Resident Manual of Trauma to the Face, Head and Neck

CHAPTER 3: Upper Facial Trauma

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.

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Resident Manual of Trauma to the Face, Head, and Neck