Introduction

Lacrimal disorders need not necessarily always have only a physical or a functional dimension; there may be emotional, social, and economic or a combination of these aspects to them. Understanding the different facets of patient and the caregiver’s perspectives of the disease before and after medical or surgical interventions contributes significantly to overall patient satisfaction. Rather than objective anatomical outcomes of a surgery alone, patient satisfaction is what all the surgeons should ideally aim for. It is in this context that the validated quality of life (QOL) questionnaires help the health-care providers. They are also a very useful tool for clinical research and standardization of outcomes.

CNLDO: Patient and Parental Quality of Life

Congenital nasolacrimal duct obstruction or CNLDO is the commonest pediatric lacrimal disorder that effects up to 20% of the newborns with spontaneous resolution in vast majority [1]. The symptomatology or the success rates have been largely assessed using isolated elementary questionnaires that included both parental perception and examinations [2, 3]. Holmes et al. [4] published a novel and comprehensive parental questionnaire addressing symptoms and health-related quality of life in CNLDO. The questionnaire included 17 questions with the first three questions having four subtypes each. All the questions were evaluated on five parameters (always, often, sometimes, rarely, and never) with scoring for each parameter. The questionnaire is briefly listed in Table 47.1. Holmes et al. [4] enrolled 87 children 56 with and 31 without NLDO. The Cronbach’s values were impressive for not only the overall questionnaire (0.95) but also for its two subscales, namely, symptoms scale (0.95) and health-related quality of life (HRQL) scale (0.85). The CNLDO patients had worse scores for both the scales as compared to normal children, and the affected eye had worse score as compared to the normal fellow eye. Both these scales showed improvement in scores following intervention in the form of probing. The study found that the questionnaire is very useful in quantifying parental perception of symptoms and HRQL in CNLDO.

Table 47.1 Brief Holmes Questionnaire for CNLDO
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The author’s group has compared the parental quality of life (QOL) in CNLDO children who were successful following intervention versus complex CNLDO with poor outcomes. However, we did not include the last two (16, 17) questions. The early analysis has shown the Holmes questionnaire to be very useful for comparisons within the CNLDO group as well.

Quality of Life After DCR Surgery

The quality of life after a DCR surgery has been usually assessed using the Glasgow Benefit Inventory or GBI Questionnaire which was developed by Robinson et al. [5] for evaluating otorhinolaryngology procedures. This questionnaire is well known and validated in many studies across subspecialties of otology and rhinology [6, 7]. It consists of 18 questions, each assessed on a five-point Likert scale. Twelve questions are related to general perception of well-being and three each for physical health and social parameters. A positive GBI score represents a beneficial effect. The range of scoring extends from −100 (maximal negative benefit) to 0 (no change) to +100 (maximum positive benefit). Table 47.2 lists briefly the 18 questions that constitute the GBI.

Table 47.2 Brief Glasgow Benefit Inventory Questionnaire
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Bakri et al. [8] assessed the benefits of external DCR versus endoscopic laser-assisted DCR and found no statistical difference in GBI scoring between the two groups. Mansour et al. [9] studied the long-term patient satisfaction following an external DCR and concluded that long postoperative times negatively affect the exact subjective symptom scoring after surgery. Yeniad et al. [10] compared the patient satisfaction between external and transcanalicular laser DCR and found that the mean symptoms scoring reduced from 24.2 ± 4.6 at baseline to 3.5 ± 1.8 in the external group and 22.8 ± 3.4 to 3.37 ± 1.2 in the transcanalicular group (p = 0.67). The GBI scoring was similar and did not reach statistical significance in either group. However there were concerns regarding follow-ups [11].

Ho et al. [12] studied the impact of endonasal DCR on quality of life and found GBI scores of +34 in successful cases as compared to −19 in failed cases. The mean total GBI for endoscopic DCR in another study was +15.04 (95% CI: 9.74–20.35). Hii et al. [13] compared patient satisfaction between external versus endonasal DCR and found no difference. The patients who underwent external DCR on one side and endonasal on the other side, retrospectively, reported preference for endonasal DCR [14, 15]. Jutley et al. [16] reported improved GBI scores following endoscopic DCR but felt it may be difficult for all patients to complete the 18 questions of GBI without appropriate guidance. In cases of bilateral NLDO, simultaneous bilateral DCR was shown to confer significant improvement of quality of life with a statistically significant GBI score difference between 1 month and 3 months post operatively [10].

Quality of Life in FNLDO and Minimally Invasive NLDO Treatments

Functional nasolacrimal duct obstruction is an under diagnosed entity [17]. Epiphora in the presence of a patent lacrimal pathway and absence of alternative etiology could be the simplest description. Cheung et al. [18] conducted a detailed study on 33 FNLDO patients and studied their symptoms in relation to the vision, reading, driving, moods, work, and embarrassment. All these parameters were affected specifically vision, reading, and embarrassment, resulting in lower quality of life. Overall symptom scores significantly reduced after dacryocystorhinostomy (DCR) from a mean preoperative score of 3.50 (SD = 2.07) to 2.0 (SD = 1.65) in the postoperative period (p < 0.05).

Kabata et al. [19] studied the effects of silicone intubation using Nunchaku-style tube on vision-related quality of life in patients with lacrimal passage obstructions. They used the 25 item National Eye Institute Visual Function Questionnaire (NEI-VFQ). Silicone intubation showed a significant improvement in NEI-VFQ composite score (p = 0.0001), ocular pain score (p < 0.0001), and mental health score (p = 0.0003).

