Keratometry. Keratometry is already used when examining the organ of vision in a child in maternity hospital. This is necessary for early detection congenital glaucoma. Keratometry, which can be performed by almost everyone, is based on measuring the horizontal size of the cornea using a ruler with millimeter divisions or a strip of sheet from a squared notebook. By placing the ruler as close as possible, for example, to the child’s right eye, the doctor determines the division on the ruler that corresponds to the temporal edge of the cornea, closing his right eye, and corresponding to the nasal edge, closing the left eye. The same should be done when a “cell strip” is brought to the eye (the width of each cell is 5 mm). When performing keratometry, it is necessary to remember the age norms for the horizontal size of the cornea: in a newborn 9 mm, in a 5-year-old child 10 mm, in an adult about 11 mm. So, if in a newborn it fits into two cells of a strip of paper and a small gap remains, then this is normal, but if it goes beyond two cells, then pathology is possible. To more accurately measure the diameter of the cornea, devices have been proposed - a keratometer and a photokeratometer (Fig. 37).
It should be noted that when examining the cornea, it is important to determine not only its transparency, sensitivity, integrity and size, but also its sphericity. Especially great importance this research has become increasingly popular in recent years contact correction vision. Keratoscopes are used to determine the sphericity of the cornea.
Algesimetry. An important criterion in diagnosis, assessment of severity and dynamics pathological process is the state of corneal sensitivity. The simplest known method, although crude and allowing only an approximate idea of the sensitivity of the cornea, is algesimetry using a cotton lint or hair. In order not to frighten children, you should bring a lint or hair to the eye not directly, but from the temporal side, doing it slowly, as if imperceptibly, with your right or left hand, slightly parting the eyelids (opening the palpebral fissure) with the other hand from the side of the nose . Such a study allows us to judge the presence of pronounced sensitivity or its significant impairment.
A more complex, but quite accessible and quite informative study is to determine the sensitivity of the cornea using a set of hairs (according to Samoilov) of varying elasticity (0.5; 1.0; 3.0; 5.0; 10.0, etc.), which can be fixed in the crevice of the end of the match. First, the elasticity of the hairs (mass, the force of movement at which the hair bends) is determined on an analytical balance. As a rule, 4-6 different hairs are prepared and each of them is numbered. Store the hairs in a box (small sterilizer for a syringe). First, the study is carried out at different points along the periphery and in the center of the cornea (6-8 points or more), using the least elastic hair. If sensitivity is not determined using this hair, then hairs with greater elasticity are successively used. The sensitivity of the cornea is determined by the hair that caused the reaction. Sensitivity at different points may be different; in these cases, sensitivity is recorded at each point. In order to assess the dynamics of corneal sensitivity during the disease process and under the influence of treatment, it is necessary to compare the results of repeated studies with the initial data, but the study must again begin, as in the first study, with the hairs of the least elasticity.
The most advanced devices for studying and recording the state of corneal sensitivity are algesimeters various designs, which were proposed by A. N. Dobromyslov and B. L. Radzikhovsky. However, they are used, as a rule, in the course of research and clinical experimental work. In practice, it is enough to conduct a study of the hair sensitivity of the cornea, but always in dynamics and in each eye.
Research methods tear ducts. The study of the lacrimal ducts in children must be carried out in the maternity hospital, and then throughout the first six months of life. In almost 5% of newborns, the nasolacrimal duct is closed by a gelatinous plug, which dissolves in the first days of life as a result of exposure to muco-tear fluid containing the enzyme lysozyme, and the path for lacrimal drainage is open. However, in approximately 1% of newborns, this plug does not dissolve, but is organized into a connective tissue septum, as a result of which tear drainage becomes impossible. In addition, the cause of obstruction of the lacrimal ducts may be changes in each of their sections, as well as in the nose. The first sign of pathology of the lacrimal ducts is constant lacrimation, and often lacrimation. In order to establish the cause or causes of lacrimation and lacrimation, it is necessary to consistently carry out a series of studies, starting with a simple visual determination of the position of the eyelids in relation to the eyeball. Normally, the upper and lower eyelids are in contact with eyeball, and thus we can assume that the tear stream is fully functioning. The presence of eversion, entropion, coloboma of the eyelids, lagophthalmos and other changes predominantly in the edges of the eyelids can cause lacrimation and lacrimation.
