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Cherkunov B. F. Diseases of the lacrimal bodies.
The author of the book - the honored doctor of Russia, the doctor of medical sciences, professor, the consultant of the Samara ophthalmologic hospital of T.N. Broshevsky.
Are lit the anatomist - physiological features of the lacrimal bodies, their value in pathology and clinic of diseases. Modern dakriologichesky methods of research are stated. The clinic, an etiopathogenesis and the principles of treatment of diseases of the lacrimal glands and slezootvodny ways are in details considered. The special attention is paid to surgical treatment. For the first time in domestic literature with the broad range operations on the lacrimal bodies are in detail described and illustrated.
The book is counted on ophthalmologists.
Light memory of my teacher Geroya of Socialist Work, corresponding member of the USSR Academy of Medical Sciences, professor
I devote Tikhon Ivanovich Eroshevsky
Diseases of the lacrimal bodies meet quite often and come to light at 25,0% of patients with diseases of eyes. The most part from them has persistent dacryagogue owing to strictures and obliterations of slezoprovodyashchy ways. Not stopping dacryagogue is painful and unpleasant, especially for people whose profession demands visual tension, and a hand are too contaminated or busy constantly to wipe the tear preventing work. Patients with gross violations of function of the slezootvodyashchy device are not fit for military service. Surplus of a tear breaks external beauty of eyes, and the noticeable cosmetic shortcoming depresses patients and becomes the reason of moral experiences, especially women of young age. The stagnant tear and a mucous secret are a medium for emergence of microflora and favor to an inflammation of slezootvodyashchy ways, creating the increased risk of development of a purulent keratitis with heavy complications, up to death of an eye.
Treatment of diseases of slezootvodyashchy ways - a task quite difficult and most often is solved surgical intervention. Many ophthalmologists at a meeting with the patients having dacryagogue test confusion because of a lack of knowledge of this question. Even the experienced doctors owning difficult eye operations become helpless, facing surgical pathology of the lacrimal bodies. Against the most important achievements of ophthalmology connected generally with broad implementation of microsurgical equipment in the solution of many questions of lacrimal pathology progress more modest. In many respects it is connected with the fact that the large federal and regional ophthalmologic centers are occupied with the solution of the main problems having important social value and, with rare exception, do not pay the corresponding attention to pathology of the lacrimal bodies. On this matter in special literature actually there is no separate rather full management. The present monograph to a certain extent has to meet this lack.
Work is based as on data of the available literature, with use of sources of the last years, and on the wide personal professional experience of the author which is saved up for many years of work in eye clinics of the Samara and Ryazan medical universities.
The book consists of 3 parts. In the 1st part the data concerning anatomofiziologichesky features of the lacrimal bodies and their value in clinic are stated; dacryagogue origins are considered; research methods in a dakriologiya are described.
In chapters of the 2nd part the structure of diseases of the lacrimal bodies, their etiopathogenesis, diagnosis and the principles of treatment are provided.
The 3rd part is devoted to surgery of the lacrimal bodies and in essence covers all its aspects. The description of both classical operations, and little-known, but deserving attention of ways is given. Found reflections and new offers.
The special attention is paid to the exemplariness of material provided by a large number of photos and the author's drawings. Even not really experienced surgeon, having seen drawings and having read the description of operation, it is clear will provide its essence and will manage to execute independently.
The author did not set as the purpose an exhaustive statement and the solution of all problems of a dakriologiya (it is not in power to one person), but tried to give information, most useful to the practical ophthalmologist, on questions which he should solve in daily work. All notes according to this book will be accepted by the author with gratitude.
I consider a duty to express deep gratitude to the Samara and Ryazan colleagues for the help during the work on the monograph.
I express hearty thanks to the chief physician of the Samara ophthalmologic hospital of T.N. Broshevsky, the doctor of medical sciences A.V. Zolotarev with whose warm support the book is published.
Honored doctor of Russia,
doctor of medical sciences, professor B. F. Cherkunov
ANATOMY AND PHYSIOLOGY OF THE LACRIMAL BODIES. DACRYAGOGUE AND ITS REASONS. RESEARCH METHODS IN DAKRIOLOGIYA
Chapter 1. Anatomo-fiziologichesky features of the lacrimal bodies and their value in clinic
The lacrimal bodies for the anatomo-topographical and functional features are subdivided into two independent departments: slezoprodutsiruyushchiya, the lacrimal openings, tubules, the bag and a nasal duct consisting of the lacrimal gland and additional lacrimal glands, and slezootvodyashchiya, including.
1.1. Structure and functions of slezoprodutsiruyushchy department
The lacrimal gland (glandula lacrimalis) is located under verkhnenaruzhny edge of an orbit in the pole of a frontal bone of the same name (fossa gl. lacrimalis). The lacrimal gland is divided by a dense leaf of a tarzoorbitalny fascia (septum orbitale) into big - orbital and smaller - palpebral parts (pars orbitalis et palpebralis). Both parts are delimited from surrounding fabrics by a well-marked connective tissue capsule. The palpebral part of the lacrimal gland like a cap covers a verkhnenaruzhny segment of an eyeglobe. The orbital part an outside convex surface prilezhit to a periosteum of an orbit (fig. I).
