LACRIMAL DRAINAGE FUNCTION

1. T H E JONES FLUORESCEIN TEST

ROBERT J. ZAPPIA, M.D., AND BENJAMIN MILDER, M.D. St. Louis, Missouri

Over the years, the clinician has had at his disposal many methods of evaluating the function of the lacrimal apparatus. The fact that these tests have not been subjected to careful evaluative study has not diminished the enthusiasm for their use. One of the most widely used tests for this purpose is the flu­orescein test as described by Lester Jones1 in 1961.

The Jones test has several attractions for the busy ophthalmologist. It is simple, atrau-matic, consumes little time, and requires no sophisticated equipment. Most important, it is an objective test and the results can be ob­served and interpreted directly.

The test, as described by Jones2 is per­formed in the following manner: One drop of 1% fluorescein is instilled in the conjunc-tival sac. The dye is recovered in the nose by means of a cotton-tipped applicator within one to five minutes. If no dye appears in the nose, a "secondary dye test" is performed; the lacrimal system is flushed with clear sa­line and the fluid emanating from the nose is checked for fluorescein staining. From Jones' interpretation of the primary and secondary tests, he draws specific conclusions about mal­function and its localization. It is the pur­pose of this paper to evaluate the primary and secondary Jones tests of lacrimal drain­age function.

MATERIALS AND METHODS

Jones' tests were performed on 155 pa­tients in this series, examining a total of 308 lacrimal systems. One-half of the population was derived from the clinic and approxi­mately one-half from an office practice. A

From the Jewish Hospital of St. Louis and the Department of Ophthalmology, Washington Uni­versity School of Medicine, St. Louis, Missouri.

Reprint requests to Robert J. Zappia, M.D., The Beaver Medical Clinic, 2 West Fern Avenue, Red-lands, California 92373.

history was taken from each patient concern­ing the presence or absence of pertinent ocu­lar disease or lacrimal dysfunction. The pa­tients were examined externally for relaxa­tion of the eyelids, puncta eversion, and ex­ternal disease. Slit lamp examinations were performed. A Schirmer test was performed using litmus paper placed in the lower cul-de-sac at the junction of the middle and outer thirds of the lower eyelids. The degree of wetting at the end of five minutes was measured in millimeters and recorded.

Our replication of the Jones test was per­formed as follows : The patients were seated in an ophthalmic chair with the head back against the headrest. The nose was sprayed with 4% cocaine. One drop of 2% fluores­cein solution was instilled in each conjuncti-val sac from an Alcon 2-ml Drop-tainer. This drop measures 0.12 to 0.14 ml. At one minute, two minutes, and five minutes after instillation of the dye, a cotton-tipped nasal applicator was introduced into the nose un­der the inferior turbinate. The applicator was then moved posteriorly across the floor of the nose and removed. An indirect oph­thalmoscope was used for illumination. If the cotton swab had any amount of fluores­cein staining at one, two, or five minutes, the test was considered a positive primary Jones test and indicative of normal tear excretion.

If after five minutes no dye had been recovered, the remaining fluorescein was flushed from the conjunctival sac with clear irrigant until the washings appeared free of dye. Anesthesia of the puncta and eye was effected with 0.5% proparacaine HC1 (Ophthaine) drops followed by cotton pled­gets moistened with the same anesthetic agent and placed between the puncta for a period of two minutes. The puncta were then di­lated with a punctum dilator. A lacrimal can-nula was introduced and, with the head tilted

154

VOL. 74. NO. 1 LACRIMAL DRAINAGE FUNCTION 155

TABLE 1 AGE RANGE

Sex

Males Females

11-20

2 16

21-30

0 14

31-10

0 12

No. Patients (Age in years)

41-50

9 18

51-60

17 48

61-70

12 52

Over 70

28 80

forward over the emesis basin, clear irrigant was flushed through the lacrimal system. If the irrigant emerged from the nose stained with fluorescein, this was considered a posi­tive secondary Jones test. If the irrigant came through clear, this secondary test was considered negative.

RESULTS

This test was performed on a total of 308 lacrimal systems. Of these, 200 were consid­ered normal by history and by physical ex­amination. The remaining 108 lacrimal sys­tems were considered abnormal according to a history suggestive of lacrimal disease or actual abnormal examination findings. The age range was from 14 to 85 years (Table 1)·

To determine if the skills involved in the Jones test are a factor in the results ob­tained, our normal patients were divided into a first group of 99 eyes and a subsequent group of 101 eyes. In the first group, 8 1 % of the primary Jones tests were positive within the first five minutes. In 19%, no dye was recovered until the secondary Jones test was performed (Fig. 1).

In the subsequent group, 75% of the Jones tests were positive within five minutes. In 25%, no dye was recovered until the sec­ondary Jones test was performed (Fig. 1).

Combining the statistics for both groups, we find that the primary Jones test is posi­tive in 78% within five minutes and 22% were positive by subsequent irrigation (posi­tive secondary Jones test). There thus ap­peared to be no significant learning factor between the two groups.

