effect is not achieved.
When using a wait-and-see approach, it is necessary to ensure eye hygiene: instill drops recommended by an ophthalmologist into the eyes and rinse the eyes with warm, freshly brewed tea. Required condition is also providing a massage.
Self-healing will be indicated by the absence of manifestations of dacryocystitis. But even in this case, a repeated consultation with an ophthalmologist is necessary.
The lacrimal apparatus includes the lacrimal gland and lacrimal ducts. The lacrimal gland is located in the upper outer part of the orbit. Tear fluid from the gland enters the upper fornix of the conjunctiva (under upper eyelid at the outer corner of the eye) and washes the entire front surface of the eyeball, covering the cornea from drying out.
- Colored nasolacrimal test Vesta - allows you to determine functional state lacrimal ducts, starting from the lacrimal openings. A 2% fluorescein solution is instilled into the eye and the patient's head is tilted down. If the paint has been applied within 5 minutes, the test is positive (+); slow - 6-15 minutes; absence of paint in the nasal passage - test (-).
- Determination of indicators of total tear production - Schirmer test - carried out using a strip of graduated filter paper bent at an angle of 45°, which is placed behind the lower eyelid to the bottom of the lower fornix of the conjunctiva. Eyes closed. After 5 minutes, the length of wetting is measured. Normally it is 15 mm.
- Norn's Test - allows you to determine the stability of the precorneal film. After cleansing the conjunctival sac of mucus and pus, the patient is instilled with 1-2 drops of a 2% collargol solution twice with an interval of 0.5 minutes. The test is considered positive if collargol is completely absorbed within 2 minutes, and when pressing on the area of the lacrimal sac, a drop appears from the lacrimal punctum. If collargol is not released from the lacrimal openings, the test is considered negative.
- At the same time, a nasal collarhead test is checked.. To do this, a cotton swab is inserted under the inferior nasal concha to a depth of 4 cm. If it is stained after 2-3 minutes, the test is considered positive, after 10 minutes - delayed, and if there is no coloring - negative.
- Lacrimal duct rinsing - performed after anesthesia of the conjunctiva with a three-fold installation of 0.25% dicaine solution. A conical Sichel probe is inserted into the inferior lacrimal punctum, first vertically and then horizontally, along the lacrimal canaliculus to the nasal bone. Then, using a syringe with a blunt needle or with a special cannula, a physiological or disinfectant solution is injected in the same way. The patient's head is tilted downwards, and when the lacrimal ducts are in a normal state, liquid flows out of the nose in a stream. In cases of narrowing of the nasolacrimal duct, the liquid flows out in drops, and in case of obstruction of the lacrimal ducts, it pours out through the upper lacrimal punctum.
- Probing the lacrimal ducts - performed after expansion of the inferior lacrimal punctum and canaliculus with a Sichel probe. Along this path, a Bauman probe No. 3 is passed to the nasal bone, after which the probe is turned vertically and, adhering to the bone, passes through the lacrimal sac into the nasolacrimal canal. Probing is used to localize strictures and widen the nasolacrimal ducts.
- To diagnose changes in the lacrimal ducts It is better to use radiography. After anesthesia of the conjunctival sac with dicain and dilation of the lacrimal punctum and canaliculi with a conical probe, 0.4 ml of an emulsion of bismuth nitrate in vaseline oil is injected into the lacrimal ducts with a syringe. Then, placing the patient in the chin-nasal position, a picture is taken. In this case, violations are easily detected normal structure lacrimal ducts. After radiography, the lacrimal ducts are washed with saline to remove the emulsion.