Patient satisfaction following endoscopic endonasal dacryocystorhinostomy: a quality of life study

Cost-effectiveness analysis of endoscopic dacryocystorhinostomy using Markov modelling

OBJECTIVE

To determine the cost-effectiveness of endoscopic dacryocystorhinostomy (DCR).

METHODS

We constructed a Markov model in which patients with nasolacrimal duct obstruction received endoscopic DCR or no surgery. Incremental cost-effectiveness ratios, 1-way sensitivity analyses, and probabilistic sensitivity analyses were used to evaluate for model sensitivity to multiple model inputs.

RESULTS

Endoscopic DCR was found to be cost-effective with an incremental cost-effectiveness ratio of US$2162 per quality-adjusted life-year. The model was most sensitive to the health utility deduction from epiphora. Probabilistic sensitivity analysis found endoscopic DCR to be cost-effective over no surgery 93.7% of the time.

CONCLUSIONS

Endoscopic DCR is a cost-effective treatment for patients with epiphora. The model is very sensitive to the negative effect epiphora has on quality of life. With the advancement of health care technology and surgical techniques, the success rates of endoscopic DCR continue to improve and to be an even more efficacious and economical treatment for nasolacrimal duct obstruction.

Evaluation of the relationship between tear meniscus changes and quality of life outcomes after external dacryocystorhinostomy

PURPOSE

This study aims to investigate the effects of external dacryocystorhinostomy (DCR) surgery on tear meniscus parameters and assess its relationship with improvements in quality of life (QoL) in patients with nasolacrimal duct obstruction (NLDO).

METHODS

This prospective study included 30 patients diagnosed with NLDO who underwent external DCR surgery. Tear meniscus (TM) parameters, including height, depth and area, were measured using anterior segment optical coherence tomography. Lacrimal symptom questionnaire (LacQ), Munk scores and Glasgow benefit inventories (GBI) were collected. Statistical analysis was performed to evaluate the correlation between tear meniscus changes and improvements in QoL.

RESULTS

TM height, depth and area decreased from preoperative median measurements (0.09 mm2, 0.37 mm, 0.56 mm) to postoperative median measurements (0.03 mm2, 0.21 mm, 0.30 mm) (p < 0.001). Lacrimal symptom scores and Munk scores showed a significant improvement at 3-month postoperatively (p < 0.001). The GBI scores also demonstrated a significant improvement, indicating a positive impact on the patients' QoL. (p < 0.001). A statistically significant correlation was found between the change in TM parameters and LacQ lacrimal symptom scores.

CONCLUSION

External DCR surgery leads to significant improvements in tear meniscus parameters and quality of life outcomes in patients with NLDO. The decreased in TM height and TM area indicates improved tear film dynamics and decreased tear volume, which positively impact the patients' ocular comfort and overall well-being. This study highlights the importance of tear meniscus evaluation as a potential market for assessing the success of DCR surgery and its impact on patients' QoL.

QoL Following Dacryocystorhinostomy: Linguistic Adaptation of Italian Version of GBI

The Glasgow Benefit Inventory (GBI) is a generic patient recorded outcome measure assessing the quality of life of patients undergoing ear nose and troth surgery. Although largely used in the clinical practice, it has never been adapted and validated in the Italian language. The aim of the study was to translate the original GBI from English to Italian and to examine its reliability for use in the Italian adult population of patients undergoing endonasal endoscopic dacryocystorhinostomy. After translation and back-translation of the original English we evaluated the reliability of GBI for use in 79 Italian adults undergoing dacryocystorhinostomies. Reliability of GBI-IT was examined by the internal consistency of the scale (using the Cronbach's alpha coefficient), and by the test-retest analysis. The GBI-IT showed adequate internal consistency (Cronbach's alpha = 0.85 for the total scale). The total GBI-IT score showed a strong correlation in retests (CCC 0.87). In conclusion, our study showed that the GBI-IT has satisfactory internal consistency and reliability and is equivalent to the original English version. In addition, it can be considered a valuable measure for both clinical and research uses.

Revision dacryocystorhinostomy: systematic review and meta-analysis

PURPOSE

The goal of this study is to determine if a certain revision DCR approach (external, endoscopic endonasal, laser transcanalicular) is superior to others. Additionally, this investigation evaluates the effect of the primary surgery on success of revision.

METHODS

This investigation is a systematic review and meta-analysis. All studies specifying type of primary DCR and revision DCR were included. Proportion of successes of each revision for every primary surgery was obtained from the included studies. Meta-analyses were performed to determine cumulative proportions of successes across studies.

OUTCOME MEASURES

Significant differences in the proportions yielded by meta-analysis of successes among different surgical approaches.

RESULTS

The type of primary surgery did not significantly influence overall revision success if the same procedure was used for the revision. Overall successes per each revision type were not significantly different. When performing subgroup analyses per each primary surgery, all methods of revisions were similar in efficacy with one exception: when the primary surgery was done using the laser transcanalicular approach, external revision outperformed repetition of the primary method.

CONCLUSIONS

Regarding success of re-operation, surgeons can use the method they are most comfortable with to perform DCR revisions. However, primary transcanalicular laser DCRs should be revised, if necessary, using the external approach.

Quality of life outcomes after transnasal endoscopic pituitary surgery using the Glasgow Benefit Inventory

PURPOSE

This study assesses postoperative quality-of-life outcomes via the Glasgow Benefit Inventory (GBI) in patients undergoing transnasal endoscopic pituitary surgery for pituitary adenoma.

METHODS

This was a retrospective cohort study in a UK tertiary referral centre. 145 patients who had undergone transnasal endoscopic pituitary surgery for pituitary adenoma over a 6-year period at one institution completed the GBI with at least 3 months' follow up. Patients with prior radiotherapy were excluded. The GBI is a patient-reported outcome measure that assesses post-intervention outcomes in three domains: 'general' functioning, 'social support' and 'physical' functioning. Pre- and post-operative visual loss scores were additionally assessed via a 1-5 Likert scale. GBI scores were assessed alongside these visual loss scores, clinical and surgical parameters and demographics.

