Dry Eye Outcomes after Endonasal Dacryocystorhinostomy: Tear Film Changes and Risk Factors for Symptom Deterioration

Dry Eye Outcomes after Endonasal Dacryocystorhinostomy: Tear Film Changes and Risk Factors for Symptom Deterioration | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Dry Eye Outcomes after Endonasal Dacryocystorhinostomy: Tear Film Changes and Risk Factors for Symptom Deterioration Muhammad Abumanhal, Mayari Ito, Keiji Sugiura, Yasuhiro Takahashi This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8727321/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose To evaluate postoperative changes in tear film, ocular surface, and meibomian gland parameters following successful endonasal dacryocystorhinostomy (en-DCR) and predictive factors in postoperative dry-eye symptom deterioration in patients with primary acquired nasolacrimal duct obstruction (PANDO). Methods This prospective study included 50 patients with unilateral PANDO who underwent successful en-DCR. Tear film break-up time (TFBUT), Schirmer test, tear meniscus height (TMH), meibomian gland parameters, and dry eye–related symptoms were assessed preoperatively and 3 months postoperatively. Measurements were compared between affected and unaffected eyes, and between pre- and postoperative visits. Patients were categorized into unchanged/improvement or deterioration groups based on postoperative symptom changes. Multivariate logistic regression was performed to identify risk factors for postoperative deterioration. Results Postoperatively, the affected eyes demonstrated significant reductions in TFBUT, Schirmer values, and upper and lower TMH, while the fellow eyes remained unchanged. Meibomian gland function significantly improved after surgery. Subjective dry eye symptoms remained unchanged or improved in majority of the patients. However, 15 patients (30.0%) experienced postoperative symptom deterioration. Patients in the deterioration group had significantly longer preoperative TFBUT and lower DEQS scores. Multivariate analysis showed that lower preoperative upper TMH tended to be associated with an increased risk of postoperative symptom deterioration. Conclusions Restoration of lacrimal drainage by en-DCR was associated with significant postoperative changes in tear film and ocular surface parameters, together with improvement in meibomian gland function. Lower preoperative upper TMH may be a potential risk factor for postoperative worsening of dry eye symptoms. epiphora dry eye dacryocystorhinostomy nasolacrimal duct obstruction Figures Figure 1 Key Message What is known? Primary acquired nasolacrimal duct obstruction and dry eye disease frequently coexist. Successful endonasal dacryocystorhinostomy (en-DCR) can alter tear dynamics and ocular surface status and may be associated with worsening of dry eye symptoms in a subset of patients. What is new? En-DCR was associated with significant postoperative changes in objective tear film and ocular surface parameters, accompanied by improvement in meibomian gland function. Patients with relatively mild preoperative dry eye symptoms and apparently stable tear film parameters may be at increased risk of postoperative symptom deterioration. Lower preoperative upper tear meniscus height may serve as a potential marker of masked dry eye and a risk factor for postoperative worsening of dry eye symptoms. INTRODUCTION Epiphora is a common ophthalmic symptom that may result from excessive tear production due to reflex hypersecretion, such as dry eye disease (DED), impaired lacrimal drainage, or a combination of both mechanisms [ 1 ]. These conditions often coexist rather than being mutually exclusive. Previous studies have reported that approximately 30% of patients with primary acquired nasolacrimal duct obstruction (PANDO) have concomitant DED and that eyes with PANDO exhibit a higher prevalence of meibomian gland dysfunction [ 2 , 3 ], underscoring the complex interplay between tear dynamics and ocular surface homeostasis. Successful endonasal dacryocystorhinostomy (en-DCR) may alleviate epiphora while potentially unmasking or exacerbating DED [ 4 , 5 ]. This phenomenon may be related to the relatively prolonged tear film break-up time (TFBUT) observed in eyes with PANDO and to the reduction in tear retention on the ocular surface following restoration of lacrimal drainage, which may decrease surface wetting and contribute to DED [ 7 ]. This hypothesis is further supported by the reported efficacy of lacrimal drainage occlusion as a treatment strategy for DED [ 7 ]. In addition, previous reports have indicated that patients with concomitant PANDO and DED who undergo successful en-DCR may continue to experience epiphora postoperatively and may not demonstrate significant improvements in quality of life (QOL) [ 4 , 5 , 8 ]. These observations highlight the importance of careful preoperative and postoperative evaluation of dry eye in patients with PANDO. The purpose of this prospective observational study was to comprehensively evaluate changes in tear film parameters, meibomian gland function, eyelid characteristics, and dry eye–related QOL following unilateral en-DCR for PANDO. We also aimed to identify preoperative risk factors associated with postoperative deterioration of dry eye symptoms. METHODS Ethics Approval The institutional review board (IRB) of our institution approved this study, which was conducted in accordance with the tenets of