Endoscopy of the William Fein, Clain Beeder,
Lacrimal Outflow
System
MD; Leon Daykhovsky, MD; Thanassis Papaioannou, MSc; MD; Warren S. Grundfest, MD
Management of obstructions in the drainage system would be greatly aided by improvements in the ability to visualize the blockages. We describe a new method of observation using miniature fiberoptics to view the entire lacrimal excretory system. We employed flexible endoscopes of fiberoptic bundles \s=b\
lacrimal
with outside diameters of from 0.5 to 0.7 mm. These endoscopes were inserted through the puncta and canaliculi. Sixteen patients were examined. A range of pathologic conditions were found, including slightly stenosed passages and severely destroyed canalicular mucosal lining. Our results indicate that this technique is feasible and useful in the diagnosis of lacrimal excretory disease.
(Arch Ophthalmol. 1992;110:1748-1750)
loon catheter inflation2; congenital mal¬ formations may need little more than probing; while scars, adhesions, stones, diverticuli, and tumors require direct observation with excision of tissue. When the damage is too severe for re¬ construction to be effective, a bypass procedure such as a Jones tube installa¬ tion is employed. These preoperative decisions are based on tests that may include the use of metal probes, colored or radioactive solutions or those with distinctive tastes, roentgenography, and computed tomography or magnetic resonance
imaging.
Direct visualization has been limited to the two ends of the system: slit-lamp examination of the puncta and nasal en-
doscopy of
the nasolacrimal duct ostium. While many ophthalmologists have become so expert with metal probes that they can almost "see" with their fingers, most have encountered situations in which visual examination of the interior of the canaliculi, sac, and duct would be greatly desired. To select appropriate endoscopes, close attention must be paid to the an¬ atomic size restrictions of the lacrimal excretory system. The diameter of a lacrimal punctum ranges from approxi¬ mately 0.3 mm in youth to 0.5 mm or more in a slitlike configuration in the elderly. The size, shape, and elasticity of a punctum varies with the condition of the fibroelastic ring that surrounds it
/^Vbstructions in the lacrimal drainage ^ system usually result in tearing, which may be accompanied by mucoid or mucopurulent discharges. Ulti¬ mately, the treatment of lacrimal duct obstructions for many is surgical inter¬ vention.1 Because the location of an ob¬ struction determines the type of repair to be undertaken, preoperative evalua¬ tions are designed to establish the dis¬ tance between the lesion and either the lacrimal punctum or the nasolacrimal duct ostium. The nature of the blockage is also of significance when planning therapy; un¬ complicated inflammatory conditions may be treated medically, and with balAccepted for publication June 17, 1992. From the Division of Ophthalmology (Dr Fein) and the Laser Research Center (Drs Daykhovsky, Beeder, and Grundfest and Mr Papaioannou), Cedars-Sinai Medical Center, Los Angeles, Calif. The authors have no proprietary interest in any of the endoscopes described. Reprints not available.
Fig 1.—Endoscopie equipment, including No. 1 and No. 2 lacrimal probes (a), a laser-light fi¬ ber guide (outer diameter, approximately 0.85 mm) used with a xenon chloride excimer laser (b), a flexible guide wire (c), a microendoscope (d), a catheter introducer (e), a Touhy-Borst adapter (f), and irrigation tubing (g).
Downloaded From: http://archopht.jamanetwork.com/ by a University of Michigan User on 06/14/2015
Fig 2.—Endoscopie view of a normal com¬ canaliculus at the junction of the supe¬ rior canaliculus (top) and common internal punctum (bottom).
3.—Mucosal flap partially blocking inter¬ nal punctum, hinged at 1 o'clock. Pushed away from the camera by irrigating fluid, the flap appears smaller than the punctum. With¬ out irrigation, the flap falls forward, blocking the punctum. The flap required removal by conventional surgery or laser ablation.
