The postsaccal, idiopathic dacryostenosis ? experimental and clinical aspects

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Abstract
The ‘idiopathic’ dacryostenosis has not yet been cleared up in its aetiological aspects. For further explanation of aetiology and pathomechanisms an experimental, anatomical study was made. Its object was to define the angles and measurements within the bony lacrimal structures and to establish possible connections between the development of the postsaccal stenosis and certain bony constellations of the lacrimal system. The main goal of these examinations was to determine the angle between the lacrimal fossa and the main direction of the nasolacrimal canal, as well as the angles which are found in the course of the nasolacrimal canal. Macerated half skulls obtained from anatomical dissection courses were used for this study. After cleaning the bony lacrimal passages, the distal orifice of the nasolacrimal canal was closed with bone wax. The canal and the lacrimal fossa were filled with epoxy resin. After hardening the preparations were radiographed in order to make sure that the whole system was completely filled with resin. Then the surrounding bone was removed chemically and the resin casts were laid free. They were photographed and the photographs were traced and measured. A trigonometric method was then used for constructing the maximum angle between the lacrimal fossa and nasolacrimal canal. This angle was mainly directed dorsomedially and showed a considerable amount of variation. A bony system with a large angle increases the possibility of acquiring a postsaccal dacryostenosis. The bony angle is one of many factors facilitating an ascending inflammation in the lacrimal mucosa. Clinically we have to differentiate the acute, fresh dacryocystitis from the chronic, recurrent dacryocystitis. The main symptoms are epiphora, pain and inflammation in the medial canthal area and headache. The most important diagnostic examinations are the slitlamp examination of the eyelids, of the lacrimal puncta and of the anterior segment of the globe, the ‘lacrimal punctum excursion test’, the diagnostic rinse of the lacrimal passages, the dacryocystography and the rhinological examination. The result of a successful treatment of the acute, beginning dacryocystitis is to open the incomplete, transitory, distal stenosis of the nasolacrimal duct. The stenosis is caused by an ascending inflammation from the nose and by the swelling of the lacrimal mucosa. The blockage can be solved by massage after application of vasoconstrictory drops. The therapy of a complete, postsaccal lacrimal stenosis always has to be a dacryocystorhinostomia externa (‘Toti-operation’). The Kaleff-Hollwich modification proved successful and is extended by a fibrin sealing method. The operation technique is described and the results are reported. The experimental data and clinical findings are correlated; in conclusion they point out, that an ascending inflammation is mainly responsible for the development of the idiopathic dacryocystenosis.

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