10.14639/0392-100X-N0881
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.
text/xml
1827-675X
881
en
Frank Rikki Canevari
https://creativecommons.org/licenses/by-nc-nd/4.0
ACTA Otorhinolaryngologica Italica
quality of life
Application of a symptoms score questionnaire after conjunctivodacryocystorhinostomy: outcomes
Text.Serial.Journal
https://www.actaitalica.it/
41
Rhinology
2021-07-07
2020-05-26
2021-07-08
2021-07-08
248-254
1
Frank Rikki Canevari
2021/07/07
10.14639/0392-100X-N0881
248
IRCCS Ospedale Policlinico San Martino, Genoa, Italy; Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
1827-675X
quality of life
en
254
Application of a symptoms score questionnaire after conjunctivodacryocystorhinostomy: outcomes
https://www.actaitalica.it/article/download/881/623
41
ACTA OTORHINOLARYNGOLOGICA ITALICA 2021;41:248-254; doi: 10.14639/0392-100X-N0881




Rhinology


Application of a symptoms score questionnaire
after conjunctivodacryocystorhinostomy: outcomes
L’applicazione di un questionario sui sintomi dopo congiuntivodacriocistorinostomia:
risultati
Andrea Iandelli1,2, Andrea Luigi Camillo Carobbio1,2, Renata Migliardi3, Maurizio Catalani4, Francesco Mazzola5,
Giampiero Parrinello1, Giorgio Peretti1,2, Frank Rikki Canevari1,2
1
 IRCCS Ospedale Policlinico San Martino, Genoa, Italy; 2 Department of Surgical Sciences and Integrated Diagnostics (DISC),
University of Genoa, Genoa, Italy ; 3 Department of Ophthalmology, Ospedale Policlinico di Monza, Monza, Italy; 4 Department of
Otorhinolaryngology, Istituto Clinico Cellini Humanitas, Turin, Italy; 5 Department of Otorhinolaryngology, Head and Neck Surgery,
National Cancer Institute Regina Elena, Rome, Italy


SUMMARY
Objective. To evaluate medium/long term outcomes and patient satisfaction through re-
lief of symptoms and improved quality of life (QoL) after Jones tube conjunctivodacryo-
cystorhinostomy (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.
                                                                                                Received: May 25, 2020
Results. We enrolled 16 patients, for a total of 21 eyes operated. The success rate for pro-    Accepted: January 10, 2021
cedures 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%.                Correspondence
Conclusions. JT-CDCR was a reliable procedure, able to solve symptoms in a majority of          Andrea Iandelli
patients and guaranteed a good quality of life over a long period of time                       IRCCS Ospedale Policlinico San Martino
                                                                                                largo Rosanna Benzi 10, 16132 Genoa, Italy
KEY WORDS: conjunctivodacryocystorhinostomy, nasolacrimal duct obstruction,                     E-mail: iandelliandrea@gmail.com
epiphora, symptom score, quality of life
                                                                                                Funding
                                                                                                None.
RIASSUNTO
Obiettivo. Valutare gli esiti a lungo termine e la soddisfazione del paziente, attraverso la
                                                                                                Conflict of interest
risoluzione della sintomatologia e il miglioramento della qualità della vita (QoL) dopo
                                                                                                The Authors declare no conflict of interest.
intervento di congiuntivodacriocistorinostomua e posizionamento di Tubo di Jones CDCR-
JT, mediante l’utilizzo del questionario “Naso Lacrimal Duct Obstruction Symptoms-Score
(NLDO-SS)”.                                                                                       How to cite this article: Iandelli A, Carob-
                                                                                                  bio ALC, Migliardi R, et al. Application of a
Metodi. Abbiamo condotto uno studio retrospettivo, non comparativo, multicentrico, inclu-
                                                                                                  symptoms score questionnaire after conjunc-
dendo pazienti con ostruzione completa della lacrimale prossimale superiore e inferiore.          tivodacryocystorhinostomy: outcomes. Acta
Tutti i pazienti sono stati sottoposti a JT-CDCR, la pervietà del tubo di Jones è stata valu-     Otorhinolaryngol Ital 2021;41:248-254. https://
tata con irrigazione di soluzione fisiologia ed endoscopia trans-nasale. A ciascun paziente       doi.org/10.14639/0392-100X-N0881
è stato poi somministrato il questionario NLDO-SS.
Risultati. Abbiamo arruolato 16 pazienti, per un totale di 21 occhi operati. Il tasso di        © Società Italiana di Otorinolaringoiatria
successo delle procedure è stato dell’81%. Il tasso di successo per i singoli parametri è       e Chirurgia Cervico-Facciale

