• Users Online: 143
  • Print this page
  • Email this page


 
 
Table of Contents
ORIGINAL ARTICLE
Year : 2022  |  Volume : 4  |  Issue : 1  |  Page : 52

Etiology and management of epiphora in an underserved, minority population


Department of Ophthalmology, Boston Medical Center, Boston University School of Medicine, Boston, MA, USA

Date of Submission08-Oct-2022
Date of Decision03-Nov-2022
Date of Acceptance03-Nov-2022
Date of Web Publication22-Nov-2022

Correspondence Address:
Alberto G Distefano
Department of Ophthalmology, Boston Medical Center, Boston University School of Medicine, 85 East Concord St., 8th Floor, Boston 02118, MA
USA
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/pajo.pajo_56_22

Rights and Permissions
  Abstract 


Objective: There is value in understanding the common etiologies of epiphora within different patient populations as well as identifying barriers to adequate treatment and symptom relief. The primary goal of the study is to report common etiologies of epiphora and the impact of treatment in patients of a large, inner-city hospital.
Methods: This is a retrospective review of 10 years of data from the charts of 516 adult patients. The most common diagnoses and interventions linked to this symptom were evaluated. Subjective symptom improvement and adherence to follow-up were also analyzed.
Results: Three hundred (58.1%) patients carried a diagnosis of dry eye syndrome and, of these, 40.1% did not have other ocular findings to explain their epiphora. Conservative management (CM) was recommended to the majority (86.4%) of the study population. 27.5% of the 357 patients who received CM as the only intervention reported symptom improvement. 90.1% of patients who underwent DCR reported symptom improvement. Nearly half of the patients were lost to follow-up.
Conclusion: Epiphora is a common symptom that may be multifactorial in etiology, making effective treatment a challenge. Reflex tearing secondary to ocular surface dryness was the most common etiology linked to epiphora in this study. Low rates of follow-up limit the ability to fully assess the impact of current interventions on symptoms. Addressing the socioeconomic barriers that lower patient adherence to follow-up should allow more effective treatment of epiphora.

Keywords: Blepharitis, dry eye, epiphora, lacrimal, tearing


How to cite this article:
Murdock N, Pinto RT, Distefano AG. Etiology and management of epiphora in an underserved, minority population. Pan Am J Ophthalmol 2022;4:52

How to cite this URL:
Murdock N, Pinto RT, Distefano AG. Etiology and management of epiphora in an underserved, minority population. Pan Am J Ophthalmol [serial online] 2022 [cited 2022 Nov 29];4:52. Available from: https://www.thepajo.org/text.asp?2022/4/1/52/361719




  Introduction Top


Epiphora, or excessive tearing of the eye, is a common complaint in ophthalmology and oculoplastic clinics. The disorder, though often benign, can greatly impact patients' vision-related quality of life. This has been shown to be particularly true with outdoor activities, computer work, and activities involving downward gaze, such as reading and using stairs.[1],[2],[3] The visual disability in some patients with epiphora has been compared to that in patients awaiting cataract surgery.[2],[3] Other nonvisual symptoms and social impacts of epiphora have been reported, such as “spattered glasses,” periorbital irritation, and feelings of embarrassment.[4]

There are a number of etiological factors that, alone or in combination, may contribute to the development of epiphora. It often occurs secondary to reflex hypersecretion from ocular surface disease and may present in the absence of other symptoms, such as burning and foreign body sensation.[5],[6],[7] Alternatively, it may be a consequence of poor tear drainage secondary to obstruction of or trauma to the nasolacrimal system. Anatomic factors, such as eyelid malposition or laxity, may also result in epiphora, particularly in older populations.[8],[9],[10],[11] Importantly, patients presenting with tearing may have more than one etiology contributing to their symptoms.[7],[12],[13]

The potential for epiphora to have multiple causes is important to consider when assessing management options and efficacy of treatment. Considering its multifactorial nature, obtaining a comprehensive history and physical exam is paramount to ensure accurate diagnosis and proper intervention. In some cases, persistent tearing may warrant extensive workup and imaging to diagnose uncommon masses.[14],[15],[16],[17] Misdiagnosis and lack of follow-up may result in vision-threatening complications, such as dacryocystitis. The workup and treatment of this disorder can be multifaceted, which may lead to provider and patient frustration when proposed interventions fail. The motivation behind effective treatment of epiphora is to improve patient comfort and quality of life. Additionally, follow-up in these patients is necessary to assess symptom improvement and evaluate the need for subsequent testing or intervention.