the Declaration of Helsinki and its later amendments (approval number, 2021-001). The IRB granted a waiver of informed consent for this study based on the ethical guidelines for medical and health research involving human subjects established by the Japanese Ministry of Education, Culture, Sports, Science, and Technology; and by the Ministry of Health, Labour, and Welfare. The waiver was granted because the study was not an interventional study. Nevertheless, at the request of the IRB, an outline of the study was published on our university website that was available for public viewing, which also gave the patients an option to refuse to participate in the study, although none did. Personal identifiers were removed from the records prior to data analysis. Study Design This prospective observational study enrolled patients who underwent unilateral en-DCR for PANDO from January 2021 to September 2025. All procedures were performed by one of the authors (YT) or by surgeons under the direct supervision of the same author. Inclusion criteria were: 1) complete unilateral nasolacromal duct obstruction (NLDO) with a patent contralateral lacrimal drainage system confirmed by lacrimal syringing; 2) a minimum postoperative follow-up of 3 months; 3) an anteroposterior rhinostomy length ≥ 5 mm at 3 months postoperatively on endoscopic examination; and 4) complete mucosal epithelization of the rhinostomy site at 3 months postoperatively. Exclusion criteria included: 1) any history of refractive, eyelid, lacrimal or paranasal sinus surgery; 2) use of contact lenses, lubricating eye drops, or topical antiglaucomatous medications; and 3) incomplete or missing data. Data Collection Data on age, sex, laterality were collected. The following examinations were performed by one of the authors (YT) and experienced orthoptists preoperatively and 3 months postoperatively. Dry eye status was assessed by measuring tear film break-up time (TFBUT) and evaluating tear film break-up pattern (TFBUP). During fluorescein staining, meticulous care was taken to avoid increasing the subjects’ tear volumes. A drop of saline solution was applied to a fluorescein test strip, and excess saline solution was shaken off before the strip was gently touched to the center of the lower eyelid margin. The interval between the eyelid opening and the first appearance of a dry spot on the tear film was recorded as TFBUT. TFBUP was classified into the following five patterns: area, line, spot, dimple, and random breaks, according to a previously described classification system [ 9 ]. Corneal fluorescein staining was graded for area (A) and density (D) using the classification system reported by Miyata et al [ 10 ]. (Table 1 ). The Schirmer’s test I was performed without topical anesthesia by placing a Schirmer’s test strip in the lower conjunctival sac without touching the cornea. The length of the wetted portion was measured after 5 min. Tear meniscus height (TMH) was measured on the sagittal plane passing through the center of the upper and lower eyelids using anterior segment optical coherence tomography (CASIA 2; TOMEY Corporation; Aichi, Japan) (Fig. 1 a). All patients completed the 15-item Dry Eye-Related Quality of Life Score (DEQS) questionnaire [ 11 ]. It consists of two subscales: the “bothersome effects of ocular symptoms (6 items)” and the “impact of dry eye on daily life (9 items)” scores. For each item, the patients rated both the frequency (A-column) and severity (B-column) of symptoms. The DEQS score as follows: the sum of scores in the B-column ÷ number of valid responses × 25. Total scores range from 0 to 100, with a higher score representing a greater impairment in dry eye–related quality of life. Additionally, this questionnaire includes a 6-points self-assessment scale evaluating the general condition related to dry eye as follows: 1, extremely good; 2, very good; 3, good; 4, not so good; 5, bad; and 6, very bad. Table 1 Grading scales. Measurement parameters Grading Findings A score 0 No punctate staining 1 The staining involving less than one-third of the cornea 2 The staining involving one-third to two-thirds of the cornea 3 The staining involving more than two-thirds of the cornea D score 0 No punctate staining 1 Sparse density 2 Moderate density 3 High density and overlapped lesions Marx line 0 The line runs entirely along the conjunctival side of the meibomian gland orifices 1 Parts of the line touch the meibomian orifices 2 The line runs through the meibomian orifices 3 The line runs along the eyelid margin side of the meibomian orifices Meibum expression 0 Easy expression of clear meibum with mild eyelid compression 1 Cloudy meibum expression with mild compression 2 Cloudy meibum expression with moderate compression 3 Toothpaste-like meibum expression with more than moderate compression 4 No expression even with hard compression Meibography 0 No loss of meibomian glands 1 Area loss less than one-third of the total meibomian gland area 2 Area loss between one-third and two-thirds of total meibomian gland area 3 Area loss more than two-thirds of total meibomian gland area Meibomian gland dysfunction (MGD) was evaluated by assessing the Marx line, the presence or absence of eyelid abnormalities, meibum expression, and meibomian glands loss. Following fluorescein staining of the ocular surface, the stained lines along the eyelid margins were examined after several blinks by slit-lamp biomicroscopy (Fig. 