Development and validation of a symptom questionnaire for recording outcomes in adult lacrimal surgery

A New Patient-reported Outcomes Measure for Surgically Treated Epiphora: Tearing Assessment and Rating Scale-12 (TEARS-12)

BACKGROUND

No widely accepted, validated instrument currently exists to measure clinical outcomes in patients who undergo dacryocystorhinostomy (DCR) for treatment of epiphora.

OBJECTIVE

To develop a patient-reported outcome measure applicable to this population.

METHODS

Psychometric evaluations, consultation with experts, and review of the literature informed item generation of a 12-question questionnaire to incorporate the most relevant symptoms experienced by patients with nasolacrimal duct obstruction. This questionnaire, known as the Tearing Assessment and Rating Scale-12 (TEARS-12), was administered to 32 patients before and after intervention, in the form of endoscopic DCR. Statistical analysis was performed to measure internal consistency, responsiveness, and test-retest reliability.

RESULTS

Pre-operative and post-operative TEARS-12 scores (28.2 [standard error (SE) 3.19] vs 11.8 [SE 3.25], respectively, P = 0.001) demonstrated improved patient outcome within 6 weeks following endoscopic DCR. Cronbach's alpha for the questionnaire was 0.90, indicating high overall reliability. Additionally, each question demonstrated internal reliability, with a corrected item-total correlation greater than 0.30. The intraclass correlation between the two pre-operative scores was 0.858 (P < 0.001), indicating high test-retest reliability.

CONCLUSION

TEARS-12 is a statistically valid, easy-to-administer instrument to measure clinical outcomes in patients who undergo endoscopic DCR.

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.

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 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.

Injection of Botulinum Toxin A in the Lacrimal Gland for Treatment of Epiphora in Crocodile Tears Syndrome – A Case Report

Purpose

Crocodile tears syndrome is a rare autonomic synkinesia, in which patients tear excessively in response to salivary stimuli. It usually occurs after idiopathic or traumatic facial palsy, as a result of aberrant reinnervation of the lacrimal gland by salivary efferent fibers from either the seventh or ninth cranial nerve.

Patients and Methods

We report the case of a 54-year-old woman, with a history of left Bell’s palsy, who attended our ophthalmology clinic due to epiphora of the left eye while eating or speaking, for 6 months.

Results

The ophthalmologic evaluation revealed a mild weakening of the frontal and left orbicularis oculi muscles without lagophthalmos. No other abnormalities were found, namely ocular surface swelling, ectropion, or obstruction of the lacrimal outflow system. Schirmer test II in the left eye increased from 12 to 23 mm while the patient was chewing. All these clues led to the diagnosis of crocodile tears syndrome and treatment with botulinum toxin A injection was proposed. One month after the injection of the palpebral lobe of the left lacrimal gland with 6 units of botulinum toxin A, the patient reported an almost complete resolution of the complaints, stated by a decrease in Munk scale and Lac-Q scores. Six months after injection, the patient conveyed recurrence of symptoms and a new treatment session was performed with comparable results.

Conclusion

Since crocodile tears syndrome is rare, it is crucial to increase awareness and knowledge about it among ophthalmologists and other medical doctors. Botulinum toxin is a safe and effective treatment modality, dramatically improving these patients’ quality of life.

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.

Evaluation of the efficacy of postoperative triamcinolone in endoscopic dacryocystorhinostomy using lacrimal symptom questionnaire

PURPOSE

To evaluate the effect of postoperative nasal triamcinolone spray use in primary endoscopic dacryocystorhinostomy using The Lacrimal Symptom Questionnaire.

METHODS

This study included a series of 50 consecutive retrospective cases with primary endoscopic dacryocystorhinostomy and with silicone stent implantation who were followed up for 6 months postoperatively. Patients using nasal triamcinolone spray for 3 months postoperatively were included in the triamcinolone group. Patients not using triamcinolone were included in the control group. Lacrimal stents were removed 3 months postoperatively. The Lacrimal Symptom Questionnaire (Lac-Q) was performed in the preoperative and postoperative 6th month. Anatomical success, functional success, and changes in lacrimal symptom and social impact scores were compared between the two groups 6 months after surgery.

