Quality of Vision in Eyes With Epiphora Undergoing Lacrimal Passage Intubation SHIZUKA KOH, YASUSHI INOUE, SHINTARO OCHI, YOSHIHIRO TAKAI, NAOYUKI MAEDA, AND KOHJI NISHIDA PURPOSE: To investigate visual function and optical PIPHORA, THE MAIN COMPLAINT OF PATIENTS WITH quality in eyes with epiphora undergoing lacrimal passage lacrimal passage obstruction, causes blurred vision, intubation. discomfort, and skin eczema, and may even cause so- E DESIGN: Prospective case series. cial embarrassment. Several studies have assessed the qual- METHODS: Thirty-four eyes of 30 patients with ity of life (QoL) or vision-related QoL of patients suffering lacrimal passage obstruction were enrolled. Before and from lacrimal disorders and the impact of surgical treat- 1 month after lacrimal passage intubation, functional vi- ments on QoL, using a variety of symptom-based question- sual acuity (FVA), higher-order aberrations (HOAs), naires.1–8 According to these studies, epiphora negatively lower tear meniscus, and tear clearance were assessed. affects QoL physically and socially; however, surgical An FVA measurement system was used to examine treatment can improve QoL. Increased tear meniscus changes in continuous visual acuity (VA) over time, owing to inadequate drainage contributes to blurry and visual function parameters such as FVA, visual main- vision.9 However, quality of vision (QoV) has not been tenance ratio, and blink frequency were obtained. fully quantified in eyes with epiphora, and the effects of Sequential ocular HOAs were measured for 10 seconds lacrimal surgery on such eyes are unknown. after the blink using a wavefront sensor. Aberration Dry eye, a clinically significant multifactorial disorder of data were analyzed in the central 4 mm for coma-like, the ocular surface and tear film, may cause visual distur- spherical-like, and total HOAs. Fluctuation and stability bance.10 However, decreased visual function is difficult to indices of the total HOAs over time were calculated. detect using conventional visual acuity (VA) measurements. Lower tear meniscus was assessed by anterior segment op- Tear film presents at different phases of the tear cycle and thus tical coherence tomography. is not static, and this may affect optical or visual performance. RESULTS: After lacrimal passage intubation, visual Increasing attention to changes in the tear film has expanded function significantly improved, as indicated by improved the ability for continuous sampling of optical quality or visual FVA (P [ .003) and visual maintenance ratio (P < function data in dry eyes.11 Serial measurements of corneal .001). Blink frequency decreased significantly after treat- topographic data or wavefront aberrations are an objective, ment (P [ .01). Optical quality significantly improved, as quantitative way to assess optical quality by measuring irreg- indicated by a decrease in coma-like aberrations (P [ ular corneal astigmatism or higher-order aberrations .003), spherical-like aberrations (P [ .018), and total (HOAs). In contrast, functional visual acuity (FVA), which HOAs (P [ .001). Stability index increased (P < evaluates the time course in VA,12,13 is a subjective method .001) and fluctuation index decreased (P [ .019), and to quantify visual function. These techniques assess tear meniscus dimension decreased (P < .001). dynamic changes in visual function and detect slight visual CONCLUSIONS: Lacrimal passage intubation for eyes deterioration induced by various conditions such as dry eye with epiphora significantly improved visual function despite showing normal VA. and optical quality via patency of the lacrimal It is of interest to know if surgical treatment for eyes with passage. (Am J Ophthalmol 2017;181:71–78. Ó 2017 epiphora can improve QoV in accordance with changes in Elsevier Inc. All rights reserved.) tear film dynamics. The purpose of this study was to inves- tigate subjectively assessed visual function and objectively assessed optical quality, and to evaluate tear film dynamics in eyes with epiphora before and after lacrimal passage Supplemental Material available at AJO.com. intubation. Accepted for publication Jun 21, 2017. From the Departments of Innovative Visual Science (S.K.) and Ophthalmology (S.K., Y.T., N.M., K.N.), Osaka University Graduate School of Medicine, Osaka, Japan; Inoue Eye Clinic (Y.I., S.O.), Okayama, Japan; and Research & Development Division, Rohto (Y.T.), METHODS Kyoto, Japan. Inquiries to Shizuka Koh, Department of Innovative Visual Science, THE STUDY WAS DESIGNED AS A PROSPECTIVE CASE SERIES. Osaka University Graduate School of Medicine, Room E7, 2-2 Yamadaoka, Suita, Osaka 565-0871, Japan; e-mail: [email protected]. The institutional review board of Osaka University Hospi- osaka-u.ac.jp tal approved this study, which adhered to the tenets of the 0002-9394/$36.00 © 2017 ELSEVIER INC.ALL RIGHTS RESERVED. 