When we separate our 200 normal tests into patients who were bilaterally normal and those with unilateral lacrimal disease, we find 169 eyes in the first group and 31 uni­laterally normal eyes in the second group. In the group of 169 normal eyes, we find the Jones test was positive in 8 1 % within five minutes and 19% had a positive secondary Jones test. In the 31 that were unilaterally normal, only 58% positive primary Jones tests were found and 42% positive secon­dary tests were found (Fig. 2 ) .

This dramatic difference between the uni­laterally and bilaterally normal supports the impression that lacrimal excretory abnor­malities, whether congenital or acquired, tend to be bilateral. This tendency for bilat-erality has been pointed up in the literature for many years, and the differences elicited

80 Ö f» 0 60

1 | 4 0

^ 20

0

-

JONES 2

1 9 *

JONES 1

« 1 %

ieries 1

JONES 2

25%

JONES 1

75 %

Series 2

JONES 2

22 %

JONES 1

78%

Series 1&2 Fig. 1 (Zappia and Milder). Percent of posi­

tive and secondary Jones tests in two sérier of normal eyes.

156 AMERICAN JOURNAL OF OPHTHALMOLOGY JULY, 1972

100

s 80

60-

40

20

JONES 2

19X

JONES 1

81%

Bilatera

JONES 2

42%

JONES 1

58«

Uni lateral

Fig. 2 (Zappia and Milder). Percent of positive primary and secondary Jones tests in bilaterally normal patients and unilaterally normal patients.

by the primary Jones test appear to support its validity as a means of appraising lacrimal function.

There were 108 lacrimal systems excluded from the normal series because of (1) a his­tory suggestive of lacrimal disease or of some form of ocular disease which could in­fluence lacrimal function, or (2) abnormal examination findings. These findings could include gross epiphora, chronic dacryocysti-tis, everted or stenosed puncta, malposition of the eyelid margins, conjunctivitis, or ker-atitis. We separated those cases which were abnormal by history but not by examination from those in which we obtained definite ab­normal examination findings. Of the 108 lac­rimal systems, 55 were excluded from the normal series because of history and could

not be prejudged to be either normal or ab­normal ; 53 were excluded because of abnor­mal physical findings.

Of the 55 who were abnormal by history alone, 40% (22 eyes) had a positive primary Jones test, 49% (27 eyes) had a positive sec­ondary Jones test and 11% (six eyes) were positive for neither. Fifty-three eyes were noted to have abnormal examinations; of these, 10% (five eyes) had a positive pri­mary Jones test, 49% (26 eyes) had a posi­tive secondary Jones test, and 4 1 % (22 eyes) were negative for both tests (Table 2 ) .

Analysis of the group that was abnormal by history is difficult because we are dealing with a mixture of normals and abnormals in-. sofar as lacrimal function is concerned.

The results in the group that was abnor­mal by examination show that the secondary Jones test is not a test of lacrimal function because the percentage of positive tests did not differ from the group that was abnormal by history alone. On the other hand, the per­centage of positive primary Jones tests showed a dramatic drop when comparing the results in subjects abnormal by history with results in those abnormal on examination (Table 3) . Of five judged abnormal by examination, there were two cases of postop­erative dacryocystorhinostomy, and one case of postoperative repair of ectropion, one subject had a conjunctival discharge, and the fifth had small tight puncta. The positive primary Jones tests in the first three indicate success in the surgery, while the positive pri­mary Jones test in the patient with conjunc­tival discharge probably indicated that this in no way impaired lacrimal function. We con-

TABLE 2 AVERAGE SCHIRMER TEST RESULTS FOR DIFFERENT AGE GROUPS

Test 11-20 21-30 31-40

No. Patients (Age in years)

41-50 51-60 61-70 Over 70

Schirmer results 19 20 18 13 13 10 9 (in mm)

VOL. 74, NO. 1 LACRIMAL DRAINAGE FUNCTION 157

96r

80-

I S 16

4 JO 14

J5 19

20 24

25+

SCHIRMER TEST VALUES

Fig. 3 (Zappia and Milder). The distribution of Schirmer test values in all eyes.

sidered the last patient to be the only one who represented a false-positive test.

In order to determine the influence of the Schirmer test on the Jones test, Schirmer tests, using litmus paper, were performed on 305 normal and abnormal eyes. The average Schirmer tests results for the different age groups appear in Table 2.

If we plot the spread of Schirmer tests in millimeters for the total number of eyes, we find a curve that peaks at 10-14 milimeters (Fig. 3) .

If we now plot the Schirmer tests versus the Jones tests that were positive at one min­ute, we find a similarly-shaped curve except for a smaller number of lower Schirmer tests—i.e., those with 0-4 mm of secretion (Fig. 4 ) .

If we plot the Schirmer tests against the Jones tests that were positive at two minutes and at five minutes, we find the shape of the curve has changed. We now have no peak at 10-40 mm and note a progressive increase in the number of lower Schirmer tests (Fig. 5).

The longer the delay before the primary Jones test becomes positive, the greater the

number of lower Schirmer tests. If we now plot the Schirmer tests versus the group that had negative primary Jones tests and posi­tive secondary Jones tests, we find a dramatic change, with one-third of the tests having Schirmer tests of 4 mm or less, and 60% have Schirmer tests below 9 mm (Fig. 6) .