stato globalmente del 95,9%; se considerati separatamente, i sintomi oculari e quelli nasali
                                                                                                               OPEN ACCESS
erano rispettivamente del 94,3% e del 100%.
Conclusioni. L’intervento di JT-CDCR ha dimostrato di essere in grado di risolvere i sin-       This is an open access article distributed in accordance with
tomi nella maggior parte dei pazienti e di garantire una buona qualità di vita per un lungo     the CC-BY-NC-ND (Creative Commons Attribution-Non-
                                                                                                Commercial-NoDerivatives 4.0 International) license. The
periodo di tempo.                                                                               article can be used by giving appropriate credit and mentio-
                                                                                                ning the license, but only for non-commercial purposes and
PAROLE CHIAVE: congiuntivodacriocistorinostomia, ostruzione del dotto nasolacrimale,            only in the original version. For further information: https://
epifora, questionario sintomi, qualità di vita                                                  creativecommons.org/licenses/by-nc-nd/4.0/deed.en




248
                                                           Quality of life after endoscopic conjunctivodacryocystorhinostomy with Jones tube




Introduction                                                    flexed tearing. The preoperative examination included lac-
                                                                rimal irrigation, probing of canaliculi, general ophthalmic
Nasolacrimal duct obstruction (NLDO) surgery is a shared
                                                                evaluation and nasal cavity examination by office-based
field between ophthalmologists and otorhinolaryngolo-
                                                                endoscopy. All patients underwent CT evaluation to assess
gists. The development of endoscopic surgery has encour-
                                                                nasal anatomical variations and to customise the surgical
aged rhinological specialists to extend their skills in the
                                                                strategy.
management of this pathology.
Conjunctivodacryocystorhinostomy (CDCR) was first de-
                                                                Surgical technique
scribed by Von Hoffman in 1904, and later by Kraupa and
                                                                Endoscopic-assisted CDCR was performed under general
Goar 1. CDCR using the insertion of a Pyrex bypass tube,
                                                                or local anaesthesia based on comorbidities and age. An
the Jones tube (JT), was first described by Lester Jones in
                                                                endoscopic minimal-invasive bypass tube was used without
1962 2 and revolutionised the management of proximal ob-
                                                                dacryocystorhinostomy (DCR) in all patients. A 14-gauge
struction of the lacrimal drainage system. Nowadays, it rep-
                                                                intravenous catheter was introduced through the caruncle
resents the gold standard for complete or severe canalicular
                                                                with a 45° downward direction to the nasal cavity. The
obstruction and is performed as an additional procedure for
                                                                penetration of the lateral wall of the nasal mucosa, anterior
failed canalicular surgery, unsuccessful dacryocystorhinos-
                                                                to the middle turbinate, was confirmed by trans-nasal en-
tomy (DCR), and refractory lacrimal pump failure 2.
                                                                doscopic control. A graduated Bowman’s probe was then
Endoscopically-assisted placement of the JT gives the sur-
                                                                passed through the caruncle into the tract using increased
geon a chance to assess the proper position of the device
                                                                diameter probes to enlarge the fistula. The probe gradua-
and, later, tailor its length and angle to avoid painful mu-
                                                                tion reflects the length of Jones tube required. The authors
cosal contact or decubitus. Considering the presence of a
                                                                used a 2 mm Pyrex tube with a flange of 4 mm, inserted
permanent foreign body in the lacrimal canaliculum, it is
                                                                through the caruncola. Endoscopic transnasal control was
mandatory to investigate patient discomfort and the ability
                                                                performed to verify the correct position of the tube. At the
of the JT to resolve symptoms related to the underlying pa-
thology; while the majority of the published articles on JT     end of the procedure, the tube was fixed with a suture to the
conjunctivodacryocystorhinostomy (JT-CDCR) outcomes             inferior eyelid. A saline solution irrigation verified that the
have focused on the primary surgery and initial success         tube was not obstructed. No nasal packing was required for
rate 3, few studies have reported results exceeding one year    the procedures.
postoperative and have not considered patient satisfaction
and improvement of quality of life (QoL) 4; therefore, the      Follow-up
purpose of this study was to evaluate results after a me-       All patients underwent an endoscopic nasal toilette and de-
dium/long period of time and patient satisfaction through       bridement 15 and 30 days after the surgery. Patients were
relief of symptoms and improved QoL using the Naso Lac-         followed-up with transnasal endoscopic evaluation and JT
rimal Duct Obstruction symptom-score (NLDO-SS).                 effectiveness assessment with saline solution irrigation 6
                                                                months post-op and, subsequently, once per year.
Materials and methods                                           NLDO-SS questionnaire
Study design                                                    All patients eligible for the study were contacted by tel-
A multicentric, retrospective and non-comparative study         ephone to administer the NLDO-SS questionnaire. The an-
was performed. Patients who underwent endoscopic-guid-          swers were collected by a third party, unrelated to the team
ed JT-CDCR from January 2006 to January 2019 in the             that performed the surgery. Patients were assured that their
Otorhinolaryngological Department of San Martino Hos-           answers would be kept strictly confidential and anonymous
pital, Genoa and the Ophthalmology Department of Koel-          and signed consent for the use of collected data. Patients
liker Hospital, Turin, were enrolled. In order to avoid any     were guided through the questionnaire by the interviewer.
procedural or surgeon bias, all patients enrolled underwent     The NLDO-SS questionnaire 5 consists of five items focus-
the same surgical technique, step-by-step, as long as each      ing on the common ocular symptoms of NLDO: tearing,
procedure was both anatomically and surgically successful.      discharge in the eye, swelling around the eye, pain around
Each eye and nasal fossa was considered separately.             the eye, change in visual acuity; along with two items de-
                                                                scribing the conditions in the nasal cavity: nose blockage,
Preoperative assessment                                         nasal cavity discharge (Tab. I). In the NLDO-SS, symptoms
Patients were subjected to accurate evaluation to rule out      are graded using an 11-point numeric rating scale (NRS;
any other common causes of epiphora such as dry eye re-         0 = no symptoms, 10 = worst imaginable symptoms). The