1 b). Marx line grading was performed according to the classification system reported by Yamaguchi et al [ 12 ]. (Table 1 ). The total score for each eyelid was defined as the sum of scores from three regions of the eyelid (the outer third, middle third, and inner third), yielding a maximum score of 9 per eyelid. The overall Marx line score was defined as the combined score of the upper and lower eyelids (maximum score of 18). Similarly, the MGD score was defined as the sum of the presence of the three eyelid abnormalities (irregular eyelid margin, vascular engorgement, and plugged meibomian gland orifices) in both the upper and lower eyelids (maximum score of 6). Meibum expression was assessed using the grading system previously reported by Vaidya et al. [ 13 ] (Table 1 ), and the score was defined as sum of the grades for the upper and lower eyelids (maximum score of 8). Meibomian gland loss was evaluated using a mobile pen-shaped meibography (Meibom Pen; Japan Focus Co., Ltd.; Tokyo; Japan) (Fig. 1 c). Gland dropout was graded according to the scale described by Arita et al. [ 14 ] (Table 1 ), and the meibography score was defined as the sum of grades for the upper and lower eyelids (maximum score of 6). Pinch test was performed to assess the effect of horizontal eyelid laxity and subsequent lacrimal pump failure. The lower eyelid was gently pulled anteriorly away from the globe, and the distance from the lower eyelid margin to the ocular surface was measured using a caliper. Statistical Analyses Patient characteristics and measurement results were expressed as means ± standard deviations. Pre- and postoperative measurement results were compared between the affected and unaffected sides using Student’s t-test or Mann-Whitney U test. Comparison between pre- and postoperative measurement results were carried out using the paired t-test or Wilcoxon signed-rank test. Patients were classified into 2 groups: the improvement group included patients in whom both the DEQS score and 6-point self-evaluation scale either improved or remained unchanged postoperatively; and the deterioration group included patients who demonstrated postoperative worsening of the DEQS score and/or 6-point self-evaluation scale. Demographic characteristics and measurement outcomes were compared between the groups using Mann-Whitney U test, chi-square test, and Fisher’s exact test. Comparison of the preoperative measurement results between the groups was only carried out because disclosure of the risk factor of postoperative dry eye symptoms was the main purpose of this study. The multivariate logistic regression analysis was used to calculate the odds ratio (OR) with 95% confidence interval (CI) for the relationship between deterioration of dry eye symptoms and patient demographic and preoperative dry eye conditions. All statistical analyses were performed using SPSS™ version 26 software (IBM Japan, Tokyo, Japan). Two-tailed P values < 0.05 were deemed to indicate statistical significance. RESULTS Data on patient characteristics are shown in Table 2 . This study included 50 patients with unilateral PANDO (8 males and 42 females; 21 right and 29 left; mean age, 68.2 ± 13.8 years). Three patients were aged 50 years or younger (17, 42, and 49 years). All patients showed TFBUT of 5 s or shorter in the unaffected eyes (range, 0–4 s), which corresponded to the diagnostic criteria of DED [ 15 ]. Table 2 Data on patient characteristics and pinch test results. M, male; F, female; R, right, L left Total Deterioration Improvement P value Number of patients 50 15 35 Age (years) 68.2 ± 13.8 71.7 ± 10.2 66.7 ± 15.0 0.313 Sex (M/F) 8/42 5/10 3/32 0.043 Side (R/L) 21/29 7/8 14/21 1.000 Pinch (mm) Affected side 7.2 ± 1.5 7.5 ± 1.5 7.1 ± 1.6 0.354 Unaffected side 7.1 ± 1.4 7.3 ± 1.5 7.0 ± 1.4 0.609 Comparison of measurement outcomes between the affected and unaffected sides and between pre- and postoperative assessments are shown in Table 3 . Preoperatively, TFBUT and Schirmer test values were significantly longer on the affected side (P = 0.008 and P < 0.001, respectively). Both upper and lower TMH were also significantly higher on the affected side (both, P 0.050). Postoperatively, although lower TMH tended to be higher on the affected side, the difference did not reach statistical significance (P = 0.098). All other postoperative parameters were not significantly different between the affected and unaffected sides (P > 0.050). Table 3 Statistical comparison between the affected and unaffected sides and between pre- and postoperative ones. Pre-OP P value: Affected vs. unaffected sides Post-OP P value: Affected vs. unaffected sides P value: Pre- vs. Post-OP Affected side Unaffected side Affected side Unaffected side Affected side Unaffected side TFBUT (s) 1.9 ± 2.6 0.8 ± 1.0 0.008 1.0 ± 1.5 0.9 ± 1.6 0.424 0.005 0.321 TFBUP (area/line/spot/dimple/random) 1/36/13/0/0 1/37/10/0/2 0.493 1/30/19/0/1 1/33/14/0/2 0.747 0.447 0.827 A score 0.2 ± 0.5 0.3 ± 0.5 0.533 0.4 ± 0.6 0.4 ± 0.5 0.957 0.158 0.275 D score 0.4 ± 0.8 0.4 ± 0.7 0.570 0.6 ± 1.0 0.7 ± 1.1 0.739 0.242 0.059 Schirmer test (mm) 13.5 ± 8.3 7.3 ± 6.2 < 0.001 9.8 ± 7.6 8.8 ± 6.2 0.473 0.003 0.054 TMH (µm) Upper 285.8 ± 115.6 183.2 ± 84.8 < 0.001 220.3 ± 100.2 202.3 ± 100.5 0.373 < 0.001 0.212 Lower 469.6 ± 273.1 227.3 ± 98.8 < 0.001 308.3 ± 213.5 252.5 ± 100.7 0.098 < 0.001 0.117 DEQS Total 18.6 ± 17.0 13.0 ± 15.6 0.018 Self-evaluation 3.7 ± 1.0 3.2 ± 0.8 < 0.001 