Morphological and morphometric evaluation of lacrimal groove

The nasolacrimal canal is placed at the anterior part of the inferior lateral wall of the orbit and opens to the inferior nasal meatus. The canal can be obstructed by acquired diseases such as dacryocystitis and posttraumatic epiphora due to nasoorbitoethmoidal fractures. Furthermore in nasolacrimal canal obstructions, dacryocystorhinostomy with balloon dilatation is used frequently. In evaluation of the nasolacrimal canal's acquired diseases, obstruction etiologies and during the reopening of the canal with balloon dilatation, knowing the lacrimal groove's morphology and morphometry play an important role. The aim of the present study was to evaluate not only the morphological features and types but also the morphometric measurements of lacrimal groove. A total of 60 (30 right, 30 left) adult human dry bone maxillae (both male and female samples) from the collection of the Department of Anatomy of Dokuz Eylül University Medical School were used. Digital compass with 0.01 mm sensitivity was used for measurements. Average length of lacrimal groove was 9.62 +/- 2.10 mm. Average width of lacrimal groove was 5.88 +/- 1.53 mm at upper one-third, 8.04 +/- 2.05 mm at middle one-third, and 5.94 +/- 1.28 mm at lower one-third. In 87.7% of cases a crista was observed at the end of the lacrimal groove. Among them, 34.0% were directed to inferior, 54.0% were directed to posterior and 12.0% were horizontal. The present results on the width, length, shape and direction of the lacrimal groove could mediate the etiology of nasolacrimal canal obstructions and could be helpful in surgical approaches and clinical treatment.     

耳内窥镜经鼻观察泪囊前泪道阻塞鼻泪管下口的形态

目的　应用30o斜耳内窥镜镜头经鼻观察泪囊前泪道阻塞患者鼻泪管下口的形态,总结内窥镜下泪囊前泪道阻塞患者鼻泪管下口的影像解剖形态特征,为临床开展经鼻泪管下口逆行插管造影检查打下基础。  方法　选取患有泪囊前泪道阻塞性疾病患者54例（75眼）,上下泪点闭锁3例（5眼）、上下泪小管阻塞15例（24眼）、泪总管阻塞18例（28眼）、陈旧性上下泪小管断裂18例（18眼）,均应用30°斜耳内窥镜镜头观察鼻泪管下口,总结活体泪囊前泪道阻塞患者鼻泪管下口的形态特点。  结果　54例（75眼）,66眼鼻泪管下口开放,开放率88%,其中1例鼻泪管下口开放者,受刺激后,Hanser瓣膜完全遮盖鼻泪管下口,导致其呈线形关闭;9眼鼻泪管下口闭锁,占12%。根据鼻泪管下口开放的形态将其分为椭圆形宽大状（30眼,45.45%）、三角形裂隙状（12眼,18.18%）、条形裂隙状（24眼,36.36%）三种类型。21例（42眼）双眼患病的患者,双侧鼻泪管开口形态不同者15例（30眼,71.42%）,双侧鼻泪管开口形态相同者6例（12眼,28.57%）。  结论　应用30°斜耳内窥镜镜头经鼻观察泪囊前泪道阻塞患者的鼻泪管下口的可行性好,对于鼻泪管下口开放的患者有进行内窥镜引导下的逆行插管造影检查的解剖基础。     

Eponymous “valves” of the nasolacrimal drainage apparatus. II. Frequency of visualization on dacryocystography

Developmental remnants may follow segmental canalization of ectodermal epithelial cords forming the nasolacrimal drainage apparatus (NDA). This can result in false luminal “valves” along the path of the NDA, many of which have been named, but most have not been anatomically identified with consistency. By 1908, eight such “valves” were documented, those of: Foltz, Bochdalek, Rosenmüller, Huschke, Aubaret, Béraud or Krause, Taillefer, and Hasner or Cruveilhier or Bianchi. Digital subtraction dacryocystography (DS‐DCG) is the highest spatial resolution imaging technique available to outline in vivo NDA anatomy, luminal profile, and pathology. We believe this is the first report of the conspicuousness and frequency of these “valves” on DS‐DCG. We retrospectively analyzed routine DS‐DCGs with normal findings for the presence and frequency of the eight NDA “valves.” We examined 92 normal DS‐DCGs on patients aged 14–82 years (71% female, 29% male). We observed “valves” most reliably in the inferior nasolacrimal duct: the inferior valve of Hasner (plica lacrimalis) was present in 98.9% of cases, and more superiorly, the valve of Taillefer (93.5%) and the valve of Krause (79.3%). Contrastingly, we infrequently identified the very superior “valves”: Foltz or Bochdalek in 17.1%, Rosenmüller or Huschke in 46.4%, and Auberat in 40% of cases. Therefore, unlike the inferior NDA valves, these more superior “valves” were less consistently identified and are presumed to be simple mural mucosal irregularities rather than true structural valves. These findings will be useful in diagnostic interpretation of DS‐DCGs and therapeutic planning for patients undergoing luminal procedures on the NDA. Clin. Anat., 2018. © 2018 Wiley Periodicals, Inc.     

