Clinical research, comparison of the subjective visual function in patients with epiphora and patients with second-eye cataract

Ultrasound-Guided Injections for Treatment of Facial Paralysis Sequelae: A Randomized Study on Body Donors

BACKGROUND

Botulinum toxin injection is the accepted standard treatment for synkinesis and gustatory hyperlacrimation in patients with facial paralysis. However, poor injection accuracy can result in inconsistent treatment outcomes, variable treatment durations, and complications. Ultrasound guidance should increase injection accuracy in the facial region; however, this has not been proven.

METHODS

Twenty-six hemifaces of nonembalmed cadavers were studied in a randomized split-face manner. Ink was injected with ultrasound or landmark guidance into the lacrimal gland and three common synkinetic muscles: the orbicularis oculi, depressor anguli oris, and mentalis. Injection accuracy was evaluated using several measures.

RESULTS

Using ultrasound guidance, most ink (>50%) was found inside the correct target in 88% of cases, compared with 50% using landmark guidance ( P < 0.001). This was most pronounced in the lacrimal gland (62% versus 8%), depressor anguli oris (100% versus 46%), and mentalis (100% versus 54%) ( P < 0.05). All ink was found inside the correct target (no ink outside) in 65% using ultrasound guidance versus 29% without ( P < 0.001). Injection accuracy (any ink in target) was 100% when using ultrasound guidance versus 83% without ( P < 0.01). Twenty-three percent of the landmark-guided depressor anguli oris injections stained the facial artery ( P = 0.22).

CONCLUSIONS

Ultrasound guidance significantly increased injection accuracy and reduced the amount of ink lost in the surrounding tissue compared with landmark guidance. Clinical trials are needed to explore the effects of ultrasound guidance on treatment outcome, duration, and complications in patients with facial paralysis.

The 'tears' score: A tool for grading and monitoring epiphora

PURPOSE

To test the reliability, validity and utility of the TEARS score, a scale of clinical and patient-reported severity in patients with epiphora, comprising 4 subscales: Times wiping (T), clinical Effects (E), Activity limitation (A), and symptoms of Reflex epiphora (R).

METHODS

The TEARS score was completed by 136 patients with epiphora (78 treated surgically, and 51 non-surgically). Inter-rater reliability was evaluated using Cohen's Kappa and Bland-Altman analysis. 129 (95%) participants were followed up 2-6 months after baseline (non-surgical patients) or 3-6 months post-operatively (surgical patients). For each TEARS subscale, differences in scores were compared. Convergent validity was evaluated by testing correlation between TEARS and both The Lacrimal Symptom Questionnaire (Lac-Q) and The Watery Eye Quality of Life Score (WEQOL).

RESULTS

Inter-rater reliability (Cohen's K) ranged from 0.5 for 'A' and 'R' to 0.8 for 'T' and 'E' subscales. Scores were lower post-operatively in surgical patients (p < 0.001). 'R' scores (reflex tearing) were higher in non-surgical cases compared with surgical (p = 0.02) but no difference was observed in other subscales at baseline. TEARS subscale scores were positively correlated with both WEQOL (r = 0.51 to 0.73) and Lac-Q score (r = 0.55 to 0.63).

CONCLUSION

The TEARS score is quickly and easily implemented in a busy clinical setting. It provides an overview of both subjective and objective clinical severity in patients with epiphora, with appropriate reliability, post-operative responsiveness and convergent validity for this purpose and in this setting. It is a valuable template to be used alongside individualised symptomology.

Lacrimal gland botulinum toxin injection for epiphora management

PURPOSE

Epiphora remains an often difficult to manage ocular complaint for ophthalmologists in all subspecialties. This review seeks to examine the safety and efficacy of botulinum toxin injection for management of chronic epiphora.

METHODS

The authors conducted a Pubmed search for studies on the use of lacrimal and transplanted salivary gland botulinum toxin injections for the management of epiphora within the past 20 years. Studies included had a minimum of four glandular injections.

