Videoreflective dacryomeniscometry in normal adults and in patients with functional or primary acquired nasolacrimal duct obstruction

PURPOSE: Videoreflective dacryomeniscometry (VRD) for evaluation of marginal tear film has not been performed in patients with watery eye or in a controlled study. We used VRD to evaluate the height of the central marginal lower lid tear film in normal adults and compared it with two watery-eye groups and a postoperative dacryocystorhinostomy (DCR) group. DESIGN: Case-controlled interventional case series. METHODS: We evaluated with VRD 20 subjects with normal lacrimal drainage function, 21 patients with primary acquired nasolacrimal duct obstruction (PANDO), 28 patients with functional nasolacrimal duct obstruction (FNLDO), and a postoperative group of 14 patients derived from the previous two pathologic groups. Comparison between the four groups was performed to determine statistically significant differences between tear film height. RESULTS: PANDO and FNLDO groups were shown to have significantly greater median tear meniscus heights ([TMH] PANDO: 620 microm, interquartile range [IQR] 453 microm; FNLDO: 731 microm, IQR 529 microm) than normal subjects (296 microm, IQR 214 microm; P < .001) and postoperative PANDO patients (265 microm, IQR 159 microm). There was no significant difference in TMH between PANDO and FNLDO groups preoperatively (P = .275). There was a reduction in median TMH postoperatively of 355 microm (P = .008) in PANDO and 360 microm (P = .068) in FNLDO. CONCLUSIONS: PANDO and FNLDO patients have similar preoperative TMH. In both these groups, TMH is significantly greater than in normal control subjects. Lacrimal drainage surgery substantially reduces TMH as measured using VRD in PANDO.     

The diagnostic significance of Fourier‐domain optical coherence tomography in Sjögren syndrome,aqueous tear deficiency and lipid tear deficiency patients

Purpose: To determine the role of Fourier‐domain optical coherence tomography (FD‐OCT) in tear meniscus imaging and evaluate its diagnostic significance in Sjögren syndrome (SS), non‐Sjögren’s aqueous tear deficiency (ATD) and lipid tear deficiency (LTD) patients. Methods: Two hundred and thirty‐six dry eye patients and 174 healthy controls were enrolled in this study. All subjects were grouped as follows: group A (ATD), group B (LTD), group C (SS) and group D (normal controls). All subjects underwent dry eye questionnaire, FD‐OCT scanning, tear film break‐up time (BUT), corneal fluorescence staining and Schirmer I test (SIT). Tear meniscus height (TMH), tear meniscus depth (TMD) and tear meniscus cross‐sectional area (TMA) were measured using FD‐OCT (RTVue‐100). The area under the receiver operating characteristic curve and the cut‐off point were determined using a logistic regression model. Results: Mean TMH, TMD, TMA, BUT and SIT of dry eye patients were significantly lower than those of the controls (p < 0.05). Tear meniscus values were significantly decreased in patients with SS compared with ATD and LTD patients. Tear meniscus values were significantly correlated with clinical examination results in all groups. Accuracy of dry eye diagnosis by FD‐OCT is highest in patients with SS and lowest in LTD patients. The clinical diagnostic critical points were quite different between groups. Conclusions: Fourier‐domain optical coherence tomography could provide precise measurement of the tear meniscus with favourable repeatability. Diagnostic significance is more conspicuous in patients with SS. Tear meniscus measurement by FD‐OCT is expected to become a valuable technique in ATD dry eye screening and diagnosis.     

Prospective controlled study of vapor pressure tear osmolality and tear meniscus height in nasolacrimal duct obstruction

PURPOSE: To determine tear osmolality (TO) and tear meniscus height (TMH) in patients with functional (FNLDO) and primary acquired (PANDO) nasolacrimal duct obstruction. Additionally, to determine the effect of successful dacryocystorhinostomy surgery on these tear parameters. DESIGN: Prospective case-controlled interventional case series. METHODS: Up to 20 microl of basal tears were collected from 20 age- and gender-matched control subjects, 33 patients with FNLDO, 28 patients with PANDO, and 31 patients after successful dacryocystorhinostomy. TMH was measured with videoreflective dacryomeniscometry, and TO was measured with vapor pressure osmometry. RESULTS: Thirty-nine percent of the patients with FNLDO (13/33) elected to undergo dacryocystorhinostomy surgery, compared with 64% of the patients with PANDO (18/28; P = .09). TMH was significantly higher in the disease groups (FNLDO median, 630 +/- 187 microm; PANDO median, 620 +/- 210 microm) compared with the control subjects (median 262 +/- 50 microm; P < .01). In those patients who underwent surgery, TMH was slightly higher in FNLDO than PANDO (P = .08), and TMH reduced significantly after surgery (P < .05). Mean TO in the control subjects was 313 +/- 17 mmol/kg, in FNLDO was 309 +/- 19 mmol/kg, and in PANDO was 315 +/- 24 mmol/kg (P > .05). TO was similar in those patients who progressed to surgery compared with the total group and was unaffected by surgery. CONCLUSION: TO was similar in normal control subjects and in the watery eye group and was unchanged after dacryocystorhinostomy surgery. Despite the slightly higher TMH in patients with FNLDO, a higher proportion of patients PANDO elected to have surgery. Relative to FNLDO, patients with PANDO who progressed to surgery had lower TMH and normal TO, which suggests that a complete lacrimal drainage obstruction induces negative feedback that results in no reduction in TO.     

