Symptom assessment in patients with functional and primary acquired nasolacrimal duct obstruction before and after successful dacryocystorhinostomy surgery: a prospective study

The Light Switch and the Dimmer: Qualitative Observations to Improve Diagnostic Lacrimal Irrigation

PURPOSE

To emphasise the importance of "soft" observations during lacrimal irrigation in diagnosing lacrimal outflow dysfunction and reporting outcomes of soft factors post-DCR.

METHODS

A retrospective study of patients with ≤ 20% of regurgitation on lacrimal irrigation who underwent DCR surgery. A comparative analysis of percentage reflux of saline (RFX), initial mucus in reflux (IMR), patient-reported transit time of saline (PR-TTS), and resistance encountered (RES) during LS was performed. Validated TEARS score was used. Subjective success was defined as ≥ 2-point improvement in T subscale of TEARS score. Objective success, as a decrease in RFX, RES, PR-TTS and absence of IMR, post-operatively.

RESULTS

From a total of 253 patients who underwent DCR surgery, 8 patients met the inclusion criteria. All patients were T4 (wiping >10× daily) indoors and outdoors. TEARS score improved after surgery with a mean reduction of T = 2.62, E = 1.63 and A = 1.35 (p < .05) with no significant change in R scores (p = .10). A mean reduction in RFX of 11.75 ± 6.74% and a median improvement of 1 point in PR-TTS and 2 point in RES was observed (p < .05). No significant changes of these parameters occurred in the contralateral side during this period. Subjective and objective success of DCR was 75% and 100%, respectively.

CONCLUSIONS

This study is the first to attempt to combine qualitative "soft" observations during lacrimal irrigation such as IMR, RES and PR-TTS for identifying nasolacrimal outflow dysfunction and reporting outcomes using these parameters of DCR in patients with epiphora and ≤ 20% of fluid regurgitation. These parameters were greater in the more symptomatic side and successfully improved after DCR, making them a valuable tool to reach a provisional diagnosis.

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.

Modified Horner-Duverney's muscle plication in the treatment of functional epiphora

BACKGROUND

The orbicularis oculi muscle, especially its part (Horner-Duverney's muscle), which is surrounded by the pericanalicular and located deep in the lacrimal sac, is of primary importance in all stages of tear fluid flow.

PURPOSE

This study aimed to demonstrate that tightening the pretarsal-preseptal orbicularis oculi and Horner-Duverney muscles may improve the function of the lacrimal pump and may be a surgical alternative for treating functional epiphora.

MATERIAL AND METHODS

This was a prospective interventional case series of 28 patients with functional epiphora. During surgery, sutures were used to perform the intervention, and these were first passed through the upper and lower eyelid pretarsal-preseptal orbicular muscles, through the Horner-Duverney's muscle, and finally, through the dacriocystorhinostomy incision and tightened. Each patient completed the Lac-Q questionnaire and Munk scale prior to surgery, as well as six weeks and six months later. Before surgery, a fluorescein dye disappearance test was performed, which was repeated at follow-up appointments. Pre- and post-operative data were analyzed and compared at the most recent visit.

RESULTS

Twenty-eight patients (10 males and 18 females) with a mean age of 59 ± 35 years were included in this study. The severity of epiphora and its tearing effect on daily life significantly improved following the operation. The fluorescein dye disappearance test result was significantly improved after 6 weeks of followup in %89.3 of eyes and at 6 months followup in 92.9% of eyes. The Lac-Q questionnaire's mean social impact scores improved significantly postoperatively, from 3.76 to 0.77 (p < 0.001). The changes in total scores (7.29 before surgery to 1.71 after 6 months) were statistically significant (p < 0.001). The Munk score success rate was 64.3% and 85.7%, respectively. No significant complications or adverse effects were observed.

CONCLUSION

Our findings suggest that a beneficial and seemingly simple, safe, and easy procedure to reduce functional epiphora is to tighten the preseptal-pretarsal orbicularis and Horner-Duverney's muscles.

Functional epiphora: an under-reported entity

PURPOSE

To determine the etiology of epiphora in a tertiary Australian lacrimal clinic and highlight the high proportion of 'functional' cases.

