CONGENITAL ATRESIA OF THE LACRIMAL DUCT.

C. S. G. NAGEL, M.D.,

SAN FRANCISCO.

Read before Eye, Ear and Nose Section, San Francisco County Med. Society, April, 1919.

With reports of two illustrative cases this paper discusses the practical aspects of con-genital lacrimal obstruction.

The condition made the subject of this paper is not of every day occur-rence. Still, aside from being of spe-cific interest to the ophthalmologist, it is of practical moment, from the dif-ferential diagnostic viewpoint, to the family physician and the obstetrician. The following two histories are offered as typically representative.

1. A healthy baby girl, first born, 10 days old, referred for purulent dis-charge from left eye. There is mod-erate irritation of the eye. No swell-ing over tear sac. On pressing upon the latter a little mucopurulent fluid comes from the lower lacrimal punc-tum. Examination of pus smear nega-tive. Strong pressure by finger on sac with slight massage of the region once a day on this and the following day are followed by' prompt permanent cure. Diagnosis dacryocystitis.

2. V. G., normal first born, boy of 4 months, seen for the first time Febru-ary 14, 1918, "has always a tear in his left eye since one week old"—to quote his mother's words. Had been treated with eye drops only. Examination shows moderate conjunctivitis of af-fected eye, no swelling over tear sac. Pressure on the latter brings quite a liberal amount of purulent discharge from lacrimal puncta, much to the sur-prise of the parents, the examination heretofore having always consisted in mere inspection of the eye. Diagnosis dacryocystitis.

Pressure and massage on sac and ap-plication of zinc drops upon the con-junctiva almost daily for a month only tend to temporarily check the secretion, so that parents consented to a general anesthesia on March 13. Repeated at-tempts to probe the tear duct thru the upper canaliculus proving abortive, the lower canaliculus was slit, and a No. 3 probe passed thru the whole length of

the duct without any difficulty. There was a little pus on pressure the fol-lowing day. Since then the eye re-mained normal, the child having been seen frequently up to the present.

It is now generally accepted that dacryocystitis of the new born is due to atresia of the tear duct. Normally open at birth, the duct may still be closed at its nasal end by a thin sep-tum, a fetal residue. Usually this sep-tum becomes atrophic thru being stretched as the canal widens, finally leading to perforation. According to the anatomic studies of 13 fetuses by Mayou1, the lower end of the lacrimal canal is very narrow thruout the whole fetal period; and remains so at birth, being partly closed at its nasal end by pressure from the lower concha. It is filled at birth with detritus, which is derived from the solid chord of prolifer-ating epithelial cells which formed the original anatomic substratum of the tear passages, and by degeneration of the central cells of which canalization had taken place.

This detritus is ordinarily soon re-moved by aspiration. If the lumen be particularly narrow aspiration will re-main ineffectual and a secondary in-fection take place. The lack of an open passage may after a time lead to con-siderable extension of the sac, which, thanks to the elasticity of infantile tissue, will promptly disappear after a removal of the stoppage. Axenfeld2

remarks expressly that in some cases it is only after strong pressure with a glass rod that the contents of the sac can be emptied. This, according to Mayou3 is because the sac fills but part of the fossa lacrimalis in the new born; and may therefore become extended to a considerable degree, before swell-ing will be noticeable externally; secre-tion will therefore be gathered for a

CONGENITAL, ATRESIA OF LACRIMAL DUCT 407

considerable time and the trouble be discovered only after weeks.

Other possible contributing etiologic factors are blocking of lumen by cir-cular folds of mucosa (valves of Huschke and Hasner) , stenosis thru infraction of bones in forceps delivery, also the curved course of the lacrimal duct in the fetus, as against its straight course in the adult. Rochon-Duvig-neaud4 found anatomically among 30 heads of all fetal stages incomplete nasal opening of the duct three times; and once this condition was bilateral. It is more rare by far that inflamma-tion of the nose or its sinuses will lead to secondary infection of the sac. Dis-eased bone conditions of the neighbor-hood, from tuberculous and gum-matous processes, also may bring about similar conditions.

The secretion is generally sterile, at first consisting of epithelial cells, detritus and mucus. Later secondary infection will take place, and there is then no longer any real difference from dacryocystitis of later life, the pneumo-coccus predominating, and staphylo-cocci also common.

The clinical picture of dacryocystitis neonatorum can simulate ophthal-nioblcnnorrhea, impressing itself as such on the medical attendants in the first of the histories given above. The only reference I know of, to bilateral occurrence in life is by Secfelder.5

There has been described by Pe-ters" and later by Pechin7 a per-sistent form of conjunctivitis in the new born, without any muco-pus from the lacrimal sac. It resists all treat-ment by instillations, but is promptly cured by pressure upon the sac or oth-erwise by probing— evidently pointing to closure of the duct as the cause.

It is of practical importance in oph-thalmia neonatorum to bear in mind the possibility of secondary infection of the lacrimal passage, if impermeable thru atresia. I, therefore, would advo-cate an occasional pressure and slight massage of the sac as a routine prac-tice in ophthalmia neonatorum. With a clear passage into the nose the sac does not become infected even in gon-orrhcic or diphtheritic conjunctivitis,

altho inundated with their microbes; hence we must conclude that its mu-cosa possesses quite different "af-finities" or receptors from those of the conjunctiva.8 It is more nearly related to the mucous membrane of the nose than to the conjunctiva, may, indeed, be looked upon as a continuation of Schneider's membrane, and the sac thus as a quasiaccessory sinus of the nose ■—a qualification borne out by its ready involvement in acute rhinitis.

