Content uploaded by Jane M Olver
Author content
All content in this area was uploaded by Jane M Olver on Nov 19, 2014
Content may be subject to copyright.
Patient satisfaction
following endoscopic
endonasal
dacryocystorhinostomy:
a quality of life study
G Jutley, R Karim, N Joharatnam, S Latif, T Lynch
and JM Olver
Abstract
Purpose To assess the subjective success
and quality of life of adult patients post
endoscopic endonasal dacryocystorhinostomy
(EE-DCR) for acquired nasolacrimal duct
obstruction.
Design Retrospective, questionnaire study
performed at least 6 months post EE-DCR.
Participants Hundred and ten of the
282 consecutive patients who underwent
EE-DCR.
Methods A standardised questionnaire
(Glasgow Benefit Inventory, GBI) was used to
analyse the quality of life. The questionnaire
examines four parameters, providing total,
subscale, social, and physical scores.
Main outcome measures We aimed to assess
patient experience following EE-DCR
surgery. Total GBI scores range from 100 to
þ 100, the former reflecting maximal negative
benefit and corresponding to subjective
worsening of tearing and impact on quality
of life. Any positive score reflects a
satisfactory surgical outcome and þ 100
represents maximal positive benefit. A score
of zero is no perceived benefit.
Results The average age was 62 years, 63%
were female. In three of the parameters
measured, there was a subjective
improvement post surgery: subscale score
22.16 (95% CI: 15.23–29.09), total score 15.04
(95% CI: 9.74–20.35), and social support score
4.67 (95% CI: 0.93–8.42). Physical health
scored 4.47 (95% CI: 10.25 to 1.32).
Secondary analyses demonstrate no statistical
significance with respect to outcome whether
a trainee or consultant performed the
procedure. Younger patients (under split
median of 63.5) had a better total score 19.04
(95% CI: 11.35–27.74) than those older than
63.5 years (11.04, 95% CI: 3.61–18.47).
Discussion This study shows that EE-DCR
gave patients improvement in quality of life,
proven by a validated questionnaire. The
mean total score of 15.04 found in our study
compares with the 18.7 recorded by Feretis
et al in 2009. Results were irrespective of the
grade of surgeon, similar to the findings of
Fayers et al for functional successes.
Conclusion This study supports the use of
EE-DCR for the improvement of quality of
life in adult patients.
Eye (2013) 27, 1084–1089; doi:10.1038/eye.2013.96;
published online 12 July 2013
Keywords: patient satisfaction; postoperative;
epiphora; endoscopic endonasal DCR;
Glasgow Benefit Inventory
Introduction
Epiphora impacts on quality of life in adult
patients by causing blurred vision, spattered
glasses, and sore skin.
1,2
Tearing is socially
embarrassing as it mimics the appearance of
persistent crying. An important cause of
epiphora is narrowing or occlusion of the
nasolacrimal duct.
3
Nasolacrimal duct blockage
is circumvented by surgically creating an
anastomosis between the lacrimal sac and nasal
cavity above the site of occlusion, by either
external dacryocystorhinostomy (DCR) or
endoscopic endonasal dacryocystorhinostomy
(EE-DCR). The external approach has remained
the mainstay of treatment for over a century.
4
With the advent of fibreoptic endoscopes
utilising the principles of total internal reflection
and the simultaneous use of a light pipe within
the lacrimal sac to guide placement of the
osteotomy, the endoscopic endonasal approach
to DCR gained popularity from the 1990s.
5
Oculoplastic and Orbital
Service, The Western Eye
Hospital, London, UK
Correspondence:
JM Olver, Oculoplastic and
Orbital Service, The
Western Eye Hospital,
153-173 Marylebone Road,
London NW1 5QH, UK.
Tel: þ 44 (0)203 312 6666;
Fax: þ 44 (0)207 886 3259.
E-mail: janeolver@aol.com
Received: 29 August 2012
Accepted in revised form:
23 March 2013
Published online: 12 July
2013
CLINICAL STUDY
Eye (2013) 27, 1084–1089
& 2013 Macmillan Publishers Limited All rights reserved 0950-222X/13
www.nature.com/eye
Using a laser to create the rhinostomy is outdated
because of high rates of fibrosis secondary to charring,
with mechanical approaches using a diamond bur
showing greater successes.
6,7
We offer all patients endoscopic endonasal surgery,
with its advantages of no scar, shorter postoperative
recovery, greater heamostasis, and shorter operating
time. In this study, we aimed to measure the impact of
EE-DCR on patients’ quality of life, using the Glasgow
Benefit Inventory (GBI).