Rice. 1. Structure of the lacrimal bodies: 1 - orbital part of the lacrimal gland; 2 - tarzoorbitalny fascia; 3 - palpebral part of the lacrimal gland; 4 - upper lacrimal tubule; 5 - the lacrimal meat; 6 - deep fascia of a dacryocyst; 7 - Mayer's sine; 8 - dacryocyst; 9 - nasolacrimal channel; 10 - srednenosovy sink; 11 - nizhnenosovy sink; 12 - Highmore's bosom: 13 - lower lacrimal tubule.
In the situation gland is kept by the special copular and fascial device. Own sheaf (lig. suspensorium gl. lacrimalis) supports gland in a bone pole of verkhnenaruzhny edge of an orbit; from below fascial fibers of gland are connected to Lokvud's team (lig. Loqudi) supporting as a hammock, an eyeglobe. Take in strengthening of gland also part a sinew of the muscle lifting more true an eyelid, and a tarzoorbitalny fascia.
The sizes of orbital part of gland make about 20-25 mm in length, 12-14 mm in width and about 5 mm in height. The orbital part of gland hidden by the hanging supraorbital edge of a frontal bone and shipped in its lacrimal pole is almost unavailable to a palpation and is probed only at pathological increase owing to an inflammatory or tumoral infiltration.
The lower palpebral part of gland represents a conglomerate of the segments which are unevenly disseminated in friable cellulose, with a total number from 15 to 40. The sizes make it about 9-10 mm in length, 7-8 mm in width and about 2-3 mm in height. This part is available to research. It is possible to see it at an ectropion of an upper eyelid and sharp turn of an eye from top to bottom and knutr. In this case the palpebral portion of the lacrimal gland acts as hilly lobular formation of a yellowish shade under a conjunctiva of the upper arch from above and outside from an eyeglobe.
Output channels of orbital part of gland penetrate a tarzoorbitalny fascia, pass between segments of palpebral part, accept from them output capillaries and then a small time open in outside part of the upper conjunctival arch. Some segments of the lower portion of gland open also independent channels. Total number of the output channels opening in a conjunctival sac from both segments of gland varies from 12 to 20. These anatomic features need to be considered at the choice of ways of operative measures on the lacrimal gland. So, for example, at the strong omission of palpebral part caused by a relaxation of ligaments, its removal which in these cases is recommended by some researchers inevitably leads from both portions of the lacrimal gland to destruction of all output channels. For the same reason the identical effect of complete cessation of receipt of a tear from the lacrimal gland comes not only after its total extirpation, but also during removal of a palpebral share or at conjunctival section of all output channels (Jameson, 1937).
It is pertinent to notice that in fight against persistent dacryagogue of operation, directed to suppression of activity of the lacrimal gland, physiologically are not proved as continuous moistening of an eyeglobe is provided generally with a secret of additional lacrimal glands of a conjunctiva. Such operations can be useful only at treatment of reflex dacryagogue.
Small additional lacrimal glands of Krause are disseminated in the thickness of a conjunctiva of an upper transitional fold, find them also in a conjunctiva of the lower arch. On border of tarzalny and orbital parts of a conjunctiva of an upper eyelid there are three conjunctival glands, so-called tarzalny glands of Volfringa (fig. 2), considerable by the size.
On the structure the lacrimal gland belongs to number of difficult and tubular lobular glands and reminds sialadens. The anatomic relationship of the lacrimal and sialadens is shown also in a community of their innervation. At irritation of a conjunctiva along with hypersecretion of a tear there comes salivation. Also the community of their pathology is known that it takes place, for example, at Sjegren's syndrome. In an epithelium of the lacrimal gland there are two types of secretory cells: the ferruterous, representing apocrine cells, and myoepithelial, or basket cells. In gland secretion the main role belongs to myoepithelial cells, but not a ferruterous epithelium (to Chiquoine, 1958). A morphological difference between secretory cells of the main lacrimal gland and exclaves it is not revealed (Gillette T., etc., 1980).
Fig. 2. Secretory device of an eye:
1 - orbital part of the lacrimal gland; 2 - palpebral part of the lacrimal gland; 3 - Krause's glands; 4 - Mants's glands; 5 - glands of Volfringa; 6 - Genle's crypts; 7 - Meybomiyeva of iron; 8 - a sweat gland Asking; 9 - sebaceous gland of Tseys
The lacrimal gland receives blood supply from the lacrimal artery (a. lacrimalis) which represents one of numerous branches of an orbital artery (ophthalmica). Flows blood on the lacrimal vein (v. lacrimalis) which falls into an upper orbital vein (v. ophthalmica superior).
The secretory innervation of the lacrimal gland carries very difficult and not absolutely precisely found out yet character. Participate in it: I and II branches of a trifacial, a facial nerve and sympathetic fibers from an upper cervical node.
