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There is a lack of knowledge regarding the connection between the ocular and nasal epithelia. This narrative review focuses on conjunctival, corneal, ultrastructural corneal stroma, and nasal epithelia as well as an introduction into their interconnections. We describe in detail the morphology and physiology of the ocular surface, the nasolacrimal ducts, and the nasal cavity. This knowledge provides a basis for functional studies and the development of relevant cell culture models that can be used to investigate the pathogenesis of diseases related to these complex structures. Moreover, we also provide a state-of-the-art overview regarding the development of 3D culture models, which allow for addressing research questions in models resembling the in vivo situation. In particular, we give an overview of the current developments of corneal 3D and organoid models, as well as 3D cell culture models of epithelia with goblet cells (conjunctiva and nasal cavity). The benefits and shortcomings of these cell culture models are discussed. As examples for pathogens related to ocular and nasal epithelia, we discuss infections caused by adenovirus and measles virus. In addition to pathogens, also external triggers such as allergens can cause rhinoconjunctivitis. These diseases exemplify the interconnections between the ocular surface and nasal epithelia in a molecular and clinical context. With a final translational section on optical coherence tomography (OCT), we provide an overview about the applicability of this technique in basic research and clinical ophthalmology. The techniques presented herein will be instrumental in further elucidating the functional interrelations and crosstalk between ocular and nasal epithelia.

Purpose: To investigate how cheese wiring affects lacrimal drainage function by quantitative assessment of tear function and punctal dimensions., Methods: Patients who underwent lacrimal passage intubation between January 2017 and September 2018 were enrolled prospectively. Among these patients, those with postoperative cheese wiring who received lacrimal passage intubation in one eye met the criteria for further investigation. The subjective symptoms of epiphora, dimensions of puncta, lower tear meniscus, and tear clearance were assessed postoperatively in both the involved eye and untreated contralateral eye. Punctum dimensions were analysed using the digital slit-lamp image. Tear meniscus and tear clearance were assessed by anterior segment optical coherence tomography., Results: Postoperative cheese wiring was observed in 68 of 314 eyes. Among these cases, 36 patients (age 70.5 ± 11.7 years) had cheese wiring only in one eye: with the involvement of both puncta in 15 patients (group A) and only the lower punctum in 21 patients (group B). There was no patient with the involvement of only the upper punctum. While tear function of the involved eyes in group B did not differ from that of the untreated eye, it was significantly decreased in group A compared with that in untreated control eyes (p < 0.05). The tear clearance rate correlated significantly with the upper punctum dimensions (p < 0.05), but not with the lower punctum., Conclusion: Analysis of cheese wiring after lacrimal passage intubation with tear function demonstrated that the integrity of the puncta and the canaliculus is important for lacrimal drainage.

Objective: To characterize diagnostic findings, test-retest repeatability, and correlations among lacrimal tests in dogs of diverse cephalic conformations., Animal Studied: Fifty healthy dogs (25 brachycephalic, 25 nonbrachycephalic)., Procedures: A series of diagnostics were performed in each dog, allowing for a 10-minute interval between tests and repeating each test 24 hours later under similar conditions: corneal tactile sensation (CTS), strip meniscometry test (SMT), phenol red thread test (PRTT), endodontic absorbent paper point tear test (EAPPTT), Schirmer tear test-1 without (STT-1) or with nasolacrimal stimulation (NL-STT1), and Schirmer tear test-2 (STT-2)., Results: Mean ± SD test values were lower in brachycephalic vs. nonbrachycephalic dogs (except for SMT; 7.4 ± 2.0 mm/5 seconds vs 7.3 ± 2.4 mm/5 seconds), with statistically significant differences noted for CTS (1.8 ± 0.5 cm vs 3.4 ± 0.8 cm), PRTT (37.2 ± 4.0 mm/15 seconds vs 41.1 ± 5.5 mm/15 seconds), STT-1 (20.1 ± 3.4 mm/min vs 23.3 ± 5.7 mm/min), STT-2 (13.0 ± 3.4 mm/min vs 16.9 ± 3.9 mm/min), and NL-STT1 (23.2 ± 3.6 mm/min vs 27.1 ± 5.4 mm/min), and nonsignificant differences for EAPPTT (16.6 ± 2.7 mm/15 seconds vs 17.5 ± 2.9 mm/15 seconds). Nasolacrimal stimulation increased STT-1 values by 18% on average. Correlations among tests were generally weak to moderate (r < .70) except for a strong correlation between STT-1 and NL-STT1 (r = .83, P < .001). Test reliability was good although test-retest repeatability was generally poor to moderate, as depicted by low intraclass correlation coefficients (ICC ≤ 0.75) and wide 95% limits of agreement, except for CTS (ICC = 0.91)., Conclusions: Corneal sensitivity and aqueous tear secretion are lower in brachycephalic dogs. A comprehensive assessment of the ocular surface requires the combination of several diagnostic tests. The nasolacrimal reflex may provide a useful diagnostic and therapeutic tool in dogs., (© 2020 American College of Veterinary Ophthalmologists.)

