Canalicular and nasolacrimal test. Avoided eye probing

Maybe my story will help someone who currently has problems with their eyes.
When Nastya was born in the maternity hospital, they told me that she had conjunctivitis and sent me to another hospital, we spent 10 days there and smeared her eye with tetracycline ointment, but as soon as we stopped applying it, the eye began to fester again. But when we arrived home, I called my relative, she I have a nurse and she told me: “Natasha, it doesn’t look like you have conjunctivitis, because after tetracycline it goes away on the third day, and you most likely have an obstruction of the lacrimal canal, it’s better to go to the ophthalmologist.” But we don’t go to the ophthalmologist We got there, there was a huge line there. At 1.5 months we met our nurse and she said that we would have to wash out the eye, the word “wash” for such a baby felt like a knife to my heart, I immediately began looking for information on how to avoid this procedure and found the following article:

In the first days after birth, children often develop purulent discharge from the eyes. One of the reasons for purulent discharge may be dacryocystitis of newborns- inflammation of the lacrimal sac.

Why does this disease develop?

Usually, in all people, tears from the eye go through the lacrimal ducts into the nasal passage. The lacrimal ducts include: lacrimal puncta (superior and inferior), lacrimal canaliculi (superior and inferior), lacrimal sac and nasolacrimal canal, which opens
under the inferior nasal concha (here the tear fluid evaporates due to the movement of air during breathing), this is 1.5 - 2.0 cm from the external nasal opening. At the back, the nasal cavity communicates with the upper part of the pharynx (nasopharynx). During intrauterine life, the child has a gelatinous plug or film in the nasolacrimal duct that protects it from amniotic fluid. At the moment of birth, with the first breath and cry of the newborn, the film breaks through, and the patency of the canal is created. If this does not happen, then the tear stagnates in the lacrimal sac, an infection develops, and acute or chronic dacryocystitis develops.
The first signs of dacryocystitis, which are detected already in the first weeks of life, are the presence of mucopurulent discharge from the conjunctival sac of one or both eyes, lacrimation, lacrimation (rarely) in combination with mild redness of the conjunctiva. This process is often mistaken for conjunctivitis.
The main symptom of dacryocystitis is the release of mucopurulent contents through the lacrimal openings when pressing on the area of ​​the lacrimal sac. Sometimes this symptom is not detected, which may be due to previous drug therapy. To clarify the diagnosis, a collarhead test (Vest test) is performed. 1 drop of a 3% solution of collargol (dye) is instilled into the eyes. First, a cotton wick is inserted into the nasal cavity. The appearance of a dye on the wick 5 minutes after instillation is assessed as positive test. The sample is considered delayed if paint is detected in the nose after 6-20 minutes and negative after 20 minutes. The test can also be considered positive if, after instillation of Collargol, the conjunctiva clears eyeball within 3 minutes. Negative result nasolacrimal test indicates a conduction disorder in the lacrimal drainage system, but does not determine the level and nature of the lesion, therefore consultation with an ENT doctor is necessary, because canal - nasolacrimal, so if a child has a runny nose, mucous tear ducts swelling, the lumen narrows and the outflow of tears becomes difficult. Severe complication Unrecognized and untreated dacryocystitis of newborns may be phlegmon of the lacrimal sac, accompanied by a significant increase in body temperature and anxiety of the child. As an outcome of the disease, fistulas of the lacrimal sac are often formed.
At chronic course main process clinical sign is a profuse purulent discharge from the lacrimal sac, which fills the entire palpebral fissure, usually after sleep or crying.
Once the diagnosis is made, treatment must begin immediately. First, study the anatomy of the lacrimal ducts, the projection of the lacrimal sac (see above). Before starting the massage, wash your hands thoroughly, cut your nails short, and you can use sterile gloves.
1. Squeeze out the contents of the lacrimal sac.
2. Instill a warm solution of furatsilin 1:5000 and use a sterile cotton swab to remove the purulent discharge.
3. Massage the lacrimal sac area by gently pressing 5 times index finger from top to bottom using jerky movements, trying to break through the gelatinous film.
4. Apply disinfectant drops (chloramphenicol 0.25% or Vitabact)
5. Carry out these manipulations 4 – 5 times a day. The massage is carried out for at least 2 weeks. According to the literature and our data, the gelatinous plug resolves or breaks through by 3-4 months, if parents correctly and carefully follow the above recommendations.
If these manipulations did not give desired result, then it is necessary to carry out probing of the nasolacrimal canal in an eye office. Probing the nasolacrimal canal is a complex, painful and far from safe procedure. Under local anesthesia (pain relief), using conical Sichel probes, the lacrimal openings and lacrimal canaliculi are dilated, then a longer Bowman probe No. 6; No. 7; No. 8 is inserted into the nasolacrimal canal and breaks through the plug there, then the canal is washed with a disinfectant solution. After probing, it is necessary to carry out massage for 1 week (see above) to prevent relapse associated with the formation of adhesions.
Probing is ineffective only in cases where dacryocystitis is due to other reasons: an anomaly in the development of the nasolacrimal duct, a deviated nasal septum, etc. These children need complex surgery– dacryocystorhinostomy, which is performed no earlier than 5–6 years.