Despite the high prevalence and multifactorial nature of this complaint, large cohort studies presenting a comprehensive analysis of the various etiologies of epiphora and the efficacy of various interventions are lacking. These studies would be helpful, particularly in underserved, minority populations, where socioeconomic barriers to proper intervention and follow-up should be readily identified and addressed. A retrospective chart review was performed with two aims. The first was to identify the most common diagnosis linked to epiphora in patients presenting to an inner-city ophthalmology clinic within a large, safety-net hospital. The second aim was to assess follow-up rates and symptom improvement in this population following various surgical and nonsurgical interventions.


  Methods Top


We performed a retrospective chart review of all patients presenting to a single ophthalmology clinic at Boston Medical Center (BMC) between January 2008 and June 2019 with complaints of “epiphora” based on International Classification of Diseases (ICD) codes. The following ICD-10 codes were used: H04.2, H04.20, H04.201, H04.202, H04.203, H04.22, H04.229, H04.209, H04.219, H04.211, H04.212, H04.213, H04.222, and H04.223. We obtained IRB approval prior to the onset of data collection and the study was Health Insurance Portability and Accountability Act (HIPAA). Patients were included if they met the following criteria: (1) diagnosed or presented with symptoms of unilateral or bilateral epiphora, (2) evaluated for epiphora by a BMC ophthalmologist or optometrist, and (3) age 18 years or older at time of initial presentation. Exclusion criteria included: (1) no mention of epiphora or tearing in chart notes, (2) incomplete or ambiguous documentation (e.g., tearing mentioned in history but no mention in assessment/plan or subsequent notes).

Chart review was completed by two independent reviewers. The extracted data included patient demographics, clinical presentation, relevant ocular and medical history, exam findings, surgical and nonsurgical interventions, and subjective response following intervention. Patients were defined as having “complete” nasolacrimal duct obstruction (NLDO) if canalicular probing and irrigation resulted in 100% reflux and absence of oropharyngeal fluid. “Functional” NLDO was defined as <100% reflux on irrigation and presence of oropharyngeal fluid. Patients with a history of dry eye syndrome (DES) and no other ocular history or exam findings to explain their epiphora were considered to have dry eye-related reflex tearing. “Conservative management (CM)” included the use of artificial tears and warm compresses. Eyelid surgeries classified as “other” included: Mohs reconstruction, gold weight eyelid implants, or nonspecific “lid surgeries” performed outside the country. Patients who were lost to follow-up (LTF) automatically fell under the “N/A” cohort in regard to symptom improvement unless symptom improvement had been documented prior to loss to follow-up.

The collected data were organized and analyzed using Microsoft Excel 2011 (Redmond, Washington). Descriptive statistics were presented as raw numbers and percentage for nominal variables. Statistical differences between groups were analyzed using Pearson's Chi-squared test for categorical factors. A P < 0.05 was considered statistically significant. Of note, statistical analysis excluded patients falling under “N/A” categories.


  Results Top


A total of 1072 patients presenting with epiphora symptoms were seen between January 2008 and June 2019. Of these, 628 adult and pediatric patients met the first two inclusion criteria. The final study population included 516 adults. There were 190 (36.8%) males and 326 (63.2%) females (male-to-female ratio of 0.58). The median age was 61 (range: 18–96) years. In the population studied, 189 (36.6%) patients were African American and 110 (21.3%) were Hispanic [Table 1].
Table 1: Demographic information of adult patients presenting with epiphora