Importance: Nasolacrimal occlusion (NLO) is effective in reducing systemic absorption of eye drop medication but it is difficult and often performed poorly. We propose an alternative easier and equally effective technique., Background: To test the effectiveness of systemic absorption, we evaluated plasma concentration and ocular effects after topically administered timolol and compared to NLO., Design: Cross-over trial carried out in Capital Eye Specialist, Wellington., Participants: A total of 21 subjects over 18 years without contraindications for topical beta-blocker medication and not using systemic beta-blockers., Methods: During three clinic visits separated by at least one week, alternative approaches to reduce systemic eye drop absorption were tested. These were: (a) nasolacrimal (punctal) occlusion for 5 min, (b) tissue press method or (c) no intervention. Timolol plasma levels were measured 1 h after drop application. At each visit, baseline measurement of blood pressure, heart rate and intraocular pressure (IOP) were performed, and repeated 1 h after timolol 0.5% eye drop application., Main Outcome Measures: Comparison of timolol plasma concentration after each intervention. Secondary outcome measurements included effects on blood pressure, heart rate and IOP., Results: Plasma timolol concentrations after tissue press method and NLO were significantly lower than those without intervention. Comparing tissue press method to NLO, there were no significant differences in plasma levels of timolol, blood pressure, heart rate or IOP., Conclusion and Relevance: The tissue press method is equally effective as NLO in reducing systemic absorption of timolol. It is also easier and faster to administer., (© 2019 Royal Australian and New Zealand College of Ophthalmologists.)

Purpose: The aim of this study is to provide a comprehensive and clinically relevant review of the lacrimal drainage anatomy in the Japanese population., Methods: A thorough search on the lacrimal drainage anatomy in the Japanese population was performed using PubMed and Ichushi Web, which is managed by the Japan Medical Abstracts Society, for related studies up to December 2018. Published books on the same topic were also reviewed. Data from all articles and book chapters were reviewed, analyzed, and incorporated in this review., Results: This review presents the subparts of the lacrimal drainage anatomy in a chronological manner, from proximal to distal. The location, dimensions, position or angle, histology (with some reference to the essential clinical functions and physiology of the lacrimal drainage system) are described in this review., Conclusions: Understanding lacrimal drainage anatomy in the Japanese population is essential to provide insight as to how it is important to consider patients as individuals, with unique and specific anatomies, and uphold a patient-specific approach., (Copyright © 2019 Elsevier GmbH. All rights reserved.)

Purpose: To elucidate the mechanisms underlying nasolacrimal air regurgitation (AR) in the setting of continuous positive airway pressure therapy., Methods: Twelve nasolacrimal systems of 6 fresh female human cadavers were evaluated individually for AR using continuous positive airway pressure therapy before any nasolacrimal procedure. Cadavers were then randomly assigned to undergo nasolacrimal duct probing or endoscopic dacryocystorhinostomy and then each hemisystem was again evaluated for AR. The pressure where AR was first observed (discovery pressure) or maximum possible pressure in systems without AR was recorded. In systems that demonstrated AR, the pressure was then gradually decreased to the lowest pressure where regurgitation persisted. This pressure was recorded as the secondary threshold pressure., Results: None of the 12 unoperated nasolacrimal systems or the 6 systems that underwent nasolacrimal duct probing demonstrated AR through the maximum continuous positive airway pressure therapy (30 cm H2O). After endoscopic dacryocystorhinostomy, all 6 nasolacrimal systems demonstrated AR. The mean discovery pressure was 16.0 cm H2O (range, 14.0-18.0 cm H2O) and mean secondary threshold pressure was 7.25 cm H2O (range, 6.5-8.0 cm H2O)., Conclusions: Air regurgitation during continuous positive airway pressure therapy in the setting of prior endoscopic dacryocystorhinostomy can be replicated in a cadaver model. The secondary threshold pressures required for AR in this model were similar to AR pressures reported clinically. Prior to dacryocystorhinostomy, patients using continuous positive airway pressure therapy should be counseled on AR, and physicians should consider this phenomenon when evaluating ophthalmic complaints in postoperative patients on positive airway pressure therapy.

Ophthalmologists and interventional radiologists are not the only professionals for whom diseases of the efferent tear duct system occupy centre stage; this applies also to ENT specialists involving endonasal conservative or surgical treatment. On the basis of current knowledge and taking account of results yielded by own research in recent years and of clinical aspects, we here give an overview of basic knowledge on the anatomy and physiology of the nasolacrimal system. In doing so functional aspects regarding tear transport as well as embryological and pathophysiological issues are integrated.