Marx line score 10.5 ± 4.3 9.2 ± 4.2 0.117 10.2 ± 4.3 9.2 ± 4.7 0.336 0.457 0.769 MGD score 1.8 ± 1.6 1.8 ± 1.5 0.885 1.9 ± 1.6 1.9 ± 1.6 0.863 0.160 0.143 Meibum expression score 2.5 ± 2.5 2.1 ± 2.5 0.321 2.1 ± 2.5 2.0 ± 2.5 0.701 0.037 0.466 Meibography score 2.0 ± 2.0 2.1 ± 2.0 0.852 1.7 ± 1.8 2.1 ± 1.9 0.257 0.005 0.782 OP, operative; TFBUT, tear film break-up time; TFBUP, tear film break-up pattern; TMH, tear meniscus height; DEQS, dry eye-related quality of life score; MGD, meibomian gland dysfunction On the affected side, TFBUT (P = 0.005) and Schirmer test values (P = 0.003) decreased significantly after surgery. Upper and lower TMH also showed significant postoperative reductions (both, P < 0.001). In contrast, meibom expression (P = 0.037) and meibography scores (P = 0.005) demonstrated significant improvement. Patient-reported outcomes also improved, with significant reductions in both the DEQS score (P = 0.018) and 6-point-self-evaluation scale (P 0.050). Comparison of preoperative measurements between the groups are presented in Table 4 . Postoperative deterioration of dry eye symptoms was observed in 15 patients (30.0%). The deterioration group demonstrated significantly longer preoperative TFBUT on both the affected (P = 0.005) and unaffected sides (P = 0.031). Upper TMH on the affected side tended to be lower in the deterioration group (P = 0.077). In addition, preoperative DEQS scores were significantly lower in the deterioration group (P = 0.024). The other variables did not significantly differ between the groups (P > 0.050). Table 4 Statistical comparison between the groups. Pre-OP (affected side) P value Pre-OP (unaffected side) P value Deterioration Improvement Deterioration Improvement DEQS Total 11.2 ± 11.8 22.8 ± 18.0 0.024 Self-evaluation 3.7 ± 1.0 3.8 ± 1.0 0.610 TFBUT (s) 2.9 ± 2.1 1.4 ± 2.7 0.005 1.3 ± 1.2 0.6 ± 0.9 0.031 TFBUP (area/line/spot/dimple/random) 0/13/2/0/0 1/23/11/0/0 0.827 0/13/1/0/1 1/24/9/0/1 0.390 A score 0.1 ± 0.4 0.3 ± 0.5 0.324 0.1 ± 0.4 0.3 ± 0.5 0.134 D score 0.2 ± 0.6 0.5 ± 0.9 0.327 0.2 ± 0.6 0.5 ± 0.8 0.151 Schirmer test (mm) 14.8 ± 9.1 13.0 ± 8.0 0.538 5.5 ± 4.8 7.9 ± 6.6 0.208 TMH (µm) Upper 248.7 ± 100.9 301.7 ± 119.2 0.077 175.4 ± 65.6 186.6 ± 92.5 0.719 Lower 444.7 ± 257.2 480.2 ± 282.5 0.597 234.3 ± 100.8 224.3 ± 99.3 0.775 Marx line score 10.9 ± 2.4 10.4 ± 4.9 0.873 8.7 ± 3.4 9.4 ± 4.6 0.559 MGD score 2.1 ± 1.6 1.7 ± 1.6 0.351 2.2 ± 1.6 1.6 ± 1.5 0.227 Meibum expression score 2.3 ± 2.5 2.6 ± 2.5 0.602 2.1 ± 2.3 2.1 ± 2.7 0.625 Meibography score 2.0 ± 2.0 2.0 ± 2.0 0.983 2.3 ± 2.3 2.0 ± 1.9 0.689 OP, operative; TFBUT, tear film break-up time; TFBUP, tear film break-up pattern; TMH, tear meniscus height; DEQS, dry eye-related quality of life score; MGD, meibomian gland dysfunction The results of the multivariate logistic regression analysis are summarized in Table 5 . A higher upper TMH tended to decrease the risk of postoperative deterioration of dry eye symptom (OR, 0.984; 95% CI, 0.965–1.003; P = 0.099). Table 5 Results of multivariate logistic regression analysis Variables OR 95% CI P values Age 1.120 0.917–1.368 0.269 TFBUT Affected side 0.984 0.536–1.803 0.957 Unaffected side 1.274 0.266–6.106 0.762 A score Affected side 0.093 0-504.682 0.588 Unaffected side 0.030 0-463.121 0.475 D score Affected side 1.691 0.012-232.013 0.834 Unaffected side 8.248 0.055-1241.062 0.409 Schirmer test Affected side 1.200 0.945–1.524 0.134 Unaffected side 0.841 0.626–1.131 0.253 Upper TMH Affected side 0.984 0.965–1.003 0.099 Unaffected side 1.006 0.989–1.022 0.510 Lower TMH Affected side 0.997 0.984–1.009 0.611 Unaffected side 0.997 0.977–1.017 0.745 Marx line score Affected side 0.857 0.492–1.493 0.586 Unaffected side 0.706 0.370–1.345 0.290 MGD socre Affected side 0.340 0.028-187.898 0.229 Unaffected side 7.324 0.449–6.374 0.437 Meibum expression score Affected side 0.388 0.097–1.551 0.181 Unaffected side 1.693 0.449–6.374 0.437 Meibography score Affected side 0.506 0.116–2.203 0.364 Unaffected side 1.954 0.643–5.938 0.238 Pinch test Affected side 1.395 0.117–16.715 0.793 Unaffected side 1.227 0.087–17.370 0.880 TFBUT, tear film break-up time; TMH, tear meniscus height; MGD, meibomian gland dysfunction DISCUSSION In this prospective observational study, we evaluated changes in ocular surface parameters and dry eye–related symptoms following unilateral en-DCR for PANDO. Successful restoration of lacrimal drainage resulted in significant reductions in tear volume–related parameters on the operated side, accompanied by improvements in meibomian gland function. Although dry eye–related QOL improved in most patients, a substantial subset experienced postoperative worsening of dry eye symptoms. En-DCR significantly altered tear film and ocular surface parameters. In the present study, TFBUT and Schirmer test values decreased postoperatively. Consistent with previous reports, we also observed a reduction in TMH on the operated side following en-DCR [ 16 , 17 ], while the contralateral eye remained unchanged. These changes likely reflect normalization of tear retention after relief of nasolacrimal obstruction. However, they may also predispose a subset of patients to ocular surface instability. Previous studies reported subjective worsening of dry eye symptoms after DCR. Kang et al. demonstrated that approximately 27% of patients developed dry eye symptoms following successful en-DCR [ 5 ], and Kim et al. reported that 15% of patients