Robinson et al
8
developed the GBI, a post-
interventional questionnaire to be used in
otolaryngological (ORL) procedures. It is a validated
questionnaire that is both sensitive to the change in
health status due to a surgical procedure and patient
orientated. It is comprised of 18 questions, each of which
is based on a five-point Likert scale.
8
The questions are
specifically tailored to measure a change in health status,
defined as the general perception of well-being (12
questions). Social and physical health parameters are also
assessed, with three questions each. The total GBI scores
from 100 (maximal negative benefit), through zero (no
change) to þ 100 (maximal positive benefit in health
status).
8
Any positive score represents patient
satisfaction with the intervention. Robinson aimed to
control response bias by having half the answers range
from large improvement to large deterioration and the
remaining half conversely. We applied the GBI to collect
data for EE-DCR, as quality of life is a significant
contributor to overall success of the procedure.
Materials and methods
A postal questionnaire was sent out retrospectively, at
least 6 months post EE-DCR. The study was carried out
in accordance with ethical guidelines of the Declaration
of Helsinki with institutional ethics approval. Patients
were listed for surgery based on clinical assessment
(including syringing and probing), plus/minus
radiological diagnosis with lacrimal scintigraphy. Those
with nasolacrimal duct obstruction (NLDO) were offered
EE-DCR surgery.
Endoscopic endonasal DCR was performed under
general anaesthesia. All patients had the nasal mucosa
decongested with Moffats solution, combination of 1 ml
adrenaline 1 in 1000, 2 ml of 10% cocaine, and 2 ml
sodium bicarbonate. The lateral nasal wall was infiltrated
with 1 ml of 2% xylocaine (with 1 in 200 000 adrenaline).
The lacrimal crest was identified using a rigid 01 and/or
301 Hopkins endoscope. The nasal mucoperiosteoum over
the frontal process of the maxilla and lacrimal bone was
elevated. A Medtronic diamond bur was used to create the
bony rhinostomy. A fibreoptic light pipe was inserted into
the lacrimal sac, enabling visualisation and subsequent
vertical incision of the sac and flaps with a keratome. An
oscillating blade was used as needed to fashion mucosa.
O’Donoghue tubes are inserted and knotted.
Theatre records and operation notes were reviewed,
and demographic data collected. Patients were eligible
for our study if they had a NLDO and were aged 18 and
over. Exclusion criteria included patients undergoing
external or laser procedures, revision procedures for
failed primary surgical procedures, pregnancy and
secondary acquired NLDO (such as from sarcoid or
Wegener’s granulomatosis), and those with obstruction
at the canaliculi or common canaliculus.
Each patient was sent the GBI questionnaire, enclosed
with an information leaflet, consent form, and a stamped
addressed envelope (see Appendix). We gave patients a
3-month period to respond, after which they were called
twice, once during the day and once in the evening. We
entered the data into an excel database and statistical
analysis was performed.
Results
The records of 282 consecutive patients who underwent
EE-DCR surgery were analysed. We sent out 250 surveys,
as 32 addresses were not available. Out of the responses,
14 were returned anonymously and hence we were
unable to add demographic data.
We received 97 posted responses, 3 months from
sending out the questionnaires, representing an overall
response rate of 38.7%. Three were incomplete and hence
were not included in the analysis. We than rang all
non-responders to improve the compliance rate, and
overall were able to fill 16 further questionnaires over the
phone, giving a total of 110 responders.
The mean age of patients, at surgery, was 62 years
(95% CI: 59.36–65.08), with a range of 18–94. Overall 63%
were female, 37% were male and 56% were British. From
the 110 questionnaires analysed, the mean total score
from the GBI was þ 15.04 (95% CI: 9.74–20.35). The
general subscale score was þ 22.16 (95% CI: 15.23–29.09).
Social support scale resulted in a mean of þ 4.67 (95% CI:
0.93–8.42) and physical health scored 4.47 (95% CI:
10.25 to 1.32). Figure 1 shows box-plots of both total
and subscale scores, when individual ratings are
categorised as either plus or minus scores.
Table 1 shows a breakdown of the operating surgeon in
all 110 procedures. A t-test was performed for rank of
operator and showed that consultant only (n ¼ 67) had a
mean total score of 13.18 (95% CI: 7.14–19.21). The other
group included any patients who had a trainee operating
on them (even if that was together with a consultant,
n ¼ 26) and had a mean of 20.82 (95% CI: 9.12–32.54). This
difference was not statistically significant (P ¼ 0.2199),
similar to functional successes noted by Fayers et al.