Background: Movement of the lacrimal canalicular wall has been speculated to occur during blinking. Movement of the common internal ostium has been observed under nasal endoscopy, and pressure changes in the lacrimal canalicular cavity have been observed with a pressure sensor; however, lacrimal canalicular wall movement under pressure changes has not been observed., Purpose: To examine movement of the lacrimal canalicular wall under intracanalicular pressure changes using dacryoendoscopy., Methods: The authors examined 20 obstruction-free lacrimal canaliculi in 10 patients. A dacryoendoscope was inserted, and water was poured into the intracanalicular cavity via the dacryoendoscope's water channel. The water was then poured or suctioned to cause positive or negative pressure changes in the intracanalicular cavity, and movement of the lacrimal canalicular wall was examined., Results: The lacrimal canalicular wall moved flexibly with pressure changes. Under positive pressure, the intracanalicular cavity was dilated; however, it narrowed under negative pressure. The extent of movement was more dramatic in the common canalicular portion than the proximal canalicular portion., Conclusions: Intracanalicular pressure changes cause movement of the lacrimal canalicular wall. There was a consistent relationship between intracanalicular cavity changes and pressure changes, possibly contributing to lacrimal drainage of the canaliculus.

Purpose: To examine movement of the intrasac cavity under intrasac pressure changes with dacryoendoscopy., Methods: The authors examined 10 lacrimal sacs (3 right and 7 left) without lacrimal tract obstruction in 10 Japanese patients (3 men and 7 women) aged 35 to 86 years (average, 62.8 years). These were the contralateral sides of the sides with nasolacrimal duct obstruction that were treated with dacryocystorhinostomy. After enlarging a superior lacrimal punctum, a dacryoendoscope (FT-203F; FiberTech) was inserted. When the tip of the dacryoendoscope passed through the common internal ostium, the handgrip was rotated 90° superiorly to face the tip inferiorly. Water was poured into the cavity throughout this process via the water channel of the dacryoendoscope. Then, with the water poured or suctioned from the same channel, namely causing positive or negative pressure changes in the intrasac cavity, movement of the lacrimal sac wall was examined with dacryoendoscopy., Results: The lateral wall of the lacrimal sac moved with pressure changes fairly flexibly. Under positive pressure, the wall moved outward, but it moved inward under negative pressure., Conclusions: The present study demonstrated movement of the lacrimal sac wall with intrasac pressure changes, which was suggestive of its contribution to lacrimal drainage of the sac.

Background: Continuous positive airway pressure (CPAP) is the gold standard treatment for moderate to severe obstructive sleep apnoea (OSA). Eye-related side effects of CPAP are commonly attributed to a poorly sealed mask, allowing leaked air to blow over the eye., Cases: We present 3 cases where attended polysomnography (A-PSG) demonstrated CPAP-associated retrograde air escape via the nasolacrimal system (CRANS) in the absence of any mask leaks. Symptoms included dry eye, epiphora, air escape from the medial canthus, and eyelid flutter. Symptoms were controlled with a variety of surgical and nonsurgical techniques., Conclusions: CRANS represents a previously undescribed clinical entity. CRANS may be responsible for some CPAP-related eye side effects and possibly for rarer secondary eye complications, including conjunctivitis and corneal ulceration. CRANS should be suspected in any patient on CPAP complaining of eye symptoms. CRANS may be diagnosed through careful observation during A-PSG and confirmed by performing a "saline bubble test." Management options include nonsurgical (mask alternatives, humidification, nasopharyngeal airway) and surgical techniques (nasal airway surgery, inferior turbinate out-fracture and adhesion, injection of bulking agent around Hasner's valve).

Excessive watering of the eye is a common condition in ophthalmological practice. It may be the result of excessive production of tear fluid or obstruction and insufficiency of efferent tear pathways. The differentiation between obstruction and insufficiency of the lacrimal pathways is still clinically questionable. In the diagnostic process it is necessary to perform clinical tests and additional diagnostic imaging is often needed. Dacryocystography, with or without the extension of the dynamic phase or subtraction option, still remains the criterion standard for diagnostic imaging of the lacrimal obstruction. It may help to clarify the cause and exact place of the obstruction and provide information for further management, especially surgical treatment. Increasingly, new techniques are used in diagnostic imaging of the lacrimal tract, such as computed tomography, magnetic resonance, and isotopic methods. Adequate knowledge of the anatomy and physiology of the lacrimal system and the secretion and outflow of tears is the basis for proper diagnostic imaging. The purpose of this paper is to present the exact anatomy of the lacrimal system, with particular emphasis on the radiological anatomy and the current state of knowledge about the physiology of tear secretion and drainage.