It is also very important to establish whether the newborn has lacrimal openings, how they are expressed and where they are located. To do this, it is necessary to slightly pull each eyelid at the inner corner of the palpebral fissure and determine the condition of each lacrimal punctum. If, in the normal position of the eyelids, the lacrimal openings are not visible and appear only when the eyelid is gently pulled back, then it means that they are positioned correctly. Normally, lacrimal puncta are clearly defined as a miniature funnel-shaped depression in the lacrimal tubercle.
By pressing a finger or a glass rod on the area of the lacrimal canaliculus with the eyelid retracted, check whether there is mucous or other discharge from the lacrimal openings. As a rule, there is no discharge from the lacrimal openings during this manipulation.
The next stage of the study is to determine the presence and functioning of the lacrimal sac. For this purpose, press the skin near the lower inner corner of the orbit with a finger or a glass rod, i.e., in the area of the projection of the lacrimal sac. In this case, the eyelid should be pulled away from the eyeball so that the lacrimal punctum is visible. If when pressing on this area There is no discharge from the lacrimal punctum or it is very scanty, transparent and liquid (tear), which means there is a lacrimal sac. However, it is impossible to say with certainty that it functions well and has the correct location and dimensions. If during this manipulation there is abundant mucous or mucopurulent discharge from the lacrimal openings, then this indicates obstruction of the nasolacrimal duct. In those rare cases, when when you press on the area of the lacrimal sac, its contents come out not through the lacrimal openings, but through the nose (under the lower turbinate), one can think about the irregular structure and shape of the lacrimal sac and the patency of the bony part of the nasolacrimal duct.
Finally, the area of the inferior turbinate is examined and the condition of the nasal septum is determined. In addition, pay attention to the presence or absence (difficulty) of nasal breathing.
After visual-manual examinations, functional lacrimal and nasolacrimal tests should be performed.
Functional tests are carried out in two stages. The first stage is the assessment of the functioning of the lacrimal ducts from the lacrimal opening to the lacrimal sac (Vest's canalicular test), the second - from the lacrimal sac to the release of fluid from under the inferior nasal concha (lacrimal nasal test Vesta). The Vesta nasolacrimal test is performed as follows. A loose swab of cotton wool or gauze is inserted under the inferior turbinate; 2-3 drops of a 1-3% solution of collargol or fluorescein are instilled into the conjunctival cavity; The time of instillation and the time of disappearance of the dye from the conjunctival sac are noted (normally it should not exceed 3–5 minutes). 5 minutes after instillation of the dye, every minute the swab is removed from the nose with tweezers and the time for the appearance of its staining is determined.
The West nasolacrimal test is considered positive if staining of the tampon occurred in the first 7 minutes after installation of the dye, and weakly positive or negative if staining was noted later than 10 minutes or did not occur at all.
In cases where the canalicular or nasolacrimal West test, or both together, are slow or negative, diagnostic probing should be performed with a Bowman probe (No. 1). In the process of careful probing, either free patency of each section of the lacrimal duct is revealed, starting from the lacrimal punctum and ending with the bony part of the nasolacrimal duct, or an obstacle in any of the sections. Before or after probing, the lacrimal ducts are washed. To do this, using a syringe and a blunt-ended straight or curved needle under pressure, a weak solution of an antiseptic, antibiotic, sulfonamide drug, isotonic sodium chloride solution, and lidase is injected through the upper (if necessary, through the lower) lacrimal opening. If the solution is excreted only through the nose, then this test is positive, if through both the nose and through the second lacrimal punctum, then it is weakly positive, and if only through the second lacrimal punctum, then negative. In cases where fluid is released from the same lacrimal opening, that is, does not pass through the tubules, the sample is considered sharply negative. In order to exclude the presence of an obstruction in the nasolacrimal duct in such cases, retrograde sounding is performed together with an otolaryngologist.
Finally, in order to finally establish the location and extent of the pathology of the lacrimal ducts, an X-ray examination should be performed. Iodolipol is used as a contrast agent, which is administered through the lacrimal openings, after which X-ray. The X-ray contrast picture reveals strictures and diverticula, obstruction of various parts of the lacrimal canaliculi, lacrimal sac, and the bony part of the nasolacrimal duct.