前节OCT泪河测量的相关参数在干眼诊断中的应用研究

目的 探讨前节相干光断层扫描（optical coherence tomography, OCT）测量泪河的相关参数与干眼诊断指标间的相关性,并对其在干眼诊断中的敏感性和特异性进行分析。设计 前瞻性病例系列。研究对象 2015年6-12月北京同仁眼科中心干眼患者69例（69眼）及对照组44例（44眼）。方法 所有被检查者均按如下顺序进行检查：眼表疾病评分指数（ocular surface disease index, OSDI）问卷调查、泪河的OCT测量、泪膜干涉成像仪检查、泪膜破裂时间（BUT）测定、角结膜荧光素染色、基础泪液分泌试验（SchirmerⅠ）。比较干眼组与正常对照组各项参数的差异。干眼组中各参数相关性分析使用Spearman相关分析法,各参数敏感性及特异性采用受试者工作特征（ROC）曲线及ROC曲线下面积（AUC）来计算。主要指标 OSDI评分、BUT、Schirmer I、角结膜染色评分、泪膜脂质层评分、泪河高度（tear meniscus height,TMH）、泪河深度（tear meniscus depth,TMD）及泪河横截面积（tear meniscus area,THA）。结果 干眼组患者OSDI评分（49.03 ±22.791）、角结膜染色评分（1.18±1.84）明显高于对照组的（8.91 ±4.99）和（0.24 ± 0.52）（P<0.001、 P=0.016);干眼组患者BUT （4.32 ±1.92 s）及Schirmer I（4.29 ±3.77 mm）明显低于对照组的（7.43 ±5.39 s）及（7.48 ±3.65 mm） （P<0.001、P=0.006）。两组泪膜脂质层评分无明显统计学差异 （P=0.158）。干眼组患者TMD、TMH、TMA平均值分别为（127.12 ± 86.95）μm、（152.52 ± 125.15）μm、（12119 ± 1342）μm2,均明显小于对照组的（188.25±87.38）μm、（235.41±135.90）μm、（23099 ±1965）μm2（P<0.001、0.001、0.001）。干眼组TMD、TMH、TMA值三项参数分别与OSDI、Schirmer I、TBUT之间有相关性（P均<0.05）,其诊断干眼的AUC值分别为0.934、0.890、0.925。结论 前节OCT检测的泪河相关参数与干眼临床诊断的指标（OSDI、TBUT、Schirmer I）存在较好的相关性,是一种较为可靠的干眼诊断及随诊方法。     

Assessment of tear meniscus by optical coherence tomography in patients with canalicular laceration repair

To analyze tear meniscus measurements with optical coherence tomography (OCT) in patients with canalicular laceration repair. Thirty-four consecutive patients who underwent unilateral canalicular repair due to canalicular laceration between January 2014 and December 2018 were included. All patients had canalicular repair followed by monocanalicular or annular silicone tube intubation. Anatomic patency of canalicular system was tested with probing and irrigation, while functional patency was evaluated with Munk score. Tear meniscus measurements of all patients were obtained following tube removal by spectral OCT. Tear meniscus height (TMH), tear meniscus depth (TMD) and tear meniscus area (TMA) of eyes with canalicular laceration repair and contralateral uninvolved eyes were compared. Average age of 34 patients was 32.8 ± 21.3 years (range 4–68 years). Lower canaliculus was involved in 27 (79.4%), upper canaliculus in five (14.7%), and both canaliculi in two (5.9%) patients. Mean follow-up period was 6.5 ± 5.7 months. Anatomic patency rate was 100%, and functional patency (patients free of epiphora) was 91.2%. Average TMH (317.9 ± 133.1 µm), TMD (198.1 ± 82.5 µm) and TMA (29,792.1 ± 21,285.3 μm2) values of eyes with canalicular repair were not significantly different from TMH (308.9 ± 111.9 µm), TMD (184.5 ± 61.4 µm) and TMA (26,682.5 ± 16,178.1 μm2) values of contralateral control eyes (p values: 0.758, 0.225 and 0.778, respectively). There was a strong positive correlation between TMA and Munk score (r = 0.637, p < 0.001) and moderate positive correlation between TMH (r = 521, p = 0.002), TMD (r = 0.481, p = 0.004) and Munk score. Tear meniscus measurement with OCT is a rapid, quantitative and objective tool for evaluation of canalicular patency in patients with canalicular laceration repair.     