Fig 5.—A Jones lacrimal probe pushes against a fibrous band in the common cana¬ liculus. The probe was passed from the superior canaliculus, and the endoscopie
Fig 6.—Hyperemic lacrimal sac mucosa in dacryocystitis. The mucopurulent ma¬ terial that had filled the sac was removed by irrigation during the introduction of the endo¬ scope through the common internal punctum.
mon
view is from the distal end of the inferior canaliculus.
and with the adjacent fibers of the orbicularis muscle, which may atrophy in old age.3 Immediately distal to the punctum is the vertical canaliculus. The ampulla, with a diameter of 1.5 to 2.0 mm, leads to the horizontal canalic¬ ulus,4 which is 0.5 mm in diameter and has elastic walls that allow it to be dilated to two or three times its normal diameter.5 The canaliculi, either indi¬ vidually or joined in a common punc¬ tum, then enter a sac several millime¬ ters wide.6 At its distal end, the lacrimal sac passes through a 3.0-mm-wide opening into an osseus canal and emerges in the inferior meatus under a mucosal flap referred to as Hasner's valve.7 Duke-Elder and MacFaul8 note that "stenosis of the lacrimal passages occurs preferentially at four sites: (a)
Fig
acute
The vertical line at the left is
the
an
artifact.
puncta, (b) the canaliculi at their juncture with the sac, (c) in the
common
and duct particularly at the junction of the two, and (d) at the lower ostium." A dilating catheter balloon can be use¬ ful at each of these sites and in cases of failed dacryocystorhinostomy,9 al¬ though the lower ostium may best be reached with an intranasal approach.10 sac
PATIENTS, MATERIALS, AND METHODS Patient Population Patients were eligible for study if they had an obstruction anywhere in the excretory system as determined with lacrimal probing and irrigation. Excluded from the study were patients who were pregnant or who had a bleeding disorder. Patients were also ex¬ cluded if they or their parents could not un¬ derstand the informed consent form. This
Downloaded From: http://archopht.jamanetwork.com/ by a University of Michigan User on 06/14/2015
Fig 4.—Complete
obstruction of
a common
punctum perforated near 3-o'clock position by a lacrimal probe. Bleeding internal
ensued.
Fig 7.—Fused silica laser fiber in the inferior canaliculus aimed at the common punctum. The fiber was connected to a xenon chloride 308-mm laser. This view is from the superior canaliculus immediately after laser treatment to reopen the common punctum. The excimer laser used was set at a 130-ns pulse width at 20 Hz. study was not intended to be a correlative investigation between computed tomogra¬ phy or magnetic resonance imaging and direct visualization. Consequently, no pa¬ tient underwent computed tomography or magnetic resonance imaging as part of a preoperative evaluation. The protocol for lacrimal endoscopy was reviewed and ap¬ proved by the Medical Center's human sub¬ jects committee. Fiberoptic Equipment To achieve satisfactory visualization of the entire lacrimal excretory system, we em¬ ployed flexible endoscopes of fiberoptic bun¬ dles with outside diameters of from 0.5 to 0.7 mm (Fig 1). The bundles were coated with polytetrafluoroethylene and contained a lens at the distal end. Two endoscopes were used. The first was an angioscope (Intramed Lab¬ oratories Ine, San Diego, Calif) with an outer
diameter of 0.7 mm, a field of view of approximately 72° in air and 54° in water, and a depth of field ranging from approxi¬ mately 2 mm to infinity. The second was an angioscope (Olympus Corp, Lake Suc¬ cess, NY) with an outer diameter of 0.5 mm, a field of view of approximately 55° in air and 41° in water, and a depth of field ranging from approximately 2 to 50 mm. Two 300-W xenon light sources were used (model 610, Karl Stortz Endoscopy of America Ine, Culver City, Calif, and model CLV10, Olympus). A monitor (PVM1343MD, Sony, Park Ridge, NJ) and videocassette recorder (VO-9600, Sony) were used for monitoring and recording images. The endoscope was inserted through the punctum and canaliculi. This occasionally required dilation with conventional lacri¬ mal probes. In cases of mild proximal strictures, dilating balloon catheters were passed after infiltration of 1% lidocaine hy¬ drochloride with epinephrine. The balloons were inflated for 3 minutes, then deflated and reinflated for an additional 3 minutes. By passing the endoscope through one punctum and additional equipment through the punctum of the