71 http://dx.doi.org/10.1016/j.ajo.2017.06.022 Declaration of Helsinki. All patients provided informed consent after receiving an explanation of the nature and TABLE 1. Preoperative Underlying Diseases possible consequences of the study. Underlying Disease No. of Cases PATIENT POPULATION: Patients with lacrimal passage Nasolacrimal duct obstruction 13 obstruction who received lacrimal passage intubation from Common canalicular obstruction 8 December 2015 to July 2016 at Inoue Eye Clinic and had a Lower canalicular obstruction 1 best-corrected distance VA of 20/20 or better were considered Single punctal obstruction 1 for enrollment. The inclusion criteria were as follows: symp- Upper and lower punctal obstruction 2 toms of epiphora and the presence of 1 or a combination of Partial nasolacrimal duct obstruction 2 dacryoendoscopic findings (canalicular obstruction and par- Partial common canalicular obstruction 1 Upper and lower canalicular obstruction 2 tial canalicular obstruction, nasolacrimal duct obstruction, combined with nasolacrimal duct and partial nasolacrimal duct obstruction). The exclusion obstruction criteria were congenital lacrimal duct obstruction, acute Partial common canalicular obstruction 1 dacryocystitis, bony obstruction of the nasolacrimal duct, combined with partial nasolacrimal duct and any history of ocular surface surgery. obstruction Common canalicular obstruction combined 3 SURGICAL TECHNIQUE: All surgeries were performed by with nasolacrimal duct obstruction the same surgeon (Y.I.). The surgical procedure of lacrimal passage intubation performed in the current study was a combination of sheath-guided endoscopic probing (SEP) ASSESSMENT OF TEAR MENISCUS: Cross-sectional images and sheath-guided intubation (SGI). This technique en- of the lower tear meniscus were captured vertically across the ables surgeons to perform lacrimal passage reconstruction central cornea using Fourier-domain swept-source OCT (SS- procedures under dacryoendoscopic observation without 2000; Tomey Corp, Nagoya, Japan). This system operates at blind manipulation.14,15 Lacrimal passage anesthesia was 1310 nm and obtains high-resolution imaging at 10 mm performed using an infratrochlear nerve block with 1% (axial) and 30 mm (transverse). The principles, technique, lidocaine and canalicular system irrigation with 4% and reproducibility of this device have been described previ- lidocaine solution, after which both puncta were dilated. ously.16,17 The OCT images were processed by a single trained Prior to SEP, a dacryoendoscope (RUIDO Fiberscope observer (S.O.) using equipped software. Lower tear meniscus MD10; FiberTech Co, Ltd, Tokyo, Japan) was covered height (TMH) and lower tear meniscus area (TMA) were with a sheath that was created from an 18 gauge plastic calculated from the cross-sectional OCT images of the lower cannula (SurFlash Polyurethane IV Catheters; Terumo tear meniscus. The measurement was performed between 4 Corporation, Tokyo, Japan). After a dacryoendoscope and 5 seconds after a blink with spontaneous eye opening. equipped with a sheath was inserted into the punctum, SEP was performed by widening the blocked section. The FUNCTIONAL VISUAL ACUITY MEASUREMENT: We outer diameter of the dacryoendoscope is 0.9 mm (20 used the FVA measurement system (AS-28; Kowa, Nagoya, gauge). After the removal of the dacryoendoscope, the Japan) to assess the change in continuous VA over time. sheath was temporarily retained in the lacrimal passage The measurement system has been described previously.13,18 and used as a guide for tube insertion during SGI. An 11- In brief, FVA was measured monocularly with best spectacle cm-long polyurethane Nunchaku-style lacrimal tube (PF correction under photopic condition, during a 60-second catheter; Toray Industries Inc, Tokyo, Japan) was period. During the measurement, subjects were instructed connected with the sheath. By retrieving the sheath to blink naturally and to identify the orientation of automat- through the nasal cavity, the surgeon was able to draw ically demonstrated Landolt rings with the use of a joystick. the lacrimal tube into the recanalized passage. The same The outcomes recorded were baseline VA, FVA, visual main- steps were repeated for the other punctum using the combi- tenance ratio (VMR), and blink frequency (FVM index). nation of SEP and SGI. Definition of these parameters were as follows: baseline VA is the baseline best-corrected VA measured using the FVA EXAMINATION PROTOCOL: Clinical measurements measurement system; FVA is the mean value of VA during were performed in the following order preoperatively the 60-second measurement; and VMR is the FVA