干眼患者使用表面麻醉剂后泪河形态的改变

目的：探讨干眼患者使用表面麻醉剂后泪河的变化。
　　方法：随机选取干眼患者50例。随机选取一眼滴用表面麻醉剂纳入试验组,另一眼用9g/L生理盐水点眼纳入对照组,点药15 min 后通过眼前节相干光学断层扫描仪( anterior segment optical coherence tomography,AS-OCT)记录并比较两组的泪河高度( tear meniscus height,TMH)、泪河深度( tear meniscus depth,TMD)以及泪河横截面面积( tear meniscus area,TMA)。
　　结果：表面麻醉剂使用后TMH为0.173±0.040mm,TMD为0.166±0.019mm,TMA为0.049±0.013mm2,与点药前相比,差异均有统计学意义( tTMH=2.78,P<0.01;tTMD=2.31,P<0.01;tTMA=2.69,P<0.01),点药后两组相比,差异均有统计学意义(tTMH=5.87,P<0.01;tTMD=2.04,P<0.05;tTMA=4.63,P<0.01)。
　　结论：表面麻醉剂减少干眼患者泪液分泌量,临床工作中应加强预防和干预。     

Case-controlled clinical and histopathological study of conjunctivochalasis

BACKGROUND/AIMS: Conjunctivochalasis, a secondary cause of the watery eye, is frequently seen in the older age group as an elevation of the bulbar conjunctiva lying along the lateral or central lower lid margin. A prospective, interventional, case-controlled clinical and histopathological study was conducted. The relevant features of 18 patients (29 eyes) who had their conjunctivochalasis resected as part of the surgical management of their watery eye syndrome were examined. In the control group, tissue was obtained from an age matched series of 24 normal subjects undergoing routine cataract surgery. METHODS: 24 controls (24 specimens) and 18 patients (29 specimens) had conjunctival strip biopsies, taken from the usual lid margin level bulbar conjunctiva in line with the inferior limbus (controls), and the clinically apparent conjunctivochalasis (patients). These were submitted for histological study. RESULTS: 23 of 24 control sections demonstrated normal conjunctival variation. Four of 29 patient specimens demonstrated a chronic non-granulomatous conjunctivitis, while three eyes of the patient group (two patients) demonstrated features of elastosis. Of the four patients who had the inflammatory infiltrates, three had functional nasolacrimal duct obstructions (FNLDOs) and one had a primary acquired nasolacrimal duct obstruction (PANDO). Of the two patients who had elastosis, one had an FNLDO and the other had normal lacrimal drainage and was Jones 1 positive. CONCLUSION: Six of 18 patients--that is, seven of 29 specimens of conjunctivochalasis demonstrated signs of elastosis or of chronic non-granulomatous inflammation. Clinically, patients had a spectrum of aetiologies of their watery eye syndrome.     

The diagnostic significance of Fourier-domain optical coherence tomography in Sjögren syndrome, aqueous tear deficiency and lipid tear deficiency patients

Purpose: To determine the role of Fourier-domain optical coherence tomography (FD-OCT) in tear meniscus imaging and evaluate its diagnostic significance in Sj?gren syndrome (SS), non-Sj?gren's aqueous tear deficiency (ATD) and lipid tear deficiency (LTD) patients. Methods: Two hundred and thirty-six dry eye patients and 174 healthy controls were enrolled in this study. All subjects were grouped as follows: group A (ATD), group B (LTD), group C (SS) and group D (normal controls). All subjects underwent dry eye questionnaire, FD-OCT scanning, tear film break-up time (BUT), corneal fluorescence staining and Schirmer I test (SIT). Tear meniscus height (TMH), tear meniscus depth (TMD) and tear meniscus cross-sectional area (TMA) were measured using FD-OCT (RTVue-100). The area under the receiver operating characteristic curve and the cut-off point were determined using a logistic regression model. Results: Mean TMH, TMD, TMA, BUT and SIT of dry eye patients were significantly lower than those of the controls (p?相似文献   