with concomitant PANDO and DED experienced significant postoperative dry eye symptoms deterioration [ 4 ]. In line with these observations, our study demonstrates not only subjective worsening in a subset of patients but also significant postoperative changes in objective parameters related to DED. These findings emphasize the close interaction between PANDO and the ocular surface and highlight the impact of lacrimal drainage restoration on tear film homeostasis. Meibomian gland function was found to improve significantly following en-DCR. Although preoperative impairment of meibomian gland function on the affected side was not observed in our cohort, in contrast to findings reported in previous studies [ 2 , 3 , 18 ], both meibum expressibility and meibography scores improved significantly after surgery. These findings suggest a favorable effect of lacrimal drainage restoration on the lipid layer–related components of the tear film. This improvement is consistent with the report by Goel et al., who demonstrated that DCR can reverse functional meibomian gland changes and improve tear film stability [ 19 ]. Although the underlying mechanism remains unclear, it is plausible that reduced tear stagnation and improved clearance of inflammatory mediators from the ocular surface and lacrimal system contribute to the observed improvement in meibomian gland function. Interestingly, patients who experienced postoperative worsening of dry eye symptoms demonstrated longer preoperative TFBUT and lower DEQS scores, reflecting relatively mild subjective complaints and apparently stable tear film parameters prior to surgery. One possible explanation is that tear pooling secondary to NLDO masks underlying ocular surface vulnerability by increasing tear volume, thereby prolonging TFBUT and reducing symptom perception. Following restoration of lacrimal outflow, this compensatory effect may be lost, leading to the unmasking of subclinical or compensated DED. In addition, patients with mild preoperative symptoms may be more susceptible to noticeable postoperative deterioration due to a ceiling effect in symptom scoring, whereas those with more severe baseline symptoms have limited capacity for further worsening. These findings suggest that seemingly favorable preoperative tear film parameters and minimal subjective symptoms do not necessarily confer protection against postoperative dry eye deterioration and may, paradoxically, identify a subgroup at increased risk after en-DCR. Lower preoperative upper TMH may represent a potential marker for postoperative deterioration of dry eye symptoms. Unlike lower TMH, which can be elevated by tear retention in NLDO, upper TMH is less influenced by tear pooling and may better reflect true basal tear volume. In this context, a relatively low upper TMH may indicate preexisting but masked aqueous tear deficiency despite apparently normal tear film parameters, such as prolonged TFBUT. Following restoration of lacrimal drainage, inferior tear pooling resolves, unmasking underlying tear insufficiency and predisposing these patients to postoperative ocular surface instability. These findings suggest that upper TMH may serve as a useful preoperative parameter for identifying patients at risk of dry eye deterioration after en-DCR. This study has several limitations. Although prospectively designed, it was conducted at a single center with a relatively limited sample size. The postoperative follow-up period was relatively short and may not fully reflect long-term tear film and ocular surface changes after en-DCR. In addition, inflammatory biomarkers and detailed lacrimal functional assessments were not included, which could have provided further insight into the underlying mechanisms. In conclusion, successful en-DCR was associated with significant postoperative changes in tear film and ocular surface parameters in the affected side. While several aqueous tear–related indices declined after surgery, meibomian gland function improved significantly. Notably, a distinct deterioration group (30%) experienced worsening of dry eye symptoms despite favorable preoperative parameters, indicating that tear retention may mask underlying ocular surface vulnerability. These findings emphasize the complex interplay between PANDO, tear dynamics, and ocular surface health and support the need for careful preoperative dry eye evaluation and patient counseling before en-DCR. Declarations Funding: None. Authors’ contributions: Conceptualization , YT; methodology , YT; data curation , MI, KS, and YT; validation , YT; formal analysis , YT; investigation , YT; writing-original draft preparation , MA; writing-review and editing , MI, KS, and YT; supervision , YT; project administration , YT. All authors have read and agreed to the published version of the manuscript. No one contributed to the work who did not meet our authorship criteria. Meeting Presentation: None. Data availability statement: The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request. Declaration of Generative AI in scientific writing: The authors did not use generative AI and AI-assisted technologies in the writing process. Clinical trial number : Not applicable. 