Tear secretions discharged by the Harderian gland are suggested to function as a solvent for molecules sensed by the vomeronasal organ (VNO) in anurans. It has been assumed that chemical stimuli are absorbed at the surface of the eye to be carried - together with the lacrimal fluid - into the nasal cavity via the nasolacrimal duct. In the study presented herein, we examined the intranasal anatomy of 10 different anuran species to analyse the opening region of the nasolacrimal duct and its functional relationship with the VNO and the external naris. In addition, vital staining of the nasal cavities was conducted. Our results indicate that stimuli reaching the VNO are more likely to be ingested through the nostril than via the eye. In many cases the intranasal orifice of the nasolacrimal duct shows a close proximity to the external naris and simultaneously we observed a noticeable distance to the VNO. We suggest that the secretions of the Harderian gland are carried to the external naris by the nasolacrimal duct, where they bind chemical stimuli that are subsequently actively transported into the VNO. In some of the investigated species the opening region of the tear duct was situated in a more caudal part of the nasal cavity and closer to the VNO. In these cases a conspicuous system of channels can be found, which is suspected to carry the intruding medium of smell from the nostril to the nasolacrimal aperture.

Unlabelled: PURPOSE/AIM OF STUDY: The purpose of this work was to determine whether rat nasal-associated lymphoid tissue is required for the induction of tear IgA responses., Materials and Methods: Particulate antigen in the form of DNP-BSA encapsulated in cationic microparticles was applied topically to the eyes (ocular topically) of rats that had the nasolacrimal ducts temporarily plugged with chromic gut suture material. Eye washes and serum were monitored for development of antigen specific IgA and IgG, respectively. To track the particulate uptake, fluorescent latex beads were applied topically to the eyes of plugged and unplugged animals. The nasal-associated lymphoid tissue and the draining lymph nodes were then examined for the presence of the fluorescent beads., Results: It was found that the chromic gut suture was effective in blocking the passage of antigen into the nasopharyngeal cavity for at least 24 hr. Tear antigen-specific IgA levels found in the eyes of plugged animals were not significantly lower from those of unplugged animals. Serum IgG antibody levels were also similar between the two groups. In animals with plugged nasolacrimal ducts, fluorescent beads were found predominately in the superficial cervical lymph nodes, which have been shown to drain the surface of the eye., Conclusions: These results indicate that particulate antigen can be taken up by the conjunctiva and transported to the draining lymph nodes, showing that antigen does not need to access nasal-associated lymphoid tissue to induce tear IgA antibody responses.

Objective: To evaluate the results of endoscopic dacryocystorhinostomy performed to treat acquired nasolacrimal duct obstruction., Design: Retrospective analysis of the outcome of endoscopic dacryocystorhinostomy performed in the conventional manner (i.e. without power instruments or laser) to treat acquired nasolacrimal duct obstruction., Subjects: Outcomes for 300 patients with acquired nasolacrimal duct obstruction were evaluated. Cases with congenital or traumatic blockages were excluded. All the cases were evaluated for nasolacrimal duct blockage by the syringing and regurgitation test. Surgery was performed under local anaesthesia with sedation. Follow up was conducted by syringing and nasal endoscopy, up to one year. Results were compared with published data for endoscopic and external dacryocystorhinostomy., Results: Outcomes were evaluated subjectively using patient symptoms, syringing results and endoscopic appearance. All cases were symptom-free following endoscopic dacryocystorhinostomy. Revision surgery was performed in 18 cases. Stents were placed in 10 patients, of which two developed granulations. Septoplasty was performed in 25 cases to gain access to the lacrimal sac area., Conclusion: The results were comparable with published data for endoscopic and external dacryocystorhinostomy.

Purpose: To review the effects of nasolacrimal occlusion (NLO) and eyelid closure (ELC) on the ocular and systemic absorption of topically applied glaucoma medications and emphasize the need for the universal application of these techniques during patient treatment and in clinical studies of topically applied glaucoma medications., Methods: Following a review of data suggesting great clinical benefit from NLO and ELC, the absence of inclusion of these simple techniques in published studies of topical glaucoma medications is identified. The effect of this oversight on these studies is noted with reference to each of the 5 major groups of glaucoma medications., Results: A review of the literature suggests that NLO and ELC improve intraocular penetration of topically applied glaucoma medications and discourage systemic absorption. The US Food and Drug Administration and the National Institutes of Health discourage the inclusion of these techniques in studies of the efficacy and toxicity of topically applied glaucoma medications. Consequently, all glaucoma studies reported in the literature lack the inclusion of these techniques for 5 minutes. This omission has major implications for patient informed consent, study protocol consistency, and the value of clinical studies, and directly affects the therapeutic index of glaucoma medications in unpredictable and undesirable ways. The undesirable influence on the therapeutic index of each drug influences the safety and efficacy and has implications for the cost of medical treatments, the reproducibility of clinical study results, and dosing regimens, including those of combination therapy, as reflected in the peer-reviewed literature., Conclusions: Patients should use NLO or ELC for 5 minutes following eye drop treatment with topically applied glaucoma medications. Furthermore, it is essential that these techniques be included in all clinical studies of topically applied glaucoma medications to ensure the most favorable therapeutic index and its accurate determination. This will also help provide the most consistent, reliable, and reproducible study results.