Only after sequentially carrying out all diagnostic studies you can make a correct diagnosis and choose an adequate treatment method (bougienage, probing, reconstructive surgery on the lacrimal ducts, in the nose).
Due to the fact that pathology lacrimal organs consists not only of impaired tear drainage, but also of changes in the tear-producing apparatus ( lacrimal gland), you need to know that dysfunction of the lacrimal gland can be judged by the indicators of the Shprimer test. The essence of this test is that a strip of filter paper 0.5 cm wide and 3.5 cm long is placed behind the lower eyelid for 3-5 minutes. If all the paper becomes homogeneously moist during this time, this indicates normal functioning of the gland. if it is faster or slower, then it means that its hyper- or hypofunction is noted, respectively.
Fluorescein test. A fluorescein test is performed if there is a suspicion of a violation of the integrity of the cornea (keratitis, damage, dystrophy). 1-2 drops of fluorescein solution are installed into the conjunctival cavity (on the cornea) (in cases where there is no fluorescein solution, the test can be performed using a collargol solution), and then the cavity is quickly washed with an isotonic sodium chloride solution or any ophthalmic solutions of antiseptics, antibiotics, sulfa drugs. After this, the cornea and conjunctiva are examined using a combined method using a binocular loupe, a manual or stationary slit lamp. If there is a defect in the cornea (the integrity of the epithelium and its deeper layers is damaged), then a yellowish-greenish color will be visible in this place. In the process of treating a disease (damage) of the cornea, the sample is used many times, which makes it possible to monitor the dynamics of the process, the effectiveness of treatment and the restoration of its integrity.
N.N. Arestova
Dacryocystitis is one of the most common inflammatory diseases eyes in children, accounting for 7 to 14% of ophthalmopathology 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. Contents of the lacrimal sac (mucus, fetal detritus, 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 canal with dysostosis of the 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). Important in ensuring normal tear drainage there is an absence of pathology in the nasal cavity and preservation of nasal breathing (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 severe congenital or post-inflammatory stenosis, occlusion of the lacrimal canaliculi, or during 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, and 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
The study of the condition of the lacrimal organs begins with an external examination: the presence of lacrimation or lacrimation in the calm state child, position of the eyelids, costal edge of the eyelids, eyelash growth. In newborns, especially with chubby cheeks, a Mongoloid type of face, a 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 opacification (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 of infectious agent. Voluminous yellow pus is characteristic of a staphylococcal infection, copious mucopurulent discharge, sometimes with a greenish tint, can be with gonorrheal infection, liquid yellowish pus or mucus - with chlamydial infection
is often a manifestation 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 of the 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.
Functional study of the lacrimal ducts
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).
In case of a slow nasal or nasopharyngeal test or the presence of a rhinogenic factor is suspected, a “double Vesta test” is performed - the test is repeated after inserting 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 appears in the nose 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).
Washing 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 have been described, fatal outcome 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 horizontal position to vertical;
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 difficult 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 canaliculi, sac, nasolacrimal duct, canal, sinuses nose, 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 structure of the nasal cavity and its paranasal sinuses in newborns (see above for more details), inflammation and pathology occur in almost half of newborns, endoscopy of the nasal cavity should be considered a mandatory study in children with neonatal dacryocystitis.
So, when probing it is important to take into account different variants 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 makes it possible to identify various pathological changes in the nasal cavity, but also to select the optimal algorithm for subsequent treatment dacryocystitis of newborns, congenital obstruction of the lacrimal ducts, to increase its effectiveness.