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A. Iandelli et al.




Table I. NLDO-SS results.
 Case        Tearing       Purulent         Swelling     Pain   Loss of   Total ocular     Nasal         Nasal     Total nasal   Total    FU
                          discharge                              vision    symptoms      obstruction   discharge   symptoms      Score   time
 1                    2          0              0         3       0            5             0             0           0           5      49
 2                    1          0              0         0       0            1             0             0           0           1      17
 3                    0          1              0         0       0            1             1             1           2           3      29
 4                    3          2              0         1       0            6             2             1           3           9      29
 5                    3          2              2         0       2            9             1             2           3          12      14
 6                    3          3              0         0       1            7             0             0           0           7      21
 7                    3          0              0         1       1            5             0             0           0           5      21
 8                    3          2              0         0       0            5             0             0           0           5      61
 9                    5          2              5         3       5           20             0             1           1          21      58
 10                   6          2              4         3       5           20             0             1           1          21      58
 11                   2          0              0         0       0            2             0             3           3           5      53
 12                   0          0              0         0       0            0             1             2           3           3      47
 13                   1          0              0         0       0            1             0             0           0           1      46
 14                   5          3              0         2       3           13             0             0           0          13      42
 15                   3          4              2         0       0            9             0             0           0           9      36
 16                   3          3              2         0       0            8             0             0           0           8      36
 17                   1          0              0         0       0            1             0             0           0           1      24
 18                   1          0              0         0       0            1             0             0           0           1      24
 19                   1          0              0         0       0            1             0             0           0           1      75
 20                   1          0              0         0       0            1             0             0           0           1     160
 21                   0          3              2         3       1            9             0             0           0           9      24
 Min                  0          0              0         0       0            0             0             0           0           1      14
 Max                  6          4              5         3       5            2             2             3           3          21     160
 Mean                2.2        1.3            0.8       0.8     0.9          6.0           0.2           0.5         0.8         6.7    50,0
 Median               2          1              0         0       0            5             0             0           0           5     36,5
NLDO-SS: Naso Lacrimal Duct Obstruction Symptom Score.