RESULTS

Mean age was 59.5 years (range 20-87 years) and mean follow up was 36 months. A total of 46 of 145 (31.7%) patients had secreting tumours. The most common primary symptom was visual loss. Mean total score for all patients was positive (+8.4); with 'general' domain score the most positive (+10.5). All patient groups had overall positive, 'general' and 'social support' domain scores. Patients with Cushing's disease reported significantly higher mean total scores (+29.6) than all other groups. Acromegaly (+7.9) and non-functioning adenoma (NFA) groups (+5.2) reported lower mean total scores. 'Physical' domain mean scores were negative for acromegaly and NFA groups. There was statistical significance between a pre- to post-operative improvement in visual score and mean total GBI score (p = 0.02) and mean 'general' domain GBI score (p = 0.02).

CONCLUSIONS

These findings can aid preoperative counselling of patients undergoing this surgery. Those with NFA and no anticipated improvement to visual loss symptoms may be advised of possible worsened physical outcomes and of the option to delay the surgery until symptoms are present.

Association between tear meniscus dimensions and higher-order aberrations in patients with surgically treated lacrimal passage obstruction

PURPOSE

To analyze the relationship between tear meniscus dimensions and higher-order aberrations (HOAs) in patients with lacrimal passage obstruction using anterior segment optical coherence tomography (AS-OCT).

METHODS

This study was a retrospective observational study of 71 eyes of 49 patients with lacrimal passage obstruction. These patients received sheath-guided dacryoendoscopic probing and bicanalicular intubation (SG-BCI) at Toyama University Hospital between August 2020 and October 2021. Using AS-OCT, tear meniscus height (TMH), tear meniscus area (TMA), and total corneal HOAs values were measured before and after surgery.

RESULTS

Surgical success was achieved in 69 eyes (97.1%). At the final observation, 62 eyes showed lacrimal patency (89.8%). The preoperative TMH, TMA, and HOAs values were 1.55 ± 0.96 mm, 0.11 ± 0.14 mm², and 0.37 ± 0.27 µm, respectively, and the final postoperative TMH, TMA, and HOAs values were 0.97 ± 0.74 mm (p < 0.0001), 0.06 ± 0.11 mm² (p = 0.02), and 0.29 ± 0.16 µm (p = 0.001), respectively. The results showed a significant improvement. The changes in HOAs before and after surgery were positively correlated with the changes in TMH (r = 0.3476, p = 0.0241) and TMA (r = 0.3653, p = 0.0174).

CONCLUSION

SG-BCI for lacrimal passage obstruction resulted in a significant decrease in measured HOAs. The decrease in HOAs was correlated with decreases in tear meniscus dimensions.

Outcomes of bicanalicular nasal stent inserted by sheath-guided dacryoendoscope in patients with lacrimal passage obstruction: a retrospective observational study

Background

The dacryoendoscope is the only instrument that can observe the luminal side of the lacrimal passage with minimal invasiveness. It was developed to treat lacrimal passage obstructions by inserting a bicanalicular nasal stent with sheath-guided bicanalicular intubation (SG-BCI). The purpose of this study was to determine the outcomes of SG-BCI to treat lacrimal passage obstructions. In addition, to determine the effects of SG-BCI treatment on the quality of life.

Methods

This was a retrospective observational study of 128 patients (mean age 70.9 ± 11.0 years, range 28–93 years) diagnosed with a unilateral lacrimal passage obstruction. There were 73 patients with a nasolacrimal duct obstruction, 37 with a lacrimal canaliculus obstruction, 7 with a lacrimal punctum obstruction, and 11 with common lacrimal canaliculus and nasolacrimal duct obstructions. They were all treated with SG-BCI. The postoperative subjective outcomes were assessed by the answers to the Glasgow Benefit Inventory (GBI) questionnaire and to an ocular specific questionnaire on 6 symptoms including tearing, ocular discharges, swelling, pain, irritation, and blurred vision. The objective assessments were the surgical success rates and the patency at 6 months after the bicanalicular nasal stent was removed. The patients were divided into those with a pre-saccal obstruction, Group 1, and with a post-saccal obstruction, Group 2. The subjective and objective outcomes were compared between the two groups.

Results

One hundred twenty-four sides (96.9%) had a successful probing and intubation of the lacrimal passage obstruction by SG-BCI. Of the 124 sides, 110 sides (88.7%) retained the patency after the stent was removed for at least 6 months. The GBI total, general subscale, social support, and physical health scores were + 37.1 ± 29.0, + 41.5 ± 30.0, + 28.0 ± 39.4, and + 24.1 ± 37.7, respectively, postoperatively. All of the 6 ocular specific symptom scores improved significantly postoperatively. The postoperative score of tearing improved in Group 1 (P < 0.0001), while the postoperative scores of all symptoms improved significantly in Group 2.

Conclusions

The relatively high surgical success rates and positive GBI scores, and improved ocular symptom scores indicate that SG-BCI is a good minimally invasive method to treat lacrimal passage obstructions.

Postoperative Quality of Life in Oculoplastic Patients

PURPOSE

To conduct a literature review on postoperative quality of life in oculoplastic patients.

METHODS

The authors conducted a database search to evaluate the evidence available for the change in quality of life after oculoplastic surgery.

RESULTS

There was a wide disparity of evidence available for different oculoplastic conditions. Certain conditions, such as nasolacrimal duct obstruction, were well-researched while other conditions, such as epiblepharon, had little to no research supporting improvement in quality of life after surgery. The scales used to measure quality of life displayed heterogeneity.