Click here to view


Of the 516 patients, 143 reported unilateral epiphora (14.3% and 13.4% for right eye and left eye, respectively); 373 (72.3%) reported bilateral epiphora. Symptoms were more often chronic, lasting months in 146 (28.3%) patients and years in 166 (32.2%) patients. The majority (63.2%) of the patients reported additional ocular symptoms; irritation (32.8%), pruritus (25.0%), or redness (12.6%) were the most common [Table 2]. Three hundred (58.1%) patients carried a diagnosis of DES and, of these, 207 (40.1%) did not have NLDO, eyelid malposition, or other ocular history to explain their epiphora. Of patients with a history of DES, 248 (82.7%) were treated for epiphora with CM only and, excluding those LTF, 72 (66.7%) reported symptom improvement with CM alone. Additional relevant ocular history was reported in 145 (28.1%) patients, most commonly pinguecula/pterygium (14.1%) and ocular trauma (7.6%). A minority (21.7%) of the patients had medical history considered to be relevant to their symptoms, with the most common being thyroid disease (8.7%) and obstructive sleep apnea (7.0%) [Table 3]. A total of 179 (34.7%) patients were either current or former smokers, which was comparable to the average of current smokers reported in Massachusetts over the same time frame (12.6% vs. 14.7%, respectively; P = 0.17).[18] Nearly a quarter (22.5%) of the patients had a history of cataract surgery.
Table 2: Ocular symptoms reported in patients complaining of epiphora

Click here to view
Table 3: Pertinent medical, ocular, and surgical history of the study population

Click here to view


On the slit-lamp exam, 299 (57.9%) patients had evidence of blepharitis or meibomian gland dysfunction. Thirty (5.8%) patients had conjunctivochalasis, 56 (10.9%) had ectropion, and 7 (1.4%) had entropion. A total of 47 (9.1%) patients had punctal stenosis and 122 (23.6%) were diagnosed with NLDO. The majority of patients with NLDO had complete obstruction (62.3%).

Approximately half (52.9%) of the study population were referred to and evaluated by oculoplastics. Of these, 17 (13.3%) denied symptom resolution despite treatment. Overall, symptom resolution was reported more often by patients treated by oculoplastics (39.9% vs. 25.9%, P < 0.001). The majority of the study population received CM as part of their treatment regimen (86.4%). Of 357 (69.2%) patients who received CM as the only intervention, 98 (27.5%) reported symptom improvement. In terms of procedures and surgical intervention, 16 (3.1%) patients had NLD stent placement, 11 (2.1%) underwent punctoplasty, and 63 (12.2%) underwent DCR. A minority of patients underwent ectropion (3.9%) and entropion (0.4%) repair [Table 4]. A total of 231 (44.8%) patients were LTF, with no significant difference in LTF rate among the four age groups. About half (54.8%) of the patients were omitted from the analysis of symptom improvement due to lack of documentation regarding symptom persistence or resolution on follow-up. Of the remaining 233 patients, 61 (26.2%) denied symptom improvement. Following any intervention, 172 (73.8%) patients reported symptom improvement, higher than the values seen in prior reports.[13],[19] Of patients who underwent DCR, 90.1% reported symptom improvement – a value similar to that seen in prior reports.[20],[21]
Table 4: Distribution of surgical and nonsurgical interventions performed

Click here to view



  Discussion Top


Epiphora is a presenting complaint that is familiar to both general ophthalmology and oculoplastic clinics. Although relatively benign, epiphora significantly impacts patient comfort, quality of life, and daily activities. The multifactorial nature of epiphora can make treatment more challenging, particularly in patient populations with poor adherence to interventions or follow-up visits. In the present study, nearly half of the patients did not present to subsequent appointments. The predictors of patient “no-shows” have been studied extensively across multiple specialties, with particular emphasis on age, race, income level, and insurance status.[22],[23],[24],[25],[26] The diversity of this study cohort is evidenced by the relatively low percentage of White Americans (18.2%), with over half of the patients identifying as African American or Hispanic. Prior studies have demonstrated the high rates of patient absenteeism in urban health centers, similar to BMC, that serve predominantly low-income and minority populations.[27],[28],[29],[30] The link between missed appointments and poor outcomes, particularly in minority and underserved populations, has been demonstrated time and again.[27],[31] Low follow-up rates may be affected as well by the reality that patients with improvement in their symptoms may be less motivated to present to subsequent appointments. Interventions to improve patient follow-up in future will allow a more comprehensive and accurate review of symptom improvement in these underserved populations.