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Ophthalmology 116:2058–2063e1 Shimazaki J (2018) Definition and diagnostic criteria of dry eye disease: historical overview and future directions. Invest Ophthalmol Vis Sci 59:DES7–DES12 Doran MA, Ayintap E, Aytogan H (2024) Evaluation of the relationship between tear meniscus changes and quality of life outcomes after external dacryocystorhinostomy. Int Ophthalmol 44:105 Ohtomo K, Ueta T, Fukuda R, Usui T, Miyai T, Shirakawa R, Amano S, Nagahara M (2014) Tear meniscus volume changes in dacryocystorhinostomy evaluated with quantitative measurement using anterior segment optical coherence tomography. Invest Ophthalmol Vis Sci 55:2057–2061 Wang G, Jin H, Sheng Y, Ji F, Liu Y, Han L, Wang X, Chen Z, Ding H, Liu J, Fu Q (2024) Higher incidence of meibomian gland dysfunction in postmenopausal women with primary acquired nasolacrimal duct obstruction. Int Ophthalmol 44:70 Goel R, Saini S, Golhait P, Shah S (2024) Association of primary chronic dacryocystitis and meibomian gland dysfunction. Indian J Ophthalmol 72:185–189 Additional Declarations Competing interest reported. YT received speaker and consultant honoraria from Amgen Inc., Chugai Pharmaceutical Co., Ltd., Santen Pharmaceutical Co., Ltd., and Ono Pharmaceutical Co., Ltd. The other authors have no financial or conflicts of interest to disclose. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8727321","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":589695118,"identity":"3e7bc555-09da-4432-b919-9e087498b1d4","order_by":0,"name":"Muhammad Abumanhal","email":"","orcid":"","institution":"Tel Aviv Sourasky Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Muhammad","middleName":"","lastName":"Abumanhal","suffix":""},{"id":589695126,"identity":"da2c1483-a9c7-4e30-9d5d-fb9ccd50cd64","order_by":1,"name":"Mayari Ito","email":"","orcid":"","institution":"Aichi Medical University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Mayari","middleName":"","lastName":"Ito","suffix":""},{"id":589695127,"identity":"fde64cfb-3e46-4bc7-94d2-c3bb4d0e1e37","order_by":2,"name":"Keiji Sugiura","email":"","orcid":"","institution":"Aichi Medical University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Keiji","middleName":"","lastName":"Sugiura","suffix":""},{"id":589695129,"identity":"015c1976-346f-467d-9aa5-0b71c9c990c1","order_by":3,"name":"Yasuhiro Takahashi","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA/klEQVRIiWNgGAWjYJACZgYDKP2BgSEBKshGhBY2BmbGGcRrgahhZuZBaMENDI4ffyZdUHBPjkG++bGxbZtdHj97A+OHDwx8eTi1nMkxk55hUGzMwMZmnJzbllws2XOAWXIGA1sxTi0HctikeQwSEhvYGIwP57YxJ264kcAGdCFbYgMuLeefP4NqYf982LKtnggtNxLMoFp4jJMZ2w4T1iJ5442xNVAL0C85xYY9544nzuw52Cw5wwC3X/jOpz+8zfMnQY6B+fhmiR9l1Yn97M0HP3yoOIYzxBQOQBn2IAYjOAIZgU4yOJaAS4s8qov/wFk1OLWMglEwCkbBiAMAu+pP2D1fxIYAAAAASUVORK5CYII=","orcid":"","institution":"Aichi Medical University Hospital","correspondingAuthor":true,"prefix":"","firstName":"Yasuhiro","middleName":"","lastName":"Takahashi","suffix":""}],"badges":[],"createdAt":"2026-01-29 05:25:54","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8727321/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8727321/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":102839040,"identity":"342c8a6e-990d-4097-b734-1895ed943a8a","added_by":"auto","created_at":"2026-02-17 11:41:19","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":384190,"visible":true,"origin":"","legend":"\u003cp\u003eRepresentative images showing measurement of tear meniscus height (\u003cstrong\u003ea\u003c/strong\u003e), assessment of the Mark line (\u003cstrong\u003eb\u003c/strong\u003e, arrow), and evaluation of meibomian gland morphology by meibography (\u003cstrong\u003ec\u003c/strong\u003e)\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8727321/v1/ddad2795603318db2d9369ca.png"},{"id":106909627,"identity":"31116349-cb95-4bfb-a741-632edc9039ba","added_by":"auto","created_at":"2026-04-14 16:11:44","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1531758,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8727321/v1/dc9b3ce9-f37c-40fc-9037-9195c53f4bda.pdf"}],"financialInterests":"Competing interest reported. YT received speaker and consultant honoraria from Amgen Inc., Chugai Pharmaceutical Co., Ltd., Santen Pharmaceutical Co., Ltd., and Ono Pharmaceutical Co., Ltd. The other authors have no financial or conflicts of interest to disclose.","formattedTitle":"Dry Eye Outcomes after Endonasal Dacryocystorhinostomy: Tear Film Changes and Risk Factors for Symptom Deterioration","fulltext":[{"header":"Key Message","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eWhat is known?\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003ePrimary acquired nasolacrimal duct obstruction and dry eye disease frequently coexist.\u003c/li\u003e\n \u003cli\u003eSuccessful endonasal dacryocystorhinostomy (en-DCR) can alter tear dynamics and ocular surface status and may be associated with worsening of dry eye symptoms in a subset of patients.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eWhat is new?\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eEn-DCR was associated with significant postoperative changes in objective tear film and ocular surface parameters, accompanied by improvement in meibomian gland function.\u003c/li\u003e\n \u003cli\u003ePatients with relatively mild preoperative dry eye symptoms and apparently stable tear film parameters may be at increased risk of postoperative symptom deterioration.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003eLower preoperative upper tear meniscus height may serve as a potential marker of masked dry eye and a risk factor for postoperative worsening of dry eye symptoms.