RESULTS

The authors identified 14 studies and divided them by indication for injection; either functional epiphora, non-functional epiphora, or mixed studies. Seven studies examined injections for cases of functional epiphora, four for non-functional epiphora, and four for mixed cases. The number of glandular injections reported ranged from 4 to 65. Side effects reported were limited to diplopia, eyelid or lacrimal gland hematoma, papillary conjunctivitis, dry eye, ptosis, and bleeding.

CONCLUSIONS

Glandular botulinum toxin injection should be considered as a viable treatment strategy for both functional and nonfunctional epiphora. From the studies reviewed, botulinum toxin injection was shown to be effective in both children and adults. Injection can be performed in the outpatient setting, is minimally invasive, technically easy to administer, has a favorable side effect profile, and good efficacy. Furthermore, repeat injections can be performed with similar efficacy.

Current practice trends for lacrimal gland neurotoxin in the management of epiphora-a BOPSS survey

PURPOSE

Injection of botulinum neurotoxin A (BoNTA) to the lacrimal gland (LG) offers a simple and effective treatment in the management of epiphora. However, there is little data on current practice trends or uptake as an alternative to surgery. This study assesses current practice trends of such treatment amongst BOPSS (British Oculoplastic Surgery Society) members.

METHODS

All consultant BOPSS members were invited to participate in a web-based survey which consisted of 5 questions, with a reminder invitation to participate. The role, dose, potential side effects, use as an alternative to surgical intervention, and impact on service delivery were assessed.

RESULTS

Fifty-one BOPSS consultants (43% uptake) completed the survey. Ninety percent of respondents were regularly using LG BoNTA in their management of epiphora. The main indicators for considering BoNTA use were medical comorbidities and elderly patients. The mean first treatment dose of Botox® was 3.6 units (SD 1.5). Diplopia and ptosis complications were always discussed in the consent for treatment in addition to dry eye. Twenty-five percent of surgeons reported doing less conjunctivo-dacryocystorhinostomies (cDCR) due to the availability of LG BoNTA. No respondents felt that the requirement for repeated BoNTA treatments was impacting on their service delivery.

CONCLUSION

Uptake of LG BoNTA in the management of epiphora is at a similar rate to all other available treatments. As a result, respondents are performing less surgical procedures, particularly cDCR in patients at higher surgical morbidity.

The watery eye quality of life (WEQOL) questionnaire: a patient-reported outcome measure for surgically amenable epiphora

OBJECTIVE OR PURPOSE

To develop and test a patient-reported outcome measure for assessing health-related quality of life (HRQOL) in surgically amenable epiphora.

DESIGN

Questionnaire development and validation study.

PARTICIPANTS

201 patients with a cause of epiphora amenable to surgical intervention, recruited across three independent centres.

METHODS, INTERVENTION OR TESTING

The watery eye quality of life (WEQOL) questionnaire was developed and refined according to defined psychometric standards. Both surgical and non-surgical participants completed WEQOL at baseline and follow-up (>3 months), along with the Lacrimal Symptom Questionnaire (Lac-Q), RAND Short Form Health Survey (SF-36) and Glasgow Benefit Inventory (GBI). Convergent validity of WEQOL was evaluated according to correlation (R > 0.40) with each of these additional tests. Responsiveness of WEQOL to intervention was evaluated according to patient-reported success. Test-retest reliability was assessed by the Bland-Altman method and intraclass correlation (ICC) in a subset of 64 participants at baseline.

MAIN OUTCOME MEASURES

WEQOL construct validity, responsiveness and test-retest reliability.