Morphogenesis of the human excretory lacrimal system

The aim of this study was to determine the principal developmental stages in the formation of the excretory lacrimal system in humans and to establish its morphogenetic period. The study was performed using light microscopy on serial sections of 51 human specimens: 33 embryos and 18 fetuses ranging from 8 to 137 mm crown-rump length (CR; 5-16 weeks of development). Three stages were identified in the morphogenesis of the excretory lacrimal system: (1) the formative stage of the lacrimal lamina (Carnegie stages 16-18); (2) the formative stage of the lacrimal cord (Carnegie stages 19-23); and (3) the maturative stage of the excretory lacrimal system, from the 9th week of development onward. A three-dimensional reconstruction of the excretory lacrimal system was performed from serial sections of an embryo at the end of the embryonic period (27 mm CR).     

Clinical considerations of the glandular branch of the lacrimal artery

The lacrimal artery is classically described as a branch of the ophthalmic artery supplied by the internal carotid. In this study, 25 orbits were dissected to identify variations in glandular branching and to compare them to previously published accounts. The glandular branching patterns of the lacrimal artery fall into two categories, those that branch (56%) and those that do not branch (44%). We found the medial and lateral glandular branches to be equal in diameter with a divergence of 2.67–40.58 mm proximal to the gland parenchyma. The long glandular branches run alongside the superolateral aspect of the orbit. The lateral branch runs lateral to the lateral rectus muscle. The medial branch runs superomedial to the lateral rectus muscle and lateral to the superior rectus muscle. In relation to the lacrimal gland, the medial branch enters the superior aspect of the gland parenchyma and the lateral branch enters its inferior aspect. The average branch lengths were 17.88 mm (medial) and 13.51 mm (lateral) as measured with a Mitutoyo Absolute 1/100 mm caliper. We could not confirm the existence of a third branch supplying the lacrimal gland, as posited by other authors. The key finding in this study is that the lacrimal gland is predominantly supplied by two significant arterial branches, both of which must be identified during procedures involving the lateral orbit. Clin. Anat. 28:844–847, 2015. © 2015 Wiley Periodicals, Inc.     

无皮肤切口Medpor义管植入泪道旁路术的临床分析

目的分析无皮肤切口的Medpor义管植入泪道旁路手术的有效性和安全性。方法回顾分析我院2011年3月至2012年12月收治的7例(7眼)行无皮肤切口的Medpor义管植入泪道旁路术的病例资料,观察其手术效果和并发症情况,分析手术的有效性和安全性。结果本组术后随访5~17个月。最后一次随访时溢泪症状消失或明显改善且义管冲洗通畅者5例,随访期间3例出现结膜肉芽增生物,2例出现鼻黏膜肉芽增生物,4例有不适感。结论 Medpor义管植入泪道旁路术可作为难治性泪道阻塞患者的备选治疗方法,但存在肉芽增生和不适感等不良反应。     

Primary ductal adenocarcinoma of the lacrimal gland

The morphological similarity of salivary and lachrymal gland tumors is known. Many clinicopathological studies and characteristics of salivary duct carcinoma, which bears histological similarlties to mammary duct carcinoma, have been recently reported; however, only one case of lacrimal duct carcinoma is reported. A second case of lacrimal duct carcinoma is presented. A 67-year-old male with a painlass mass in the right upper eyelid underwent total removal of the tumor mass. Microscopic examination of the tumor mass revealed ductal adenocarcinoma of the lacrimal gland, which was the equivalent of salivary duct carcinoma. The Immunohistological studies of the lacriml duct carcinoma showed similar results to those reported for salivary duct carcinoma. The recurrent tumor in the subdural spaces was removed 2 years after the initial surgery and the patient is followed as an outpatient.     