Similar to prior reports, this study found that middle- and older-aged adults are more likely to present with epiphora.[12],[19],[32] The population had a mean age of 61 years, with only one quarter of patients falling between 18 and 50 years old. Prior studies have suggested that older-aged adults present more commonly with multifactorial epiphora, which is more challenging to treat and less likely to fully resolve following interventions.[12],[19] This could explain the lower percentage of patients reporting symptom improvement in the oldest age bracket (age 71+) relative to the other age groups, despite similar LTF rates. The study population had a slight female predominance with no significant association between gender and LTF.

A range of symptoms were reported in association with epiphora. The most common of these was pruritus, followed by redness and irritation. Interestingly, although over half of the patients had a history of DES, dryness and foreign body sensation were not commonly reported symptoms. In this cohort, ocular surface dryness was deemed a common cause of epiphora since nearly half of the patients did not have other findings to explain their symptoms and the majority of patients with this diagnosis reported symptomatic improvement with CM alone. About one quarter of the patients had a history of cataract extraction. Epiphora secondary to DES is not uncommon following cataract surgery.[33] However, in the present study, it is not possible to establish a correlation between cataract extraction and epiphora without further delineation of timeline and chronicity as well as adjustment of confounders, such as patient age.

Despite the long-standing nature of epiphora in most patients, only half were evaluated by oculoplastics. This may reflect low referral rates, patients' lack of interest in surgical interventions, or poor adherence to referral appointments. Overall, patients evaluated and treated by oculoplastics were more likely to report symptom improvement. Again, this could reflect increased patient adherence to treatment and follow-up appointments once evaluated by a subspecialist.

In recent years, there have been a handful of studies published that explore the causes of epiphora. Despite similarity in the data among some of these studies, there is no general consensus as to the most common etiology.[7],[19],[34] Select studies make the point of emphasizing the multifactorial nature of epiphora.[13] Epiphora attributed to dry eye-related reflex tearing varies in the literature from about 20% to 80%.[34],[19],[35] This variability can be attributed to discrepancies in confirmation of the diagnosis, particularly if studies rely on patient follow-up and resolution of symptoms with conservative treatment.[7],[13],[19],[36] Other factors to consider include the clinic (general ophthalmology vs. oculoplastics) and population characteristics (e.g., age, health literacy). One would expect a higher proportion of DES at a general ophthalmology clinic, with obstructive pathology or lid malposition more often warranting referral to plastics.[35] When considering variations in the study population, a cohort of older adults may have a higher proportion of DES, and a cohort of patients with high health literacy may be less likely to present for dry eye symptoms that can be managed with over-the-counter lubricant eye drops. Finally, studies have also reported the potential for DES to cause NLDO, in which case patients whose epiphora is attributed to one diagnosis may, in fact, be attributed to both.[37]

It is important to consider the role that language plays in adherence to recommendations and follow-up visits. Language barriers shape the patient experience and can impact health outcomes in patients with Limited English Proficiency (LEP).[38],[39] Some studies demonstrate poor medical comprehension in patients with LEP, despite communication in their primary language via interpreter services or language-concordant physicians.[40] While the present study does not include data regarding patient language, about 30% of patients at BMC do not speak English as their primary language. Further studies can be done to investigate how socioeconomic factors such as ethnicity, language, education, and employment contribute to patient willingness to proceed with surgical interventions for epiphora. These barriers are likely also impacting patient adherence to CM (e.g., ability to purchase artificial tears).

The significant portion of patients who were LTF leads to one limitation to this study. Another is potential underrepresentation of patients with epiphora symptoms that may not have fallen under the ICD-10 codes used. Floppy eyelid syndrome (FES), though a well-documented etiology of epiphora, was reported in <2% of patients in this cohort.[41] Providers in this case may have excluded the code for “epiphora” and coded only for FES. Similarly, patients with thyroid eye disease who present with dry eye-related reflex tearing may have been missed in this limited search.[42] Patients with entropion and ectropion in this cohort were fewer than expected: 1.4% and 10.9%, respectively. Eyelid malposition is a well-documented and relatively common etiology for excess tearing in patients, particularly in older populations. Patients with ICD-10 codes limited to diagnoses of eyelid malposition were missed in this study as well.