不同大小透明角膜切口对白内障超声乳化术后泪膜的影响

目的　采用光学相干断层扫描（ｏｐｔｉｃａｌｃｏｈｅｒｅｎｃｅｔｏｍｏｇｒａｐｈｙ,ＯＣＴ）和其他泪膜检测指标评估不同大小的角膜切口对白内障超声乳化术后泪膜的影响。方法　随机将年龄相关性白内障患者７９例９８眼分为２．２ｍｍ组（４６眼）和３．０ｍｍ组（５２眼）,均行超声乳化白内障吸出联合人工晶状体植入术,于术前、术后１ｄ、７ｄ、１个月及３个月检测基础泪液分泌（ｓｃｈｉｒｍｅｒＩｔｅｓｔ,ＳⅠＴ）、泪膜破裂时间（ｂｒｅａｋ-ｕｐｔｉｍｅ,ＢＵＴ）、干眼症状（ｄｒｙｅｙｅｓｙｍｐｔｏｍｓ,Ｓｘ）评分,并采用ＲＴＶｕｅＯＣＴ检测泪河面积（ｔｅａｒｍｅｎｉｓ-ｃｕｓａｒｅａ,ＴＭＡ）、泪河高度（ｔｅａｒｍｅｎｉｓｃｕｓｈｅｉｇｈｔ,ＴＭＨ）及泪河深度（ｔｅａｒｍｅｎｉｓｃｕｓａｒｅａｄｅｐｔｈ,ＴＭＤ）,对两组各项检测结果进行比较。结果　与术前相比,术后１ｄ、７ｄ、１个月时２．２ｍｍ组及３．０ｍｍ组的Ｓｘ评分均升高（均为Ｐ＜０．０５）,术后３个月时与术前差异均无统计学意义（均为Ｐ＞０．０５）;术后７ｄ时２．２ｍｍ组及３．０ｍｍ组的ＢＵＴ、ＳⅠＴ均不同程度降低（均为Ｐ＜０．０５）,至术后１个月时２．２ｍｍ组的ＳⅠＴ仍较低（Ｐ＜０．０５）,而ＢＵＴ与术前差异无统计学意义（Ｐ＞０．０５）,３．０ｍｍ组的ＢＵＴ、ＳⅠＴ仍不同程度降低（均为Ｐ＜０．０５）;术后１ｄ、７ｄ时２．２ｍｍ组及３．０ｍｍ组的ＴＭＡ、ＴＭＨ及ＴＭＤ均比术前明显减小（均为Ｐ＜０．０５）,术后１个月时２．２ｍｍ组的ＴＭＡ、ＴＭＨ及ＴＭＤ与术前差异均无统计学意义（均为Ｐ＞０．０５）,而３．０ｍｍ组的ＴＭＡ及ＴＭＤ仍比术前明显减小（均为Ｐ＜０．０５）,ＴＭＨ与术前差异无统计学意义（Ｐ＞０．０５）。两组之间相比,２．２ｍｍ组的Ｓｘ评分在术后１ｄ、７ｄ时均比３．０ｍｍ组低,差异均有统计学意义（均为Ｐ＜０．０５）,术后１个月及３个月时两组的Ｓｘ评分差异均无统计学意义（均为Ｐ＞０．０５）;２．２ｍｍ组的ＢＵＴ、ＳⅠＴ在术后７ｄ时均明显高于３．０ｍｍ组（均为Ｐ＜０．０５）,术后１个月及３个月时两组差异均无统计学意义（均为Ｐ＞０．０５）;术后１ｄ、７ｄ时,２．２ｍｍ组的ＴＭＡ、ＴＭＨ及ＴＭＤ均显著高于３．０ｍｍ组（均为Ｐ＜０．０５）,术后１个月及３个月时两组差异均无统计学意义（均为Ｐ＞０．０５）。结论　与３．０ｍｍ透明角膜切口相比,２．２ｍｍ透明角膜切口对眼表泪膜的影响更小,恢复更快。     

The height and radius of the tear meniscus and methods for examining these parameters

PURPOSE: To investigate the relationship between the radius of tear meniscus curvature (TMR) and tear meniscus height (TMH). METHODS: Twenty-nine eyes of dry-eye patients (all left eyes; two males, 27 females, aged 26 to 85 years [mean +/- SD; 60 +/- 14.4]) were enrolled in the study. TMR was measured at the tear meniscus of the central lower lid with a newly developed videomeniscometer. At the same region of the eye, TMHs were measured without fluorescein (TMH-M) and after 5 minutes with fluorescein (TMH-MF), using a slit lamp equipped with a micrometer. TMHs were also measured on cross-sectional photographs of the fluorescein-stained meniscus (TMH-P). RESULTS: The values of TMR, TMH-M, TMH-MF, and TMH-P (mean +/- SD, mm) were 0.22 +/- 0.09, 0.19 +/- 0.09, 0.21 +/- 0.14, and 0.24 +/- 0.09, respectively. There was significant correlation between TMR and TMH-M, TMH-MF, and TMH-P values (TMR versus TMH-M: r = 0.596, p = 0.0005; TMR versus TMH-MF: r = 0.587, p = 0.0006; TMR versus TMH-P: r = 0.605, p = 0.0003). CONCLUSION: There is a significant correlation between TMR and TMH. Videomeniscometry has some merits over conventional methods for obtaining tear meniscus parameters.     