METHODS

Single-center retrospective review: Records of adult patients presenting to a tertiary lacrimal clinic from January 2011 to February 2021 with epiphora were reviewed. Patients underwent testing with syringing/probing and lacrimal imaging to reach a diagnosis of functional epiphora. Functional epiphora was diagnosed based on the exclusion of alternate causes of epiphora on clinical examination, patent lacrimal syringing, normal dacryocystography, and delay on dacryoscintigraphy.

RESULTS

Five hundred and seventy-six symptomatic eyes of 372 adult patients (mean 66.2 ± 15.5 years, 63.4% females) with epiphora were evaluated for causes. Post-sac obstruction (stenosis/complete obstruction) and functional epiphora (non-anatomical delay) were the most common causes of presentations to the lacrimal clinic (26% each). Functional epiphora with post-sac delay was substantially more common than functional epiphora with pre-sac delay (89% vs. 11% of functional epiphora cases). In 16% of the cases, no cause for the epiphora was found while more than one cause (multifactorial) was present 11% of the time.

CONCLUSION

Functional epiphora was found to be as common as a nasolacrimal anatomical obstruction when lacrimal imaging is utilized.

Non-contrast MR dacryocystography for the evaluation of epiphora and recurrent dacryocystitis: A preliminary study

INTRODUCTION

Obstruction of the lacrimal drainage represents a common ophthalmologic issue. The blockage may interest any level of the lacrimal drainage pathway, and it is important to find the site of obstruction to plan the most appropriate treatment. In this study, findings from magnetic resonance (MR) dacryocystography were compared with findings from endoscopic and surgical procedures to evaluate the accuracy of MR dacryocystography in localizing the site of nasolacrimal duct obstruction.

METHODS

We enrolled twenty-one patients with clinical suspicion of nasolacrimal duct obstruction who underwent dacryoendoscopy and surgery. MR dacryocystography was performed with a heavily T2-weighted fast spin echo sequence in the coronal planes. Before the MRI was performed, a sterile 0.9% NaCl solution was administered into both conjunctival sacs. For each examination, two independent readers (with 8 and 10 years of experience in head and neck imaging) evaluated both heavily 3D space T2-weighted and STIR sequences.

RESULTS

Stenosis/obstruction of nasolacrimal duct or lacrimal sac was diagnosed in all 21 patients who underwent MRI dacryocystography. In particular, the site of the obstruction was classified as lacrimal sac in 12 (57%) patients, nasolacrimal duct in 6 (29%) patients, and canaliculi in 3 (14%) patients by both readers. By comparison with the evidence resulting from the endoscopy, there were differences between MRI dacryocystography and dacryoendoscopy in the evaluation of the obstruction's site in three patients, with an overall accuracy of 85.7%.

CONCLUSION

MR dacryocystography allows a non-invasive evaluation of the lacrimal drainage pathway, valid for the planning of the most appropriate treatment.

DCR for nasolacrimal duct stenosis may be less effective than for complete obstruction

OBJECTIVES

To ascertain the success of endo-DCR in nasolacrimal duct stenosis (NLDS) versus nasolacrimal duct obstruction (NLDO).

METHODS

Consecutive adult patients with epiphora attending a tertiary lacrimal clinic from February 2012 to February 2021 were reviewed. NLDS was diagnosed by patent lacrimal syringing and combined dacryocystography (NLD stenosis) and dacryoscintigraphy (post-sac delay) findings in all eyes. Cases with evidence of canalicular stenosis or other identifiable causes of epiphora were excluded. The epiphora resolution and improvement rates following endo-DCR were compared between NLDS and complete NLDO cases.

RESULTS

DCRs in 24 NLDS (23 patients, 69.6% females, mean age 61.0 ± 17.07) and 58 NLDO (56 patients, 69.6% females, mean age 61.9 ± 17.4) were included. Resolution of epiphora was achieved in 10 (41.7% [95% CI 0.24-0.61]) of the NLDS cases compared to 40 (69.0% [95% CI 0.56-0.79]) in NLDO (p = 0.021). Improvement of epiphora (i.e., either improvement or resolution) was noted in 17 (70.8% [95% CI 0.51-0.85]) of NLDS and 53 (91.4% [95% CI 0.81-0.96]) of NLDO cases (p = 0.034). Three patients (12.5%) with NLDS had subsequent lacrimal procedures (one DCR revision, two Jones tube) at a median of 14 (range 11-21) months. 71.4% of the NLDS patients responded to a phone questionnaire at a median of 93 months postoperatively. Of these, 46.7% reported resolution or significant improvement, and 33.3% reported slight improvement. 64.3% said they would recommend DCR to others suffering from epiphora.