2
Endoscopic endonasal dacryocystorhinostomy
G Jutley et al
1085
Eye
A t-test for total score by patient age category was
performed, split at the median of 63.5. The younger
group’s mean was 19.04 (95% CI: 11.35–27.74), compared
with 11.04 (95% CI: 3.61–18.47) in the older group.
From undergoing surgery to receiving the
questionnaire, there was a mean time of 47.01 months
(with a range of 6–133).
Discussion
In this study, we have shown by using a validated tool
that quality of life improves with EE-DCR. Modern
medicine has moved full circle from the paternalistic
approach practiced by previous generations. An
important requirement of contemporary medicine is the
patient experience: with particular emphasis on
measuring the effect of an intervention on patient benefit.
Vast improvements occurred in this area when Robinson
et al
8
devised the GBI, a validated questionnaire enabling
assessment of the patients’ health status post
otolaryngeal or ophthalmic intervention.
We sent the questionnaires by mail, without seeing the
patients. We aimed to avoid clinical bias from objective
measures and use patient experience exclusively to
assess the success of the procedure. To further highlight
the importance of using the patients’ experience as the
primary outcome measure, Tarbet and Custer
9
found that
62% of all patients with patent DCR’s to irrigation still
had persistent epiphora clinically. Furthermore, Delaney
and Khooshabeh
10
described only 38% of patients with
patent DCRs clinically classed themselves as completely
asymptomatic through questionnaire. It should be kept
in mind that a significant number of these patients may
represent epiphora of multifactorial cause.
We chose outcomes of at least 6 months
postoperatively to assess success.
2,7,11
Our response
rate of 38.7% was markedly lower than other postal
questionnaire studies for OLR procedures
12,13
and
most likely reflects our population of an inner city
multi-cultural mix of patients, with 44% of the study
population non-British. We found that the EE-DCR gave
patients improvement in areas of general perception of
well-being, including the social and psychological
components contributing to health. The predominantly
positive scores demonstrate that patients perceive
EE-DCR as a beneficial procedure, with improvement in
parameters including mucoid discharge, blurry vision,
and soreness peri-orbitally from persistent wiping of the
skin. Unlike the other three parameters, the mean
physical health score was 4.47. We were unable to fully
account for this negative finding, but analysis of the
GBI questionnaire shows that the questions enquiring
about physical well-being are quite generic and relate
to systemic health, with little correlation to the original
symptoms (refer to questions 8, 12, and 16). Overall, as
well as a lack of scarring, shorter operating time and
minimal blood loss, EE-DCR now also receives positive
feedback from validated patient assessments, giving
credence to offering it as a first-line management of
NLDO.
The ENT literature has published the use of
questionnaires to assess patient symptoms post EE-DCR
procedures, and authors have shown patient subjective
improvement of symptoms. For instance Agarwal
14
followed up 300 patients a year after EE-DCR and noted
94% were symptom free after the primary intervention.
Figure 1 (a) Box plot of total scores. Total GBI scores, broken
down into separate plus and minus scores. (b) Box plot of
subscale scores. General GBI scores, broken down into separate
plus and minus scores.
Table 1 Representation of all procedures performed by various
operators
Performed Success Failure
Consultant only 51 43 8
Consultant and trainee 32 24 8
Trainee only 11 10 1
Anonymously returned forms 16 12 4
Success is indicative of plus total scores.
Endoscopic endonasal dacryocystorhinostomy
G Jutley et al
1086
Eye
Validated quality of care data were not collected. Karim
et al
15
found 84% in the endoscopic cohort were symptom
free at least 4 months postoperatively. Zenk et al
16
gained a greater perspective into long-term symptom
improvement, after performing a retrospective analysis
of 165 patients who underwent EE-DCR. Total or partial
resolution of symptoms, as described by patients,
occurred in 81.8% (total resolution in 67.9%).
The GBI has been used in a wide variety of ORL
procedures, including rhinoplasty,
17
acoustic neuroma
surgery,
18
endoscopic sinus surgery,
12
and EE-DCR.
