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CHAPTER 3: Upper Facial Trauma
Resident Manual of Trauma to the Face, Head, and Neck
58
horizontal lacerations at the medial canthus can also disrupt the
canaliculi but are less common.
Fracture(s) that involve the lacrimal fossa can rupture the lacrimal sac
or avulse the common canaliculus from the lacrimal sac. This may only
be identified by inserting a lacrimal probe into the system via the upper
and/or lower puncta and noting a failure of the probe to pass easily into
the lacrimal sac.
The floor of the lacrimal fossa contains the opening to the superior
portion of the lacrimal duct. Fractures involving this region can be
subtle. Unless identified on imaging or suspected from the location of
the fractures, they can be overlooked, leading to persistent epiphora.
Identifying patency of the nasolacrimal system after NOE injuries
usually necessitates performing primary and secondary Jones dye tests.
1. Primary Jones Dye Test
a. Test Procedure
y
y
Instill one drop of fluorescein in the inferior cul-de-sac of the lower
eyelid
y
y
Insert a cotton pledget minimally soaked in a topical anesthetic, such
as 2 percent lidocaine beneath the inferior turbinate.
y
y
After 5 minutes, remove the pledget and examine for fluorescein.
b. Interpreting Test Results
y
y
If fluorescein is present, then this is a positive primary Jones dye test,
indicating that the lacrimal drainage system is patent.
y
y
If fluorescein is not present, this is a negative primary Jones dye test,
and further testing is required to determine the level of obstruction.
2. Secondary Jones Dye Test
a. Test Procedure
y
y
Place a clean cotton pledget beneath the inferior turbinate.
y
y
Flush the fluorescein from the cul-de-sac with saline.
y
y
Irrigate the lacrimal sac via the inferior canaliculus using a special
blunt canalicular needle and syringe.
b. Interpreting Test Results
y
y
If fluorescein is identified on the fresh pledget, then this is a positive
secondary Jones dye test, indicating a functional obstruction in the
nasolacrimal duct.
y
y
If no dye is present on the pledget, but saline is observed, then this is
a negative secondary Jones dye test, indicating pathology at the
lacrimal punctum or canaliculus.