opposing lid, visualiza¬ tion of the distal portion of the horizontal canaliculi can accompany other intracanalicular procedures such as balloon catheter dilation, forceps or basket retrieval of dacryoliths, and biopsy performed with ro¬ tating brushes. The lacrimal sac can then be entered by both the observer scope and another piece of apparatus if the common internal punctum can be dilated suffi¬ ciently or if the two horizontal canaliculi pierce the sac separately. We have also developed another tech¬ nique for observing the central areas of the lacrimal outflow system. A thin, steerable polytetrafluoroethylene-coated guide wire was passed from a punctum through the canaliculus, sac, and duct into the nose, where it was fitted inside a catheter. The catheter was then passed in a retrograde manner back up into the sac. Instrumenta¬ tion introduced from one end of the sys¬ tem can then be observed from a scope entered from the other end. We have found that continuous irrigation through a Touhy-Borst adapter (Fig 1) is essential for good observation. In this way, saline, which can be slightly hypertonic, flows through the system under gentle pressure during the entire procedure. A collecting system is kept adjacent to the face to avoid soaking the patient.
RESULTS
Endoscopy provided useful images (Fig 2) in all 16 patients examined. (It
should be noted that endoscopie photo¬ graphs in this article were taken from videotape recordings. These still-frame images, in addition to suffering reduc¬ tion in resolution due to generational
loss inherent in the transfer of the im¬ age to static photographs, do not pro¬ vide the quality or quantity of informa¬ tion present in the moving video images.) Complete and partial stenosis of common canaliculi, common internal puncta (Fig 3), and nasolacrimal ducts were observed, along with acute infec¬ tious changes and scar tissue. Figure 3 illustrates a mucosal flap hanging in front of a common internal punctum. Originally blocking the opening, it was dislodged by probing under direct visu¬ alization. The flap acts as a ball-valve and will probably readhere at its circum¬ ference when it is allowed to return to its
original point. Surprisingly, endoscopie views of total occlusion (Fig 4) appeared
similar to observations of normal luminal wall. In three cases, a presumed total occlusion was found to be a tight steno¬ sis with multiple mucosal folds. In four examinations, scar fibers clearly demar¬ cated the duct obstruction (Fig 5). Three other patients had plugs of debris block¬ ing narrowed common internal puncta and a nasolacrimal duct. These plugs were removed by irrigation but re¬ formed within 1 month. The increased pressure required to remove the plugs by irrigation also resulted in saline infil¬ tration into the surrounding lid tissue. This infiltration had resolved by the end of the first week. Direct visualization of wire probing permitted identification of the true lu¬ men with subsequent passage of the probe. This technique helped us avoid false passages. This was particularly gratifying in two infants who had previ¬ ously undergone probing that failed to open the nasolacrimal duct. In three pa¬ tients, we found that trauma had re¬ sulted in such severe destruction of the mucosa lining the horizontal canaliculi that we recommended the installation of Jones tubes to resolve the tearing prob¬ lems. Three other patients were seen to have markedly inflamed lacrimal sacs (Fig 6). Intensive medical therapy re¬ sulted in relief of the congestion of the sac mucosa and in cessation of tearing
Downloaded From: http://archopht.jamanetwork.com/ by a University of Michigan User on 06/14/2015
for one of these patients. Surgery (Fig 7) required for the others.
was
COMMENT
Our results indicate that the use of endoscopes to examine the lacrimal ex¬ cretory system can yield valuable data. Disease was found in the canalicular system, at the common internal punc¬ tum, and in the sac and nasolacrimal duct. Choosing appropriate treatment was made easier by visualizing the pathologic conditions. As with all new
techniques, we experienced a learning curve in performing our endoscopie ob¬ servations. As we learned to recognize landmarks and disease, we were better able to avoid unwittingly creating false passages.11 Disposable lacrimal endo¬ scope systems are feasible, and im¬ proved endoscopie instrumentation at decreased cost should permit wide¬ spread application of this technology.