CONCLUSION

There is a lack of published evidence concerning postoperative quality of life in patients with certain oculoplastic conditions such as brow ptosis, entropion, ectropion, epiblepharon, and orbital wall fracture. There is a need to standardize the quality of life data collection tools and scoring systems to allow better comparison and scrutiny of the current literature.

Long-term Outcomes for Revision Endoscopic Dacryocystorhinostomy-The Effect of the Primary Approach

OBJECTIVES/HYPOTHESIS

Revision endoscopic dacryocystorhinostomy (END-DCR) is the preferred approach for failed primary surgeries, yet quality data on long-term outcomes are lacking. This study aimed to evaluate three aspects of revision END-DCR: 5-year success rates, patient satisfaction, and the primary surgical approach's possible impact on revision.

METHODS

This retrospective study included all revision END-DCRs conducted at Kaplan Medical Center between the years 2002 and 2015. For long-term follow-up analysis, two subgroups of first and second revision END-DCRs with a minimum of documented 5-year follow-up after surgery were defined. Data were analyzed according to the primary surgical approach. Surgical success was defined by either anatomical (observed patent lacrimal flow) or functional (symptoms cessation) success. Patient satisfaction was measured by a questionnaire.

RESULTS

After exclusions, a total of 45 eyes from 38 patients who underwent revision END-DCR surgeries were included in the study. The yearly success rates from immediate to 5 years following the first revision were 93.3%, 75.5%, 71.1%, 68.9%, 68.9%, and 68.9% for the entire cohort, respectively. Immediate and 5-year success rates following the second revision were 88.8% and 77.8%, respectively. Primary END-DCR showed favorable 5-year success rates and patient satisfaction over primary external dacryocystorhinostomy (EXT-DCR) in both first and second revisions, but this did not reach significance.

CONCLUSIONS

Revision END-DCR carries an excellent short-term success rate, which decreases mainly throughout the first 2 years following surgery. Postoperative follow-up should be maintained within this timeframe. Revision END-DCR following either primary endoscopic or EXT-DCR produces comparable surgical outcomes and patient-reported satisfaction.

LEVEL OF EVIDENCE

3b Laryngoscope, 131:E682-E688, 2021.

Changes of Visual Symptoms and Functions in Patients with and without Dry Eye after Lacrimal Passage Obstruction Treatment

Purpose: To determine the quality of life (QOL) and quality of vision (QOV) of patients who developed and did not develop dry eye disease (DED) after nasolacrimal duct obstruction (NLDO) treatment. Methods: This was a retrospective nonrandomized observational study of 91 patients diagnosed with unilateral NLDO. The subjects underwent lacrimal stent insertion, and the stent was removed after 10-12 weeks. The QOL and QOV of the patients were examined preoperatively and at 6 months after the stent was removed. The postoperative outcomes were assessed subjectively with the Glasgow Benefit Inventory (GBI) questionnaire and an ocular specific questionnaire of 6 symptoms. The best-corrected visual acuity, functional visual acuity, and dry eye scores were also determined. Results: Of the 91 eyes, 19 eyes (20.9%) were diagnosed with DED (D group) and 72 were not (N group). Five of the 6 symptoms improved in the N group, while only 3 symptoms improved in the D group without blurred vision. For the GBI questionnaire, the social support and physical health scores were significantly higher in the N group than in the D group. The functional visual acuity improved significantly in the N group but not significantly in the D group. Conclusions: Patients who develop DED after treatments for NLDO may not have an improvement of their QOL or QOV. Therefore, careful dry eye assessments are important before treatments for NLDO.

Postoperative Bioresorbable Chitosan-Based Dressing for Endoscopic Middle Meatal Dacryocystorhinostomy With Balloon Dilation

PURPOSE

To evaluate the improvement in epiphora and need for surgical revision in patients with acquired nasolacrimal duct obstruction following balloon-assisted, middle meatal endoscopic dacryocystorhinostomy with chitosan-based dressing versus bioresorbable polyurethane packing versus no packing.

PATIENTS AND METHODS

This was a retrospective study of consecutive adult patients seen from 2015 to 2018 with follow-up evaluation of epiphora at least 3 months after balloon-assisted, middle meatal endoscopic dacryocystorhinostomy. Patients with a history of prior punctoplasty, septoplasty, sinus surgery, or dacryocystorhinostomy of any kind were excluded. Those meeting criteria were stratified by postoperative hemostatic intervention: no packing, bioresorbable packing, and chitosan-based dressing (groups 1, 2, and 3, respectively). Procedural outcomes were graded as successes or failures based on subjective report and anatomical findings at most recent visit within an 18-month postoperative window. Instances of recommendation for revision surgery were also recorded.

RESULTS

Forty-three cases (36 patients) met the abovementioned criteria. Groups 1, 2, and 3 comprised 12, 17, and 14 cases each, respectively. Average patient age was 55.3 years old, and average duration of follow-up was 6.7 months. Significant variation in outcomes was detected across the 3 groups (P = .0495), particularly between groups 1 and 3 (P = .033). Use of chitosan-based dressing trended toward reduced rates of recommendation for surgical revision (P = .203, P = .113).

CONCLUSIONS

Use of chitosan-based dressing after endoscopic dacryocystorhinostomy was associated with improved subjective and anatomical outcomes. It may also contribute to less frequent need for revision surgery. Further study in a larger prospective trial is recommended.

Lacrimal Drainage Obstruction and Gastroesophageal Reflux Disease: A Nationwide Longitudinal Cohort Study

GOALS

This study aimed to evaluate the association between gastroesophageal reflux disease (GERD) and development of lacrimal drainage obstruction (LDO).

BACKGROUND

It has been hypothesized that GERD may contribute toward the development of LDO.

STUDY

This was a retrospective study of Koreans aged 40 to 79 years registered in the Korean National Health Screening Cohort from 2002 to 2013. Incident cases of LDO were identified according to the Korean Classification of Disease. We compared hazard ratios (HRs) for LDO between 22,570 patients with GERD and 112,850 patients without GERD by 1:5 propensity score-matched analysis.