RESULTS

Results of 48 endoscopic dacryocystorhinostomies performed on 48 patients (23 triamcinolone group, 25 control group) meeting the inclusion criteria were analyzed. The anatomical success rate (95.7% vs. 84.0%, p = 0.350) and the functional success rate (91.3% vs. 76.0%, p = 0.249) were higher in the triamcinolone group, but this difference was not statistically significant. No complications were observed in the triamcinolone group, whereas complications developed in two patients in the control group (p = 0.490). The mean change in total lac-Q score was 11.0 in the triamcinolone group and 9.0 in the control group (p = 0.011). The mean change in social impact score was 4.0 in the triamcinolone group and 3.0 in the control group (p = 0.005). Mean change in lacrimal symptom score was 6.0 in the triamcinolone group and 6.0 in the control group (p = 0.368) CONCLUSIONS: Our study indicated that postoperative use of triamcinolone spray increases the success rate of endoscopic dacryocystorhinostomy and also revealed that triamcinolone may also lead to greater improvement in quality of life scores than the control group using a validated questionnaire.

Application of a symptoms score questionnaire after conjunctivodacryocystorhinostomy: outcomes

Objective

To evaluate medium/long term outcomes and patient satisfaction through relief of symptoms and improved quality of life (QoL) after Jones tube conjunctivodacryocystorhinostomy (JT-CDCR) using the Naso Lacrimal Duct Obstruction symptom-score (NLDO-SS).

Methods

We conducted a retrospective, non-comparative, multicentric study including patients with complete obstruction of the superior and inferior proximal lacrimal drainage system. All patients underwent JT-CDCR, and the patency of the tube was evaluated with saline irrigation and endoscopic examination. We assessed patient satisfaction and quality of life administering the NLDO-SS.

Results

We enrolled 16 patients, for a total of 21 eyes operated. The success rate for procedures was 81%. The success rate for single parameters was globally 95.9%; if considered separately, ocular symptoms and nasal symptoms were respectively 94.3% and 100%.

Conclusions

JT-CDCR was a reliable procedure, able to solve symptoms in a majority of patients and guaranteed a good quality of life over a long period of time.

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.

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.

Assessment of Lacrimal Duct Patency in Patients Undergoing Endoscopic Medial Maxillectomy

Purpose: The risk of epiphora after medial maxillectomy with lacrimal duct transection is difficult to assess. The data available in the literature are inconclusive due to various operating techniques used by the authors of medical publications, different additional procedures aimed at improving tear drainage after maxillectomy, and a variety of lacrimal duct patency assessment techniques. The aim of our work was to assess the anatomical and functional patency of lacrimal ducts after medial maxillectomy without performing additional procedures to improve tear drainage as well as comparison of the results obtained with different assessment tests. Materials and methods: 21 patients who underwent medial maxillectomy in the years 2016–2019 were assessed for discomfort and epiphora based on patients’ own reports and basic clinical examination, lacrimal duct rinse test, the Munk score, and a modified endoscopic Jones I test. Results: Gradually increasing the sensitivity of the assessment method resulted in an increase in the number of patients with potential tear drainage disorders, starting from 0% in the rinsing test, 4.8% self-reported tearing complaints, 14.3% Munk score, and 19% modified endoscopic Jones I test. Conclusions: The study results revealed that a small fraction of patients tend to report epiphora as a consequence of medial maxillectomy themselves. Subtle functional disorders, which are not particularly bothersome to patients, are more common. More sensitive lacrimal duct patency tests reveal more cases of tear drainage disorders. The results of studies assessing the incidence of epiphora after medial maxillectomy appear to depend on the type of test used.

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.

Assessing the outcomes of mini-Monoka stent dilatation for primary punctal stenosis using the lacrimal symptom questionnaire

Purpose:

The objective of this study was to assess the quality of outcomes of mini-Monoka stent dilatation for punctal stenosis using the lacrimal symptom (Lac-Q) questionnaire.

Methods:

Prospective interventional case series of 45 eyes of 25 consecutive patients who underwent mini-Monoka stent dilatation for primary punctal stenosis were included in the study. The stents were extubated at 4 weeks. The Lac-Q questionnaire was administered preoperatively and at 12 weeks and 24 weeks following the intervention. Outcomes assessed were anatomical success, functional success, and changes in the questionnaire scores including total, social impact, and lacrimal symptom scores. Statistical analysis was performed using the Wilcoxon signed-rank test, and the probability of obtaining a certain score was calculated using the multinomial log-linear model. P < 0.05 was considered as significant.

Results:

Monoka stents were performed for 45 eyes. A total of 75 questionnaire responses were analyzed. At the last follow-up of 24 weeks, the anatomical and functional success rates were 93.3% (42/45). The changes in the mean total score (7.68 preoperatively to 0.82 at 24-week follow-up) were statistically significant (P ≤ 0.001). The mean social impact scores showed significant improvement postoperatively from 4.06 to 0.53 (P ≤ 0.001). The mean lacrimal symptom score changed from a preoperative value of 3.62 to 0.28 (P ≤ 0.001) at the last follow-up. Postoperative scoring correlated well with the anatomical and functional success rates. The symptom scores corroborated with changes in the clinical outcomes.