1
Ho
et al
19
used the GBI questionnaire in a prospective study of
55 patients undergoing EE-DCR. The patients were
reviewed at 6 months by a consultant ophthalmologist
and graded as a success if the symptoms were either
cured or better. Surgery was successful in 78% of patients;
the mean total GBI scores for successful and failure
groups were þ 34 and 19, respectively (comparable
with figures from our study of þ 23 and 24,
respectively). This study demonstrated that the GBI is a
sensitive measure, as it can differentiate between success
and failure. Most recently, Hii et al
20
have prospectively
evaluated adults treated with external or EE-DCR,
analysing patient satisfaction with the GBI, economic cost,
and surgical success. The study differed from ours as it
was prospective, the authors aimed to compare the two
procedures directly, and objective measures of success
were also observed. Thirty-seven patients underwent
external DCR and 40 were in the EE-DCR group. The
questionnaire was posted 6 weeks postoperatively and the
mean GBI scores were þ 16.1 and þ 24.1, respectively. The
difference of 8 between the scores did not reach statistical
significance,
20
suggesting that although both operations
produce positive post-interventional change in health
status, the difference between both is negligible. As
anatomical and functional success at 3-month follow-up
in both groups were similar (91.7 and 92.1% in the
external and EE-DCR groups respectively) and the cost
difference did not reach statistical difference,
20
one can
conclude that patient choice and surgeon preference key
in deciding what approach is adopted. We feel the
advantages of no scar, shorter postoperative recovery,
greater heamostasis, and shorter operating time
advocate the use of EE-DCR as front-line surgery,
substantiated with the results from the Hii et al
20
study
showing no difference between the surgeries in three
parameters.
In our study, we found that younger patients had
statistically significant improved general perception of
well-being compared with older patients. This is a
consistent finding in the literature, for instance, Tripathi
et al
21
showed a statistical correlation between complete
resolution 12 month post endoscopic laser DCR
(EL-DCR) in 46 patients and the younger the age of the
patient. It is well recognised that the incidence of NLDO
increases with age: it is plausible to consider that an 18
score questionnaire of the GBI could be difficult to fill in
for our more elderly patients, particularly, if no guidance
notes are presented to them. If a simpler questionnaire can
be used, which is more user friendly, a more accurate
assessment of patient symptomatology can be surmised.
A Finnish group have recently devised a Nasolacrimal
Duct Obstruction Symptom Score (NLDO-SS), and
published their results following endoscopic DCR on 64
consecutive patients.
22
The questionnaire had only five
items that focused on the common ocular symptoms of
NLDO, and as such it was more appropriate for
nasolacrimal surgery than the GBI. The authors showed a
statistically significant correlation between the GBI and
the NLDO-SS: although not validated, perhaps the future
step would be to use this simple and sensitive tool
routinely to assess symptoms post EE-DCR in an
ophthalmic setting.
Mistry et al
23
questioned the use of GBI in assessing the
success of EE-DCR. They argued that this is a quality of
life assessment and patients with anatomical obstruction
at the lacrimal apparatus may not have great overall
disability. Furthermore, the GBI is intended to measure
change in health status, yet it is only distributed
post-procedure and thus is not appropriate for assessing
symptoms before surgery. The authors developed a
new Lac-Q questionnaire after reviewing the presenting
complaints of 100 consecutive patients referred for
treatment of lacrimal obstruction. The questions account
for both eye-specific symptoms as well as the overall
social impact of the disease. In a pilot study of 22 DCR
surgeries, they showed that compared with preoperative
scores, the reduction postoperatively was significant.
23
Also noted was the correlation between Lac-Q scores
and objective assessments, giving merit to the use of
the questionnaire in a larger study.
Our study has all the limitations associated with being
retrospective in nature. The range of time from surgery to
receiving questionnaire was 6–133 months and recall bias
may have contributed to the results, even though the
questionnaire used was validated. For future studies,
the Lac-Q or NLDO-SS questionnaires can be used
prospectively for patients undergoing EE-DCR.
Conclusions
EE-DCR can be considered the first-line surgical
procedure for the treatment of acquired NLDO. As it
improves quality of life, ophthalmologists should use
measures such as GBI, Lac-Q, or NLDO-SS scores to
evaluate success as an adjunct to auditing their results.
Ultimately patients are not concerned with functional or
anatomical outcome, but how an operation can help
Endoscopic endonasal dacryocystorhinostomy
G Jutley et al
1087
Eye
improve the quality of their life. Our study shows that
EE-DCR gives an improvement of general well-being, as
assessed by a validated questionnaire. This information
should be made available to all patients before deciding
their management options.
Summary
What was known before
K Limited knowledge about patient satisfaction post
EE-DCR.
What this study adds
K We can use various questionnaires to improve our
practice.
Conflict of interest
The authors declare no conflict of interest.
References
1 Feretis M, Newton JR, Ram B, Green F. Comparison of
external and endonasal dacryocystorhinostomy. JLO 2009;
123: 315–319.
2 Fayers T, Laverde T, Tay E, Olver JM. Lacrimal surgery
success after external dacryocystorhinostomy: functional
and anatomical results using strict outcome criteria. Ophthal
Plast Reconstr Surg 2009; 25(6): 473–475.