CONCLUSION

Endo-DCR may benefit approximately 70% of patients with NLDS. The success of endo-DCR in complete NLDO may be higher.

Functional Versus Anatomical Nasolacrimal Obstruction: Are There Differences in Epiphora Severity, Symptoms, or Effects on Quality of Life?

PURPOSE

To elucidate whether the specific cause of nasolacrimal duct drainage impairment impacts the severity, symptoms, and implications on visual tasks and quality of life (QOL) in epiphora.

METHODS

A retrospective review of consecutive adult patients with epiphora attending a tertiary lacrimal clinic from June 2011 to March 2021 was conducted. Cases with evidence of canalicular stenosis, a mucocele, or other identifiable causes of epiphora were excluded. A structured interview assessed the epiphora severity (Munk), symptomatology, precipitating factors, and effects on visual tasks and QOL. Following lacrimal syringing, all eyes were investigated with dacryocystography and dacryoscintigraphy. The domains of the interview were compared between nasolacrimal duct obstruction (NLDO), stenosis (NLDS), and nonanatomical functional delay (FNLDO).

RESULTS

One hundred twenty-two symptomatic eyes (63 patients; mean age 63.3 ± 17.2 years; 59% females) were included. There was no difference in Munk score between the groups (NLDO = 3.71 ± 0.18, NLDS = 3.79 ± 2.0, FNLDO = 3.85 ± 0.15; p = 0.82). In all 3 groups, most cases had a Munk >2 (86.8%, 75.9%, and 89.1%, respectively; p = 0.25). Discharge was more common in NLDO (65.7%) compared with NLDS (30.0%) and FNLDO (36.4%, p = 0.006). Worsening in the cold/wind was more frequent in FNLDO (77.1%) compared with NLDO (48.5%, p = 0.029). Effects on visual tasks and QOL were not significantly different.

CONCLUSIONS

FNLDO patients experience a high severity of epiphora, comparable to patients with NLDS and those with complete NLDO. The distinction between FNLDO and NLDS had little consequence on reported symptoms, precipitating factors, visual tasks, and QOL. Discharge may be more specific to NLDO, whereas precipitating cold or wind is more specific to FNLDO.

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 intubation and endoscopic DCR in functional nasolacrimal duct obstruction

BACKGROUND

To ascertain the success of lacrimal intubation and DCR in alleviating epiphora due to functional nasolacrimal duct obstruction (FNLDO).

METHODS

Consecutive adult patients with epiphora attending a tertiary lacrimal clinic from May 2010 to February 2021 were reviewed to identify cases with FNLDO. FNLDO was defined as epiphora with the exclusion of alternate causes of watering on clinical examination, patent lacrimal syringing, normal DCG, and post-sac delay on DSG. Epiphora resolution and improvement rates in FNLDO were compared between lacrimal intubation and endo-DCR.

RESULTS

23 endo-DCRs (20 patients, 65% females, mean age 68.9±12.2) and 41 intubations (29 patients, 61.2% females, mean age 65.0±14.1) performed in FNLDO were included. Resolution of epiphora was achieved in 15 of the DCR procedures (median follow-up 9 months) compared to 14 of intubations (median follow-up 10 months). Significant epiphora improvement (i.e., either improvement or resolution) was noted in 21 DCRs and 24 intubations. Seven patients undergoing intubation as the primary procedure had endo-DCR performed following the intubation. Among respondents to a phone questionnaire, 53.8% who had endo-DCR (median 69 months) and 50% that had intubation (median 28 months) reported significant improvement in epiphora.

CONCLUSIONS

Improvement in epiphora due to FNLDO was approximately 59% in intubations, while the success of endo-DCR was higher (91%). The long-term results of these interventions warrant further investigation.