Dacryocystitis is an inflammation of the lacrimal sac and occurs in 1-5% of newborns. Dacryocystitis is diagnosed in the first days and weeks of life, so it happens that the baby is diagnosed already in the maternity hospital.

The causes of the disease may be:
– Pathology of the nose and surrounding tissues due to inflammation or injury.
– Obstruction of the nasolacrimal duct at the time of birth of the child, due to the presence of the so-called gelatinous plug, which did not resolve by the time of birth.

Normally, free communication between the nasolacrimal duct and the nasal cavity is formed in the 8th month intrauterine development. Until this time, the outlet of the lacrimal canal is closed by a thin membrane. By the time of birth, in most cases, the membrane dissolves or breaks through at the first cry of the child. If the film does not dissolve or does not break through, then problems with tear drainage arise. As in most cases, the outcome of the disease depends on timely diagnosis and time of treatment.

The first signs of the disease are mucous or mucopurulent discharge from the eye, swelling in the inner corner of the eye.
Quite often, pediatricians regard this as conjunctitis and prescribe anti-inflammatory drops, but this treatment does not help.
The distinctive signs of dacryocystitis are mucopurulent discharge when pressing on the area of ​​the lacrimal openings.

Treatment begins with massage of the nasolacrimal duct. The purpose of the massage is to break through the gelatinous film. Massage of the nasolacrimal canal is performed with several jerking or vibrating movements of the finger with some pressure directed from top to bottom, from the top of the inner corner of the eye down. Due to the created high blood pressure in the nasal duct, the embryonic membrane breaks through. (Does this remind you of the plunger principle?)
Massage should be done 8-10 times a day. If there is no effect in the coming days, then it should be continued for a month. Purulent discharge, which is squeezed out of the lacrimal sac, must be removed with a cotton ball soaked in a decoction of chamomile, tea leaves, or calendula.

If massage does not help, then hard probing of the nasolacrimal canal is necessary. It is better to do it in 2, 3 one month old.

To carry out this procedure, it is necessary to undergo a blood test for coagulation and an examination by an ENT doctor to exclude pathology of the nasal cavity. After the probing procedure, treatment in the form of drops continues for another week as prescribed by the doctor, and massage is preferably carried out for a month

I followed the steps (which are highlighted in bold and underlined) and the next day Nastya began to have a strong tear with pus - and our eye almost stopped festering. And a day later the eye returned to a normal “human” state. But I still massaged Nastya week. I did the massage when I was breastfeeding, the baby is calmer at this time and does not fidget. It’s so good that we got rid of this disease, thanks to such an instructive article. Now our eyes are completely fine.

general information

To start working in the Vesta.Acceptance subsystem after authentication, in the window that appears, click on the link "Acceptance"(Fig. 1):

Rice. 1. List of available subsystems in the Vesta system

Colored icons located at the top above the button "Add sample"(Fig. 2) mean:

• Green- link to | official website of Rosselkhoznadzor;
• Blue- link to a website dedicated to the state information system in the field of veterinary medicine | "Vetis" ;
• Yellow- link to help system dedicated to the automated system "Vesta" .

Rice. 8. Form for searching for a counterparty in the Vesta.Acceptance subsystem (05/12/2015)

If the counterparty is not found, you can add it yourself by going to the tab "Add new".

The form of filling may vary depending on the type of counterparty; for an individual, the following fields are filled in (Fig. 8):

• Counterparty type- selection of counterparty type: Entity, Individual, Individual entrepreneur;
• Full name- indicate the full name of the counterparty;
• Passport- indicate the passport details of the counterparty;
• TIN- indicate the TIN of the counterparty, if any;
• A country- selection of the counterparty country;
• Region- region selection;
• Locality, Street, House, Structure, Office/Apartment.

After filling out the fields, click on the button "Add".