£ D J5 20 9 14 19 24

SCHIRMER TEST VALUES

25*

Fig. 4 (Zappia and Milder). Distribution of Schirmer test values in eyes with a positive Jones test at one minute.

48r

40-

32-

HJ 24 -Jonts 1 test positif in 2 minutes -Jones 1 test Positivs in S minutes

S_ 10 15 20 9 14 19 24

SCHIRMER TEST VALUES

25*

Fig. S (Zappia and Milder). Distribution of Schirmer test values in eyes with positive Jones tests at two and five minutes.

158 AMERICAN JOURNAL OF OPHTHALMOLOGY JULY, 1972

48 r

£ _5_ 10 15 20 4 9 14 19 24

SCHIRMER TEST VALUES

25+

Fig. 6 (Zappia and Milder). Distribution of Schirmer test values in eyes with negative Jones 1 and positive Jones 2 tests.

These data show that the more rapid ap­pearance of fluorescein in the nose tends to be associated with the higher Schirmer test values.

CONCLUSIONS

The primary Jones test, if positive, must be accepted as a valid indication of a nor­mally-functioning excretory system. It de­tects only 77% of normal, subjects, however, and therefore, it is not highly reliable. A negative primary Jones test does not neces­sarily indicate pathology.

In the unilaterally normal patients, the percentage of positive primary Jones tests drops to 58%, and the percentage of positive secondary Jones tests rises to 42%. Compar­ison of the percentage of positive tests be­tween subjects in this group and those hav­ing two normal eyes emphasizes the potential for lacrimal abnormalities in the normal eye of those unilaterally normal.

In this series, no normal patient had a negative primary and negative secondary Jones test. This combination was found only in patients having a history or findings of lacrimal system disease.

The secondary Jones test indicates that the upper excretory system (eyelid margin, puncta, and canaliculi) is functioning since fluorescein enters the canaliculus and sac. The recovery of fluorescein in the nose indi­cates that the lower system is patent. The data derived in this study indicate that one cannot make an unequivocal diagnosis of partial obstruction from a positive secondary Jones test, since 22.5% of our normal series had negative primary Jones tests and posi­tive secondary Jones tests.

In dealing with subjects with a known ab­normality, 49% had a positive secondary Jones test, and in dealing with patients who were abnormal by history alone, 49% also had positive secondary Jones tests. The fact that both of these groups had identical per­centages of positive secondary Jones tests would indicate that the secondary Jones test is not a measure of physiologic lacrimal function, but rather of patency, as deter­mined by flushing fluid through the excre­tory system.

In patients having known lacrimal abnor­malities, false-positive Jones tests are very uncommon (one out of 53 eyes in this group), again suggesting that a positive pri­mary test is a valid indication of normal function, but no conclusions can be drawn from a negative test.

The results of the Jones test were found to be reproducible, indicating that the skill

TABLE 3 JONES TEST RESULTS IN ABNORMAL SUBJECTS

Test Abnormal Abnormal History Examination

Jones 1 positive: One minute Two minutes Five minutes

7 7 8

1 0 4

Totals 22(40%) 5(9.5%)

Jones 2 positive 27(49%) 26(49%) Jones 1 and 2 negative 6 (11%) 22 (41.5%)

Totals 55 53

VOL. 74. NO. 1 LA'CRIMAL DRAINAGE FUNCTION 159

gained from repetition of administering the test is not a significant factor.

In order to interpret and evaluate the Jones test, the physician must know the rate of tear secretion. When the Jones test was positive within one minute, the average Schirmer test was 14 mm ; at two minutes, 10.5 mm ; and at five minutes, 10.5 mm. The average Schirmer test was less than 10 mm in the group in which the primary Jones test was negative and the secondary Jones test was positive. These data indicate that in patients having lower Schirmer values positive pri­mary Jones tests may be delayed or negative.

SUMMARY

When the ability of the primary and sec­ondary Jones tests to evaluate lacrimal func­tion was assessed, it was found that in nor­mal individuals the primary Jones test was positive in 78% and the secondary Jones test was positive in 22%. Analysis of individuals with known lacrimal abnormalities showed

that the secondary Jones test was an indica­tion of patency of the system as determined by mechanical flushing, rather than partial obstruction.

The Schirmer test was performed by plac­ing litmus paper in the lower cul-de-sac at the junction of the middle and outer thirds of the lower eyelids. The degree of wetting at the end of five minutes was measured in millimeters. Schirmer tests were performed in 305 normal and abnormal eyes in order to determine its influence on the Jones test. Analysis of the data indicates that in patients having lower Schirmer values, the positive primary Jones test may be delayed or nega­tive.

R E F E R E N C E S 1. Jones, L. T. : An anatomical approach to prob­

lems of the eyelids and lacrimal apparatus. Arch. Ophth. 66:111, 1961.

: The cure of epiphora due to canalicular disorders, trauma and surgical failures on the lacri­mal passage, Tr. Am. Acad. Ophth. Otolarvng. 66 : 506, 1962.