Direct visualization of the entire lacrimal excretory system can be a useful addition to ophthalmologists' armamentaria. This research was supported in part by the generous contributions of the Eleanor and Arthur Ellis Eye Center and the Medallion Fund of Cedars-Sinai Med¬ ical Center.
References 1. Steinsapir KD, Glatt HJ, Putterman AM. A 16-year study of conjunctival dacryocystorhinostomy. Am J Ophthalmol. 1990;109:387-393. 2. Becker BB, Berry FD. Balloon catheter dilation in lacrimal surgery. Ophthalmic Surg. 1989;
20:193-198. 3. Wolff E. Anatomy of the Eye and Orbit. Philadelphia, Pa: WB Saunders Co; 1961:204. 4. Werb A. The anatomy of the lacrimal system. In: Milder B, Weil BA, eds. The Lacrimal System. East Norwalk, Conn: Appleton & Lange; 1983:23\x=req-\ 32. 5. Viers ER. Lacrimal Disorders: Diagnosis and Treatment. St Louis, Mo: Mosby\p=m-\YearBook; 1976:6. 6. Smith BC, Della Rocca RC, Nesi FA, Lisman RD. Ophthalmic Plastic and Reconstructive Surgery. St Louis, Mo: Mosby\p=m-\YearBook; 1987; 1:21. 7. Linberg JV. Lacrimal Surgery. New York, NY: Churchill Livingstone Inc; 1988:9. 8. Duke-Elder S, MacFaul PA. System of Ophthalmology. St Louis, Mo: Mosby\p=m-\YearBook; 1974; 13:759. 9. Becker BB, Berry FD. Balloon catheter dilation in lacrimal surgery. Ophthalmic Surg. 1989; 20:193-198. 10. Becker BB. Flexible endoscopy in primary testing of the lacrimal system. Ophthalmic Surg.
1990;21:577-580.
Lacrimal Outflow
System
MD; Leon Daykhovsky, MD; Thanassis Papaioannou, MSc; MD; Warren S. Grundfest, MD
Management of obstructions in the drainage system would be greatly aided by improvements in the ability to visualize the blockages. We describe a new method of observation using miniature fiberoptics to view the entire lacrimal excretory system. We employed flexible endoscopes of fiberoptic bundles \s=b\
lacrimal
with outside diameters of from 0.5 to 0.7 mm. These endoscopes were inserted through the puncta and canaliculi. Sixteen patients were examined. A range of pathologic conditions were found, including slightly stenosed passages and severely destroyed canalicular mucosal lining. Our results indicate that this technique is feasible and useful in the diagnosis of lacrimal excretory disease.
(Arch Ophthalmol. 1992;110:1748-1750)
loon catheter inflation2; congenital mal¬ formations may need little more than probing; while scars, adhesions, stones, diverticuli, and tumors require direct observation with excision of tissue. When the damage is too severe for re¬ construction to be effective, a bypass procedure such as a Jones tube installa¬ tion is employed. These preoperative decisions are based on tests that may include the use of metal probes, colored or radioactive solutions or those with distinctive tastes, roentgenography, and computed tomography or magnetic resonance
imaging.