The multifactorial nature of epiphora makes diagnosis and treatment a challenging prospect. Considerations must be given to contributing systemic medical problems, eyelid position, ocular surface disease, and disorders of the nasolacrimal system. Efforts to increase patient understanding will positively impact treatment compliance. The minority and low-income populations that present to safety-net hospitals are particularly vulnerable to undertreatment for a variety of reasons. These range from limited English and medical proficiency to high cost of treatment or limited transportation to visits. Barriers should be further identified and addressed to increase follow-up and treatment success as well as improve quality of life in patients suffering from epiphora.


  Conclusion Top


Epiphora is a common symptom and can be multifactorial in etiology, at times requiring multiple office visits for adequate symptom management. This study found reflex tearing to be the most common diagnosis linked to epiphora among patients presenting to a large inner-city clinic. The majority of patients treated and followed up in this cohort reported symptom improvement with intervention, particularly after surgical interventions such as DCR. Issues with patient adherence to follow-up remain prevalent, particularly in underserved and minority populations. These patients face socioeconomic barriers to health, which makes effective treatment of epiphora more challenging. Addressing the socioeconomic barriers that lower patient adherence to follow-up should allow more effective treatment of epiphora.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Shin JH, Kim YD, Woo KI, Korean Society of Ophthalmic Plastic and Reconstructive Surgery (KSOPRS). Impact of epiphora on vision-related quality of life. BMC Ophthalmol 2015;15:6.  Back to cited text no. 1
    
2.
Bohman E, Wyon M, Lundström M, Dafgård Kopp E. A comparison between patients with epiphora and cataract of the activity limitations they experience in daily life due to their visual disability. Acta Ophthalmol 2018;96:77-80.  Back to cited text no. 2
    
3.
Kafil-Hussain N, Khooshebah R. Clinical research, comparison of the subjective visual function in patients with epiphora and patients with second-eye cataract. Orbit 2005;24:33-8.  Back to cited text no. 3
    
4.
Jutley G, Karim R, Joharatnam N, Latif S, Lynch T, Olver JM. Patient satisfaction following endoscopic endonasal dacryocystorhinostomy: A quality of life study. Eye (Lond) 2013;27:1084-9.  Back to cited text no. 4
    
5.
Messmer EM. The pathophysiology, diagnosis, and treatment of dry eye disease. Dtsch Arztebl Int 2015;112:71-81.  Back to cited text no. 5
    
6.
The Definition and Classification of Dry Eye Disease: Report of the Definition and Classification Subcommittee of the International Dry Eye WorkShop (2007) DEWS Definition and Classification. Vol 5.; 2007. doi:10.1016/S1542-0124(12)70081-2.  Back to cited text no. 6
    
7.
Mainville N, Jordan DR. Etiology of tearing: A retrospective analysis of referrals to a tertiary care oculoplastics practice. Ophthalmic Plast Reconstr Surg 2011;27:155-7.  Back to cited text no. 7
    
8.
Bedran EG, Pereira MV, Bernardes TF. Ectropion. Semin Ophthalmol 2010;25:59-65.  Back to cited text no. 8
    
9.
Damasceno RW, Osaki MH, Dantas PE, Belfort R Jr. Involutional entropion and ectropion of the lower eyelid: Prevalence and associated risk factors in the elderly population. Ophthalmic Plast Reconstr Surg 2011;27:317-20.  Back to cited text no. 9
    
10.
Piskiniene R. Eyelid malposition: Lower lid entropion and ectropion. Medicina (Kaunas) 2006;42:881-4.  Back to cited text no. 10
    
11.
Marshall JA, Valenzuela AA, Strutton GM, Sullivan TJ. Anterior lamella actinic changes as a factor in involutional eyelid malposition. Ophthal Plast Reconstr Surg. 2006;22(3):192-194. doi:10.1097/01.iop.0000217561.41150.68.  Back to cited text no. 11
    
12.
Nemet AY. The Etiology of Epiphora: A Multifactorial Issue. Semin Ophthalmol. 2016;31(3):275-279. doi:10.3109/08820538.2014.962163.  Back to cited text no. 12
    
13.
Sibley D, Norris JH, Malhotra R. Management and outcomes of patients with epiphora referred to a specialist ophthalmic plastic unit. Clin Experiment Ophthalmol. 2013;41(3):231-238. doi:10.1111/j.1442-9071.2012.02866.x.  Back to cited text no. 13
    