total number of points for NLDO-SS ranges from 0 to 70                         ed bilaterally in 5 patients (31.2%) and unilaterally in 11
points. As reported by Pentilla et al., we consider a cut-off                  (68.8%), and thus a total of 21 eyes underwent CDCR. The
point of ≥ 21/70 for failed procedures and ≤ 10/70 for suc-                    mean age at the moment of surgery was 54 years (range 16-
cessful ones. Respecting the 1/3 ratio, each variable was                      76 years). The mean duration of follow-up was 50 months
investigated considering cut-off points of ≤ 3/10 for suc-                     (range 14-160 months), with a median of 36.5 months. The
cesses and ≥ 4/10 for failures in the ability of the procedure                 demographic data of the cohort is shown in Table II. All JT
to resolve the specific symptom 6.                                             were active, and no granulation was detected around the
                                                                               tube rim. The most frequent cause that led to surgery was
Statistical analysis                                                           acquired obstruction secondary to infection and inflamma-
GraphPad Prism (San Diego, CA, USA) was used for statisti-                     tion (10/21; 47.6%), followed by idiopathic stenosis (5/21;
cal analysis. Primary surgery versus revision surgery groups                   23.8%). The majority of patients underwent revision sur-
comparison analysis was performed using Fisher’s exact test                    gery (15/21; 71.4%), while 6/21 cases (28.6%) were pri-
or Mann-Whitney test (MWt), as appropriate. A two-tailed                       mary surgery cases.
p-value < 0.05 was considered statistically significant.                       The NLDO-SS questionnaire results for each patient are
                                                                               listed in Table II. The total score in our series ranged from
                                                                               a minimum of 1 to a maximum of 21 points. The mean
Results                                                                        value was 6.7 points with a median of 5 points. The success
A total of 16 patients were recruited. There were 4 males                      rate for the procedures in our series was 81% (17/21 proce-
(25%) and 12 females (75%). The procedure was conduct-                         dures) and was defined by a total score ≤ 10 points; the fail-



250
                                                                       Quality of life after endoscopic conjunctivodacryocystorhinostomy with Jones tube