RESULTS

A total of 135,420 patients, representing 1,237,909 person-years, were evaluated. LDO developed in 1998 (8.9%) patients with GERD and 8565 (7.6%) patients without GERD (P<0.001). The incidence of LDO per 1000 person-years in patients with GERD was 9.7 and 8.3 in those without GERD; the age-adjusted and sex-adjusted HR was 1.17 (95% confidence interval, 1.11-1.23). This association between GERD and LDO was more pronounced among younger individuals (HR, 1.20 for patients 40 to 59-y old; HR, 1.12 for patients 60 to 79-y old) and among men (HR, 1.20 for men; HR, 1.14 for women). Patients with GERD had a higher risk of LDO than those without GERD, irrespective of history of proton-pump inhibitor use. In the sensitivity analysis, GERD patients with esophagitis had a higher risk of LDO than those without esophagitis.

CONCLUSIONS

Our findings suggest that GERD is associated with an increased risk of subsequent LDO and that this effect is more pronounced among adults aged 40 to 59-years old and men.

Bilateral Simultaneous Endoscopic Dacryocystorhinostomy: Outcome and Impact on the Quality of Life of the Patients

Introduction  Bilateral simultaneous endoscopic dacryocystorhinostomy (endo-DCR) has received little attention in the literature, thus many surgeons continue to address bilateral nasolacrimal duct obstruction at two stages, rather than in the same setting.

Objective  To evaluate the feasibility and the outcome of simultaneous bilateral Endo-DCR and its impact on the quality of life of the patients.

Methods  We have conducted a retrospective analysis of patients who underwent bilateral simultaneous endo-DCR between March 2013 and February 2017 at our tertiary care institution. The reviewed data included clinical presentation; operative details; success rate; pre and postoperative evaluation of the symptoms of the patients, using the Nasolacrimal Duct Obstruction Symptom Score Questionnaire; satisfaction of the patients, and improvement in the quality of life, assessed by the Glasgow Benefit Inventory (GBI) questionnaire.

Results  Out of 128 cases in which endo-DCRs were performed, 13 were bilateral (26 sides). Postoperative success was documented in 24 of the 26 sides (92.3%), with a mean follow-up duration of 16.2 months. The two failed sides were reported in the same case. The preoperative symptom score ranged between 12 and 80 (mean ± standard deviation [SD]: 38.23 ± 15.7). The postoperative symptom score was significantly lower (mean ± SD: 5.4 ± 12.9). The success rates in unilateral and bilateral cases were comparable, with no statistically significant difference. A notable improvement in the quality of life of the patients was also reported, with a mean GBI score of 81.38 ± 12.37.

Conclusion  Our results support that a simultaneous bilateral endo-DCR is a safe procedure that offers a high success rate, spares the patient from the stress of a second surgery, provides the patient with a bilateral resolution of the symptoms, and confers an immediate improvement in the quality of life of the patients.

A Systematic Review of Patient-Reported Outcomes for Surgically Amenable Epiphora

PURPOSE

In evaluating epiphora and its management, the bottom line for all stakeholders is whether an intervention confers any real benefit on quality of life. A review was conducted to identify and appraise patient-reported outcome measures (PROMs) in surgically amenable epiphora.

METHODS

A systematic search was conducted of studies relating to surgical intervention for epiphora. Patient-reported outcome measures were identified and assessed against standard criteria.

RESULTS

Of 30,544 identified articles, 227 were eligible for data extraction. Of these, 69% reported a PROM as the primary outcome. PROMs identified included single-item symptom scores (48% of primary outcome PROMs), single-item reports of improvement (30%), the Glasgow Benefit Inventory (3%), Lacrimal Symptom Questionnaire (0.5%), Nasolacrimal Duct Obstruction Symptom Score (0.5%), Ocular Surface Disease Index (0.5%), Visual Function Questionnaire-25, the Short Form-36 Health Survey, and 3 other symptom scores. None were developed through consultation with the target population, and there was inadequate testing of content validity. The strengths and limitations of each PROM are presented, with regard to interpretation, responsiveness, reliability, and validity.

DISCUSSION

The importance of robust and psychometrically sound PROMs is essential if the under-reporting of quality of life improvement in patients treated for epiphora is to change. Recommendations for the use of each identified PROM are discussed.

CONCLUSIONS

Several PROMs have been used in the recent literature to evaluate patients undergoing surgery to treat epiphora. Assessed against standard criteria, no PROM has proven to be both psychometrically robust and clinically meaningful for use in this population. Future PROM development should be guided by this standard framework.

Effects of tear film dynamics on quality of vision

The precorneal tear film is maintained by blinking and exhibits different phases in the tear cycle. The tear film serves as the most anterior surface of the eye and plays an important role as a first refractive component of the eye. Alterations in tear film dynamics may cause both vision-related and ocular surface-related symptoms. Although the optical quality associated with the tear film dynamics previously received little attention, objective measurements of optical quality using wavefront sensors have enabled us to quantify optical aberrations induced by the tear film. This has provided an objective method for assessing reduced optical quality in dry eye; thus, visual disturbances were included in the definition of dry eye disease in the 2007 Dry Eye Workshop report. In addition, sequential measurements of wavefront aberrations have provided us with valuable insights into the dynamic optical changes associated with tear film dynamics. This review will focus on the current knowledge of the mechanisms of wavefront variations that are caused by different aspects of tear film dynamics: specifically, quality, quantity and properties of the tear film, demonstrating the respective effects of dry eye, epiphora and instillation of eye drops on the quality of vision.

A comparison between patients with epiphora and cataract of the activity limitations they experience in daily life due to their visual disability

PURPOSE

The objective of this study was to compare patients with epiphora and cataract in terms of the activity limitations they experience in daily life due to their visual disability and to validate the use of the Catquest-9SF questionnaire for epiphora patients.