Syringing has limited reliability in differentiating nasolacrimal duct stenosis from functional delay

PURPOSE

To elucidate the role of syringing in assessing nasolacrimal duct (NLD) stenosis and non-anatomical functional NLD delay.

METHODS

Consecutive adult patients with epiphora attending a tertiary lacrimal clinic from June 2011 to March 2021 were reviewed. Cases with evidence of canalicular stenosis or other identifiable causes of epiphora were excluded. Following syringing, patients were investigated with dacryocystography (DCG) and dacryoscintigraphy (DSG). The sensitivity and specificity of syringing were evaluated using the combined findings on DCG and DSG.

RESULTS

A total of 289 symptomatic lacrimal systems (197 patients; mean age 65.5 ± 14.9 years, 66% females) were included. More than one-third of cases with both normal DCG and DSG were noted to have some degree of reflux on syringing (specificity = 65.1%, 95% CI 50.2-77.6%). The sensitivities were considerably low for NLD stenosis (i.e., stenosis on DCG and delay on DSG) and for functional NLD delay (i.e., normal DCG and delay on DSG), of which 43.7% (95% CI 32.2-55.9%) and 54.3% (95% CI 45.7-62.7%) had full patency on syringing, respectively (p = 0.17).

CONCLUSIONS

Full patency on syringing was unreliable for ruling out NLD stenosis and functional delay. Furthermore, a positive syringing may be associated with functional NLD delay and cannot reliably differentiate it from stenosis.

Lithuanian version of nasolacrimal duct obstruction symptom scoring questionnaire. Cross-cultural adaptation and validation. Short- and long-term results

OBJECTIVES

The objective of this study was to perform translation, cross-cultural adaptation and validation of the Lithuanian version of specific nasolacrimal duct obstruction symptom scoring (NLDO-SS) questionnaire and to evaluate short- and long-term results of endoscopic endonasal dacryocystorhinostomy (EN-DCRS) procedure.

DESIGN, SETTING, PARTICIPANTS

Permission for questionnaire translation, cross-cultural adaptation and validation was obtained from the authors of the original questionnaire. Translation, validation and cross-cultural adaptation were carried out according to generally accepted methodology. Validation study of the Lithuanian version of NLDO-SS (L-NLDO-SS) was performed, and short- and long-term results of EN-DCRS procedure were evaluated according to symptoms. In total, 44 patients were evaluated 2 weeks before the surgical intervention, a day before the surgery and 41 patients 2 months after the surgery, and again 10 months later.

MAIN OUTCOME MEASURES

We analysed the internal consistency and test-retest reliability of the L-NLDO-SS questionnaire. Cronbach's alpha was used to represent and evaluate internal consistency for ordinal responses. Validity was assessed by comparing scores between a control group of volunteers without NLDO and the NLDO group using Mann-Whitney test. To test the limiting score on which the sensitivity and specificity curves cross in identifying patients with NLDO, receiver operating characteristic (ROC) curve analysis was used. The pre- and post-operative scores were compared using the paired t-test.

RESULTS

The results showed an acceptable internal consistency of L-NLDO-SS questionnaire, with Cronbach's alpha-.73 in the initial test group and .71 in the retest group. Pearson's correlation coefficient was .94 (P < .001), revealing good correlation between the initial scores and the retest scores. Our sample of healthy individuals had a mean L-NLDO-SS score of 11.42 (±12.69) points, and patients being scheduled for EN-DCRS had a mean L-NLDO-SS score of 27.45 (±9.81) points. Post-operatively mean L-NLDO-SS scores improved from 27.45 (±9.81) points to 4.45 (±6.29) points in the short term and to 5.83 (±4.17) in the long term, demonstrating the statistically significant responsiveness of the instrument over both timescales.

CONCLUSIONS

Lithuanian version of NLDO-SS questionnaire is a valid instrument for assessing patients with NLDO in the Lithuanian population. It demonstrated good internal consistency, reproducibility, validity and responsiveness.

Comparison of success between external and endonasal dacryocystorhinostomy in primary acquired nasolacrimal duct obstruction in Turkish cohort

OBJECTIVE:

To evaluate the results and recurrence rates of external and endonasal dacryocystorhinostomy (DCR) surgery in patients with primary acquired nasolacrimal duct obstruction (PANDO) in Turkish Cohort.