Pediatric examination
A child with neonatal dacryocystitis needs clinical analysis blood and examination by a pediatrician to assess the child’s physical condition and exclude ARVI, allergies, and 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. Retrograde movement pus causes inflammation of the tear ducts. 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 disinfectant eye drops. To prevent skin irritation, it is necessary to remove the remaining eye drops from the skin of the eyelids with damp sterile cotton wool. 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 in more than 95% of children reveals pathogenic staphylococci (often hemolytic, aureus), 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 of 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 diagnostic procedure, which makes it possible to assess their patency, and therapeutic, 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 perform initial probing classical method- through the lower lacrimal opening, and during repeated probing and washing, sparing the lower lacrimal canaliculus, as the most important in the act of lacrimal drainage - through the upper lacrimal opening. 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 manipulation, not without risk possible complications, therefore, 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, they should be probed experienced doctor who has sufficient skills to perform 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 about the advisability of trying 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, it is advisable, if massage of the lacrimal sac in newborns with dacryocystitis is ineffective, 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 applied late, over 4-6 months of age, with highly pathogenic microflora, concomitant pathology nasopharynx, combined congenital anomalies, etc., it is necessary to carry out long-term treatment of the lacrimal sac - repeated courses of probing, bougienage and therapeutic lavage of the lacrimal ducts with individual selection of medications depending on the microbiological flora discovered during the 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, clinical form dacryocystitis, duration of the disease, 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). A 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 occur due to late treatment to an ophthalmologist, incorrect 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. General state the child may 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 relapses of inflammation, incurable incompetence of the lacrimal ducts due to late treatment and decisive factor 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 obstructions: 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 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 to 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.
In the human lacrimal apparatus, two sections are distinguished: the tear-producing (lacrimal gland, Krause's glands) and the lacrimal drainage (lacrimal openings, lacrimal canaliculi, lacrimal sac and nasolacrimal duct). Pathology of the lacrimal apparatus often manifests itself inflammatory processes and anomalies in the development of the lacrimal ducts and very rarely - pathology of the lacrimal glands.
Most constant symptom These diseases cause persistent lacrimation (epiphora).
One of the main causes of lacrimation is a violation of the patency of the lacrimal ducts, which can occur in any area.
To diagnose the patency of the lacrimal ducts, the following are carried out: collarhead test, washing, probing and radiography of the lacrimal ducts.
In order to objectively assess the functional state of the lacrimal openings and canaliculi, a collar canalicular test (Vest test) is used. 1 drop of a 3% solution of collargol is instilled into the conjunctival cavity with the patient sitting with his head slightly thrown back. It is suggested to make light but frequent blinking movements. The evacuation of a colored solution from the conjunctival cavity into the lacrimal sac is judged by the discoloration of the conjunctival cavity. The test is considered positive if discoloration of the conjunctival cavity occurs within 5 minutes, delayed - 6-10 minutes, negative - if after 10 minutes collargol is retained in the conjunctival cavity at least partially.
At the same time, a collarhead nasal test is performed to assess the patency of the entire lacrimal duct. A cotton swab is inserted under the inferior turbinate to a depth of 4 cm. Collarhead nasal test is considered positive if the dye appears on the swab after 5 minutes, delayed - 6-10 minutes, negative - if there is no dye on the swab at all.
A slow or negative tubular test indicates a mechanical obstruction along the lacrimal openings or tubules or their functional failure. A negative or delayed nasal test with a positive canalicular test indicates a difficulty in the outflow of tears from the lacrimal sac into the nose due to inflammatory or scarring changes.
In cases of delayed or negative collarhead test, they are washed to determine the patency of the lacrimal ducts. A 0.5% solution of dicaine is instilled into the conjunctival cavity. The lacrimal punctum is expanded with a conical probe, after which a blunt needle, attached to a two-milliliter syringe with a solution of furatsilin diluted 1:5000, is inserted into the lacrimal canaliculus 5-6 mm. By slowly pressing the piston, the liquid is injected into the lacrimal ducts. The patient's head is slightly tilted forward, and he holds the tray with his hand near his chin.
When washing, the following may occur:
- a) washing liquid flows out of the nose in a stream - the patency of the lacrimal ducts is good; flows out in drops - narrowing of the tear ducts;
- b) the washing liquid does not pass into the nose at all, but comes out in a stream through the upper lacrimal punctum - the lumen of the lacrimal ducts is completely blocked, the level of which can be determined radiographically.
For radiography of the lacrimal ducts, they are filled with a contrast agent (30% iodolipol solution, verografin solution).
Probing of the lacrimal ducts is usually carried out for therapeutic purposes in cases of dacryocystitis in newborns, to restore the patency of the ducts.
T. Birich, L. Marchenko, A. Chekina
“Diseases of the lacrimal organs, lacrimation, diagnosis” article from the section
Alternative names: Vesta color test, fluoroscein test, nasal test.