METHODS

Seventy-two consecutively encountered adult patients with confirmed lacrimal obstruction and listed for dacryocystorhinostomy (DCR) or lacrimal intubation at the St. Erik Eye Hospital, Stockholm, Sweden, completed the Catquest-9SF questionnaire, which measures activity limitations in daily life due to visual disability. The psychometric qualities of the Catquest-9SF results obtained from this group of patients were evaluated by Rasch analysis. Rasch analysis was further employed to convert the ordinal raw data to a Rasch score for comparison with the preoperative scores of patients registered in the Swedish National Cataract Register (NCR) during March 2013.

RESULTS

The Catquest-9SF exhibited good psychometric qualities when investigating epiphora patients, with the exception of a misfit for Item 4, the item regarding facial recognition. On the Rasch scale (-5.43 = no activity limitations to +5.01 = severe activity limitations), the mean score for epiphora patients was -0.82 while for patients listed for 1st eye and 2nd eye cataract surgery it was -0.17 and -0.76, respectively. An equivalence test confirmed that the reported visual disability of epiphora patients was not significantly different from visual disability reported by patients waiting for 2nd eye cataract surgery.

CONCLUSION

The Catquest-9SF is a valid measure of visual disability in patients with epiphora. Epiphora patients experience visual disability to the same degree as patients awaiting 2nd eye cataract surgery.

Comparison between Endoscopic and External Dacryocystorhinostomy by Using the Lacrimal Symptom Questionnaire: A Pilot Study

Background

Epiphora has a significant impact on the patient's quality of life and is commonly caused by nasolacrimal duct obstruction. Dacryocystorhinostomy (DCR) has traditionally been performed via an external approach, which involves a skin incision. With the advent of endoscopes, the endonasal approach to DCR has gained significant popularity.

Method

To prospectively compare the quality of life of adult patients who underwent either an endonasal or an external DCR for acquired nasolacrimal duct obstruction, the Lacrimal Symptom Questionnaire (Lac-Q) was administered before and after surgery. The treatment group assignment was nonrandom and performed based on patient preference. The Lac-Q is a validated questionnaire that assesses the subjective perception of one's well-being from an eye-specific symptom and social impact standpoint. Total scores range from 0 (no concerns) to 33 (maximal degree of ocular symptoms and social impact).

Results

Sixty patients (22 in the endonasal group, 38 in the external group) were recruited between January 1, 2014, and January 1, 2016. Postoperative assessment was performed at 3 and 6 months. Patients who underwent external DCR reported a median 7.0–point improvement (interquartile range [IQR], 3.0–11.0) in total Lac-Q scores. A 12.0–point improvement (IQR, 10.0–18.5) was seen in the endonasal group (p = 0.005). The median change in the social impact score was 3.0 and 4.0 in the external group and the endoscopic group, respectively (p = 0.029). Changes in the median lacrimal symptom score were 4.0 in the external group and 8.0 in the endoscopic group (p = 0.014). The anatomic patency rate was lower in the external group (60.0%) when compared with the endonasal group (90.4%). Patients in the external DCR group were significantly older (median age, 51 versus 41 years).

Conclusion

Our study indicated that both endonasal and external DCR can lead to improvement in quality of life by using a validated questionnaire. Although there are differences in age and anatomic success rates between the two groups, subgroup analyses indicated that the differences in the Lac-Q scores persisted when age and anatomic patency were removed as potential confounding factors. Further larger, randomized studies would be helpful.

Comparison of balloon dacryocystorhinostomy with conventional endonasal endoscopic dacryocystorhinostomy for relief of acquired distal nasolacrimal drainage obstruction and its impact on quality of life: A prospective, randomized, controlled study

Background

We compared balloon dacryocystorhinostomy with conventional endoscopic dacryocystorhinostomy for the management of acquired distal nasolacrimal obstruction and the quality of life post procedure.

Methods

98 patients, aged 10-73 years, were recruited and randomized into 2 groups of 49 each who underwent conventional endoscopic dacryocystorhinostomy (group 1) and 9 mm balloon assisted endoscopic dacryocystorhinostomy (group 2). Follow-up sessions were conducted at 3, 6 and 12 months post-op.

Results

Group 2 showed significantly shorter mean operative time (25.10 min versus 29.82; p < 0.001), lesser pain in the post-op evening (mean 2.12 versus 2.9 on NRS-11 pain scale; p < 0.001) as well as on first post-op day (mean 1.08 versus 1.73; p < 0.001). Success was achieved in 89.79% in group 1 and 93.87% in group 2 at 3 months (p = 0.46) which declined due to recurrences to 85.71% and 87.75% respectively at 12 months (p = 0.76). Complications occurred in 14 cases in group 1 and in 10 cases in group 2 (p = 0.34). All were minor. Mean GBI scores (for quality of life assessment) at 12 months follow-up were 27.20 and 28.38 respectively (p = 0.08).

Conclusion

The efficacy, safety and quality of life of balloon dacryocystorhinostomy and conventional endoscopic dacryocystorhinostomy were comparable. In addition, balloon dacryocystorhinostomy had significantly shorter operative time and lesser post-op pain.

Quality of Vision in Eyes With Epiphora Undergoing Lacrimal Passage Intubation

PURPOSE

To investigate visual function and optical quality in eyes with epiphora undergoing lacrimal passage intubation.

DESIGN

Prospective case series.

METHODS

Thirty-four eyes of 30 patients with lacrimal passage obstruction were enrolled. Before and 1 month after lacrimal passage intubation, functional visual acuity (FVA), higher-order aberrations (HOAs), lower tear meniscus, and tear clearance were assessed. An FVA measurement system was used to examine changes in continuous visual acuity (VA) over time, and visual function parameters such as FVA, visual maintenance ratio, and blink frequency were obtained. Sequential ocular HOAs were measured for 10 seconds after the blink using a wavefront sensor. Aberration data were analyzed in the central 4 mm for coma-like, spherical-like, and total HOAs. Fluctuation and stability indices of the total HOAs over time were calculated. Lower tear meniscus was assessed by anterior segment optical coherence tomography.