Background: The aim of this study was to evaluate the effects of lateral osteotomy of septorhinoplasty on nasolacrimal duct functions by dacryoscintigraphy., Methods: The study group comprised 60 nasolacrimal systems of 30 consecutive patients who underwent septorhinoplasty. Dacryoscintigraphy images were taken in the preoperative period and postoperative 1st week and 3rd month. After Tc-99m pertechnetate instillation, dynamic images were obtained every 15 seconds. For cases of normal drainage, the study was terminated after 10 minutes but when obstruction was suspected, external ocular massage and rapid nasal inspiration were applied and the test was extended for an additional 10 minutes. Systems were classified either as passage without massage (normal nasolacrimal test), passage with massage (physiological obstruction), or presac or postsac obstruction (partial or complete obstruction) according to test results. Transit time was determined for cases with normal test or physiological obstruction., Results: In the preoperative period eight systems (two presac and six postsac) had obstruction. There were a total of 11 (18.3%) additional systems with obstruction (4 presac and 7 postsac) in the 1st postoperative week and patient symptoms were not in complete agreement with the test results in this period. By the 3rd month, nine systems (three presac and six post sac) had obstruction. Transit time was prolonged in both the postoperative 1st week and the postoperative 3rd month tests compared with the preoperative tests (p = 0.000 and p = 0.023, respectively)., Conclusion: We did not encounter any permanent obstructions after lateral osteotomy of rhinoplasty. Temporary obstructions in the 1st postoperative week improved to normal preoperative status by the postoperative 3rd month.

The human nasolacrimal ducts are a borderland of the disciplines ophthalmology and otorhinolaryngology, which work close together in the treatment of nasolacrimal disorders. However, little knowledge exists concerning the physiology of the nasolacrimal system and, therefore, its pathophysiology. The aim of the present investigations was to obtain a better understanding of tear flow physiology, microbial defence strategies and pathophysiological processes by analysing the nasolacrimal system, thus opening new perspectives against existing therapeutical concepts of diseases of the nasolacrimal ducts. The human nasolacrimal ducts consist of the upper and the lower lacrimal canaliculus, the lacrimal sac and the nasolacrimal duct. They drain the tear fluid from the ocular surface into the lower meatus of the nose. The lining epithelium of the lacrimal sac and the nasolacrimal duct is faced by microvilli, and animal experiments in rabbits support the hypothesis that tear fluid components are absorbed in the human nasolacrimal system. Evidence of seromucous glands, intraepithelial lipids and a specific mucus layer leads to the conclusion that the normal three-layering of the tear film is also present in the nasolacrimal ducts. Based on its composition, the mucus layer, which is mainly synthesised by goblet cells and intraepithelial mucus glands, functionally serves as a simplified drainage of tear fluid, and it is attributed similar properties to epithelia of the gastrointestinal tract. Further defence mechanisms are represented by antimicrobial peptides IgA and immunocompetent cells (lymphocytes and macrophages) which show intraepithelially and subepithelially a special distribution. Moreover, organised lymphoid tissue is present, which reveals the cytomorphologic and immunophenotypic characteristics of mucosa-associated lymphoid tissue. The wall of the lacrimal sac and the nasolacrimal duct are made up of a helical system of different connective tissue fibres. Wide luminal vascular plexus are embedded in this helical system, which is comparable to a cavernous body. Caudally, the vascular system is connected to the cavernous body of the inferior turbinate. With distension the system may be "wrung out" due to its medial attachment and helically arranged fibrillar structures. Thereby, tear fluid is drained distally. The embedded blood vessels underlie vegetative control. By means of this innervation, the specialised blood vessels permit regulation of blood flow by opening and closing the lumen of the lacrimal passage as effected by the engorgement and subsidence of the cavernous body, at the same time regulating tear outflow. Related functions, such as a role in the occurrence of epiphora related to emotional responses, are relevant. Moreover, malfunctions in the cavernous body and in its innervation may lead to disturbances in the tear outflow cycle, ocular congestion or total occlusion of the lacrimal passage. Thus, the pathophysiology of primary acquired dacryostenosis can be explained: Descending inflammation from the eye or ascending inflammation from the nose initiates swelling of the mucous membrane, remodelling of the helical arrangement of connective tissue fibres, malfunctions in the subepithelial cavernous body with reactive hyperaemia, and temporary occlusion of the lacrimal passage. In the follow-up, repeated isolated occurrence of dacryocystitis leads to structural epithelial and sub-epithelial changes, which may lead either to a total fibrous closure of the lumen of the efferent tear duct or to a non-functional segment in the lacrimal passage that is manifest on syringing. The normally constant absorption of tear fluid components into the blood vessels of the surrounding cavernous body that are connected to the blood vessels of the outer eye could be a feedback signal for tear fluid production, which comes to a halt if these tear components are not absorbed. Thus, dry eye could be initiated. Defective stimulation of tear duct-associated lymphoid tissue (TALT) could result in abnormal immune deviation at the ocular surface leading to an autoimmunologic response that could cause dry eye pathology.