Colored nasolacrimal test is one of the research methods in ophthalmology, which consists of assessing the active patency of the paths along which tears flow from the eye into nasal cavity. During the test, the doctor measures the time it takes for dye instilled into the conjunctival cavity to travel from the conjunctival cavity into the nasal passage.
The purpose of this technique is to provide an integrative assessment of the active conductivity of tear fluid along the entire lacrimal duct.
This research method is the most popular method for diagnosing diseases of the lacrimal duct due to the ease of its implementation and complete absence side effects and complications.
Preparing for the test. No special preparation is required. The test can be carried out at any time of the day.
How is the color nasolacrimal test performed?
The patient sits and one drop of dye (1% sodium fluoroscein solution or 3% collargol solution) is instilled into the conjunctival cavity using a pipette. After this, the doctor asks the patient to tilt his head forward and blink a little. After 3 and 5 minutes, the patient is asked to blow his nose into a wet tissue using each nostril separately. If necessary, the doctor inserts a button-shaped probe, tightly wrapped with damp cotton wool or a bandage, under the inferior nasal concha. Based on the presence of dye on a napkin or bandage, the results are interpreted.
Interpretation of results
With normal patency of the lacrimal ducts, the dye enters the nasal cavity no later than 5 minutes. In this case, the sample is considered positive.
Staining a napkin or turunda from 6 to 20 minutes after the introduction of the dye is regarded as a delayed test. This fact may indicate stenosis of one of the sections of the lacrimal ducts.
If the dye appears later than 20 minutes or does not appear at all, the sample is considered negative. This may occur when the tear ducts or nasolacrimal duct are completely obstructed.
Indications
The main indications for color testing nasolacrimal test- This is lacrimation and lacrimation. Also, this test can be carried out as part of a comprehensive examination of the organ of vision during preventive examinations.
Contraindications for the test
The only contraindication for the test is individual intolerance to the dye (collargol or fluorescein). Considering that these substances do not have cross-allergy, if you have an allergic reaction to one drug, you can test it using another.
Complications
No complications were noted.
additional information
This test is highly specific, but in some cases it is possible to obtain false results. This happens in following cases: with severe inflammation of the nasal mucosa (rhinitis) or when squeezing dye onto the skin during blepharospasm (involuntary contraction of the orbicularis oculi muscle). In these cases, it is advisable to postpone the procedure.
The color nasolacrimal test is the most accessible method for studying the active patency of the lacrimal ducts. The only more accurate alternative method is scintigraphy of the lacrimal ducts, which is based on monitoring the passage of a radiopharmaceutical containing the technetium-99 isotope through the tracts using a gamma camera. This study allows us to assess the degree of stenosis of the tubules and canal. However, due to the difficulty of conducting this study it doesn't find wide application in clinical practice.
Based on the results of a color nasolacrimal test, the question of the need for other examination methods is most often decided: diagnostic lavage and probing of the lacrimal ducts, radiography of the lacrimal ducts. Comprehensive examination allows you to make the correct diagnosis and decide on treatment tactics.
Literature:
- Ophthalmology: National leadership. Ed. S.E. Avetisova, E.A. Egorova, L.K. Moshetova, V.V. Neroeva, Kh.P. Takhchidi. - M.: GEOTAR-Media, 2008. - 944 p.
- Cherkunov B.F. Diseases of the lacrimal organs. – Samara: Perspective, 2001. – 296 p.
An idea of the state of the tear-producing and tear-ducting apparatuses is obtained through inspection, palpation and special techniques(canalicular and nasolacrimal tests, lavage of the lacrimal ducts, x-ray examination).
When looking at the orbital area, pay focused attention to the color and nature of the skin surface in the area of projection of the lacrimal gland and lacrimal sac. When assessing the palpebral fissure, pay attention to the presence of tears between the eyeball and the edge of the eyelids (tear stream), as well as to the position of the lacrimal openings. Normally, the lacrimal openings are adjacent to the bottom of the lacrimal lake. They are not visible. There is no tearing. In order to see the lower lacrimal opening, the edge of the lower eyelid at the inner corner of the palpebral fissure is pulled back with a finger, and the patient looks up. To examine the superior lacrimal punctum upper eyelid pulled upward, and the patient should look down. Identification of lacrimal openings is facilitated by preliminary instillation of a collargol solution into the conjunctival cavity.