Table II. Patient demographics, history, pathophysiology.                   a significant difference between primary and revision sur-
 Patients                                      16                           gery was found for “tearing” score (p = 0.040) and “loss
 Eyes                                          21                           of vision” score (p = 0.002). No difference was found for
 Sex                                 F                     12 (75%)         other ocular symptoms or nasal symptoms. Table III reports
                                     M                      4 (25%)         the results of statistical analysis.
 Age (y)                            Min                        16
                                   Max                         76           Discussion
                                  Mean                         54
                                                                            Canalicular block is a challenge in treatment lacrimal path-
 Follow-up (m)                      Min                        14
                                                                            way disease. CDCR with the insertion of a Pyrex bypass
                                   Max                        160
                                                                            tube was first described by Lester Jones in 1962 2 and re-
                                  Mean                         50
                                                                            mains the gold standard in surgical treatment of proximal
                                 Median                       36.5
                                                                            obstruction of the lacrimal drainage system. Since its in-
 Cause of the          Post-infective/inflammatory        10 (47.6%)        troduction, the surgical technique has remained unchanged
 stenosis                  Idiopathic stenosis            5 (23.8%)         and only a few modifications have been described regard-
                       Autoimmune conjunctivitis           2 (9.5%)         ing the shape and angulation of the JT. Furthermore, dif-
                              Other causes                 4 (19.0%)        ferent fixation techniques have been proposed 7,8. The suc-
 Type of surgery                 Primary                  15 (71.4%)        cess rate of JT-CDCR varies from 57% to 98% in different
                                 Revision                  6 (28.6%)        studies 4,9 and there is great heterogeneity among outcomes
 Laterality                    Monolateral                11 (68.8%)        evaluated to define the effectiveness of the procedure 3. In
                                 Bilateral                 5 (31.2%)        our series, there were significantly more females subjected
                                                                            to CDCR (75%) with a mean age, similar to other studies,
                                                                            of 53 years 10,11. The demographic characteristics of our co-
ure rate was 9.5% (2/21 procedures) and corresponded to                     hort were consistent with the current literature 12. Acquired
a total score of ≥ 21 points; an intermediate value between                 NLDO is most commonly encountered in women in their
10 and 21 points was registered in 9.5% of cases (2/21                      50’s or older, which seems to be related to the narrowness
procedures). The mean value for ocular symptoms was 6.7                     of the bony nasolacrimal canal and the acute angle between
points (range 0-20), with the maximum single symptom                        the bony canal and the nasal floor possibly predisposing
score reported for tearing (6 points), followed by swelling                 women to chronic inflammation of the nasolacrimal drain-
and loss of vision (5 points), purulent discharge (4 points)                age system 13. Moreover, postmenopausal hormonal chang-
and pain (3 points). The mean value for nasal symptoms                      es may account for this difference between genders 14.
was 0.3 points (range 0-3), with the maximum single symp-                   Post-infective/inflammatory sequelae were found to be the
tom score reported for nasal discharge (3 points), followed                 most prevalent cause (47.6%) in determining the need for
by nasal obstruction (1 point). The success rate for single                 JT-CDCR. Chronic inflammation and infections such as
parameters, defined by a score of ≤ 3, was globally 95.9%                   blepharitis and recurrent conjunctivitis determine a gradual
(141/147), 94.3% (99/105) and 100% (42/42) for ocular                       thickening of the nasolacrimal duct mucosa 11; furthermore,
and nasal symptoms, respectively; on the other hand, the                    it is assumed that these conditions are a precursor to ex-
failure rate for single parameters, defined by a score of ≥ 4,              ternal punctal stenosis (EPS) based on inflammatory and
was globally 0.4% (6/147), and 0.6% (6/105) for ocular                      cicatricial changes. Chronic disease can result in inflam-
symptoms and 0% (0/42) for nasal symptoms.                                  matory membrane formation, conjunctival epithelial over-
Fisher’s exact test did not show any significant difference                 growth and keratinisation of the walls of the punctum 15.
between the “primary surgery” versus “revision surgery”                     These conditions, therefore, may lead to severe or complete
groups in terms of gender distribution (p = 0.517), laterality              obstruction of EPS with the necessity of JT insertion to re-
of the procedure (p = 0.546), or success rate (p = 0.053). The              store the patency of lacrimal drainage; an increased risk
different distribution of the causes of epiphora was investi-               of outpatient procedure failure (e.g., punctoplasty and bal-
gated by comparing the two main causes found in our pop-                    loon dilation) has been reported 16. Indeed, the majority of
ulation with the totality of all other possible causes: “post-              procedures in our case series were represented by second-
infective/inflammatory” versus “other causes” (p = 0.149)                   ary treatments after failure of outpatient surgery, compared
and “idiopathic” versus “other causes” (p = 0.011). The                     to upfront CDCR (71.4% vs 28.6%), confirming the poor
scores obtained in the NLDO-SS questionnaire for each                       trend in response to less invasive treatment. The second
symptom were compared in the two groups with the MWt:                       most represented cause of NLDO was idiopathic nasolac-



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A. Iandelli et al.




Table III. Comparison between primary and revision surgery groups and statistical significance.
 Parameter                                                                         Primary                          Revision              p-value
    Gender                                              Male                                 0/4 (0%)              4/12 (25%)              0.517†
    Laterality                                          Monolateral                         2/4 (50%)              9/12 (75%)              0.546†
    Success                                             Yes                                 3/6 (50%)              14/1 (93%)              0.053†
    Cause                                               Post-infective/                     1/6 (17%)              9/15 (60%)              0.149†
                                                        inflammatory VS others
                                                        Idiopathic VS others                4/6 (67%)              1/15 (6.7%)             0.011†
    Symptoms (median of scores)                         Tearing                                 3                       2                  0.040‡
                                                        Purulent discharge                      2                       1                  0.676‡
                                                        Swelling                                0                       0                  0.157‡
                                                        Pain                                    0                       0                  0.378‡
                                                        Loss of vision                          1                       0                  0.002‡
                                                        Nasal obstruction                       0                       0                  0.886‡
                                                        Nasal discharge                         1                       0                  0.549‡
†
    = calculated with the Fisher’s exact test; ‡ = calculated with the Mann-Whitney test