Direct visualization has been limited to the two ends of the system: slit-lamp examination of the puncta and nasal en-
doscopy of
the nasolacrimal duct ostium. While many ophthalmologists have become so expert with metal probes that they can almost "see" with their fingers, most have encountered situations in which visual examination of the interior of the canaliculi, sac, and duct would be greatly desired. To select appropriate endoscopes, close attention must be paid to the an¬ atomic size restrictions of the lacrimal excretory system. The diameter of a lacrimal punctum ranges from approxi¬ mately 0.3 mm in youth to 0.5 mm or more in a slitlike configuration in the elderly. The size, shape, and elasticity of a punctum varies with the condition of the fibroelastic ring that surrounds it
/^Vbstructions in the lacrimal drainage ^ system usually result in tearing, which may be accompanied by mucoid or mucopurulent discharges. Ulti¬ mately, the treatment of lacrimal duct obstructions for many is surgical inter¬ vention.1 Because the location of an ob¬ struction determines the type of repair to be undertaken, preoperative evalua¬ tions are designed to establish the dis¬ tance between the lesion and either the lacrimal punctum or the nasolacrimal duct ostium. The nature of the blockage is also of significance when planning therapy; un¬ complicated inflammatory conditions may be treated medically, and with balAccepted for publication June 17, 1992. From the Division of Ophthalmology (Dr Fein) and the Laser Research Center (Drs Daykhovsky, Beeder, and Grundfest and Mr Papaioannou), Cedars-Sinai Medical Center, Los Angeles, Calif. The authors have no proprietary interest in any of the endoscopes described. Reprints not available.
Fig 1.—Endoscopie equipment, including No. 1 and No. 2 lacrimal probes (a), a laser-light fi¬ ber guide (outer diameter, approximately 0.85 mm) used with a xenon chloride excimer laser (b), a flexible guide wire (c), a microendoscope (d), a catheter introducer (e), a Touhy-Borst adapter (f), and irrigation tubing (g).
Downloaded From: http://archopht.jamanetwork.com/ by a University of Michigan User on 06/14/2015
Fig 2.—Endoscopie view of a normal com¬ canaliculus at the junction of the supe¬ rior canaliculus (top) and common internal punctum (bottom).
3.—Mucosal flap partially blocking inter¬ nal punctum, hinged at 1 o'clock. Pushed away from the camera by irrigating fluid, the flap appears smaller than the punctum. With¬ out irrigation, the flap falls forward, blocking the punctum. The flap required removal by conventional surgery or laser ablation.
Fig 5.—A Jones lacrimal probe pushes against a fibrous band in the common cana¬ liculus. The probe was passed from the superior canaliculus, and the endoscopie
Fig 6.—Hyperemic lacrimal sac mucosa in dacryocystitis. The mucopurulent ma¬ terial that had filled the sac was removed by irrigation during the introduction of the endo¬ scope through the common internal punctum.
mon
view is from the distal end of the inferior canaliculus.
and with the adjacent fibers of the orbicularis muscle, which may atrophy in old age.3 Immediately distal to the punctum is the vertical canaliculus. The ampulla, with a diameter of 1.5 to 2.0 mm, leads to the horizontal canalic¬ ulus,4 which is 0.5 mm in diameter and has elastic walls that allow it to be dilated to two or three times its normal diameter.5 The canaliculi, either indi¬ vidually or joined in a common punc¬ tum, then enter a sac several millime¬ ters wide.6 At its distal end, the lacrimal sac passes through a 3.0-mm-wide opening into an osseus canal and emerges in the inferior meatus under a mucosal flap referred to as Hasner's valve.7 Duke-Elder and MacFaul8 note that "stenosis of the lacrimal passages occurs preferentially at four sites: (a)
Fig
acute
The vertical line at the left is
the
an
artifact.
puncta, (b) the canaliculi at their juncture with the sac, (c) in the
common
and duct particularly at the junction of the two, and (d) at the lower ostium." A dilating catheter balloon can be use¬ ful at each of these sites and in cases of failed dacryocystorhinostomy,9 al¬ though the lower ostium may best be reached with an intranasal approach.10 sac
PATIENTS, MATERIALS, AND METHODS Patient Population Patients were eligible for study if they had an obstruction anywhere in the excretory system as determined with lacrimal probing and irrigation. Excluded from the study were patients who were pregnant or who had a bleeding disorder. Patients were also ex¬ cluded if they or their parents could not un¬ derstand the informed consent form. This
Downloaded From: http://archopht.jamanetwork.com/ by a University of Michigan User on 06/14/2015
Fig 4.—Complete
obstruction of
a common
punctum perforated near 3-o'clock position by a lacrimal probe. Bleeding internal
ensued.
