Denervation of the lacrimal gland.

THE surgical treatment of epiphora is now well established and on the whole satisfactory. A success rate of almost 90 per cent. can be expected for the operation of dacryocystorhinostomy (Stallard, 1950). There still remains a considerable number of cases where the puncta or canaliculi are strictured or absent, where the lacrimal sac is absent or grossly damaged, or where the inner canthus is severely deformed. Every clinic has its cases of chronic epiphora due to dacryocystectomy and to trauma or irradiation of the inner canthus. Although many operations, such as canaliculoplasty, conjunctivodacryocystostomy, and canaliculo-rhinostomy have been devised, they are often very time-consuming and the results are far from good. Several operations have therefore been described for diminishing the secretion of tears. The removal of the palpebral lobe of the lacrimal gland was first performed by de Wecker (1891); the operation was made classical by Axenfeld (1911), and has recently been strongly advocated by Rycroft (1956). The operation is usually successful, but the occasional complication of keratoconjunctivitis sicca mars the usefulness of this procedure. Keratitis sicca following dacryoadenectomy has been reported by Kalt (1903), Knapp (1929), and Engelking (1928), and I have personally seen two cases. It is probable that the complication is more common than would be supposed from the literature, and that the fear of transforming awet eye into a dry one accounts for the general reluctance of ophthalmologists to perform this simple operation. Strebel (1936) attacked the palpebral lobe and the secretory ducts with diathermy. Jameson (1937) divided the lacrimal ductules sub-conjunctivally, an operation which can be graded in extent. It has not been possible to trace any long-term results of this operation. Exposure of the gland to x rays has been recommended by several workers (Hensen and Lorey, 1922; Hensen and Schiifer, 1924; Treiser, 1939), and some successful cases were reported. Tikhomirov (1935) described the injection of the palpebral lobe with alcohol. Patients with epiphora do not suffer constant discomfort and when sitting quietly in a warm room in subdued illumination, have no troublesome watering. Tearing is noticed when in the cold, in a wind, in a stuffy atmosphere such as the cinema, or when concentrating on close work. It is reasonable to suppose, then, that the constant steady level of lacrimal secretion is sufficient to prevent corneal and conjunctival drying, while the reflex excess lacrimation is the main source of disability. The logical treatment would be to abolish this reflex lacrimal secretion.