Purpose: To determine the relation between the fluorescein transit test time and postoperative relief of epiphora in patent dacryocystorhinostomies., Methods: A retrospective study of 40 patients who underwent 42 external dacryocystorhinostomies between January 1994 and January 2000 was performed. Postoperative symptomatic success was assessed by a questionnaire. Intranasal rigid endoscopy was performed to measure the fluorescein transit test time, defined as the time from instillation of fluorescein to its free flow from the osteotomy site. The main outcome measures were symptomatic success, fluorescein transit test time, and anatomic patency to irrigation. Statistical analysis was performed with the use of the Fisher exact test., Results: Of the 42 dacryocystorhinostomies studied, 92.8% were patent to irrigation. There was a statistically significant association between a fluorescein transit test time of < or = 45 seconds and subjective success (P<0.001), with 96% of patients reporting a successful postoperative outcome. A slow fluorescein transit test, with an average time of 138.9 seconds, was associated with symptomatic failure (P<0.001), with 56.2% of this group reporting significant postoperative epiphora., Conclusions: The fluorescein transit test provides a quantitative measure of lacrimal drainage function after dacryocystorhinostomy, with a fluorescein transit test time of < or = 45 seconds being the relevant parameter to characterize symptomatic success. Postoperative failure in external dacryocystorhinostomy, as evidenced by slow transit times, may result from surgical interference with the lacrimal pump.

The function of the septomaxilla of nonmammalian synapsids has long been problematic. Distinctive features of this bone, including a prominent intranarial process and a septomaxillary canal and foramen, are characteristic of pelycosaurs and nonmammalian therapsids, but are lost in their mammalian descendants. Numerous contradictory reconstructions have been proposed for the soft anatomy associated with the septomaxilla of nonmammalian synapsids. This review supports the following conclusions: 1) No particular correlation exists between the septomaxilla and the vomeronasal organ (VNO), and the most likely location for the VNO is on the dorsal surface of the palatal process of the vomer; 2) The most likely occupant of the septomaxillary canal is the nasolacrimal duct, which opened either anterior or medial to the intranarial process, near the opening of the VNO duct; and 3) The occupant of the septomaxillary foramen remains uncertain. These conclusions suggest that the functional significance of the septomaxilla in the nonmammalian synapsids is tied to that of the nasolacrimal duct. The association of this duct and the VNO in these animals resembles the condition in Recent amphibians and lepidosaurs, in which the nasolacrimal duct supplies orbital fluids to the VNO, apparently to enhance vomeronasal function. The peculiar shape of the synapsid septomaxilla may have served to collect vomeronasal odor molecules. The changes of the septomaxilla in early mammals, and its nearly complete loss in extant mammals, are probably correlated with a dissociation of the nasolacrimal duct and VNO, and functional changes in both structures., (Copyright 2000 Wiley-Liss, Inc.)

Tears undergo four processes: production by the lacrimal gland, distribution by blinking, evaporation from the ocular surface and drainage through the nasolacrimal duct. Abnormalities in any of these steps can cause dry eye. There are two kinds of tear production, basic and reflex, which can be distinguished from each other by the Schirmer test with nasal stimulation. Reflex tearing is important because it supplies such essential components as EGF and vitamin A, whose deficiency may cause squamous metaplasia. There is no reflex tearing in Sjogren's syndrome because of destruction of the lacrimal gland. In cases of diminished or absent reflex tearing, topical autologous serum is the treatment of choice. Even when there is adequate tear production, insufficient distribution, such as occurs with the decreased blinking associated with the use of video display terminals (VDT), may cause dry eye. Any process or activity that suppresses blinking interferes with tear distribution. Tear evaporation increases under certain conditions and in some diseases. When the exposed ocular surface area is increased, such as in VDT work, tear evaporation increases. Meibomian gland dysfunction (MGD) also causes increased tear evaporation by altering the quality of the oily layer in tears. Tear evaporation can be suppressed by using a warm compresser or a humidifier, narrowing the palpebral fissure, or wearing protective eyeglasses. The tear clearance rate is measured by fluorescein dye dilution in the conjunctiva. When the tear clearance is low, inflammatory cytokines or preservatives accumulate in the conjunctival sac, resulting in ocular surface diseases. Frequent use of artificial tears without preservative is the key treatment. A differential diagnosis of the abnormalities of tear dynamics can give us a proper understanding of the pathogenesis of dry eye. With this knowledge, we can formulate an efficient therapeutic approach.