METHODS:

Medical records were reviewed in all patients who underwent surgery for PANDO between January 2010 and September 2014 in a tertiary university hospital retrospectively. The patients were followed up on the first day, first month, third month and sixth month postoperatively. Lacrimal drainage system and recurrence rates were recorded.

RESULTS:

This study was conducted in 81 patients, 27 of whom were men (33.3%) and 54 were women (66.7%). The mean follow-up time was 30.13±16.42 months (range 6–62 months). The mean age was 50.51±12.47 years (range 16 to 77 years). External DCR was used in 44 (66.7%) of the cases and endonasal DCR was used in 37 (45.7%) of the cases. Surgical results of DCR were divided into three groups based on the integrity and openness of the lacrimal drainage pathway in all PANDO patients. Operation success rates of these data revealed that 45 (55.6%) cases were recorded as successful, 20 (24.7%) of the cases were accepted as partially successful and 16 (19.8%) of the cases were deemed as unsuccessful. Based on these data, surgical success rates were found in 38 (86.4%) patients in external DCR and 27 (73%) patients in endonasal DCR. Surgical failure rates were six (13.6%) in external DCR and 10 (27%) in endonasal DCR. There was no statistically significant difference between success rates and recurrences in both groups (p>0.05).

CONCLUSION:

Endoscopic DCR produced simple, minimally invasive and preferable results compared to external DCR in the Turkish population. Although the success of external DCR is higher and the recurrence is lower than endoscopic DCR, with the outcomes of this study, endoscopic DCR can be tried as the first choice to protect the patient from major surgery and anesthesia in PANDO.

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.

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.

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.

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.

Use of the Crawford tube for symptomatic epiphora without nasolacrimal obstruction

AIM

To evaluate the effectiveness of the Crawford tube in treating symptomatic epiphora without nasolacrimal obstruction.

METHODS

A protocol was adopted for the management of symptomatic epiphora without nasolacrimal obstruction. Patients who suffered symptomatic epiphora without nasolacrimal obstruction in both eyes were included in the study. One eye was treated with Crawford tube intubation and the other eye was treated with medication therapy. Degree of watering, patient satisfaction, and symptomatic improvement were carefully evaluated by one of the authors at the end of the follow-up period, after Crawford tube removal, to ascertain functional results.

RESULTS

Thirty-seven adult patients (37 eyes) underwent Crawford tube intubation for functional epiphora. The mean follow-up time after removal of the tube was 14.8±4.8mo. The procedure was an overall success in 28 eyes (75.7%), with symptoms improving significantly. Two eyes (5.4%) were relieved of indoor epiphora, two (5.4%) had minimal epiphora outdoors, but only with wind or cold, and five (13.5%) continued to experience tearing both indoors and outdoors. Thirty of the patients (81%) expressed satisfaction with the procedure.

CONCLUSION

Crawford tube insertion is an effective, safe, simple, and relatively noninvasive treatment strategy for functional lacrimal system obstruction.

External vs. endonasal dacryocystorhinostomy: has the current view changed?

In past years, external dacryocystorhinostomy has been considered the gold standard in terms of functional outcome for treatment for nasolacrimal duct obstruction. In comparison, interest in the use of the recently developed endonasal dacyocystorhinostomy procedure has been rekindled because of advances in instrumentation. For the past 10 years, differences in the outcomes between the two techniques have been reduced; thus, currently, the choice of the type of surgery is associated with the experience of the surgeon, resources available in the healthcare system and patient preferences.

Assessment of patient satisfaction following external versus transcanalicular dacryocystorhinostomy with a diode laser and evaluation if change in quality of life after simultaneous bilateral surgery in patients with bilateral nasolacrimal duct obstruction

AIM

To compare patient satisfaction and experience after external dacryocystorhinostomy (EX-DCR) versus transcanalicular DCR (TC-DCR) with a diode laser and to evaluate the change in quality of life following simultaneous bilateral DCR.