Palpation. It is most often carried out using the ends of the index or middle finger, moving along the edge of the orbit. When palpating the area of the lacrimal gland, pay attention to the temperature of the skin, the nature of its surface, the contour and density of the gland. Normally, in most cases it is not palpable, but its palpebral part can be examined. To do this, the upper eyelid should be raised at the outer corner of the palpebral fissure. The patient at this time should look strongly down and inward. In this case, normally the lobules of the lacrimal gland are visible through the conjunctiva yellowish color. In this way, it is possible to determine the prolapse of the lacrimal gland and its enlargement. When palpating the area of the lacrimal sac, attention is paid to the presence of protrusion and skin temperature. At the same time, pressure is applied to the lacrimal sac. It is located in the fossa of the same name immediately behind the edge of the orbit. This pressure is accompanied by an anterior displacement of the edge of the lower eyelid. The inferior lacrimal punctum becomes visible. In case of chronic dacryocystitis, serous or purulent contents are squeezed out of it.
(question 14) The state of tear production is determined using Schirmer tests. Strips of filter paper measuring 5x35mm are used for this purpose. One end of the strip is bent at a distance of 5 mm from the edge. This part of it is placed behind the lower eyelid. They notice the time. Normally, after 5 minutes the strip is wetted by at least 15 mm. With hypofunction of the glands, wetting slows down.
The patency of the lacrimal ducts is judged by the amount of tears in the area of the lacrimal duct and lacrimal lake, the state of the canalicular and nasolacrimal samples and the results of their washing.
Tubular test is the initial part of the nasolacrimal test. Its result allows us to judge the patency of the lacrimal canaliculi connecting the conjunctival cavity with the cavity of the lacrimal sac and the absorption capacity of the lacrimal openings. To perform this test, a drop of a 3% collargol solution or a 1% fluorescein solution is instilled into the conjunctival cavity. They record the time and observe the gradual disappearance of this coloring matter. Normally, within the first 2-5 minutes after several blinks of the eyelids, the dye disappears from the conjunctival cavity.
If the patency or absorption of tears by the tubules is impaired, the dye remains in the conjunctival cavity. The colored tear is visible in the tear stream and tear lake.
Nasolacrimal test Vesta carried out with normal patency of the tubules. Based on its results, the passage of tears from the lacrimal sac into the nasal cavity is judged. For this purpose, it is examined whether the dye has entered the nasal passage. To do this, a moist sterile turunda is inserted into the corresponding lower nasal passage using a glass rod or anatomical tweezers to a depth of 3-5 cm. It is better to do this before instilling the dye. 5 minutes after instillation, the turunda is removed. If the tear passes into the nose, a stain of dye is visible on it. The same result can be obtained if you ask the patient to blow his nose into a gauze napkin.
Lacrimal duct rinsing performed in the case of a negative nasolacrimal test. It is carried out using a special cannula placed on a syringe with a capacity of 2-3 ml. A cannula is the thinnest injection needle with a blunt tip. For rinsing, use a sterile saline solution or an antiseptic solution. Before washing, a 0.25% solution of dicaine is instilled into the conjunctival cavity three times. The subject is in a sitting position. The face should be well lit. A kidney-shaped basin is placed under the corresponding part of the face. The lacrimal punctum and canaliculus should first be expanded by introducing a sterile conical probe. The probe is inserted, like a cannula, repeating the natural direction of the lacrimal canaliculus. At first, for up to 1.5 mm, it is vertical, and then horizontal.
When inserting the probe and cannula into the lower canaliculus, the patient is asked to look up. At this time, the eyelid is slightly pulled down and outward with the thumb of the left hand. The cannula inserted into the canaliculus is advanced until it touches the back of the nose, then slightly pushed back. Resting your little finger on upper jaw, the syringe is held in such a way that the cannula does not come out of the tubule. At this time, the head of the person being examined is tilted forward. Press the plunger of the syringe. When the lacrimal ducts are blocked, rinsing fluid flows out in drops or streams from the corresponding nostril. If the patency of the nasolacrimal canal is disrupted, this fluid, without entering the nose, flows out through the upper canaliculus. If the canaliculus is obstructed, it returns through the same lacrimal punctum.