Background: The mechanism of lacrimal drainage under physiological conditions is controversial. The aim of this study was to analyze the three-dimensional architecture of human efferent tear ducts from functional and clinical points of view. A new theory of tear outflow is discussed., Methods: Thirty-two prepared lacrimal systems of adults were examined by histological, immunohistochemical and scanning electron microscopic techniques., Results: The wall of the lacrimal sac is made up of collagen bundles, elastic and reticular fibers arranged in a helical pattern. Wide luminal vascular plexus are embedded in this helical system and connected to the cavernous tissue of the inferior turbinate in the region of Hasner's valve. Immunohistochemical analysis showed evidence of type I and type III collagen as well as chondroitin 4- and 6-sulfate., Conclusion: With blinking, the lacrimal part of the orbicularis muscle contracts. The fornix of the sac moves in a cranial-lateral direction. Thus the lacrimal sac distends and may be "wrung out" due to its medial attachment and helically arranged fibrillar structures. The vascular plexus may play an important role in the absorption and drainage of lacrimal fluid.

Conventional dacryocystorhinostomy (DCR) usually involves extensive removal of bone at the lacrimal fossa and hence risks disruption of the lacrimal pump mechanism. A physiological operation for nasal lacrimal blockage is described whereby only the inferior portion of the lacrimal sac and the adjacent duct are marsupialized into the nose. The operation is safe, quick and does not involve sophisticated instruments. Result of 81 consecutive endoscopic inferior DCRs reveals a success rate of over 90% which is maintained with time. Most patients had a wide lacrimal window with preserved lacrimal pump movement at the superior sac remnant.

Purpose: To investigate the influence of gravity and blink rate on lacrimal drainage capacity and to learn whether lacrimal pump function can be measured with the drop test., Methods: The drop test for lacrimal drainage capacity was performed in 20 test subjects, aged 12 to 30 years. Drops of a known volume of lukewarm saline solution were repeatedly instilled in the tear film for 3 minutes. Excessive saline solution was then removed, and the volume drained by the lacrimal passages was calculated. The drop test was performed both with the nasolacrimal duct in a 45-degree position and with the nasolacrimal duct in a horizontal position. The drop test was performed two times in each position, with the individual reading and not reading. A lower blink rate was induced by reading., Results: There was a high correlation between blink rate and lacrimal drainage when the nasolacrimal duct was in a horizontal position. The volume drained with each blink was approximately 2 microliters. However, when gravity acted upon the fluid in the lacrimal sac-nasolacrimal duct in the direction of the tear flow, the lacrimal drainage capacity showed a significant but variable increase, and there was no significant correlation between blink rate and lacrimal drainage capacity., Conclusions: Lacrimal drainage capacity in young individuals was significantly affected by both blink rate and gravity. Lacrimal pump function can be measured quantitatively with the drop test.

Purpose: Aqueous tear production decreases after anesthetizing the ocular surface. Loss of the nasolacrimal reflex is a risk factor for neurotrophic keratopathy and keratoconjunctivitis sicca. The purpose of this study was to evaluate the effect of nasal mucosal anesthesia on aqueous tear production., Methods: Eleven healthy human volunteers with a normal ocular surface and Schirmer I tear-test scores > 10 mm participated in this study. Schirmer I values were obtained daily for 3 days to establish a normal baseline. On a separate day, the right nasal mucosa was anesthetized with aerosolized 10% lidocaine (Xylocaine). After a 10-min period to allow the anesthetic to take effect and reflex tearing to subside, the Schirmer I test was repeated. A saline nasal spray was used as a control., Results: Baseline Schirmer I values for both eyes had a mean of 22.98 +/- 1.05 mm (SEM). There was no difference in Schirmer scores between the two eyes after nasal anesthesia (p > 0.6); however, when these were compared with the baseline Schirmer I values, a significant decrease in tear production was noted (p < 0.001). The mean Schirmer I value after nasal anesthesia was 15.18 +/- 1.38 mm (SEM), a 34% decrease from baseline. The difference between the baseline and the normal saline control values was not significant (p = 0.160). There was a significant difference in Schirmer test scores between the saline control and nasal anesthesia groups (p < 0.02)., Conclusions: In addition to sensory neural stimulation from the ocular surface, sensory stimulation of the nasal mucosa also promotes aqueous tear production. These results may help explain the decreased tear production observed in patients who have nasal mucosal damage, disease, or denervation.

A cobalt blue filter adapter was constructed to fit between a rigid nasal endoscope and its halogen light source. Flooding the nasal cavity with the blue light illuminates the fluorescein-stained tears for more accurate examination of lacrimal function. We call our protocol the Jones IE test and used this new technique to examine 99 nasolacrimal systems of epiphora patients over a 15-month period. The results of this study show a six-fold increase in the ability of the Jones IE test to detect fluorescein dye within the nasal cavity over the conventional Jones I test.