rimal duct obstruction (INDO), defined as an obstruction                                   specific ocular symptoms; the most important difference
in which no cause can be established despite careful his-                                  between these two questionnaires is that Lac-Q includes
tory and detailed clinical examination, with a percentage                                  an additional score for social impact, although it does not
of 23.8%. This data is in line with the present literature 14.                             take into account nasal symptoms. Different authors in the
Involutional changes such as aging and tissue atrophy can                                  literature reported an efficient application of Lac-Q in their
cause the dense fibrous structure to become less resilient                                 experience and found the questionnaire to be responsive to
and the surrounding orbicularis fibres to become atonic,                                   changes in clinical outcomes 20,21. However, since most of
resulting in stenosis 17. This subgroup underwent primary                                  the procedures used have a nasal endoscopic phase along
CDCR (p = 0.011) significantly more often, most likely                                     with septoplasty, middle turbinoplasty, or a partial uncinec-
due to a lack of evidence of concurrent disease on which                                   tomy where appropriate to widen the space for the distal
to intervene to resolve the underlying cause. In a recent                                  part of the JT and/or avoid mucosal contact and incorrect
systematic review published by Eisenbach et al. 12 on 54                                   angle of the tube itself, we preferred to use the NLDO-SS
articles and 2372 patients, the authors reported a similar                                 to investigate nasal symptoms which could be related to the
distribution among the different aetiologies, although our                                 procedure. Moreover, the sample of patients used to vali-
group did not include any case of post-traumatic or can-                                   date Lac-Q was composed of 29 patients, compared to 76
cer related stenosis. In our retrospective study, we decided                               patients in NLDO-SS, and thus we retain that the latter to
to employ NLDO-SS to assess patient satisfaction after                                     be more reliable instrument.
an anatomically and surgically successful CDCR proce-                                      According to the NLDO-SS, we obtained a success rate of
dure. NLDO-SS was originally conceived by Smirnov et                                       81% (17/21) regarding the total score; this result is in ac-
al. 5 to assess outcomes after treatment naso-lacrimal duct                                cordance with the average outcomes reported in other stud-
obstructions, and we decided to apply the score to our pa-                                 ies, which did not use the aforementioned score 4, highlight-
tients since nasolacrimal duct obstruction and canalicular                                 ing that the NLDO-SS does not deviate consistently from
obstruction share the same plethora of symptoms 14, and                                    other evaluation systems present in literature. Among the
both the anatomical subsites participate as a whole to the                                 group of failed procedures, the two operations that did not
lacrimal drainage system.                                                                  improve the subjective symptomatology, despite objective
NLDO-SS is not the only tool available to assess post-                                     surgical success, were performed bilaterally on the same
surgical QoL: Glasgow Benefit Inventory (GBI) and Lac-                                     patient. This result reveals that a successful surgical out-
rimal Symptoms Questionnaire (Lac-Q) are also widely                                       come does not necessarily confer improvement in QoL 22.
used. Although GBI is a well known and validated measure                                   Satisfaction depends, in addition to a well-performed pro-
for otorhinolaryngological intervention 18, it does not pro-                               cedure, to a great extent on the patient’s expectations, un-
vide information about surgical outcomes, is not disease-                                  derstanding of the nature and function of the tube, as well
specific and does not include ocular symptoms. Lac-Q 19,                                   as to the ability of the surgeon to explain the procedure in
similar to NLDO-SS, takes into account the severity of                                     detail and its goals and limitations 23.



252
                                                                      Quality of life after endoscopic conjunctivodacryocystorhinostomy with Jones tube




