LACRIMAL SECRETION DISORDERS

John L. Wobig and Roger A. Dailey

The lacrimal system is something of an ophthalmological stepchild. The surgical techniques used for lacrimal system disorders are more closely related to those concerned with orthopedics, rhinology, and urology than to those that pertain to the globe and orbit. Ninety percent of the postoperative care is intranasal. Preoperative and postoperative inspection of the nose is essential. Reliable objective diagnostic tests are necessary to evaluate the success of lacrimal surgery.

HYPOSECRETION

Hyposecretion is primarily found in older adults together with fibrocystic changes in the reflex lacrimal glands. The symptoms described may vary greatly. The patient may even complain that the eyelids are wet. Sharp pains are often felt upon awakening or the eyelids may “stick together.” Photophobia and asthenopia may be severe. Fibrous strands of mucoid material may irritate the eyelids. As the condition progresses the patient may experience pain, inflammation, and impaired vision, accompanied by keratoconjunctivitis sicca and corneal abrasions. Hyposecretion may accompany chronic disease, endocrine disorders, anemia, and vitamin deficiency as in xerophthalmia. It is found in erythema multiforme exudativum (Stevens-Johnson syndrome), filamentous keratitis, ocular pemphigus, and Mikulicz’s disease (infiltration and replacement of lacrimal gland cells by lymphoid tissue). Sjögren’s syndrome is also a variant of this disease.

Trauma and surgery of the eyelid may damage major portions of the basic secretors or the ducts of the reflex secretors. Paralysis of the latter may accompany central nervous system lesions, especially in the hypothalamus. Exposure to heat, dry air, smoke, sun, and wind accentuate the symptoms. Parasympathetic blocking drugs such as atropine sulfate and scopolamine hydrobromide may decrease an already barely adequate secretion. The use of contraceptive pills often produces dry eyes.

Pseudoepiphora should be classed with hyposecretion because when the basic secretors begin to fail, the peripheral sensory nerves of the conjunctiva call upon the reflex system to make up the shortage. In response, the reflex secretors may oversecrete. In spite of such adequate or overcompensation, the symptoms of hyposecretion usually persist because of the lack of mucus in the tears of the reflex secretors.

TREATMENT

When hyposecretion accompanies a general disease, it usually improves with treatment of the general condition. This is especially true in endocrine hypofunction, anemia, and vitamin deficiencies. It is not always true of the more acute diseases that destroy the basic secretors, such as Mikulicz’s disease.

Once the diagnosis is made, the treatment is often self-evident. In ovarian deficiency the patient is started on Premarin (0.625 mg), from one tablet twice a week to one a day. Diethylstilbestrol in women and Halotestin tablets in men have also been used. Thyroid tablets are indicated when the metabolic rate is low.

For local treatment, artificial tears that are preservative-free are recommended. They serve as a lubricant to replace the loss of mucin and fluid, and they also slow the escape of the medicament through the canaliculi. Individuals must have their own treatment program with regard to amount and frequency. Artificial ointments for nighttime use should also be preservative-free.

Punctal Plugs

Collagen implants are 1.1 to 2.0 mm long and 0.2 to 0.4 mm wide and are made by Eagle Vision (Memphis, Tennessee). These implants are used to predict results before permanent punctal occlusion. The Herrick plug (Lacrimedics, Rialto, California) is shaped like a funnel. This plug is placed in the horizontal canaliculus. One problem with the plug is that it can migrate through the lacrimal excretory system.

Only gold members can continue reading. Log In or Register to continue