14.
Chaudhry IA, Taiba K, Al-Sadhan Y, Riley FC. Inverted Papilloma Invading the Orbit Through the Nasolacrimal Duct: A Case Report. Orbit. 2005;24(2):135-139. doi:10.1080/01676830590926530.  Back to cited text no. 14
    
15.
Yuen HKL, Cheuk W, Cheng ACO, Anh C, Chan N. Malignant oncocytoma of the lacrimal sac as an unusual cause of epiphora. Ophthal Plast Reconstr Surg. 2007;23(1):70-72. doi:10.1097/IOP.0b013e31802dd7f4.  Back to cited text no. 15
    
16.
Lee KH, Han SH, Yoon JS. Case reports of lacrimal sac tumors discovered in patients with persistent epiphora following dacryocystorhinostomy. Korean J Ophthalmol. 2015;29(1):66-67. doi:10.3341/kjo.2015.29.1.66.  Back to cited text no. 16
    
17.
Berry-Brincat A, Tomlins P, Hall A, Quinlan M, Cheung D. Primary extrasac orbital lymphoma presenting as nasolacrimal obstruction. Orbit. 2008;27(3):175-177. doi:10.1080/01676830701549041.  Back to cited text no. 17
    
18.
United Health Foundation. Annual Report: Smoking in Massachusetts. Accessed October 3, 2021. https://www.americashealthrankings.org/explore/annual/measure/Smoking/state/MA.  Back to cited text no. 18
    
19.
Shen G-L, Ng JD, Ma X-P. Etiology, diagnosis, management and outcomes of epiphora referrals to an oculoplastic practice. Int J Ophthalmol. 2016;9(12):1751. doi:10.18240/ijo.2016.12.08.  Back to cited text no. 19
    
20.
Mathew MRK, McGuiness R, Webb LA, Murray SB, Esakowitz L. Patient satisfaction in our initial experience with endonasal endoscopic non-laser dacryocystorhinostomy. Orbit. 2004;23(2):77-85. doi:10.1080/01676830490501415.  Back to cited text no. 20
    
21.
Tarbet KJ, Custer PL. External Dacryocystorhinostomy: Surgical Success, Patient Satisfaction, and Economic Cost. Ophthalmology. 1995;102(7):1065-1070. doi:10.1016/S0161-6420(95)30910-4.  Back to cited text no. 21
    
22.
Thompson AC, Thompson MO, Young DL, et al. Barriers to follow-up and strategies to improve adherence to appointments for care of chronic eye diseases. Investig Ophthalmol Vis Sci. 2015;56(8):4324-4331. doi:10.1167/iovs.15-16444.  Back to cited text no. 22
    
23.
Syed ST, Gerber BS, Sharp LK. Traveling towards disease: Transportation barriers to health care access. J Community Health. 2013;38(5):976-993. doi:10.1007/s10900-013-9681-1.  Back to cited text no. 23
    
24.
Calfee RP, Shah CM, Canham CD, Wong AHW, Gelberman RH, Goldfarb CA. The influence of insurance status on access to and utilization of a tertiary hand surgery referral center. J Bone Jt Surg - Ser A. 2012;94(23):2177-2184. doi:10.2106/JBJS.J.01966  Back to cited text no. 24
    
25.
Shuja A, Harris C, Aldridge P, Malespin M, De Melo SW. Predictors of No-show Rate in the GI Endoscopy Suite at a Safety Net Academic Medical Center. J Clin Gastroenterol. 2019;53(1):29-33. doi:10.1097/MCG.0000000000000928.  Back to cited text no. 25
    
26.
Chen EM, Ahluwalia A, Parikh R, Nwanyanwu K. Ophthalmic Emergency Department Visits: Factors Associated With Loss to Follow-up. Published online 2020. doi:10.1016/j.ajo.2020.08.038.  Back to cited text no. 26
    
27.
Shimotsu S, Roehrl A, Mccarty M, et al. Increased Likelihood of Missed Appointments (“No Shows”) for Racial/Ethnic Minorities in a Safety Net Health System. J Prim Care Community Health. 2016;7(1):38-40. doi:10.1177/2150131915599980.  Back to cited text no. 27
    