RESULTS

After lacrimal passage intubation, visual function significantly improved, as indicated by improved FVA (P = .003) and visual maintenance ratio (P < .001). Blink frequency decreased significantly after treatment (P = .01). Optical quality significantly improved, as indicated by a decrease in coma-like aberrations (P = .003), spherical-like aberrations (P = .018), and total HOAs (P = .001). Stability index increased (P < .001) and fluctuation index decreased (P = .019), and tear meniscus dimension decreased (P < .001).

CONCLUSIONS

Lacrimal passage intubation for eyes with epiphora significantly improved visual function and optical quality via patency of the lacrimal passage.

Anterior approach white line advancement: technique and long-term outcomes in the correction of blepharoptosis

PurposeAnterior approach white line advancement presents a novel surgical option for correction of blepharoptosis. The technique draws on several advantages of other approaches. The aim of this study was to present outcomes using this technique at a minimum follow-up of 18 months.Patients and methodsParticipants having undergone anterior approach white line advancement ptosis correction at a single institution were retrospectively recruited at a minimum of 18 months' follow-up. A total of 18 independent eyelid measurements were recorded at final review. Outcomes included long-term rate of surgical success, upper eyelid margin-reflex distance (MRD1) at both early and late post-operative follow-up, inter-eyelid asymmetry, complications, re-operation rate, patient satisfaction, and quality-of-life improvement using the Glasgow Benefit Inventory (GBI). Pre- and post-operative MRD1, as well as inter-eyelid asymmetry, were compared using a two-tailed t-test.ResultsIn total, 82 eyelids of 47 participants were included with a mean follow-up of 2.3 years (range 1.5-3.7). Surgical success was achieved in 91.5%, with a final mean MRD1 of 3.5 mm (95% confidence 3.2-3.7). An increase of 2.4 mm (2.1-2.8) in eyelid height was observed between baseline and long-term follow-up (P<0.0001). No significant change was observed between early and late post-operative follow-up. Pre-operative asymmetry was reduced from 1.0 mm (0.7-1.3) to 0.4 mm (0.3-0.5; P<0.0001). Patient satisfaction was 95.7% with a mean GBI score of +21.8 (13.2-30.3).ConclusionsAnterior approach white line advancement presents an excellent option for patients undergoing ptosis correction with favourable long-term results. Comparisons are made with other techniques with respect to anatomical, functional, and surgical factors.

Assessment of patient-reported outcome and quality of life improvement following surgery for epiphora

PurposeTo assess and compare the subjective improvement in symptoms and quality of life in adult patients who underwent commonly performed oculoplastic surgical interventions to treat epiphora.Materials and methodsA prospective study was undertaken involving all adult patients undergoing dacryocystorhinostomy (DCR), lid tightening (lateral tarsal strip or lateral wedge resection), and punctoplasty surgery at our institution. We assessed severity of epiphora preoperatively using the Munk score. At 3 months postoperatively, all patients were sent postal questionnaires comprising of Munk score, 'social impact score' from validated Lac-Q questionnaire ranging from 0 (no impact) to 5 (maximal negative impact) and Glasgow Benefit Inventory (GBI) score, ranging from -100 (maximal detriment) to +100 (maximal benefit).ResultsA total of 134 questionnaires were sent with an overall response rate of 74.6%. For the purpose of data analysis, patients were divided into four groups: DCR, lid tightening, punctoplasty, and combined group (lid tightening plus punctoplasty). There was statistically significant improvement in subjective epiphora postoperatively, as assessed by Munk score (P<0.001) in all groups. The total GBI scores were +42.67 (95% CI: 33.42-51.91) for DCR, +19.65 (95% CI: 10.33-28.97) for lid tightening, +16.06 (95% CI: 2.65-29.48) for punctoplasty, and +26.53 (95% CI: 13.15-39.90) for the combined group, demonstrating a positive change in health status for all groups. There was negative correlation between total GBI and post-operative Munk scores (r=-0.58, P<0.001), and positive correlation between Lac-Q and Munk scores (r=0.65, P<0.001).ConclusionPatients derived significant improvement in symptoms and health-related quality of life benefit following all surgical interventions for epiphora.

Assessing the Outcomes of Powered Endoscopic Dacryocystorhinostomy in Adults Using the Lacrimal Symptom (Lac-Q) Questionnaire

PURPOSE

The objective of this study was to assess the quality of outcomes of powered endoscopic dacryocystorhinostomy using the lacrimal symptom (Lac-Q) questionnaire.

METHODS

Prospective interventional case series of 50 consecutive patients who underwent primary powered endoscopic dacryocystorhinostomy were included in the study. All the patients had stent placement which were removed at 4 weeks. The Lac-Q questionnaire was administered preoperatively and at 4 weeks and 16 weeks following the surgery. Outcomes assessed were anatomical success, functional success, and changes in the social impact and lacrimal symptoms scores. Statistical analysis was performed using Dunnette's procedure with bonferroni correction.

RESULTS

Fifty-five powered endoscopic dacryocysto rhinostomies were performed on 50 patients. A total of 150 questionnaire responses were analyzed. At the 16 week follow up, the anatomical and functional success rates were 98% and 94%, respectively. The mean social impact scores showed significant improvement postoperatively from 3.88 to 0.3 (p ≤ 0.001). The changes in the total scores (12.5 preoperatively to 1.0 at 16 weeks follow up) were statistically significant (p ≤ 0.001). Postoperative scoring correlated well with the anatomical and functional success rates. The symptom scores reflected changes with change in the clinical condition.

