EPIPHORA.
The treatment of the different conditions in which the tears flow over the cheek instead of through the nasal duct will depend upon the nature of the obstructing cause. Thus if the punctum he displaced by ectropion or entropion these deformities should he removed by the operations described under Ectropion. Displacement of the punctum without apparent ectropion or entropion is best remedied by converting the minute circular orifice into a slit by the introduction of a fine probe-pointed \Veber's knife. Stricture of the nasal duct. if present. must be perma nently dilated. This may be accomplished by passing a probe down at repeated intervals through the narrowed duct ; to cause wide dilatation the probe may he kept in situ for a short time. Astringent solutions may be injected after a very large probe has been used for some time.
Should there be much difficulty in passing the probe, either canaliculus may be slit up for a portion of its extent. This is best done by inserting through .either punctum a fine grooved director into the sac along the canaliculus, and slitting up the canal in part or in its entire length. After this any form of probe, medicated bougie, tent or style, may be employed to keep up dilatation. Benson recommends the use of a piece of leaden
wire with a probe-pointed extremity, which can be worn in the duct at night and removed by the patient in the morning.
Weber, Stilling, and others overcome the obstruction by incisions made with variously shaped knives, and the actual cautery and the galvano cautery have been used with advantage to cause obliteration of the entire lachrymal sac after milder measures have failed. The lachrymal sac may be dissected out by Kuhnt's method after the injection of paraffin, and even the lachrymal gland may require removal. When, however, chronic dacryocvstitis causes epiphora without stricture of the nasal duct, the affection may be successfully treated by the patient frequently pressing upon the lachrymal sac in such a way as to force its contents down into the nose, astringent or caustic solutions being employed to relieve the conjunctival inflammation present. Acute dacryocystitis should be treated by slitting the canaliculus or the skin over the sac, and applying Nitrate of Silver freely to its interior.