Rice. 8. Filling out the form for adding a new counterparty in the Vesta.Acceptance subsystem (05/12/2015)

Block "Sampling"

Contains the following fields (Fig. 9):

Rice. 9. Filling out the “Sampling” block in the “Vesta.Acceptance” subsystem (05/12/2015)

• Owner- the counterparty is indicated - the owner of the product or material from which the sample is taken. You must press the button with three white stripes;
• Selection act number- the number of the sampling report is indicated;
• Date of the selection report- the date of the sampling act is indicated;
• Package safe number- indicate the number of the safe package;
• Date and time of selection- the date and time of sampling is indicated;
• Place of selection- the location of sampling is indicated;
• Selection made- indicated executive, which carried out the sampling.
• In the presence- the persons in whose presence the samples were taken are indicated, if any.
• ND for sampling- indicated normative document regulating sampling;
• Number of samples- the number of samples taken is indicated, and the type of packaging of the product is also indicated;
• Sample weight/volume- the mass and units of measurement of the sample are indicated;
• Accompanying document- the accompanying document for the product is indicated, if any. This could be an invoice, inventory, label.

Block "Origin"

Contains the following fields to fill in (Fig. 10):

Rice. 10. Filling out the “Origin” block in the “Vesta.Acceptance” subsystem (05/12/2015)

• Manufacturer- the manufacturer of the product is indicated. You need to click on the button with three white stripes.

The manufacturer is selected from the general Rosselkhoznadzor Register of supervised objects “Cerberus”. If the required manufacturer is not available, then it is possible to add it yourself; the form of addition is similar to the form of adding a counterparty (Fig. 11). The form of filling may vary depending on the type of counterparty. After filling out the fields, click on the button "Add";

Rice. 11. Adding a manufacturer in the “Vesta.Acceptance” subsystem (05/12/2015)

• Country of origin- country of origin is indicated;
• Region of origin- the region of the country of origin is indicated;
• Origin- a text field where you can enter information about the origin of the product;
• ND for product production- regulatory document for production;
• Fishing area.

Block “Information about the party”

Contains the following fields to fill in (Fig. 12):

Rice. 12. Filling out the “Batch Information” block in the “Vesta.Acceptance” subsystem

• Vet number document- number of the veterinary document accompanying the batch;
• Vet date document- date of the veterinary document accompanying the batch;
• Departure country- country of origin of the product (selected from the drop-down list);
• Departure region- region of the sending country (selected from the drop-down list);
• Point of departure- point of departure of products;
• Sender- name of the sender;
• Destination country- country of destination of the product (selected from the drop-down list);
• Destination region- region of the country receiving the product (selected from the drop-down list);
• Destination- the final destination where the product goes;
• Recipient- name of the recipient of the products;
• Marking- cargo marking;
• Batch weight/volume- mass/volume of the batch indicating the unit of measurement;
• Quantity per lot- quantity of products (material) indicating the unit of measurement;
• Production date;
• Best before date;
• Transport- you need to indicate the type of transport (select from the list) and indicate the number vehicle or name, then add to the batch information by clicking on the “plus” icon.

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 study gains last years due to the increasing spread 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 lint of cotton wool or a 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 is determined on an analytical balance (mass, the force of movement at which the hair bends). 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.

Methods for studying the lacrimal 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 mucolacrimal 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 the eyeball, and thus the tear duct can be considered to be 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 safe to say that it functions well and has correct location and sizes are not allowed. 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 turbinate (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 tubular or nasolacrimal tests Vesta or both together turn out to be 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 an x-ray is taken. X-ray contrast picture reveals strictures and diverticula, obstruction various departments lacrimal canaliculi, lacrimal sac, 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 lacrimal 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.

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. Lacrimal gland normally accessible to inspection and palpation only to a very small extent, when inverted upper eyelid 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:

1. Schirmer tests,
2. capillary test,
3. tubular and nasal tests,
4. probing the lacrimal canaliculi,
5. probing of the nasolacrimal canal,
6. washing the lacrimal ducts,
7. 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. In the normal state of the lacrimal 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 reveals very early functional disorders in the lacrimal system (even before pathological atopic changes become clearly expressed).

Pokhisov evaluates the capillary test using a three-point system:

1. it is normal when the tear stream looks like a hair capillary;
2. the sample is indicated by a + sign when the tear duct is slightly dilated;
3. the test is designated ++ when the tear stream is sharply expanded.
4. Volyn dignity capillary test is that it is objective and allows one to judge how justified 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, drops of the dye solution come out through the points into the conjunctival sac.

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 conditions9 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 % - a 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 with both diagnostic and therapeutic purpose, since it allows you 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:

1. insertion of the probe vertically through the lacrimal opening into the vertical surface of the lacrimal canaliculus;
2. transferring the probe to a horizontal position and moving it along the canaliculus up to the nasal wall;
3. 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 is carried out local anesthesia by multiple installation 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 to rupture the wall of the lacrimal canal 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 % rivanol solution 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 it is necessary to facilitate the release of mass light massage or washing. 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.