Directly gland is innervated by the lacrimal nerve (n. lacrimalis) (fig. 3). Before the introduction in gland the lacrimal nerve is divided into two branches, one of which anastomoses with n. zygomaticotemporalis, part II of a branch of a trifacial. It is supposed that secretory fibers begin from a kernel of a glossopharyngeal nerve from which after an exit through Vrisberg's branch join a trunk of a facial nerve. and then through n. petrosus superficialis major reach a pterygopalatine node from where through a maxillary nerve and some other anastomosis connect to the lacrimal nerve and in its structure enter the lacrimal gland. Fibers of a sympathetic nerve for are included into gland together with its blood vessels.
Communication of the lacrimal gland with endocrine system does not raise doubts. So, for example, hypersecretion of a tear takes place at a thyrocardiac craw and vice versa, the xerophthalmus is observed at hypofunction of a thyroid gland. Are suggested about incretory function of the lacrimal gland.
Fig. 3. Reflex ways and the centers of a slezootdeleniye (on Jones): 1 - the lacrimal gland; 2 - cortical center of a slezootdeleniye; 3 - basal ganglion; 4 - thalamus; 5 - hypothalamus; 6 - the lacrimal kernel in the bridge and a myelencephalon; 7 - cervical department of a spinal cord; 8 - chest department of a spinal cord; 9 - upper cervical sympathetic node; 10 - pterygopalatine node; 11 - gasser node; 12 - retina; 13 - conjunctiva
The tear represents the transparent, slightly opalescent, colourless liquid consisting of water (98,0 - 99,2%), mineral salts (0,6%) dissolved in it, proteins (0,1%) and other fractions (0,08%). Specific weight - 1,008, reaction alkalescent, pH of a tear 7,0-7,11.
In normal conditions within 16 hours of wakefulness in the absence of crying and the irritating factors about 0,5-0,6 ml of a tear are produced. Speed of its secretion about 1 mkl / min. About 10% of a tear evaporate. During a dream lacrimation almost completely stops. The main sources of secretion of a tear are the main lacrimal gland and additional lacrimal glands of Volfringa and Krause. Also the secret of scyphoid cells of a conjunctiva, Henle's loops and even a fatty secret of meibomian and sebaceous glands of edges comes a century to a tear. These components form a three-layered epikornealny film 6-10 microns thick. Directly to an epithelium of a cornea prilezhit the proteinaceous layer of mucin cosecreted by scyphoid cells of a conjunctiva. The center of a film - aqueous salt solution and the most superficial - lipidic, floating on a surface water, and giving water repellency to an epikornealny film. Biological expediency of the lacrimal film consists in the prevention of drying of a cornea, filling of microscopic roughnesses of a relief of an epithelial cover for increase of its optical properties, in ensuring trophic functions of a cornea.
The tear - a product of secretory activity of the lacrimal glands - carries out very important physiological role. It is necessary for continuous moistening of a cornea, preservation of its transparency and increase of optical properties. With the wetting termination the cornea quickly grows dull, live gloss of eyes dies away. In the conditions of pathology at insufficient secretion of a tear the cornea grows turbid, the xerosis develops. Any irritation of eyes harmful environmental factors of the physical and chemical or biological nature (a contamination, light dazzle, action of wind, a smoke, harmful gases, etc.) causes plentiful reflex allocation of tears. This most shows protective function of tears - to immediately wash out, remove the foreign bodys which got z an eye, to neutralize an irritant action of harmful substances, not to allow drying of a cornea at strong overheating.
But physiological purpose of a tear is much broader, than moistening and mechanical clarification of an eye. The lacrimal liquid bears an important role as the cornea power supply. She takes part in metabolic processes of a front piece of maid. One of the most important functions of the lacrimal liquid is protection of an eye against an infection the bactericidal proteins (a lysozyme, lactoferrin) which are contained in it, immunoglobulins, anti-infectious antibodies and other components. In recent years there was a keen interest in biochemical and immunological researches of the lacrimal liquid as the Wednesday reflecting many parties of pathological processes in an eye (Chesnokova N. B., 1986, Selinger D. et al., 1979, an der Gaag R., 1988).
The tear arriving from additional lacrimal glands of a conjunctiva call the main or basic. It is developed constantly, continuously, including, in insignificant quantities, during a dream. Some authors call it also "not stimulated" (T.E.'s Gillette et all, 1980).
The tear produced by orbital gland call reflex. Its plentiful "emergency" emission is connected with any sudden irritation of an eye, or with strong emotional and pain reactions.
The lacrimal gland develops from ectodermal rudiments of future conjunctiva by the time of the fruit birth its anatomic differentiation still is completely incomplete, the lobular structure is expressed indistinctly. Therefore newborns "cry without tears" and only at the end of the second, the beginning of the third month when cranial nerves and a vegetative nervous system begin to function, lacrimation appears. Before at newborns only the lubricant secret is allocated.
Follows from the aforesaid that at extremely important physiological function of a tear, indications to operations of suppression of its secretion "with the medical purpose" have to be carefully weighed and are with authority reasoned. The anti-physiology of these interventions is obvious therefore in all cases of treatment of dacryagogue it is necessary to use reasonable efforts to recover function of a slezootvedeniye.