\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"INTRODUCTION","content":"\u003cp\u003eEpiphora is a common ophthalmic symptom that may result from excessive tear production due to reflex hypersecretion, such as dry eye disease (DED), impaired lacrimal drainage, or a combination of both mechanisms [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. These conditions often coexist rather than being mutually exclusive. Previous studies have reported that approximately 30% of patients with primary acquired nasolacrimal duct obstruction (PANDO) have concomitant DED and that eyes with PANDO exhibit a higher prevalence of meibomian gland dysfunction [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], underscoring the complex interplay between tear dynamics and ocular surface homeostasis.\u003c/p\u003e \u003cp\u003eSuccessful endonasal dacryocystorhinostomy (en-DCR) may alleviate epiphora while potentially unmasking or exacerbating DED [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. This phenomenon may be related to the relatively prolonged tear film break-up time (TFBUT) observed in eyes with PANDO and to the reduction in tear retention on the ocular surface following restoration of lacrimal drainage, which may decrease surface wetting and contribute to DED [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. This hypothesis is further supported by the reported efficacy of lacrimal drainage occlusion as a treatment strategy for DED [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. In addition, previous reports have indicated that patients with concomitant PANDO and DED who undergo successful en-DCR may continue to experience epiphora postoperatively and may not demonstrate significant improvements in quality of life (QOL) [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. These observations highlight the importance of careful preoperative and postoperative evaluation of dry eye in patients with PANDO.\u003c/p\u003e \u003cp\u003eThe purpose of this prospective observational study was to comprehensively evaluate changes in tear film parameters, meibomian gland function, eyelid characteristics, and dry eye\u0026ndash;related QOL following unilateral en-DCR for PANDO. We also aimed to identify preoperative risk factors associated with postoperative deterioration of dry eye symptoms.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eEthics Approval\u003c/h2\u003e \u003cp\u003eThe institutional review board (IRB) of our institution approved this study, which was conducted in accordance with the tenets of the Declaration of Helsinki and its later amendments (approval number, 2021-001). The IRB granted a waiver of informed consent for this study based on the ethical guidelines for medical and health research involving human subjects established by the Japanese Ministry of Education, Culture, Sports, Science, and Technology; and by the Ministry of Health, Labour, and Welfare. The waiver was granted because the study was not an interventional study. Nevertheless, at the request of the IRB, an outline of the study was published on our university website that was available for public viewing, which also gave the patients an option to refuse to participate in the study, although none did. Personal identifiers were removed from the records prior to data analysis.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy Design\u003c/h3\u003e\n\u003cp\u003eThis prospective observational study enrolled patients who underwent unilateral en-DCR for PANDO from January 2021 to September 2025. All procedures were performed by one of the authors (YT) or by surgeons under the direct supervision of the same author. Inclusion criteria were: 1) complete unilateral nasolacromal duct obstruction (NLDO) with a patent contralateral lacrimal drainage system confirmed by lacrimal syringing; 2) a minimum postoperative follow-up of 3 months; 3) an anteroposterior rhinostomy length\u0026thinsp;\u0026ge;\u0026thinsp;5 mm at 3 months postoperatively on endoscopic examination; and 4) complete mucosal epithelization of the rhinostomy site at 3 months postoperatively. Exclusion criteria included: 1) any history of refractive, eyelid, lacrimal or paranasal sinus surgery; 2) use of contact lenses, lubricating eye drops, or topical antiglaucomatous medications; and 3) incomplete or missing data.\u003c/p\u003e\n\u003ch3\u003eData Collection\u003c/h3\u003e\n\u003cp\u003eData on age, sex, laterality were collected. The following examinations were performed by one of the authors (YT) and experienced orthoptists preoperatively and 3 months postoperatively.\u003c/p\u003e \u003cp\u003eDry eye status was assessed by measuring tear film break-up time (TFBUT) and evaluating tear film break-up pattern (TFBUP). During fluorescein staining, meticulous care was taken to avoid increasing the subjects\u0026rsquo; tear volumes. A drop of saline solution was applied to a fluorescein test strip, and excess saline solution was shaken off before the strip was gently touched to the center of the lower eyelid margin. The interval between the eyelid opening and the first appearance of a dry spot on the tear film was recorded as TFBUT. TFBUP was classified into the following five patterns: area, line, spot, dimple, and random breaks, according to a previously described classification system [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Corneal fluorescein staining was graded for area (A) and density (D) using