Fig 7.—Fused silica laser fiber in the inferior canaliculus aimed at the common punctum. The fiber was connected to a xenon chloride 308-mm laser. This view is from the superior canaliculus immediately after laser treatment to reopen the common punctum. The excimer laser used was set at a 130-ns pulse width at 20 Hz. study was not intended to be a correlative investigation between computed tomogra¬ phy or magnetic resonance imaging and direct visualization. Consequently, no pa¬ tient underwent computed tomography or magnetic resonance imaging as part of a preoperative evaluation. The protocol for lacrimal endoscopy was reviewed and ap¬ proved by the Medical Center's human sub¬ jects committee. Fiberoptic Equipment To achieve satisfactory visualization of the entire lacrimal excretory system, we em¬ ployed flexible endoscopes of fiberoptic bun¬ dles with outside diameters of from 0.5 to 0.7 mm (Fig 1). The bundles were coated with polytetrafluoroethylene and contained a lens at the distal end. Two endoscopes were used. The first was an angioscope (Intramed Lab¬ oratories Ine, San Diego, Calif) with an outer
diameter of 0.7 mm, a field of view of approximately 72° in air and 54° in water, and a depth of field ranging from approxi¬ mately 2 mm to infinity. The second was an angioscope (Olympus Corp, Lake Suc¬ cess, NY) with an outer diameter of 0.5 mm, a field of view of approximately 55° in air and 41° in water, and a depth of field ranging from approximately 2 to 50 mm. Two 300-W xenon light sources were used (model 610, Karl Stortz Endoscopy of America Ine, Culver City, Calif, and model CLV10, Olympus). A monitor (PVM1343MD, Sony, Park Ridge, NJ) and videocassette recorder (VO-9600, Sony) were used for monitoring and recording images. The endoscope was inserted through the punctum and canaliculi. This occasionally required dilation with conventional lacri¬ mal probes. In cases of mild proximal strictures, dilating balloon catheters were passed after infiltration of 1% lidocaine hy¬ drochloride with epinephrine. The balloons were inflated for 3 minutes, then deflated and reinflated for an additional 3 minutes. By passing the endoscope through one punctum and additional equipment through the punctum of the opposing lid, visualiza¬ tion of the distal portion of the horizontal canaliculi can accompany other intracanalicular procedures such as balloon catheter dilation, forceps or basket retrieval of dacryoliths, and biopsy performed with ro¬ tating brushes. The lacrimal sac can then be entered by both the observer scope and another piece of apparatus if the common internal punctum can be dilated suffi¬ ciently or if the two horizontal canaliculi pierce the sac separately. We have also developed another tech¬ nique for observing the central areas of the lacrimal outflow system. A thin, steerable polytetrafluoroethylene-coated guide wire was passed from a punctum through the canaliculus, sac, and duct into the nose, where it was fitted inside a catheter. The catheter was then passed in a retrograde manner back up into the sac. Instrumenta¬ tion introduced from one end of the sys¬ tem can then be observed from a scope entered from the other end. We have found that continuous irrigation through a Touhy-Borst adapter (Fig 1) is essential for good observation. In this way, saline, which can be slightly hypertonic, flows through the system under gentle pressure during the entire procedure. A collecting system is kept adjacent to the face to avoid soaking the patient.