Specific Lacrimal QOL Questionnaires—The Way Forward

Most of the questionnaires used so far in lacrimal surgery are of general nature, and most are administered postoperatively. The morbidity with lacrimal obstructions should ideally not be assessed using questionnaires that were designed for more general conditions where systemic morbidity may change a lot of parameters. This need for lacrimal specific questionnaires has resulted in two new models, one for NLDO and other for DCR. Smirnov et al. [20] conceptualized the NLDO-symptom score survey (NLDO-SS) which has six parameters that need to be scored on a scale of 0 (no symptoms) to 10 (severe symptoms). The timing of administration can be individualized based on the follow-up protocols of each surgeon but is usually carried out at 1 week, 1 month, and 3 months. Five of these parameters are symptoms related to NLDO. Hence this is not only more specific but also simpler to use once validated. Table 47.3 lists the parameters in the NLDO-SS questionnaire.

Table 47.3 The NLDO-Symptom Score (NLDO-SS) parameters
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Mistry et al. [21] reviewed 100 consecutive patients of lacrimal duct obstruction and studied their symptomatology and subsequently developed Lac-Q questionnaire. The questions were specific to lacrimal disorders (four questions with multiple subparameters) including their social impact (five questions). They showed that not only is Lac-Q useful in pre- and postoperative comparisons but also correlates well with objective methods of assessment. Table 47.4 lists the parameters of the Lac-Q questionnaire.

Table 47.4 The brief “Lac-Q” questionnaire parameters
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Updates (2015–2016)

Impact of Epiphora on Vision-Related Quality of Life

A stable tear film is essential for maintaining optical quality and visual clarity. Epiphora may disturb the tear stability leading to a potentially suboptimal vision. The Ocular Surface Diseased Index (OSDI) questionnaire aims to evaluate common vision-related symptoms that affect performing of daily activities and comprises three sub-measurements: vision-related functions, eye symptoms, and environmental risk factors [22]. Shin et al. [23] conducted a study to evaluate subjective vision-related discomfort using ten vision-related parameters of the OSDI (Table 47.5) for 342 patients with epiphora, of which 115 had bilateral epiphora. In their study, the analysis on age and interpersonal relations showed a statistically significant negative correlation (p = 0.048), which reflected younger patients feeling greater discomfort. Females were found to have higher scores for household activities, outdoor activities, and interpersonal relations than males. Epiphora significantly influenced outdoor activities. Patients with complete obstruction of lacrimal drainage showed higher symptom scores than those who had patent lacrimal systems. Interestingly, one-sided and two-sided epiphora patients showed no significant differences in QOL scores. This indicates that the symptom of epiphora itself creates significant discomfort in daily life without regards to laterality. There were significant improvements of scores following surgical interventions.

Table 47.5 The Ocular Surface Diseased Index (OSDI) questionnaire parameters
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Assessing the Outcomes of Powered Endoscopic Dacryocystorhinostomy in Adults Using the Lacrimal Symptom (Lac-Q) Questionnaire

A specific symptom-based social and lacrimal (Lac-Q) questionnaire was used by Ali et al. [24] to evaluate the quality of outcomes of powered endoscopic DCR. The Lac-Q questionnaire was administered preoperatively, at 4 weeks and 16 weeks (SI) following the surgery for all the 50 patients who participated in the study.

The mean preoperative total score was 12.5. Interestingly, the range of preoperative score was 5–16 for unilateral cases and 21–27 for bilateral cases. Following surgery, the total score significantly improvement to 1.59 at 4 weeks (p ≤ 0.001) and 1.0 at 16 weeks (p ≤ 0.001). Among the 50 participants in the study, one patient had anatomical and functional failure, and three additional patients had functional failure in the presence of anatomical patency at the 16th week follow-up. Minimal improvement in the scores was observed for patients with failed DCR (4/50); however, the social impact and total scores remained significantly high compared to patients with successful surgical outcomes.

Change in Quality of Life of Patients Undergoing Silicone Stent Intubation for Nasolacrimal Duct Stenosis Combined with Dry Eye Syndrome

Epiphora may occur as a result of different etiologies, and multiple mechanisms may coexist in the same patient. Inflammatory conditions, such as dry eye syndrome, and allergic conjunctivitis may impede lacrimal drainage by causing punctal stenosis and canalicular stenosis along with ocular irritation and reflex tearing.

Oh et al. [25] used the GBI to subjectively measure and evaluate vision-related QOL for 30 patients diagnosed with nasolacrimal duct stenosis combined with reflex tearing due to dry eye syndrome. All patients were initially treated with lubricants but the epiphora did not improve.

Silicone stent intubation was then performed to treat the nasolacrimal duct stenosis which resulted in relieving of tearing in 23 of 30 patients at 6 months of follow-up. The surgical success was measured by the subjective assessment of patients and the GBI scores. The preoperative total score in young patients (<58.5 years) was +19.38 (range, 10.10–28.67) and in older patients was +14.68 (range, −2.52 to 31.89). The total postoperative score in successful outcomes was +27.54 (range, 20.85–34.23) and in failed cases was −16.83 (range, −24.69 to −8.97). Apart from the therapeutic significance of silicone intubation, this study also demonstrates the utility of assessing the surgical outcomes using the GBI scores.