Ultrasonic visualization of the effect of blinking on the lacrimal pump mechanism.

Abstract

The role of the lacrimal sac (LS) and the medial canthal tendon in the lacrimal pump mechanism is controversial. This study used ultrasonic visualization to analyze this phenomenon. Movements of the LS and the medial canthal tendon during blinking were visualized with sonography. In addition, the maximal profile area of the LS was measured before and after blinking using 15-MHz sonography in 14 individuals with a normal lacrimal drainage system and in six patients with lacrimal duct obstruction. The upper part of the LS could be located as an echolucent structure between the lacrimal bone and the medial canthal tendon. The medial canthal tendon appeared to compress the LS during lid closure and release the LS during lid opening. The measured profile area of the visible normal LS at the compression time decreased by 50%. The dilated LS of patients with obstruction could also be compressed by the orbital muscle on blinking, but the maximum area decrease was only 15.5%. The findings imply that the lacrimal part of the orbicularis muscle contracts during blinking, with the medial canthal tendon compressing the LS in a cranial direction. Completion of lid closure then compresses both canaliculi and LS, forcing the intrasacral fluid through the drainage system. The expansion of the LS during the opening phase of the blink causes suction, and after opening of the punctal areas the canaliculi and LS vacuum breaks to reload with tear fluid. These findings demonstrate the importance of the orbicularis muscle and the medial canthal tendon for the lacrimal pump mechanism during blinking.