28.
Cashman SB, Savageau JA, Lemay CA, Ferguson W. Patient health status and appointment keeping in an urban community health center. J Health Care Poor Underserved. 2004;15(3):474-488. doi:10.1353/hpu.2004.0037.  Back to cited text no. 28
    
29.
Kaplan-Lewis E, Percac-Lima S. No-show to primary care appointments: why patients do not come. J Prim Care Community Health. 2013;4(4):251-255. doi:10.1177/2150131913498513.  Back to cited text no. 29
    
30.
Keenum Z, McGwin G, Witherspoon CD, Haller JA, Clark ME, Owsley C. Patients' adherence to recommended follow-up eye care after diabetic retinopathy screening in a publicly funded county clinic and factors associated with follow-up eye care use. JAMA Ophthalmol. 2016;134(11):1221-1228. doi:10.1001/jamaophthalmol.2016.3081.  Back to cited text no. 30
    
31.
George A, Rubin G. Non-attendance in general practice: a systematic review and its implications for access to primary health care. Fam Pract. 2003;20(2):178-184. doi:10.1093/fampra/20.2.178.  Back to cited text no. 31
    
32.
Bukhari A. Etiology of tearing in patients seen in an oculoplastic clinic in Saudi Arabia. Middle East Afr J Ophthalmol. 2013;20(3):198-200. doi:10.4103/0974-9233.114790.  Back to cited text no. 32
    
33.
Naderi K, Gormley J, O'Brart D. Cataract surgery and dry eye disease: A review. Eur J Ophthalmol. 2020;30(5):840-855. doi:10.1177/1120672120929958.  Back to cited text no. 33
    
34.
Williams B, Johnson D, Hurst J, Kratky V. Patterns and causes of epiphora referrals to a tertiary oculoplastic practice. Can J Ophthalmol. 2014;49(2):180-182. doi:10.1016/j.jcjo.2013.12.003.  Back to cited text no. 34
    
35.
Ishikawa S, Murayama K, Kato N. The proportion of ocular surface diseases in untreated patients with epiphora. Clin Ophthalmol. 2018;12:1769-1773. doi:10.2147/OPTH.S172503.  Back to cited text no. 35
    
36.
Ulusoy MO, Kıvanç SA, Atakan M, Akova-Budak B. How Important Is the Etiology in the Treatment of Epiphora? J Ophthalmol. 2016;2016(2016). doi:10.1155/2016/1438376.  Back to cited text no. 36
    
37.
Nemet AY, Vinker S. Associated morbidity of nasolacrimal duct obstruction-a large community based case-control study. doi:10.1007/s00417-013-2484-3.  Back to cited text no. 37
    
38.
Yeheskel A, Rawal S. Exploring the “Patient Experience” of Individuals with Limited English Proficiency: A Scoping Review. J Immigr Minor Heal. 2019;21:853-878. doi:10.1007/s10903-018-0816-4.  Back to cited text no. 38
    
39.
Stewart MA. Effective physician-patient communication and health outcomes: A review. CMAJ. 1995;152(9):1423-1433. Accessed June 11, 2021. /pmc/articles/PMC1337906/?report=abstract.  Back to cited text no. 39
    
40.
Wilson E, Chen AH, Grumbach K, Wang F, Fernandez A. Effects of limited English proficiency and physician language on health care comprehension. J Gen Intern Med. 2005;20(9):800-806. doi:10.1111/j.1525-1497.2005.0174.x.  Back to cited text no. 40
    
41.
Wang P, Yu DJ, Feng G, et al. Is Floppy Eyelid Syndrome More Prevalent in Obstructive Sleep Apnea Syndrome Patients? J Ophthalmol. 2016;2016. doi:10.1155/2016/6980281.  Back to cited text no. 41
    
42.
Alanazi SA, Alomran AA, Abusharha A, et al. An assessment of the ocular tear film in patients with thyroid disorders. Clin Ophthalmol. 2019;13:1019-1026. doi:10.2147/OPTH.S210044.  Back to cited text no. 42
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

Top
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
Abstract
Introduction
Methods
Results
Discussion
Conclusion
References
Article Tables

 Article Access Statistics
    Viewed130    
    Printed0    
    Emailed0    
    PDF Downloaded5    
    Comments [Add]    

Recommend this journal