Conclusion:

Mini-Monoka stent dilatation is a very effective intervention for the management of primary punctal stenosis, and Lac-Q questionnaire is a simple and useful tool to evaluate the quality of outcomes in such cases.

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.

Scaling the punctum and canaliculus in patients undergoing punctoplasty surgery: A prospective cohort study

Optical Coherence Tomography (OCT) is a safe and non-invasive method of high-resolution cross-sectional imaging of tissue microstructures using infrared radiation. This study investigates how the appearance of the punctum and proximal canaliculus differs pre- and post-operatively in patients undergoing punctoplasty surgery. Patients with symptomatic punctal stenosis warranting punctoplasty surgery were prospectively invited to enrol from a single centre. Spectral OCT images of the lower punctae were captured with a Topcon 3D OCT 2000 machine pre- and post-operatively (at their follow-up appointment). Measurements were made of the maximal punctal diameter, canalicular diameter and canalicular depth. Pre- and post-operative measurements were compared using a paired t-test. Twenty-three punctae of 18 patients with punctal stenosis were included in the study. They were 10 males and 8 females with a median age 71.0 (SD 12.1). Mean canalicular cross-sectional area was 56.9 × 10-3 mm² pre-operatively and 267.2 × 10-3 mm² post-operatively, showing a statistically significant increase (p = 0.0004). There was an increase in both mean canalicular width (0.253 to 0.524mm (p = 0.0001)) and depth (0.433 to 0.852mm (p = 0.0001)) from pre- to post-operatively. There was a significant improvement in symptoms from pre- to post-operatively, as measured subjectively by the Lac-Q questionnaire (p = 0.021). This study describes the change in the appearance of the punctum and proximal canaliculus in patients undergoing punctoplasty operations, by using spectral OCT to capture in vivo high-resolution images. It demonstrates that punctal OCT can be successfully applied to quantify the morphological changes of the punctum and canaliculus pre- and post-punctoplasty.

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.

Mucosal and lacrimal flaps for endonasal dacryocystorhinostomy: a systematic review

BACKGROUND

Historically dacryocystorhinostomy (DCR) has been performed externally with very good outcomes. Current literature shows comparable success rates between endonasal and external approaches. A common reason for the failure of a DCR is the reclosure of the nasolacrimal stoma by granulation tissue and synechiae.

OBJECTIVE OF REVIEW

A systematic review and critical evaluation of the evidence relating to the preservation of nasal mucosal flaps in DCR surgery.

TYPE OF REVIEW AND EVALUATION METHOD

A systematic review using the consort guidance for review of randomised control trials.

SEARCH STRATEGY

A search of the following evidence-based medicine databases was performed: Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effectiveness, Cochrane Central Register of Controlled Trials, Ovid, Medline, EMBASE and PubMed. The search was limited to English language articles, and the following key words were used: Endonasal, Endoscopic, Dacryocystorhinostomy, DCR, Mucosal Flaps, between years 1970 and 2015.

RESULTS

The best available evidence was level 1B, comprising two randomised control trials and three comparative studies included in the review. The main outcome measures used were lacrimal irrigation and absence of epiphora. Two of the studies demonstrated a statistically significant benefit of mucosal sparing either with nasal mucosal flaps or with lacrimal flaps. More debridement was needed, and granulation tissue was also seen in the groups without mucosal preservation. There was no difference in surgical complications between a mucosal and non-mucosal-sparing technique.

CONCLUSIONS

The overall quality of current evidence is poor, and there does however appear to be a trend towards improved outcomes and reduced granulation in groups where nasal mucosal and lacrimal flaps were preserved, but this is not clear-cut. There was no evidence of increased complication rates with mucosal-sparing techniques. We recommend that until further good quality research is available we should be performing a mucosal-sparing technique when performing DCR routinely.

Efficacy of tightening of orbicularis oculi muscle in patients with functional nasolacrimal duct obstruction

PURPOSE

To evaluate the efficacy of tightening of lateral portion of orbicularis oculi muscle in patients with functional nasolacrimal duct obstruction (FNLDO).

METHODS

This is an interventional cross-section study for evaluation of effect of orbicularis oculi tightening procedure in patients with FNLDO. Patients with unexplained epiphora, open lacrimal system in syringing and evidences of lacrimal pump weakness in lacrimal scintigraphy underwent surgery. In this procedure, a stripe of preseptal and pretarsal orbicularis muscle was dissected, slightly resected and secured to the periosteum of lateral orbital rim. Each subject completed a questionnaire about the intensity of epiphora before surgery and 1, 3 and 6 months after surgery. Furthermore, fluorescein dye disappearance test (FDDT) was performed before surgery and repeated in the follow-up visits. At last visit, the pre- and post-operative data were analyzed and compared.