Tear lipid layer interference changes after dacryocystorhinostomy.

PURPOSE: Specular images of the tear film in the central cornea were examined in patients with nasolacrimal duct obstruction to observe changes before and after dacryocystorhinostomy (DCR). METHODS: We observed the specular images in 4 patients (5 eyes) by a noncontact observation device and recording system. Observed patterns were classified into five grades. The specular images and tear meniscus height (TMH) were recorded. RESULTS: Three of the 4 eyes with TMH values over 0.4 mm before DCR showed decreased TMH postoperatively. The 1 eye with a TMH value of 0.2 mm showed no change after DCR. Using specular images, 4 eyes were classified grade 1 or 2, and 1 eye was classified grade 4 before DCR. After DCR, the 5 eyes were classified as grade 3 or grade 4. CONCLUSION: The results indicated that the eye after DCR has a thicker lipid layer than the eye before DCR.     

Ocular surface changes after dacryocystorhinostomy

PURPOSE: To observe changes in tear film lipid interference patterns on the ocular surface in patients with nasolacrimal duct (NLD) obstruction before and after dacryocystorhinostomy (DCR). METHODS: The tear film lipid layer on the ocular surface was observed with a specular reflection video recording system in 5 eyes of 4 patients with NLD obstruction before and after DCR. Precorneal tear lipid layer interference patterns at the central cornea, tear meniscus height (TMH), and the Shirmer I test were recorded. Observed patterns were classified into 5 grades. RESULTS: Three of four eyes with TMH values over 0.4 mm before DCR showed decreased TMH postoperatively. One eye with a TMH of 0.2 mm showed no change after DCR. Concerning the tear film lipid layer interference patterns, 4 eyes were classified as grade 1 or 2, and 1 eye was classified as grade 4 before DCR. After DCR, the 5 eyes were classified from grade 3 to grade 4. Epiphora was successfully resolved in all patients after DCR. CONCLUSION: Tear film lipid layers were classified as normal grades before DCR but most cases changed to high grades after DCR. We suggest that the eye after DCR should have a thicker lipid layer than before DCR.     

Efficacy of dye disappearance test and tear meniscus height in diagnosis and postoperative assessment of nasolacrimal duct obstruction

Objective: To evaluate the efficacy of the fluorescein dye disappearance test (FDDT) and measurement of tear meniscus height (TMH) in the diagnosis and postoperative assessment of nasolacrimal duct obstruction (NLDO). Methods: The study group included 42 eyes of 42 patients who had a diagnosis of primary acquired nasolacrimal duct obstruction (PANDO) or functional nasolacrimal duct obstruction (FNDO) and underwent endoscopic transnasal dacryocystorhinostomy. The control group included 38 eyes of 38 people without tearing. The values of the FDDT, TMH and tearing symptom score (TSS), which was evaluated in five levels based on patients’ history taking, were measured before surgery, and 1 day, 2 weeks, 1, 3 and 6 months after surgery. The values of the FDDT, TMH and TSS in the study group were compared with those of the control group. Results: The preoperative values of the FDDT, TMH and TSS were 0.7 ± 0.4, 0.22 ± 0.08 mm and 1.6, respectively, in the control group and 3.0 ± 0.8, 0.53 ± 0.15 mm and 4.4, respectively, in the study group. These differences were statistically significant. Also, at each follow‐up, the postoperative values of the FDDT and TMH decreased significantly compared to their preoperative values in the study group. The postoperative TSS decreased significantly compared to the preoperative values at each follow‐up except at postoperative 1‐day follow‐up. There were no significant differences in the preoperative values of the FDDT, TMH and TSS between the types of NLDO. The TSS had positive correlations with the FDDT and TMH before and after surgery. Conclusion: These results suggest that the FDDT and TMH measurement might be effective in the diagnosis and postoperative assessment of NLDO.     