3 Olver JM. Colour Atlas of Lacrimal Surgery. 1st edn.
Butterworth Heinemann Health: Oxford, UK, 2002,
pp 30–37.
4 Toti A. Nuovo metodo conservatore di cura radicale delle
suppurazioni croniche del sacco lacrimale. L Clin Mod 1904;
10: 385–387.
5 Massaro BM, Gonnering RS, Harris GJ. Endonasal
laser dacryocystorhinostomy. A new approach to
nasolacrimal duct obstruction. Arch Ophthalmol 1990; 108:
1172–1176.
6 Yung MW, Hardman-Lea S. Analysis of the results of
surgical endoscopic dacryocystorhinostomy: effect of the
level of obstruction. Br J Ophthalmol 2002; 86: 792–794.
7 Moore WMH, Bentley CR, Olver JM. Functional and
anatomic results after two types of endoscopic endonasal
dacryocystorhinostomy: surgical and holmium laser.
Ophthalmology 2002; 109(8): 1575–1582.
8 Robinson K, Gatehouse S, Browning GG. Measuring patient
benefit from otorhinolaryngological surgery and therapy.
Ann Otol Rhinol Laryngol 1996; 105(6): 415–422.
9 Tarbet KJ, Custer PL. External dacryocystorhinostomy:
surgical success, patient satisfaction and economic cost.
Ophthalmology 1995; 102: 1065–1070.
10 Delaney YM, Khooshabeh R. Fluorescein transit test time
and symptomatic outcomes after external
dacryocystorhinostomy. Ophthal Plast Reconstr Surg 2002;
18(4): 281–284.
11 Olver JM. The success rates for endonasal
dacryocystorhinostomy. Br J Ophthalmol 2003; 87: 1431.
12 Salhab M, Matai V, Salam MA. The impact of functional
endoscopic sinus surgery on health status. Rhinology 2004;
42(2): 98–102.
13 Kanatas AN, Mehanna HM, Lowe D, Rogers SN. A second
national survey of health-related quality of life
questionnaires in head and neck oncology. Ann R Coll Surg
Engl 2009; 91(5): 420–425.
14 Agarwal S. Endoscopic dacryocystorhinostomy for acquired
nasolacrimal duct obstruction. J Laryn Otol 2009; 123:
1226–1228.
15 Karim R, Ghabrial R, Lynch T, Tang B. A comparison of
external and endoscopic dacryocystorhinostomyfor
acquired nasolacrimal duct obstruction. Clin Ophthalmol
2011; 5: 979–989.
16 Zenk J, Karatzanis AD, Psychogios G, Franzke K, Koch M,
Hornung J et al. Long term results of endonasal
dacryocystorhinostomy.
Eur Arch Otorhinolaryngol 2009; 266:
1733–1738.
17 McKiernan DC, Banfield G, Kumar R, Hinton AE. Patient
benefit from functional and cosmetic rhinoplasty. Clin
Otolaryngol Allied Sci 2001; 26(1): 50–52.
18 Fahy C, Nikolopoulos TP, O’Donoghue GM. Acoustic
neuroma surgery and tinnitus. Eur Arch Otorhinolaryngol
2002; 259(6): 299–301.
19 Ho A, Sachidananda R, Carrie S, Neoh C. Quality of life
assessment after non-laser endonasal
dacryocystorhinostomy. Clin Otolaryngol 2006; 31:
399–403.
20 Hii BW, McNab AA, Friebel JD. A comparison of external
and endonasal dacryocystorhinostomy in regard to patient
satisfaction and cost. Orbit 2012; 31(2): 67–76.
21 Tripathi A, Lesser THJ, O’Donnell NP, White S. Local
anaesthetic endonasal endoscopic laser
dacryocystorhinostomy: analysis of patients’ acceptability
and various factors affecting the success of this procedure.
Eye 2002; 16: 146–149.
22 Smirnov G, Tuomilehto H, Kokki H, Kemppainen T,
Kiviniemi V, Nuutinen J et al. Symptom score questionnaire
for nasolacrimal duct obstruction in adults—a novel tool to
assess the outcome after endoscopic dacryocystorhinostomy.
Rhinology 2010; 48(4): 446–451.
23 Mistry N, Rockley TJ, Reynolds T, Hopkins C. Development
and validation of a symptom questionnaire for recording
outcomes in adult lacrimal surgery. Rhinology 2011; 49:
538–545.
Appendix
The GBI questionnaire
Endoscopic endonasal dacryocystorhinostomy
G Jutley et al
1088
Eye
Endoscopic endonasal dacryocystorhinostomy
G Jutley et al
1089
Eye
