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A Systematic Review of Patient-Reported Outcomes for Surgically Amenable Epiphora

Schulz, Christopher, B., B.M., B.Sc.*; Kennedy, Alasdair, B.M.B.S.; Rogers, Simon, M.B.B.S., B.Sc., F.R.C. Ophth.

Ophthalmic Plastic and Reconstructive Surgery: May/June 2018 - Volume 34 - Issue 3 - p 193–200
doi: 10.1097/IOP.0000000000000977
Major Review

Purpose: In evaluating epiphora and its management, the bottom line for all stakeholders is whether an intervention confers any real benefit on quality of life. A review was conducted to identify and appraise patient-reported outcome measures (PROMs) in surgically amenable epiphora.

Methods: A systematic search was conducted of studies relating to surgical intervention for epiphora. Patient-reported outcome measures were identified and assessed against standard criteria.

Results: Of 30,544 identified articles, 227 were eligible for data extraction. Of these, 69% reported a PROM as the primary outcome. PROMs identified included single-item symptom scores (48% of primary outcome PROMs), single-item reports of improvement (30%), the Glasgow Benefit Inventory (3%), Lacrimal Symptom Questionnaire (0.5%), Nasolacrimal Duct Obstruction Symptom Score (0.5%), Ocular Surface Disease Index (0.5%), Visual Function Questionnaire-25, the Short Form-36 Health Survey, and 3 other symptom scores. None were developed through consultation with the target population, and there was inadequate testing of content validity. The strengths and limitations of each PROM are presented, with regard to interpretation, responsiveness, reliability, and validity.

Discussion: The importance of robust and psychometrically sound PROMs is essential if the under-reporting of quality of life improvement in patients treated for epiphora is to change. Recommendations for the use of each identified PROM are discussed.

Conclusions: Several PROMs have been used in the recent literature to evaluate patients undergoing surgery to treat epiphora. Assessed against standard criteria, no PROM has proven to be both psychometrically robust and clinically meaningful for use in this population. Future PROM development should be guided by this standard framework.

Over 97% of epiphora research includes patient-reported outcome measures (PROMs), yet when evaluated against set criteria, no PROM has proven to be both psychometrically robust and clinically meaningful in this population.

*Eye Unit, Salisbury District Hospital, Salisbury

Department of Ophthalmology, Sussex Eye Hospital, Brighton

Eye Unit, Queen Alexandra Hospital, Portsmouth, United Kingdom

Accepted for publication June 8, 2017.

Study data (in part) due to be presented at the British Oculoplastic Surgery Society Annual Meeting, London (June 2017).

The authors have no financial or conflicts of interest to disclose.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (

Address correspondence and reprint requests to Christopher B. Schulz, B.M., B.Sc., Eye Unit, Salisbury District Hospital, Odstock Road, Salisbury SP2 8BJ, United Kingdom. E-mail:

© 2018 by The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc., All rights reserved.