Primary ductal adenocarcinoma of the lacrimal sac: the first reported case

Primary lacrimal sac tumor is extremely rare, and moreover, glandular tumor is exceptional. Herein, we described the first documented case of primary ductal adenocarcinoma of the lacrimal sac. A 79-year-old Japanese female presented with persistent swelling of her left lower eyelid. Computed tomography demonstrated an irregular-shaped tumor involving the left lacrimal sac, lower eyelid, sinonasal tract, and internal side of the left orbit. Biopsy from the eyelid revealed a poorly differentiated adenocarcinoma. Histopathological study of the resected lacrimal sac tumor revealed an infiltrative neoplastic growth that was composed of cribriform structures with comedonecrosis. The neoplastic cells had relatively rich granular eosinophilic cytoplasm and large round to oval nuclei containing conspicuous nucleoli. The left cervical lymph nodes had metastatic carcinoma. Immunohistochemically, the neoplastic cells were diffusely positive for gross cystic disease fluid protein-15 and androgen receptor. Moreover, mammalian target of rapamycin (mTOR), 4E-BP1, and p4E-BP1 were expressed. According to these results, an ultimate diagnosis of primary ductal adenocarcinoma of the lacrimal sac was made. Only 9 cases of primary lacrimal sac adenocarcinoma have been reported, and this is the first reported case of ductal adenocarcinoma of the lacrimal sac. Ductal adenocarcinoma of the salivary gland shows an aggressive clinical course, and the present case had multiple cervical lymph node metastases. This report is the first to demonstrate that mTOR pathway proteins, which are central proteins involved in carcinogenesis, are activated in ductal adenocarcinoma. Therefore, mTOR inhibitor may be a potential candidate for treatment of this highly aggressive carcinoma.     

Anatomical features of the opening of the nasolacrimal duct and the lacrimal fold (Hasner's valve) for intranasal surgery: A cadaveric study

The location and size of the opening of the nasolacrimal duct and the lacrimal fold (Hasner's valve) are variable. These features have clinical importance in nasal surgery because of the difficulty in determining their location. The aim of this study was to demonstrate the anatomical features of the opening of the nasolacrimal duct and the lacrimal fold and to discuss the importance of such knowledge in minimizing the risk of injury at surgery. Twenty sagittal head sections from formalin‐fixed cadavers were examined. The sections showed no evidence of pathology or trauma. The type of opening of the nasolacrimal duct was a vertical sulcus in 14 of 20 (70%), an oblique sulcus in 2 of 20 (10%), an oblique fissure in 2 of 20 (10%), a vertical fissure in 1 of 20 (5%), and an anteroposterior fissure in 1 of 20 specimens (5%). The lacrimal fold was present in 16 of 20 specimens (80%). Five different forms of this fold were observed. Some morphological features were evaluated quantitatively. We believe that detailed anatomical knowledge of the opening of nasolacrimal duct will be useful in surgical approaches to this area. Clin. Anat. 22:925–931, 2009. © 2009 Wiley‐Liss, Inc.     

An Epstein-Barr virus positive undifferentiated carcinoma in the lacrimal sac

We report a Chinese patient who presented with metastatic undifferentiated carcinoma in the cervical lymph node of unknown primary origin. Despite a raised IgA titre against Epstein-Barr virus capsid antigen, examination and biopsy of the nasopharynx were negative. Radiotherapy was given to the head and neck region with the orbit shielded. There was complete resolution of the metastatic lymph nodes. She developed proptosis of her left eye one year afterward when a large tumour was found in the lacrimal sac region. Review of the initial computerized tomography revealed a small soft tissue mass in the same region. The tumour was composed of undifferentiated carcinoma cells associated with dense lymphoid infiltrate. In situ hybridization for Epstein-Barr virus EBER RNA showed strong positive signals in the malignant cells. This is the first reported case of an Epstein-Barr virus positive undifferentiated carcinoma with lymphoid stroma in the lacrimal sac. In addition to the nasopharynx, salivary glands, nasal cavity and paranasal sinuses, the lacrimal sac should be considered as a potential primary site for Epstein-Barr virus positive metastatic undifferentiated carcinoma in the cervical lymph nodes.     

Innervation of the cavernous body of the human efferent tear ducts and function in tear outflow mechanism

