The lacrymal gland, though situated in the anterior and upper part of the orbit, and beneath the upper lid, where it is ordinarily well protected, is nevertheless liable to both acute infections and chronic irritations. When acutely inflamed it usually goes on to abscess formation. We have then acute dacryo-adenitis, which will produce the ordinary symptoms of phlegmon, with the added ocular features of vascularity and chemosis of the conjunctiva and more or less edema and immobility of the upper lid. Displacement of the eyeball may be produced by great inflammatory swelling. These abscesses tend to discharge either through the skin near the external angle or sometimes through the conjunctiva. While in the former case a scar results, it nevertheless is a preferable point either for spontaneous opening or for incision. If the case be seen in time it will be advisable to make this incision early and so limit destruction. (See [Plate XLV, Fig. 1].)
The lacrymal gland suffers occasionally in instances of constitutional syphilis, undergoing chronic and obstinate enlargement. It may also be the site of tumors either non-malignant, usually adenoma, or cancerous, most instances of the latter being expressions of extension.
The tear passages proper are composed of the canaliculi, the lacrymal sac, and the duct. These are altered, occasionally, in their relations, or absent, as the result of congenital defects. The passages proper frequently become obstructed, as the result of any chronic irritation which produces thickening of the conjunctiva, and in many laborers and others who are exposed to dust, dirt, or cold winds there will be a more or less constant stillicidium or overflow of tears. In some of these cases it is sufficient to slit up one or both canaliculi with a fine probe-pointed bistoury.
DACRYOCYSTITIS.
The lacrymal sac proper is frequently the site of both acute and chronic disease, known as dacryocystitis, which is the result of infection spreading from the conjunctival sac, rarely from the nose, or the exaggeration of conjunctival thickenings, like those mentioned above. The first symptoms are overflow of tears, accompanied by swelling or enlargement in the region of the sac. By pressure upon this a mixture of water, mucus, and sometimes pus may be expressed. As the disease goes on the fluid becomes purulent. If the sac, by pressure, can be emptied into the nose the nasal duct may be regarded as patulous and the treatment is simplified. If not there is stricture, usually at the upper end of the duct, which requires division and dilatation. The more chronic forms of trouble in this region are frequently intensified into acute phlegmonous lesions which, if neglected, will lead to spontaneous perforation and the formation of a lacrymal fistula at a point below the inner angle of the eye. (See [Plate XLV, Fig. 2].)
Treatment.
—The treatment should consist of exposure of the sac by incision of the canaliculi and its irrigation by means of a syringe and antiseptic fluid. Unless this fluid passes easily into the nose the stricture should be divided and Bowman’s probes passed, the principle of treatment being the same as that in treating urethral stricture. This part of the treatment should be referred to an oculist.
In acute dacryocystitis with suppuration the sac along the natural passages should be opened. When a diagnosis of an acute lesion of this kind is made nothing but the most radical treatment is advisable.
THE LIDS.
Congenital deformities of mild degree are not infrequent about the eyelids.