原发性获得性鼻泪管阻塞对泪膜及眼表的影响

目的：利用LipiView眼表面干涉仪和Keratograph 5M眼前节分析仪观察原发性获得性鼻泪管阻塞(PANDO)对泪膜及眼表的影响。方法：自身对照临床试验研究。将2021-09/2022-03我科收治的单侧PANDO且病程在6mo以上的患者40例纳入研究,以健眼作为对照。采用LipiView眼表面干涉仪和Keratograph 5M眼前节分析仪测量并分析双眼泪膜及眼表相关参数的差异。结果：纳入患者患眼非侵入性泪河高度(NITMH)、刺激后NITMH、上睑板腺缺失率、鼻颞侧睫状眼红指数、颞侧结膜眼红指数均高于健眼(P&#x003C;0.05),但双眼非侵入性泪膜破裂时间(NIBUT)、下睑板腺缺失率、鼻侧结膜眼红指数、干眼分级、眨眼次数、不完全眨眼率、泪膜脂质层厚度(LLT)均无差异(P&#x003E;0.05)。结论：PANDO可能导致眼表炎症加重及上睑板腺缺失,损害患者眼表健康,应重视早期PANDO的治疗。     

Apparent time‐dependent differences in inferior tear meniscus height in human subjects with mild dry eye symptoms

Purpose: The aim of the study was to track the volume of tears contained in the inferior tear meniscus over the course of the day in subjects with symptoms of mild dry eye and a control asymptomatic group. Methods: Forty non‐contact lens‐wearing subjects (aged 27 ± 6 years) were enrolled in this investigator‐masked study. They were divided into ‘dry eye’ (DE) and ‘non‐dry eye’ (NDE) individuals based on their responses to the Allergan Subjective Evaluation of Symptoms of Dryness (SESOD) questionnaire. Measurement of the tear meniscus height (TMH) was undertaken on the centre of the right eye at 9:00 am, noon, 3:00 pm, 6:00 pm and 9:00 pm on the lower lid using a non‐contact, non‐invasive optical coherence tomographer (OCT). The TMH was determined from scanned images using customised software. Results: A monotonous and significant reduction in the central TMH occurred over the course of the day in both groups (p < 0.05), with the values constantly decreasing (NDE = 0.162 to 0.125 mm; DE = 0.154 to 0.121 mm). While the TMH values in the DE group were always lower than the NDE group, these were not significantly different at any time (p > 0.05). Conclusions: A diurnal reduction in tear volume, as assessed by evaluation of the inferior TMH, may be one of the reasons responsible for the common increase in end‐of‐day ocular dryness symptoms reported by many patients in clinical practice.     

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

Aim

To evaluate symptoms in patients with functional (FNLDO) and primary acquired (PANDO) nasolacrimal duct obstruction, evaluated prospectively before and after successful dacryocystorhinostomy (DCR) surgery.

Design

A questionnaire delivered by interview, pre‐ and postintervention.

Methods

Consecutive patients with either FNLDO or PANDO were derived from a tertiary referral clinic and private practice of two surgeons (GW and ICF). The preoperative cohort consisted of 33 FNLDO patients and 28 PANDO patients. Of these, only 31 patients elected to proceed to DCR surgery. There were 12 FLNDO patients and 19 PANDO patients in the postoperative cohorts, all with definitive surgical success. Successful DCR surgery was indicated by positive endoscopic Jones 1 testing. Symptoms in relation to the patient''s vision, reading, driving, mood, work and embarrassment were assessed. The severity of these symptoms was also graded.

Results

Vision and reading in particular were affected in both preoperative cohorts, and patients suffered significantly from embarrassment. Of the postoperative cohorts, the FNLDO cohort had a reduced percentage of patients suffering each symptom type, whereas the PANDO group had a reduction in percentage of patients reporting each symptom in some but not all areas. However, the overall severity was reduced in both groups, and embarrassment was significantly reduced in both groups.