Objective: To measure any sex size differences in the bony nasolacrimal drainage systems in a normal, age-matched population., Methods: A retrospective study of axial cut maxillofacial computed tomographic scans was conducted. Three levels of the bony nasolacrimal duct (NLD) system on the right and left sides were measured along the anteroposterior diameter. The data were analyzed using 2-tail t test, analysis of variance, and linear regression methods., Results: Scans from 71 adult patients (36 men and 35 women) were reviewed. Women were found to have a smaller bony diameter at the level of the lower fossa (P = .01) and the middle NLD (P = .06) compared with those of men. The adult inferior bony fossa increased in size with age in both men and women, while the middle NLD increased in size in men only. No significant size difference was found between the right and left side at any level., Conclusions: Size differences are found in measurements of bony nasolacrimal excretory systems in men vs women. Women have significantly smaller dimensions in the lower nasolacrimal fossa and the middle NLD. The anteroposterior dimension of the bony nasolacrimal canal at the fossa level enlarged in both sexes, with age co-inciding with osteoporotic changes throughout the body. These quantitative anatomical observations provide a contributory factor to explain the increased prevalence of primary acquired NLD obstruction in women.

Purpose: To compare the fluorescein dye disappearance test with a new test for lacrimal drainage capacity, the drop test., Methods: In the fluorescein dye disappearance test, 1 microliter of fluorescein solution was instilled into the conjunctival sac of normal subjects and of patients with epiphora. Fluorescence from the tear film was measured, and the rate of dye disappearance was calculated as a measure of tear drainage. In the drop test, drops of 10 microliters of lukewarm saline solution were repeatedly instilled into the conjunctival sac for 3 minutes. Excessive saline solution was then removed from the tear film and measured. The volume of saline solution drained by the lacrimal passage could thus be calculated., Results: The fluorescein dye disappearance test showed, in normal subjects, a tear turnover rate of 10.9 +/- 3.1% (95% confidence interval) per minute, which was nor age dependent. The drop test showed a decreased lacrimal drainage capacity with increasing age in normal subjects, with a mean capacity of 150 +/- 38.5 microliters/3 min for those 41 to 80 years old. In patients with indoor epiphora, the fluorescein dye disappearance test values were significantly reduced. However, the fluorescein dye disappearance test could not differentiate among normal eyes, eyes with minor epiphora, or eyes with moderate epiphora. The drop test showed a significant decrease even in patients with minor epiphora and was further decreased with increasing severity of symptoms., Conclusion: The drop test provides a quantitative measurement for lacrimal drainage function and is more sensitive than the fluorescein dye disappearance test.

Objective confirmation of nasolacrimal patency following dacryocystorhinostomy is a desirable postoperative goal for both the surgeon and the patient. The authors describe a simple method to demonstrate dacryocystorhinostomy patency and present a study comparing the effectiveness of this novel test with Jones fluorescein testing in 32 cases seen consecutively at postoperative follow-up. The test consists of demonstrating reflux of air through the dacryocystorhinostomy as the patient performs the Valsalva maneuver. This reflux is most easily seen as bubbles rising through a drop of saline placed in the medial canthus. A high correlation was found between this test and Jones testing. The Valsalva dacryocystorhinostomy bubble test (VBT) appears to be a fast, safe, and accurate method of confirming dacryocystorhinostomy patency.

We studied the effect of manual nasolacrimal occlusion on the concentration of timolol in the aqueous humor of eyes of patients undergoing cataract extraction. Aqueous humor samples were obtained at various times after timolol maleate instillation from patients with or without 5 min of nasolacrimal occlusion; aliquots were assayed by HPLC. In patients receiving occlusion treatment, average timolol concentrations were statistically greater than those in control patients both between 15 and 90 min after instillation and also at 180 min. Pharmacokinetic analysis indicated that occlusion increased the concentration of timolol in the aqueous humor 1.7 times. In both groups, timolol concentrations were highest approximately 1 h after instillation. The decline in aqueous humor timolol concentrations occurred at similar rates in both groups.

We examined the tear drainage system of twenty-fiv normal volunteers by scintillography with Technetium Tc 99m (Pertechnetate). We photographed the changes occurring in the lacrimal sac and nasolacrimal duct during closure and opening of the eyelids. Our findings support Jones' views of normal tear drainage. The tracer was concentrated in the lacrimal sac while the lids were closed for 3 minutes and descended into the nasolacrimal duct as soon as they opened.

Eyelid closure and nasolacrimal occlusion may decrease the systemic absorption of topically applied drugs. We studied the absorption kinetics of 20 microliter 0.5% timolol eyedrops in eight healthy volunteers. Each subject was supine for 30 minutes after the drug application. In randomized order, the volunteers kept their eyelids closed (ELC), or applied nasolacrimal occlusion (NLO) or blinked normally. Blood samples were drawn up to 90 minutes and analyzed for timolol with a radioreceptor assay. There was great interindividual variation in the timolol absorption. NLO reduced the total timolol absorption, but in some subjects the initial absorption was also enhanced by this procedure.