RESULTS

WEQOL was moderately correlated (R > 0.4) with the Lac-Q and several subscales of the SF-36 (physical role limitation, social, emotional role limitation and emotional well-being). A stronger correlation was found between the change in WEQOL at follow-up and GBI (R = 0.61). An appropriate graded response was found with a significant change in WEQOL score being observed in patients reporting successful (-28%, p < 0.0001) and partially successful surgery (-6%, p = 0.04), but not in those reporting unsuccessful surgery (+2%, p = 0.9). High test-retest reliability was observed (ICC = 0.93).

CONCLUSIONS

The WEQOL questionnaire has been developed systematically according to modern psychometric standards and has been designed to evaluate the quality of life in patients with epiphora that is of a surgically amenable cause. In this study, it has demonstrated appropriate test-retest reliability, responsiveness and construct validity.

Subjective outcome and quality of life following external dacryocystorhinostomy

Purpose:

To assess the patient reported outcome and quality of life in post external dacryocystorhinostomy operated patients.

Methods:

A prospective questionnaire based study was carried out on 112 patients diagnosed with chronic dacryocystitis who underwent external dacryocystorhinostomy in the department of Orbit and Oculoplasty at a tertiary eye hospital in South India.

Results:

We included 112 cases in our study. Mean (SD) of the age of patients was 48.03 (12.79) years and ranged from 7 to 72 years of age. 44 (39.3%) patients were males and 68 (60.7%) were females. All cases had subjective symptoms of tearing, pain and swelling at baseline which were relieved by post-operative 3 in all cases. The mean (SD) best corrected visual acuity was 0.28 (0.39) at baseline and 0.25 (0.37) at postoperative 3 (p < 0.001). All four parameters studied in the GBI questionnaire - total mean GBI (32.22 vs 48.86, P < 0.001), general subscale (31.21 vs 44.08, P < 0.001), social health (46.28 vs 61.01, P < 0.001), physical outcome (22.17 vs 55.80, P = 0.0001) scores showed significant improvement from 1 vs 3 months post DCR.

Conclusion:

The GBI questionnaire is an effective tool for assessing patients’ quality of life following DCR. External DCR can not only produce a successful anatomical outcome but also bring about a measurable improvement in subjective symptoms and quality of life among patients with symptomatic NLDO.

Anatomical and functional outcomes of transcanalicular diode laser assisted dacryocystorhinostomy as a primary procedure

INTRODUCTION

The goal of this study was to assess the efficacy of transcanalicular diode laser assisted dacryocystorhinostomy (TDL-DCR) for the treatment of primary acquired nasolacrimal duct obstruction.

MATERIAL AND METHODS

This was a single center retrospective study. We included all patients who underwent TDL-DCR between July 2015 and October 2017 for chronic epiphora or chronic dacryocystitis. All procedures were performed under local anesthesia with sedation. The anatomical and functional success rates were studied as a function of each operative indication.

RESULTS

Thirty-seven patients were included (18 had chronic epiphora and 19 had chronic dacryocystitis). All but one patient had bicanalicular silicone stent intubation. Irrigation of the lacrimal system demonstrated postoperative patency in 78% of patients operated for chronic epiphora and 76% of those with chronic dacryocystitis. The functional success of the surgery (as defined by the Munk score) was higher if the operative indication was chronic dacryocystitis (62%) (whereas it was only 41% for the indication of chronic epiphora).

CONCLUSION

TDL-DCR has a lower anatomical and functional success rate than those reported in the literature for external or endonasal dacryocystorhinostomy. However, it retains a place in the treatment of primary acquired nasolacrimal duct obstruction (in particular when it is complicated by chronic dacryocystitis), especially if there is an absolute or relative contraindication to the two other dacryocystorhinostomy techniques.

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.

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.

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.

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.

Impact of epiphora on vision-related quality of life

Background

The study aimed to evaluate vision-related quality of life (QOL) in epiphora (excessive tear production) patients.

