Selection of Patients

Patients with epiphora who presented consecutively to Jikei Aoto Hospital Department of Ophthalmology from April 1, 2009 to March 31, 2010 were recruited in this prospective study. Patients were diagnosed as having unilateral lacrimal passage obstructions based on the following examinations: 1) Probing: A Bowman probe was advanced into the canaliculus. If an obstruction was encountered, measurement of the distance from the forceps to the end of the probe gave information about the location of the obstruction. 2) Dye disappearance test: A moist fluorescein strip was applied to the lower conjunctiva, and the tear lake over the punctum was examined 5 minutes later with a cobalt blue filtered light. The diagnosis of lacrimal passage obstruction was based on the presence of residual dye over the lacrimal punctum. 3) Lacrimal irrigation: We irrigated the lacrimal passage through the upper and lower puncta with sterile physiological saline. If the irrigating fluid could not pass through the patient’s lacrimal passage or if there was no flow of fluid into the posterior pharynx, the patient was diagnosed with complete lacrimal passage obstructions. 4) Imaging: Computed tomography was used to diagnose sinusitis and lacrimal passage obstructions attributable to tumor. Exclusion criteria were: presence of congenital nasolacrimal stenosis; lacrimal passage obstructions attributable to trauma, tumor, or chemotherapy; or previous lacrimal passage surgery. Partial and functional lacrimal duct obstructions were excluded in this study. After receiving informed consent about treatment of lacrimal passage obstructions and exclusion criteria, 45 patients chose the silicone tube intubation using a Nunchaku-style tube treatment and were enrolled in this study. All examinations and operations were performed by a single surgeon (S.G.).

Surgical Technique

After anesthetizing the upper and lower puncta and performing an infratrochlear nerve block with 2% lidocaine, both puncta were enlarged using a punctal dilator. We inserted the probe of the dacryoendoscope (FT-2000E; Fibertech Co, Tokyo, Japan; Figure 1 ) through the upper canaliculus. Upon reaching the lacrimal sac, the probe was thrust forward into the nasolacrimal duct to relieve the obstructions under direct visualization. During this procedure, saline was injected through the water channel to remove hemorrhage and to create space. After relieving the obstruction by the dacryoendoscopy probe, one end of the Nunchaku-style tube (Kaneka Co, Tokyo, Japan; Figure 2 ) was inserted into the upper puncta. When it reached the medial wall of the nasolacrimal sac through the canaliculus, it was turned vertically, and then inserted into the nasolacrimal duct and nasal cavity. The stainless steel probe inside the tube was then pulled out. After insertion of the tube into the upper puncta, the other side of the Nunchaku-style tube was inserted through the lower puncta in the same way. Finally, we confirmed that the silicone tube had been intubated correctly using the dacryoendoscope. The colors of apical parts of the Nunchaku-style tube are different—either blue or transparent; hence, we could recognize the appropriate intubation from the upper or lower puncta.

Dacryoendoscope. A dacryoendoscope consists of a viewing lens, an optical fiber, and a water channel. The outer diameter of the probe is 0.9 mm. The probe of the dacryoendoscope is bent at a 27-degree angle 1 cm from its tip, and has a 70-degree angle of view.

Nunchaku-style tube. The Nunchaku-style tube is 105 mm in length and has a central thin segment (25 mm in length and 0.6 mm in diameter) and a bilateral thick segment (40 mm in length, 0.5 mm inner diameter, and 1.0 mm outer diameter); it looks like the “Nunchaku” used by Chinese martial arts practitioners. The bilateral tubes are slit 30 mm from the closed points of the bilateral tube segments. A stainless steel probe (55 mm in length) with a polypropylene grip is inserted through each slit.

After intubation using the Nunchaku-style tube, all patients were treated with topical antibiotic and steroid eye drops, and the eyes were irrigated regularly until the tube was removed 2 months later. Patients were asked to quantify their symptoms as follows: (A), epiphora is worse; (B), epiphora is the same; (C), epiphora is decreased from preoperative; (D), no symptom of epiphora. Patients self-reported as A or B were defined “no improvement,” C or D as “improvement.” The operation was considered successful if the irrigating fluid passed through the lacrimal passage, if the disappearance of dye was observed over the lacrimal punctum in a dye disappearance test, and if the patient’s symptoms of epiphora improved.

NEI VFQ-25

NEI VFQ-25 was self-administered by 45 patients, both preoperatively and 3 months postoperatively. In this study, the Japanese version of the NEI VFQ-25, which had been modified to suit the Japanese culture and lifestyle, was used. This modified NEI VFQ-25 has been assessed for its reliability and validity, and has been proven to measure vision-related QOL accurately in Japanese individuals. NEI VFQ-25 comprises 12 vision-targeted scales: general health, general vision, ocular pain, near activities, distance activities, social functioning, mental health, role difficulties, dependency, driving, color vision, and peripheral vision. Each scale consists of a minimum of 1 and a maximum of 4 items. Subscales were scored on a scale of 0 (worst) to 100 points (best). Scores were calculated using the recommendations of the developers of the questionnaire and according to published guidelines for NEI VFQ-25. The mean scores and standard deviation (SD) were calculated for each subscale, and the composite score was calculated by averaging the scores of 11 subscales; the general health subscale was excluded.

Statistical Analysis

The Wilcoxon signed rank test was used to compare preoperative and postoperative results. Comparisons were considered as statistically significant if the P value was less than .05. The analyses were carried out using JMP version 8 (SAS Inc, Cary, North Carolina, USA).