Conclusion

In both FNLDO and PANDO populations, symptoms bother patients significantly, and successful DCR surgery has a positive effect on the patient''s physical and psychological well‐being.Nasolacrimal duct obstruction (NLDO) is a disorder in which the symptomatology and objective findings do not always correlate. Patients frequently report symptoms of visual blur, difficulty reading, driving, embarrassment and poor mood due to both functional (FNLDO) and primary acquired (PANDO) nasolacrimal duct obstruction. We have observed that objective surgical success does not necessarily correlate with symptom improvement. Sahlin and Rose similarly found that objective surgical success in FNLDO did not necessarily correlate with symptomatic success.¹In our study, following Jones'' definition, FNLDO was defined as a positive fluorescein dye disappearance test (FDDT),a negative Jones 1 and a positive Jones 2 test, with normal lid apposition, no ocular surface disease and a normal sac washout. We have chosen this terminology as inferred from Jones'' original article² and a 1994 American Society of Ophthalmic Plastic and Reconstructive Surgery (ASOPRS) survey.³ Jones alludes to a FNLDO, without calling it that, as being a “partial” obstruction in the nasolacrimal duct. It is characterised by demonstrating a negative Jones 1 and a positive Jones 2 test, albeit at the time determined by cotton wool pledget staining rather than by intranasal endoscopy.² In the 1994 ASOPRS survey,³ the term “functional” was first used in reference to patients symptomatic of tearing with no obvious mechanical obstruction indicated by normal syringing at a time when the approach to such watery eyes was ill‐defined. PANDO was defined as both Jones 1 and 2 tests negative, in the presence of a sac washout with total reflux from the lower to upper canaliculus.In PANDO, an objective finding of complete blockage may not necessarily correlate with more severe symptoms than those of a patient with an FNLDO and an incomplete blockage. Thus, to understand how much these disorders are bothering our patients, we aimed to assess watery eye symptomatology between the two cohorts.Dacryocystorhinostimy (DCR) surgery for FNLDO or PANDO has had objective, anatomical measures of success, as defined by an endoscopically confirmed positive Jones test.⁴ However, the effect of anatomically successful DCR surgery on patients'' symptoms has often been limited to the severity of tearing. We felt that an evaluation of a broader range of watery eye symptoms was necessary to address the issue of whether patients had actually improved in real life terms following objectively successful surgery. Thus, we were interested to see how much successful DCR surgery, as measured by positive Jones 1 testing, altered symptomatology in each of the cohorts, that is objective versus subjective success.The therapeutic index of an intervention represents the ratio of the desired effects as the numerator, to the unwanted effects of an intervention as the denominator.⁵ Fortunately, with DCR surgery, the ratio is quite high, but there are nevertheless significant risks with this surgery.⁶ Thus, it is important to know if this intervention leads to subjectively “successful” outcomes as defined by an improvement in patient symptomatology. This will aid patients in their decision‐making, regarding DCR surgery, by assessing their own therapeutic index.     

Quantitative evaluation of tear meniscus height from fluorescein photographs

PURPOSE: To describe a method of quantifying the tear meniscus height (TMH) and using these values to diagnose patients with dry eye. METHODS: Thirty-eight eyes of 19 healthy subjects and 14 patients diagnosed with dry eye were studied. Each eye received 2 microL of 1% fluorescein-sodium solution in the conjunctival sac, and digital photographs were taken of the external surface of the eye with a fundus camera. The tear meniscus was extracted from the digitalized image and used to measure the TMH with NIH image software. The correlation between the mean TMH and Schirmer test values or cotton-thread test values was evaluated. RESULTS: The means of the upper and lower TMH in healthy subjects were 0.22 +/- 0.06 and 0.24 +/- 0.08 mm, respectively. The comparable values in patients with dry eye were 0.17 +/- 0.04 and 0.17 +/- 0.07 mm (upper TMS, P = 0.01; lower TMH, P = 0.04; unpaired t test). A significant correlation was found between the TMH and Schirmer test values (r = 0.72, P = 0.01) but not with cotton-thread test values. CONCLUSIONS: Fluorescein photographs of the eye can be used to quantify the upper and lower TMH separately and simultaneously without specialized equipment. This technique can be used for the diagnosis of dry eye.     

Measurement of central corneal thickness by high‐resolution Scheimpflug imaging,Fourier‐domain optical coherence tomography and ultrasound pachymetry

Purpose: To compare the repeatability and reproducibility of central corneal thickness (CCT) measurements by high‐resolution (HR) rotating Scheimpflug imaging and Fourier‐domain optical coherence tomography (FD‐OCT). CCT measurements were compared to those determined by ultrasound pachymetry (UP). Methods: In 35 healthy eyes, intra‐observer repeatability for HR Scheimpflug (Pentacam) and FD‐OCT (RTVue) systems was determined in consecutive images taken by an observer in the shortest time possible. Imaging was repeated again by a second observer to evaluate inter‐observer reproducibility. The CCT measurements were compared among Scheimpflug, FD‐OCT and UP images. Results: Mean coefficients of repeatability were 0.48% for Scheimpflug and 0.26% for FD‐OCT. For Scheimpflug, the coefficient of inter‐operator reproducibility was 0.87%. For FD‐OCT, the coefficient of inter‐operator reproducibility was 0.45%. The CCT measurements by Scheimpflug, OCT and UP images were (mean ± standard deviation) 521.7 ± 27.6 μm, 510.8 ± 28.6 μm and 516.5 ± 27.6 μm, respectively. The differences between instruments were statistically significant. The 95% limits of agreement in CCT were ?0.7 to 22.5 μm for Pentacam‐OCT, ?13.4 to 24.0 μm for Pentacam‐UP and ?26.7 to 15.4 μm for OCT‐UP. There was a high degree of correlation between CCT measured by all 3 methods. Conclusion: Noncontact measurements of CCT with HR Scheimpflug and FD‐OCT systems yielded excellent repeatability and reproducibility and can be used interchangeably. Although both devices were comparable with UP; in clinical practice, the measurements acquired by optical modalities are not directly interchangeable with UP measurements.     