Methods

A total of 342 epiphora patients who visited ophthalmology clinics at 21 general hospitals during a 1-week period were enrolled; 245 females and 97 males with a mean age of 52 ± 13 years. Participants completed a self-administered questionnaire on the extent to which epiphora limited their daily activities. Questions on frequency of discomfort with daily activities were answered on scale of a 0–4. Daily activities that were assessed included reading, daytime and nighttime driving, working at a computer, watching TV, work-related activities, household activities, outdoor activities, interpersonal relations, and general happiness. A correlation analysis was performed between the scores and patient ages. Scores were compared with the clinical factors of gender, bilaterality, and lacrimal irrigation pattern. Presurgical and postsurgical scores in a subset of epiphora patients who underwent surgery were compared.

Results

Outdoor activities were among those that epiphora most significantly hindered. Age had a negative correlation with interpersonal relations scores. Female patients tended to have more discomfort than males in conducting household activities, outdoor activities, and interpersonal relations. Bilaterality showed no differences in QOL. Patients with complete obstruction of lacrimal irrigation recorded higher scores in all daily activities than those with partial or no obstruction. For vision-related QOL, post-surgical scores were improved significantly compared with pre-surgical scores.

Conclusion

Epiphora can affect a broad array of daily activities. Corrective measures for epiphora can improve vision-related QOL, and this may provide guidance for physicians in managing epiphora patients.

Patient-reported benefit from oculoplastic surgery

PURPOSE

It is vital that surgeons undertaking oculoplastic procedures are able to show that the surgery they perform is of benefit to their patients. Not only is this fundamental to patient-centred medicine but it is also important in demonstrating cost effectiveness. There are several ways in which benefit can be measured, including clinical scales, functional ability scales, and global quality-of-life scales. The Glasgow benefit inventory (GBI) is an example of a patient-reported, questionnaire-based, post-interventional quality-of-life scale that can be used to compare a range of different treatments for a variety of conditions.

METHODS

A cross-sectional study was undertaken using the GBI to score patient benefit from four commonly performed oculoplastic procedures. It was completed for 66 entropion repairs, 50 ptosis repairs, 41 ectropion repairs, and 41 external dacryocystorhinostomies (DCR). The GBI generates a scale from -100 (maximal detriment) through zero (no change) to +100 (maximal benefit).

RESULTS

The total GBI scores of patients undergoing surgery for entropion, ptosis, ectropion, and external DCR were: +25.25 (95% CI 20.00-30.50, P<0.001), +24.89 (95% CI 20.04-29.73, P<0.001), +17.68 (95% CI 9.46-25.91, P<0.001), and +32.25 (95% CI 21.47-43.03, P<0.001), respectively, demonstrating a statistically significant benefit from all procedures.

CONCLUSION

Patients derived significant quality-of-life benefits from the four most commonly performed oculoplastic procedures.

The quality of life impact of peripheral versus central vision loss with a focus on glaucoma versus age-related macular degeneration

PURPOSE

It is well accepted that conditions that cause central vision loss (CVL) have a negative impact on functional ability and quality of life (QoL), but the impact of diseases that cause peripheral vision loss (PVL) is less well understood. Focusing on glaucoma and age-related macular degeneration (ARMD), the effects of CVL and PVL on QoL were compared.

METHODS

A systematic literature review of publications reporting QoL in patients with CVL or PVL identified 87 publications using four generic (Short-Form Health Survey-36 and -12, EuroQoL EQ-5D and Sickness Impact Profile) and five vision-specific (National Eye Institute Visual Function Questionnaire-51, -39, and -25, Impact of Vision Impairment and Visual Function-14) QoL instruments; 33 and 15 publications reported QoL in ARMD and glaucoma, respectively.

RESULTS

QoL was impaired to a similar extent by diseases associated with PVL and CVL, but different domains were affected. In contrast to ARMD, mental aspects appeared to be affected more than physical aspects in patients with glaucoma.

CONCLUSIONS

The differential impact upon QoL might be a function of the pathology of the diseases, for example potential for blindness and better ability to perform physical tasks due to retention of central vision may explain these observations in glaucoma.