The lacrimal sac and nasolacrimal duct are surrounded by a wide cavernous system of veins and arteries comparable to a cavernous body. The present study aimed to demonstrate the ultrastructure of the nervous tissue and the localisation of neuropeptides involved in the innervation of the cavernous body, a topic not previously investigated. Different S‐100 protein antisera, neuronal markers (neuron‐specific enolase, anti‐200 kDa neurofilament), neuropeptides (substance P, neuropeptide Y, calcitonin gene‐related peptide, vasoactive intestinal polypeptide) and the neuronal enzyme tyrosine hydroxylase were used to demonstrate the distribution pattern of the nervous tissue. The ultrastructure of the innervating nerve fibres was also examined by means of standard transmission electron microscopy. The cavernous body contained specialised arteries and veins known as barrier arteries, capacitance veins, and throttle veins. Perivascularly, the tissue was rich in myelinated and unmyelinated nerve fibres in a plexus‐like network. Small seromucous glands found in the region of the fundus of the lacrimal sac were contacted by nerve fibres forming a plexus around their alveoli. Many nerve fibres were positive for S‐100 protein (S 100), neuron‐specific enolase (NSE), anti‐200 kDa neurofilament (RT 97), calcitonin gene‐related peptide (CGRP), substance P (SP), tyrosine hydroxylase (TH), and neuropeptide Y (NPY). Vasoactive intestinal polypeptide (VIP) immunoreactivity was only demonstrated adjacent to the seromucous glands. Both the density of nerve fibres as well as the presence of various neuropeptides emphasises the neural control of the cavernous body of the human efferent tear ducts. 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, malfunction in the innervation of the cavernous body may lead to disturbances in the tear outflow cycle, ocular congestion or total occlusion of the lacrimal passages.     

The fascia of the limbs and back – a review

Although fasciae have long interested clinicians in a multitude of different clinical and paramedical disciplines, there have been few attempts to unite the ensuing diverse literature into a single review. The current article gives an anatomical perspective that extends from the gross to the molecular level. For expediency, it deals only with fascia in the limbs and back. Particular focus is directed towards deep fascia and thus consideration is given to structures such as the fascia lata, thoracolumbar fascia, plantar and palmar fascia, along with regional specializations of deep fascia such as retinacula and fibrous pulleys. However, equal emphasis is placed on general aspects of fascial structure and function, including its innervation and cellular composition. Among the many functions of fascia considered in detail are its ectoskeletal role (as a soft tissue skeleton for muscle attachments), its importance for creating osteofascial compartments for muscles, encouraging venous return in the lower limb, dissipating stress concentration at entheses and acting as a protective sheet for underlying structures. Emphasis is placed on recognizing the continuity of fascia between regions and appreciating its key role in coordinating muscular activity and acting as a body-wide proprioceptive organ. Such considerations far outweigh the significance of viewing fascia in a regional context alone.     

The interpectoral fascia flap

Despite the great number of pedicled and free flaps that are available for defect and contour repair, the number of fascia flaps with an axial blood supply are sparse. Such flaps with their gliding function are mandatory, whenever coverage with very thin, well-vascularized tissue is necessary. To the currently established fascia flaps, (the temporoparietal fascia flap, the radial forearm fascia flap, the lateral arm fascia flap, and the serratus anterior fascia flap), we want to add a new fascia flap, the interpectoral fascia flap. We dissected the interpectoral fascia flap from 20 cadavers. In each of the 40 hemichests, the trunk of the thoracoacromial vessels was selectively injected with red polyurethane and the tissue containing the pectoral branches was separated from the overlying pectoralis major muscle and converted into an independent fascia flap. The maximum flap length was 13.5 cm and the maximum breadth was 10.3 cm. The length of the vascular pedicle before entering the flap was 3.9 cm +/- 1.4 cm with a range of 1.5-6.8 cm. Concerning the arc of rotation, all 40 flaps reached the posterior axillary fold, and 29 flaps (73%) reached the mandibular border. This new fascia flap has applications as pedicled and as free flap. The pedicled flap is used in the neck region, in the axillary region and as gliding tissue between the nipple-areola complex and the pectoralis major muscle. The usage of the fascia flap as a free flap has similar characteristics as the other fascia flaps.     

Functional anatomy of human lacrimal duct epithelium

 Resorption of tear fluid in the lacrimal ducts has hitherto been controversial; one reason for this has been insufficient knowledge of the anatomical structure and function of the lacrimal duct epithelium. The present study analyzes the structure of lacrimal duct epithelium by means of histological, histochemical, immunohistochemical and electronmicroscopical methods and draws a conclusion about its physiological function regarding its role in immunodeficiency. Investigations were performed on 31 lacrimal systems of 17 male and 14 female individuals (aged 54–88 years). Lacrimal ducts are surrounded by a wide-ranging cavernous system, which is embedded in an osseous canal between the maxilla and the lacrimal bone. The internal wall of the lacrimal canaliculi is lined by a stratified epithelium. The lacrimal sac and nasolacrimal duct contain a double-layered epithelium, which rests on a broad basement membrane. In their apical part epithelial cells contain large lipid droplets and secretory vacuoles. Epithelial cells are faced by microvilli and some tufts of kinociliae are also visible. Goblet cells are integrated in the epithelium as solitary cells or in a characteristical arrangement of several cells. The secretory product of these cells contains carbohydrates including fucose and sialic acid. Inside the surrounding cavernous system serous glands are found that open their excretory ducts into the lacrimal sac and nasolacrimal duct. Some T- and B-lymphocytes and macrophages may be demonstrated immunohistochemically in the submucosa partly penetrating the epithelium. Synthesized mucins of goblet cells form a specialized protective layer on the epithelium of the lacrimal ducts, which functionally serves for a simplified drainage of tear fluid into the inferior meatus of the nose. Together with immunocompetent cells, the protective layer plays a role in antigen defense and prevents invasion of pathogenic agents. The facing of epithelial cells by microvilli gives hints of reabsorption of lacrimal fluid inside the lacrimal ducts. Accepted: 13 January 1998     