Tear production and drainage after botulinum toxin A injection in patients with essential blepharospasm

Purpose: To evaluate the clinical manifestations of tear production, distribution and drainage in the essential blepharospasm patients, and to analyse the changes after botulinum toxin A injection in these patients. Methods: This prospective study was performed in 23 patients with essential blepharospasm treated with Botulinum neurotoxin A (BoNT‐A; Dysport, Ipsen Biopharm, UK) from November 2010 to February 2011. Ocular examinations, including frequency and severity of blepharospasm, tear break up time (BUT), Schirmer’s test, lower lid tear meniscus height (TMH) measured by optical coherence tomography (OCT, rtvue software version 3.5; Optovue Inc., Fremont, CA, USA), and dacryoscintigraphy using 99m technetium pertechnetate, were performed before and 2 weeks after BoNT‐A injection. We asked all patients about changes in the dry eye symptom score, before and after treatment. Results were analysed with independent t‐test using spss software version 12.0 for Windows XP, (SPSS Inc., Chicago, IL, USA). Results: Botulinum neurotoxin A treatment relieved blepharospasm in all patients. Mean injection dose was 38 ± 5.6 units. After injection, mean tear BUT was significantly increased from 4.7 ± 4.9 to 6.6 ± 1.6 seconds (p = 0.001) Lower TMH increased in all three points and most notably at the lateral point (p = 0.05). On dacryoscintigraphy, tear drainage velocity was not affected by BoNT‐A treatment. But Tc‐99m 50% clearance time in interpalpebral fissure significantly increased from 1564 to 2220 seconds on the time activity curve (p = 0.027). Subjective dry eye symptoms also improved in 16 patients (70%) after injection. Conclusion: Tear film stability and TMH increased, but tear drainage velocity was not affected by BoNT‐A treatment. Overall Tc‐99m 50% clearance time in interpalpebral fissure significantly increased, and tear storage from mild lateral lower eyelid laxity increased after BoNT‐A injection. Botulinum neurotoxin A injection was also effective for combined dry eye symptom in the essential blepharospasm patients.     

眼前节相干光断层扫描测量下方泪河高度及其在干眼症诊断中的应用

目的 探讨应用眼前节相干光断层扫描仪(AS-OCT)测量下方泪河高度(TMH)的可行性及其对干眼症的临床诊断价值.方法 诊断试验的评价.选择2007年11月至2008年8月就诊于中山大学中山眼科中心的36例(36只眼)不同程度干眼症患者和38例(38只眼)正常志愿者,应用AS-OCT和测微月镜测量下方泪河高度,采用配对t检验、组内相关系数、单因素方差分析及Spearman秩相关分析等方法,比较正常人组与十眼症患者组、两研究者同一时间获取分析同一组人的TMH值、两研究者分析同一检查者获取的TMH值、同一研究者1周前后重复的测量值,以及比较AS-OCT与裂隙灯显微镜下测微目镜的TMH值.结果 同一时间两研究者独立获取分析22只正常眼TMH值分别为(0.256±0.052)mm和(0.265±0.066)mm,同一研究者不同时间获取分析20只正常眼TMH值分别为(0.265±0.056)mm和(0.272±0.052)mm,两研究者分析20只正常眼TMH值分别为(0.266±0.059)mm和(0.259±0.062)mm,差异均无统计学意义(t=1.881,P=0.074;t=1.306,P=0.207;t=2.048,P=0.065);AS-OCT与测微目镜测量TMH结果呈正相关(r=0.713,P=0.000);正常人泪河高度明显高于干眼患者(t=9.368,P=0.000),正常眼和2、3、4级程度干眼组TMH值[(0.228±0.036)mm,(0.145±0.056)mm,(0.084±0.048)mm]的组间有明显差异(F=55.763.P=0.000).绘制受试者工作特征曲线(ROC曲线),将诊断界别值定为0.213 mm,其敏感性为77.8%,特异性为71.7%.结论 应用眼前节相干光断层扫描测量泪河高度具有良好的可重复性和町靠性,有望作为临床上诊断水样液缺乏性干眼症的客观指标之一.(中华眼科杂志,2009,45:616-620)