CONCLUSION

The Lac-Q questionnaire is a simple and useful tool to evaluate the quality of outcomes of powered endoscopic dacryocystorhinostomy.

Factors associated with rhinostomy shape after endoscopic dacryocystorhinostomy

OBJECTIVE

To determine the factors associated with rhinostomy shape after endoscopic dacryocystorhinostomy (DCR) in patients with primary acquired nasolacrimal duct obstruction.

DESIGN

Retrospective comparative study.

SETTING

University hospital.

PARTICIPANTS

One hundred and two cases in 70 patients were included in the study.

MAIN OUTCOME MEASURE

All cases were classified into three groups according to the healed appearance of the rhinostomy: flat, ladle and ice scoop type. The flat shape was characterised by an opening with a flat surrounding and no clear border between the lacrimal sac and the nasal mucosa. The ladle shape had a depressed base without markings of a lacrimal sac. The ice scoop shape had a depressed base with a clear border between the lacrimal sac and the nasal mucosa. Anatomic success was defined as patency with syringing and endoscopic evidence of ostial patency. Functional success was defined as visualisation of fluorescein dye at the ostium and relief from epiphora. Clinical information and intra- and postoperative endoscopic video findings were compared between the three groups.

RESULTS

Of the 102 cases, 19 flat, 37 ladle and 46 ice scoop type rhinostomies were observed during the follow-up examinations. Among the variables studied, patient demographics and rhinostomy size and location did not differ between the three groups. However, intraoperative lacrimal sac findings (sac size, wall thickness and mobility), postoperative ostial shrinkage and rhinostomy movement were associated with postoperative rhinostomy shape (all P < 0.05). With regard to surgical outcomes, there were no differences in anatomical patency between the three groups. However, the flat group had a worse functional success rate (73.7%) than the ladle (91.9%) and ice scoop (97.8%) groups (P = 0.008). A higher degree of ostial shrinkage and poor rhinostomy movement was observed with the flat shape appearance, which had a small, thick and poorly mobile lacrimal sac.

CONCLUSIONS

Lacrimal sac characteristics play a prominent role in determining rhinostomy shape after endoscopic DCR. The rhinostomy shape, along with the degree of ostial shrinkage and rhinostomy movement, is predictive of functional success after endoscopic DCR.

Anatomical and subjective success rates of endonasal dacryocystorhinostomy over a seven-year period

PurposeEndonasal dacryocystorhinostomy (END-DCR) is a relatively novel approach that has recently been shown in some studies to provide similar success rates to the more traditional external approach for the treatment of nasolacrimal duct obstruction (NLDO). However, a range of success rates using this approach are reported within the literature and the majority of oculoplastic surgeons are still favouring the external approach. The purpose of this study was to review the anatomical and subjective success rates of END-DCRs performed over a 7-year period.Patients and methodsWe provide a review of the success rates of 288 END-DCRs for the treatment of acquired NLDO performed over a 7-year period by a single oculoplastic surgeon in Sydney, Australia. We describe the operative technique used and define anatomical success as demonstrated patency of the nasolacrimal drainage system at 10 weeks postoperatively while subjective success is defined as complete resolution or significant improvement of symptoms as reported by patients at the same time point.ResultsIn our study, we were able to demonstrate that out of 288 END-DCRs, an average anatomical success rate of 89.6% and an average subjective success rate of 81.3% were achievable.ConclusionsWe conclude that the success rates using our endonasal approach remain similar to those obtained using the external approach, as reported within the literature, and may be considered as a primary treatment option for acquired NLDO.

The Glasgow Benefit Inventory: a systematic review of the use and value of an otorhinolaryngological generic patient-recorded outcome measure

BACKGROUND

The Glasgow Benefit Inventory (GBI) is a validated, generic patient-recorded outcome measure widely used in otolaryngology to report change in quality of life post-intervention.

OBJECTIVES OF REVIEW

To date, no systematic review has made (i) a quality assessment of reporting of Glasgow Benefit Inventory outcomes; (ii) a comparison between Glasgow Benefit Inventory outcomes for different interventions and objectives; (iii) an evaluation of subscales in describing the area of benefit; (iv) commented on its value in clinical practice and research.

TYPE OF REVIEW

Systematic review.

SEARCH STRATEGY

'Glasgow Benefit Inventory' and 'GBI' were used as keywords to search for published, unpublished and ongoing trials in PubMed, EMBASE, CINAHL and Google in addition to an ISI citation search for the original validating Glasgow Benefit Inventory paper between 1996 and January 2015.

EVALUATION METHOD

Papers were assessed for study type and quality graded by a predesigned scale, by two authors independently. Papers with sufficient quality Glasgow Benefit Inventory data were identified for statistical comparisons. Papers with <50% follow-up were excluded.

RESULTS

A total of 118 eligible papers were identified for inclusion. A national audit paper (n = 4325) showed that the Glasgow Benefit Inventory gave a range of scores across the specialty, being greater for surgical intervention than medical intervention or 'reassurance'. Fourteen papers compared one form of surgery versus another form of surgery. In all but one study, there was no difference between the Glasgow Benefit Inventory scores (or of any other outcome). The most likely reason was lack of power. Two papers took an epidemiological approach and used the Glasgow Benefit Inventory scores to predict benefit. One was for tonsillectomy where duration of sore throat episodes and days with fever were identified on multivariate analysis to predict benefit albeit the precision was low. However, the traditional factor of number of episodes of sore throat was not predictive. The other was surgery for chronic rhinosinusitis where those with polyps on univariate analysis had greater benefit than those without. Forty-three papers had a response rate of >50% and gave sufficient Glasgow Benefit Inventory total and subscales for meta-analysis. For five of the 11 operation categories (vestibular schwannoma, tonsillectomy, cochlear implant, middle ear implant and stapes surgery) that were most likely to have a single clear clinical objective, score data had low-to-moderate heterogeneity. The value in the Glasgow Benefit Inventory having both positive and negative scores was shown by an overall negative score for the management of vestibular schwannoma. The other six operations gave considerable heterogeneity with rhinoplasty and septoplasty giving the greatest percentages (98% and 99%) most likely because of the considerable variations in patient selection. The data from these operations should not be used for comparative purposes. Five papers also reported the number of patients that had no or negative benefit, a potentially a more clinically useful outcome to report. Glasgow Benefit Inventory subscores for tonsillectomy were significantly different from ear surgery suggesting different areas of benefit