RESULTS
Endoscopy provided useful images (Fig 2) in all 16 patients examined. (It
should be noted that endoscopie photo¬ graphs in this article were taken from videotape recordings. These still-frame images, in addition to suffering reduc¬ tion in resolution due to generational
loss inherent in the transfer of the im¬ age to static photographs, do not pro¬ vide the quality or quantity of informa¬ tion present in the moving video images.) Complete and partial stenosis of common canaliculi, common internal puncta (Fig 3), and nasolacrimal ducts were observed, along with acute infec¬ tious changes and scar tissue. Figure 3 illustrates a mucosal flap hanging in front of a common internal punctum. Originally blocking the opening, it was dislodged by probing under direct visu¬ alization. The flap acts as a ball-valve and will probably readhere at its circum¬ ference when it is allowed to return to its
original point. Surprisingly, endoscopie views of total occlusion (Fig 4) appeared
similar to observations of normal luminal wall. In three cases, a presumed total occlusion was found to be a tight steno¬ sis with multiple mucosal folds. In four examinations, scar fibers clearly demar¬ cated the duct obstruction (Fig 5). Three other patients had plugs of debris block¬ ing narrowed common internal puncta and a nasolacrimal duct. These plugs were removed by irrigation but re¬ formed within 1 month. The increased pressure required to remove the plugs by irrigation also resulted in saline infil¬ tration into the surrounding lid tissue. This infiltration had resolved by the end of the first week. Direct visualization of wire probing permitted identification of the true lu¬ men with subsequent passage of the probe. This technique helped us avoid false passages. This was particularly gratifying in two infants who had previ¬ ously undergone probing that failed to open the nasolacrimal duct. In three pa¬ tients, we found that trauma had re¬ sulted in such severe destruction of the mucosa lining the horizontal canaliculi that we recommended the installation of Jones tubes to resolve the tearing prob¬ lems. Three other patients were seen to have markedly inflamed lacrimal sacs (Fig 6). Intensive medical therapy re¬ sulted in relief of the congestion of the sac mucosa and in cessation of tearing
Downloaded From: http://archopht.jamanetwork.com/ by a University of Michigan User on 06/14/2015
for one of these patients. Surgery (Fig 7) required for the others.
was
COMMENT
Our results indicate that the use of endoscopes to examine the lacrimal ex¬ cretory system can yield valuable data. Disease was found in the canalicular system, at the common internal punc¬ tum, and in the sac and nasolacrimal duct. Choosing appropriate treatment was made easier by visualizing the pathologic conditions. As with all new
techniques, we experienced a learning curve in performing our endoscopie ob¬ servations. As we learned to recognize landmarks and disease, we were better able to avoid unwittingly creating false passages.11 Disposable lacrimal endo¬ scope systems are feasible, and im¬ proved endoscopie instrumentation at decreased cost should permit wide¬ spread application of this technology.
Direct visualization of the entire lacrimal excretory system can be a useful addition to ophthalmologists' armamentaria. This research was supported in part by the generous contributions of the Eleanor and Arthur Ellis Eye Center and the Medallion Fund of Cedars-Sinai Med¬ ical Center.
References 1. Steinsapir KD, Glatt HJ, Putterman AM. A 16-year study of conjunctival dacryocystorhinostomy. Am J Ophthalmol. 1990;109:387-393. 2. Becker BB, Berry FD. Balloon catheter dilation in lacrimal surgery. Ophthalmic Surg. 1989;
20:193-198. 3. Wolff E. Anatomy of the Eye and Orbit. Philadelphia, Pa: WB Saunders Co; 1961:204. 4. Werb A. The anatomy of the lacrimal system. In: Milder B, Weil BA, eds. The Lacrimal System. East Norwalk, Conn: Appleton & Lange; 1983:23\x=req-\ 32. 5. Viers ER. Lacrimal Disorders: Diagnosis and Treatment. St Louis, Mo: Mosby\p=m-\YearBook; 1976:6. 6. Smith BC, Della Rocca RC, Nesi FA, Lisman RD. Ophthalmic Plastic and Reconstructive Surgery. St Louis, Mo: Mosby\p=m-\YearBook; 1987; 1:21. 7. Linberg JV. Lacrimal Surgery. New York, NY: Churchill Livingstone Inc; 1988:9. 8. Duke-Elder S, MacFaul PA. System of Ophthalmology. St Louis, Mo: Mosby\p=m-\YearBook; 1974; 13:759. 9. Becker BB, Berry FD. Balloon catheter dilation in lacrimal surgery. Ophthalmic Surg. 1989; 20:193-198. 10. Becker BB. Flexible endoscopy in primary testing of the lacrimal system. Ophthalmic Surg.
1990;21:577-580.