泪囊窝的解剖与泪囊鼻腔吻合术

目的：为积累泪囊窝的解剖学资料，并提高泪囊手术质量。方法：采用国人颅骨132侧(男65侧、女67侧)对泪囊窝的形态、组成等进行丁观测。结果：泪囊窝多数(85.60％)由泪骨与上颌骨构成，少数(14.40％)由泪骨或上颁骨构成。测得泪囊窝长15．76mm、宽7．29mm、深2.54mm。结论：结果提示临床泪囊鼻腔吻合手术时．在泪囊窝的下部偏后凿孔，手术易于成功；当泪囊窝由上颌骨构成时，手术凿孔较困难。     

Of fat and fascia: Clinical conundrum corner

A case report involving a 76-year-old male is presented. The signs and symptoms represent a difficult diagnostic problem. The physical signs are dependent on a knowledge of the distribution of fat and fascia in the region involved. The importance of this distribution, both physiologic and pathologic, is the subject of a brief commentary. © 1995 WiIey-Liss, Inc.     

Nd：YAG泪道激光成形术治疗泪道阻塞的体会

目的 探讨应用泪道激光治疗泪道阻塞的方法及疗效。方法 应用Nd：YAG泪道激光仪按泪道探通方法连续击射阻塞部位。用抗生素和丝裂霉素C混合液冲洗畅通后植入义管，每周冲洗一次，1月后拔管。结果共治疗53例60眼，随访1～3月。治愈57眼占95％，好转2眼占3．33％，无效1眼仍有溢脓，1月后行泪囊鼻腔吻合术治愈。结论 激光泪道成形术治疗泪总管、鼻泪管阻塞及泪囊炎，方法简单、疗效满意。     

Detailed anatomy of the capsulopalpebral fascia

This study was designed to elucidate the detailed anatomy of the capsulopalpebral fascia (CPF) and capsulopalpebral head (CPH), and their relationships to the inferior rectus muscle (IRM). In this cohort study, 40 eyes from 20 cadavers were observed macroscopically. Dissection was carried out from the CPF origin to its insertion, and the CPF origin pattern was photographed in each specimen. The width, length, and tensile strength of the CPF were measured. The CPF originated 25.07 ± 1.07 mm laterally and 24.86 ± 1.10 mm medially from the origin of the IRM and extended to the lower border of the inferior oblique muscle, and it firmly adhered to the IRM surface and formed into the CPH. The CPH was 4.31 ± 0.86 mm laterally and 6.18 ± 1.94 mm medially in length and 7.47 ± 0.81 mm in width. The CPF originated from the total width or 3/4 temporal part of the IRM in 32 (80%) of 40 faces. There was asymmetry in the pattern of the CPF origin between the left and right eyes in 4 of 20 paired specimens (20%). The tensile strength of the posterior layer was 19.12 ± 11.22 N, which was significantly higher than that of the anterior layer (8.59 ± 3.88 N) (P = 0.001). This study provided a good understanding of the CPF structures conducive to performing IRM surgery.     

Nd：YAG激光泪道成形术和鼻泪管支架术治疗慢性泪囊炎的疗效对比

目的比较Nd：YAG激光泪道成形术和鼻泪管支架术治疗慢性泪囊炎的临床效果。方法 93例（102眼）慢性泪囊炎患者随机分成两组,一组应用Nd：YAG激光泪道成形术治疗,另一组应用鼻泪管支架术治疗,比较两组的治疗效果。结果应用Nd：YAG激光泪道成形术治疗57眼,有效39眼（68.42%）;鼻泪管支架术治疗45眼,有效40眼（88.89%）,两组疗效差异有统计学意义（χ2=6.03,P〈0.01）。结论鼻泪管支架术相对于同样微创的Nd：YAG激光泪道成形术治疗慢性泪囊炎疗效更加稳定,手术成功率更高,不失为微创治疗慢性泪囊炎的首选术式。