The significant difference in “tearing” (p = 0.040) and “loss              5
                                                                                Smirnov G, Tuomilehto H, Kokki H, et al. Symptom score question-
                                                                                naire for nasolacrimal duct obstruction in adults - a novel tool to as-
of vision” between patients treated with primary CDCR
                                                                                sess the outcome after endoscopic dacryocystorhinostomy. Rhinology
compared to revision group can be interpreted two-fold:                         2010;48:446-451. https://doi.org/10.4193/Rhino10.069
firstly, patients who underwent a revision CDRC usually                    6
                                                                                Pentilla E, Smirnov G, Seppa J, et al. Validation of a symptom-score
have a long history of epiphora and have already under-                         questionnaire and long therm result of endoscopic dacryocystorhinos-
gone previous procedures (punctoplasty, balloon dilatation,                     tomy. Rhinology 2014;52:84-89. https://doi.org/10.4193/Rhin. 2014
                                                                           7
                                                                                Na J, Lee S, Park J, et al. Surgical outcomes of endonasal con-
dacryocystorhinostomy) with multiple follow-ups, manip-
                                                                                junctivodacryocystorhinostomy according to Jones Tube Loca-
ulations, endoscopic nasal debridement and even correc-                         tion. J Craniofac Surg 2017;28:e500-e503. https://doi.org/10.1097/
tive procedures; furthermore, if the patient has experienced                    SCS.0000000000003801
relapses or persistence of symptoms, it might make them                    8
                                                                                Goel R, Kishura D, Nagpal S, et al. Results of a new “mirror tuck
more prone to express a higher grade of satisfaction after                      technique” for fixation of lacrimal bypass tube in conjunctivodacryo-
                                                                                cystorhinostomy. Indian J Ophthalmol 2017;65:282-287. https://doi.
relief of symptoms, given their personal clinical history 24.                   org/10.4103/ijo.IJO_741_16
Secondly, a proportion of patients may have underlying                     9
                                                                                Passos W, Schellini SA, Padovani CR. Lester-Jones tube: indica-
subclinical conditions which caused the persistence of the                      tions and results. Arq Bras Oftalmol 2004;67:863-866. https://doi.
obstruction and symptoms due to improper target therapy.                        org/10.1590/S0004-27492004000600004
The success rate of CDCR has been demonstrated to be
                                                                           10
                                                                                Woog JJ. The incidence of symptomatic acquired lacrimal outflow
                                                                                obstruction among residents of Olmsted County, Minnesota, 1976-
constant with long term follow-up, similar to other series                      2000 (an American Ophthalmological Society thesis). Trans Am Oph-
that were conducted for longer periods, and identified that                     thalmol Soc 2007;105:649-666.
heightened risk of failure (e.g. extrusion, scarring, or gran-             11
                                                                                Trimarchi M, Vinciguerra A, Resti AG, et al. Multidisci-
ulation) occurs in the first two years post-operative 25.                       plinary approach to lacrimal system diseases. Acta Otorhi-
                                                                                nolaryngol Ital 2021;41(Suppl. 1):S102-S107. https://doi.
                                                                                org/10.14639/0392-100X-suppl.1-41-2021-10
Conclusions                                                                12
                                                                                Eisenbach N, Karni O, Sela E, et al. Conjunctivodacryocystorhinos-
                                                                                tomy (CDCR) success rates and complications in endoscopic vs non-
In our experience, JT-CDCR is a reliable procedure and                          endoscopic approaches: a systematic review. Int Forum Allergy Rhi-
able to improve symptoms in the majority of patients with a                     nol 2021;11:174-194 https://doi.org/10.1002/alr.22668
good long-term quality of life. The use of a scoring system
                                                                           13
                                                                                Shigeta KI, Takegoshi H, Kikuchi S. Sex and age differences in the
                                                                                bony nasolacrimal canal: an anatomical study. Arch Ophthalmol
to assess patient-reported outcomes and satisfaction allows                     2007;125:1677-1681. https://doi.org/10.1001/archopht.125.12.1677
clinicians to evaluate results, success rates and measure any              14
                                                                                Kashkouli MB, Beigi B, Murthy R, et al. Acquired exter-
changes of symptoms during follow-up, given that the pa-                        nal punctal stenosis: Etiology and associated findings. Am J
tency of the lacrimal pathway alone does not necessarily                        Ophthalmol         2003;136:1079-1084.        https://doi.org/10.1016/
                                                                                s0002-9394(03)00664-0
mean satisfaction for the patient.                                         15
                                                                                Edelstein J, Reiss G. The wedge punctoplasty for treatment of punctal
A thorough assessment is necessary to identify which pa-                        stenosis. Ophthalmic Surg 1992;23:818-821.
tients can properly benefit from JT-CDCR. Further pro-                     16
                                                                                Offutt WN, Cowen DE. Stenotic puncta: microsurgical puncto-
spective studies analysing a larger cohort of patients and                      plasty. Ophthal Plast Reconstr Surg 1993;9:201-205. https://doi.
longer follow-up are needed to confirm the validity of NL-                      org/10.1097/00002341-199309000-00006
DO-SS in the assessment of post-surgical symptoms after
                                                                           17
                                                                                Mills DM, Meyer DR. Acquired nasolacrimal duct obstruction. Oto-
                                                                                laryngol Clin North Am 2006;39:979-99,vii. https://doi.org/10.1016/j.
JT-CDCR and the effectiveness of this procedure.                                otc.2006.07.002
                                                                           18
                                                                                Robinson K, Gatehouse S, Browning GG. Measuring pa-
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