RESULTS

Fifteen eyes of 12 patients (5 males and 7 females) with the mean age of 56.7 years included in the study. Severity of epiphora and tearing effect on daily life were significantly improved following the operation. FDDT result was improved significantly after 1 month follow-up in all eyes (15 eyes), at 3 months follow-up in 80% of eyes (12 eyes) and at the end of the 6th month in 66.7% of eyes (10 eyes). Subjective and objective success rates were 87% and 80%, respectively. No significant complications or side-effects were observed.

CONCLUSION

Tightening of lateral portion of preseptal and pretarsal orbicularis muscle seems an effective, safe, and easy procedure to decrease epiphora in patients with FNLDO.

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 dacryocystorhinostomy as treatment for lower lacrimal pathway obstructions in adults: Review article

Obstruction of the lacrimal pathway is manifested by epiphora, infection, and blurred vision as well as ocular and facial pain. Conservative treatments only achieve temporary relief of symptoms, thus surgery is the treatment of choice. Dacryocystorhinostomy (DCR) is recognized as the most suitable treatment for patients with obstructions of the lacrimal system at the level of the sac or in the nasolacrimal duct. The aim of this operation is to create a bypass between the lacrimal sac and the nasal cavity. During the past 2 decades, advances in rigid endoscopic equipment and other instruments have made it possible to obtain more information about the anatomic landmarks of the nasolacrimal system, which led to the development of less-invasive and safer endoscopic techniques. However, many parts of the treatment process related to endoscopic endonasal dacryocystorhinostomy (EN-DCR) still remain controversial. This article reviews the published literature about the technical issues associated with the success of EN-DCR, and clarifies the pros and cons of different pre- and postoperative procedures in adults with lower lacrimal pathway obstructions.

The National Institute for Health and Clinical Excellence, and otolaryngology: review of the evidence

BACKGROUND

The adoption of evidence-based practice is fundamental to good medical care; it ensures that intervention is clinically effective and safe. In a world of limited healthcare resources, consideration of cost-effectiveness must, unfortunately, restrict clinicians' choice. The National Institute for Health and Clinical Excellence has, for over 10 years, developed guidance to achieve a national consensus on best practice.

OBJECTIVES

This review describes the Institute's methodology, examines guidance relevant to otolaryngology and presents more recent research to update the evidence.

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

PURPOSE

To assess the subjective success and quality of life of adult patients post endoscopic endonasal dacryocystorhinostomy (EE-DCR) for acquired nasolacrimal duct obstruction.

DESIGN

Retrospective, questionnaire study performed at least 6 months post EE-DCR.

PARTICIPANTS

Hundred and ten of the 282 consecutive patients who underwent EE-DCR.

METHODS

A standardised questionnaire (Glasgow Benefit Inventory, GBI) was used to analyse the quality of life. The questionnaire examines four parameters, providing total, subscale, social, and physical scores.

MAIN OUTCOME MEASURES

We aimed to assess patient experience following EE-DCR surgery. Total GBI scores range from -100 to +100, the former reflecting maximal negative benefit and corresponding to subjective worsening of tearing and impact on quality of life. Any positive score reflects a satisfactory surgical outcome and +100 represents maximal positive benefit. A score of zero is no perceived benefit.

RESULTS

The average age was 62 years, 63% were female. In three of the parameters measured, there was a subjective improvement post surgery: subscale score 22.16 (95% CI: 15.23-29.09), total score 15.04 (95% CI: 9.74-20.35), and social support score 4.67 (95% CI: 0.93-8.42). Physical health scored -4.47 (95% CI: -10.25 to 1.32). Secondary analyses demonstrate no statistical significance with respect to outcome whether a trainee or consultant performed the procedure. Younger patients (under split median of 63.5) had a better total score 19.04 (95% CI: 11.35-27.74) than those older than 63.5 years (11.04, 95% CI: 3.61-18.47).

DISCUSSION

This study shows that EE-DCR gave patients improvement in quality of life, proven by a validated questionnaire. The mean total score of 15.04 found in our study compares with the 18.7 recorded by Feretis et al in 2009. Results were irrespective of the grade of surgeon, similar to the findings of Fayers et al for functional successes.

CONCLUSION

This study supports the use of EE-DCR for the improvement of quality of life in adult patients.