Regarding therapy it would seem best to first try simple pressure, eventually followed by massage; and only in case of not succeeding thus to institute careful probing and perhaps syringing. From some experience in that respect I am inclined to think that in part of the cases at least one would succeed here in probing thru the upper canaliculus (after Otto Becker).

In the light of the almost univer-sally prompt favorable results of our therapeutic measures in congenital af-fections of the lacrimal sac in the new born, in marked contrast to the situa-tion in later life, one should feel espe-cially reluctant to slit the lower canali-culus for probing.

There may be spontaneous cures, but they arc certainly the exceptions, and a case of Bernhardt0 shows that the purulent discharge may persist for years if not treated. Expulsion of a pus floccule into the nose immediately preceding cure, has been described in several instances. Groenouw8 discusses the probable occasional hereditary na-ture of the trouble. In the first of the histories given above a child of the father's brother is said to have had the same affection.

Atresia of the lacrimal duct is cer-tainly not so rare as one would have been inclined to think formerly. Bern-hardt gives 17 cases from the Rostock clinic in six years, and believes there were probably from 6 to 8 more, where the correct diagnosis was made later, but not recorded. I remember espe-cially, whilst house surgeon with Uhthoff, several cases equally as mild as the first of the two recorded here, which were all cured by simple pressure.

408 C. S." G. NAG EL,

LITERATURE.

1. Mayou. Lacrimal abscess of the new born. Roy. London Ophth. Hos. Rep. XVII, 1908.

2. Axenfeld. Bakteriologie i. d. Augenhlk., Jena, 1907. 3. Mayou. Royal London Ophth. Hosp. Rep. v. 17, 1908. 4. Rochon—Duvigneaud. Archives d'Opht. XIX pg. 81. 5. Seefclder. Angeborene Anomalien etc., in Lubarsch—Ostertag, Ergebnisse d. allgem.

Pathol. XVI, Supplement. 6. Peters. Bemerkungen iibcr Erfolge d. Na senbehdlg. bei Augcnleidcn, Zeitsch. f. Augcn-

hlkd. II, 1899. 7. Pechin, Dacryscystite congenitale attenuee.e tc. Arch. d'Oph. XXV, 1901. 8. Axenfield. 9. Graefe—Saemisch—Hess, Handbuch. der Augenheilk. 2. ed. XL, Abschn. IV.

V I S U A L A C U I T Y A T L O W I L L U M I N A T I O N A N D T H E U S E O F T H E

I L L U M I N A T I O N S C A L E F O R T H E D E T E C T I O N O F S M A L L

E R R O R S I N R E F R A C T I O N .

P R O F . C. E . F E R R E E AND G. R A N D , P H . D . ,

BRYN MAWR, PA.

This paper reporting the use of apparatus described in the last number of the JOURNAL brings out some remarkable facts regarding the effect of uncorrected errors of refraction on visual acuity at low illumination and suggests a method of great delicacy for deter-mining the amount and meridians of astigmatism. Presented before the meeting of the American Ophthalmological Society, June 1919.

A s was s ta ted in the previous paper (see p . 335) the incentive to this work was a feeling in the N a v y of the need to establish a sys tem of testing', for the selection of men for those b ranches of i ts service requ i r ing especially keen scotopic acuity. T h e first s tep t owards the accompl i shment of this pu rpose was of course the devis ing of a sui table a p p a r a t u s and test method. A further need, however , was to find out w h a t r ange of difference in scotopic acui ty migh t be expected a m o n g eyes graded as fit on the basis of the tes ts of o ther functions and capacit ies.

W e have been interes ted to make a pre l iminary survey of eves graded as normal wi th regard to photopic acui ty and o the r commonly tes ted functions in o rder to de te rmine whe the r such eyes may be expected to show signifi-can t differences in keenness of func-t ion ing a t low i l luminat ions . T h i s work can, of course, be considered only as pre l iminary . T h e final survey and es tab l i shment of n o r m s and s t anda rds , on which to base the selection, should come th ru the t e s t i ng of a la rge num-

ber of men in the service of the Navy , or in candidacy for this service.

In a thoro test of ocular fitness for vocat ions requ i r ing keenness of dis-cr iminat ion a t low i l luminat ions , t he following points should be taken into a c c o u n t : (1 ) the min imum a m o u n t of l ight required to d iscr iminate the tes t object before dark a d a p t a t i o n ; (2) the min imum a m o u n t after an appropr i -ately selected period of dark adapta-t i o n ; and (3 ) the rapidi ty as well as the a m o u n t of gain in acui ty d u r i n g the process of adap t ing . T h e s e points a re not only the obvious a priori possibilities with regard to individual differences, but they have been confirmed by us in a pre-liminary survey of a number of normal subjects.

It will be the purpose of this paper to give a brief statement of the results of this survey; also a brief exposition of a new method of using the acuity test in clinic work. Tha t is, in the process of making our acuity tests with a sensitive light control, we have found that the il-luminat ion scale can be used wi th g rea t precision in detecting small errors in re-