METHODS

Prospective evaluation of 38 eyes of 19 patients with bilateral nasolacrimal duct obstruction (NLDO) who underwent TC-DCR for the right eye (Group 1) and EX-DCR for the left eye (Group 2) simultaneously. The subjective outcomes (tearing, irritation, pain, discharge, swelling, and change in visual acuity) of the patients in the two groups at 1 week, 1 month, and 3 months were compared using a questionnaire. The patients answered the questions in the Glascow Benefit Inventory (GBI) to evaluate the change in quality of life after simultaneous bilateral DCR at 1 month and 3 months. The symptom scores were compared between Group 1 and Group 2 using a Mann-Whitney test. The Wilcoxon test was used for the comparison of intragroup differences.

RESULTS

The overall symptom scores significantly improved in both groups. The overall symptom score and six ocular symptom scores did not show a significant difference between the two groups at 1 week, 1 month, and 3 months. Quality of life of the patients significantly improved after simultaneous bilateral surgery according to GBI scoring at 1 month and 3 months.

CONCLUSION

The subjective outcomes significantly improved in similar ways after successful TC-DCR and EX-DCR during the early postoperative period. Our study shows that simultaneous bilateral DCR confers a significant quality of life improvement.

A clinical trial of endoscopic vs external dacryocystorhinostomy for partial nasolacrimal duct obstruction

OBJECTIVE

A literature review revealed there is no outcome data for endoscopic endonasal dacryocystorhinostomy (EES-DCR) in the subgroup of patients with acquired partial nasolacrimal duct obstruction (NDO). This study aimed to compare the results of EES-DCR vs external DCR (ext-DCR) in the treatment of partial NDO.

DESIGN

This study is designed as a prospective nonrandomised comparative clinical trial.

PARTICIPANTS

In total, 46 adult patients with acquired partial NDO participated in this study.

METHODS

Partial (sometimes called 'functional') NDO (epiphora in the presence of patent syringing) was confirmed by nuclear lacrimal scintigraphy or delayed drainage on dacryocystography. Patients with 'functional' epiphora from other causes were excluded. Post-operative outcome was assessed at 6 months. Overall, 21 (46%) patients had EES-DCR and 25 patients had (54%) ext-DCR.

MAIN OUTCOME MEASURES

Subjective success was based on patient symptoms, objective success on patency with syringing and a functioning rhinostomy evaluated using the functional endoscopic dye test (FEDT).

RESULTS

In total 18 out of 21 (86%) of EES-DCR patients had marked reduction (n=11) or complete resolution (n=7) and 25 out of 25 (100%) of ext-DCR had marked reduction (n=9) or complete resolution (n=16) of epiphora. In total 17 out of 18 (94%) of the EES-DCR patients with subjective success had a positive FEDT. All 25 out of 25 (100%) ext-DCR patients with subjective success had a positive FEDT. The three failed EES-DCR patients were all blocked on syringing. Statistically, EES-DCR does not achieve the same success rate as ext-DCR in this study (P=0.09, two-tailed Fisher's exact test, 0.045 one-tailed).

CONCLUSIONS

Both endoscopic and external DCRs provide satisfactory outcomes in acquired partial NDO. The success rate is nevertheless higher in ext-DCR compared with EES-DCR.

The role of mucosal flaps in external dacryocystorhinostomy

PURPOSE

To determine whether a mucosal anastomosis fashioned at the time of external dacryocystorhinostomy (DCR) influences postoperative outcome.

METHODS

The clinical records of all patients who underwent external DCR at Sydney Eye Hospital between May 2000 and August 2007 were reviewed. Data were collected in regards to surgical technique, clinical outcomes and postoperative management. Chi-square statistical analysis was done to determine the significance of the different flap techniques on surgical success.

RESULTS

A total of 260 medical records were reviewed. The main outcome measure was postoperative resolution of symptoms. The mean final follow-up time was 11 months. There was no statistically significant difference in outcome between patients who had both anterior and posterior flaps sutured, compared to those who had anterior flap sutures only (73% vs 79%, p = 0.51). Patients who had no sutured flaps had an overall success rate of 89% compared to those that had at least the anterior flaps sutured together (76%); this difference was not significant (p = 0.45).

CONCLUSION

There was no statistical difference in symptom outcome between patients in whom both mucosal flaps were sutured, those who had only the anterior flap sutured, or those who did not have either flap sutured at the time of surgery.