CONCLUSIONS

The Glasgow Benefit Inventory has been shown to differentiate the benefit between surgical and medical otolaryngology interventions as well as 'reassurance'. Reporting benefit as percentages with negative, no and positive benefit would enable better comparisons between different interventions with varying objectives and pathology. This could also allow easier evaluation of factors that predict benefit. Meta-analysis data are now available for comparison purposes for vestibular schwannoma, tonsillectomy, cochlear implant, middle ear implant and stapes surgery. Fuller report of the Glasgow Benefit Inventory outcomes for non-surgical otolaryngology interventions is encouraged.

External dacryocystorhinostomy in consultants and fellows - a comparison of the causes of failure

PURPOSE

Failure of primary dacryocystorhinostomy (DCR) often requires revision surgery to inspect the cause of failure and re-establish anatomic patency. This study aims to specifcally compare the anatomical causes of failure noted during revision DCR of primary external DCR (EX-DCR) and compare the difference between consultants and fellows.

METHODS

A retrospective review of 37 patients who underwent revision of a primary external approach DCR over a 7-year-period in a University Hospital. All primary surgery was performed by either a consultant surgeon or senior oculoplastic fellow. Details of the initial pathology prior to primary DCR and grade of operating surgeon were collected along with perioperative surgical findings. The cause of failure of the initial surgery was classified according to perioperative findings. Failure was classified as either inappropriately sized/located ostium or fibrous/membranous soft tissue obstruction of the newly created ostium.

RESULTS

The cause of failure of the initial surgery was soft tissue obstruction in 43.3% and an inappropriately sized/located ostium in 56.7%. In those patients whose primary surgery was performed by a consultant, 73.3% were found to have a soft tissue obstruction and 26.7% were found to have an inappropriately sized/ located ostium. In contrast, if initial surgery was performed by a fellow, 22.7% were found to have a soft tissue obstruction and 77.3% an inappropriately sized/ located ostium (p =0.002).

CONCLUSIONS

Where the primary surgeon has been a trainee there is a trend toward inadequately sized or located ostium being the most likely causative factor in failure of primary EX-DCR.  Hippokratia 2015; 19 (3): 216-218.

Change in quality of life of patients undergoing silicone stent intubation for nasolacrimal duct stenosis combined with dry eye syndrome

AIMS

To investigate the effect of silicone stent intubation (SI) on the quality of life of patients diagnosed with nasolacrimal duct stenosis and dry eye syndrome.

METHODS

This study is a prospective, interventional case series. Consecutive 30 patients diagnosed with nasolacrimal duct stenosis and reflex tearing due to dry eye syndrome were included. Eligible subjects underwent SI and were asked to complete the Glasgow Benefit Inventory (GBI) questionnaire. Surgical outcomes and GBI scores were investigated 6 months postoperatively.

RESULTS

The surgical success rate determined by the patients' subjective symptoms was 76.7% (23/30). Mean total GBI score was +17.19 (95% CI 8.34 to 26.03). The general subscale score was +20.36 (95% CI 10.19 to 30.54), the social support scale score was +21.54 (95% CI 11.37 to 31.71) and the physical health score was -0.56 (95% CI -8.92 to 7.80).

CONCLUSIONS

SI could be an effective treatment option for reflex tearing in patients diagnosed with dry eye syndrome and nasolacrimal duct stenosis.

Endoscopic vs external dacryocystorhinostomy-comparison from the patients' aspect

AIM

To compare the success and complication rates, duration of surgeries and clinical comfort after endoscopic dacryocystorhinostomy (END-DCR) or external dacryocystorhinostomy (EXT-DCR).

METHODS

Fifty patients who underwent EXT- or END-DCR between January 2010-2012 were involved in the study. A questionnaire was applied to patients preoperatively, and postoperatively. Subjective success was defined by absence of epiphora, objective success by a normal nasolacrimal lavage and a positive functional endoscopic dye test (FEDT). Postoperative pain and cosmetic result of surgery were interpreted by the patients, who were also asked whether they would offer this surgery to a friend or would prefer this surgery once more if necessary.

RESULTS

Twenty-five patients underwent END-DCR and 25 underwent EXT-DCR. Mean duration of surgeries were 35min both for EXT-DCR (30-50) and END-DCR (35-50) (P=0.778). Intraoperative bleeding were documented in 48% of EXT-DCR and 4% of END-DCR cases (P<0.001). In total 96% of EXT-DCR and 100% of END-DCR patients had subjective success. Objective success was 100% in each group. There was no significant difference between the epiphora scorings and FDDT results in postoperative visits among the groups. END-DCR group reported less pain in first week and month (P<0.05, P<0.05). More patients in END-DCR group were happy with the cosmetic result in first week and month (P<0.001, P<0.001). More patients in END-DCR group offered this surgery to a friend (P<0.001). All patients in END-DCR group preferred this surgery once more if necessary, only 48% in EXT-DCR preferred the same method (P<0.001).

CONCLUSION

Although both END- and EXT-DCRs provide satisfactory outcomes with similar objective and subjective success rates, we demonstrated that the endonasal approach caused significantly less pain in early postoperative period than the external approach. Clinical comfort defined by the patients was quite higher in END-DCR group, in which patients mainly were pleased to encounter a sutureless surgical area.