the classification system reported by Miyata et al [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The Schirmer\u0026rsquo;s test I was performed without topical anesthesia by placing a Schirmer\u0026rsquo;s test strip in the lower conjunctival sac without touching the cornea. The length of the wetted portion was measured after 5 min. Tear meniscus height (TMH) was measured on the sagittal plane passing through the center of the upper and lower eyelids using anterior segment optical coherence tomography (CASIA 2; TOMEY Corporation; Aichi, Japan) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ea). All patients completed the 15-item Dry Eye-Related Quality of Life Score (DEQS) questionnaire [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. It consists of two subscales: the \u0026ldquo;bothersome effects of ocular symptoms (6 items)\u0026rdquo; and the \u0026ldquo;impact of dry eye on daily life (9 items)\u0026rdquo; scores. For each item, the patients rated both the frequency (A-column) and severity (B-column) of symptoms. The DEQS score as follows: the sum of scores in the B-column\u0026thinsp;\u0026divide;\u0026thinsp;number of valid responses \u0026times; 25. Total scores range from 0 to 100, with a higher score representing a greater impairment in dry eye\u0026ndash;related quality of life. Additionally, this questionnaire includes a 6-points self-assessment scale evaluating the general condition related to dry eye as follows: 1, extremely good; 2, very good; 3, good; 4, not so good; 5, bad; and 6, very bad.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eGrading scales.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMeasurement parameters\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGrading\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFindings\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eA score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo punctate staining\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eThe staining involving less than one-third of the cornea\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eThe staining involving one-third to two-thirds of the cornea\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eThe staining involving more than two-thirds of the cornea\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eD score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo punctate staining\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSparse density\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eModerate density\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHigh density and overlapped lesions\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarx line\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eThe line runs entirely along the conjunctival side of the meibomian gland orifices\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eParts of the line touch the meibomian orifices\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eThe line runs through the meibomian orifices\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eThe line runs along the eyelid margin side of the meibomian orifices\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMeibum expression\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEasy expression of clear meibum with mild eyelid compression\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCloudy meibum expression with mild compression\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCloudy meibum expression with moderate compression\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eToothpaste-like meibum expression with more than moderate compression\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo expression even with hard compression\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMeibography\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo loss of meibomian glands\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eArea loss less than one-third of the total meibomian gland area\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eArea loss between one-third and two-thirds of total meibomian gland area\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eArea loss more than two-thirds of total meibomian gland area\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eMeibomian gland dysfunction (MGD) was evaluated by assessing the Marx line, the presence or absence of eyelid abnormalities, meibum expression, and meibomian glands loss. Following fluorescein staining of the ocular surface, the stained lines along the eyelid margins were examined after several blinks by slit-lamp biomicroscopy (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eb). Marx line grading was performed according to the classification system reported by Yamaguchi et al [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The total score for each eyelid was defined as the sum of scores from three regions of the eyelid (the outer third, middle third, and inner third), yielding a maximum score of 9 per eyelid. The overall Marx line score was defined as the combined score of the upper and lower eyelids (maximum score of 18). Similarly, the MGD score was defined as the sum of the presence of the three eyelid abnormalities (irregular eyelid margin, vascular engorgement, and plugged meibomian gland orifices) in both the upper and lower eyelids (maximum score of 6). Meibum expression was assessed using the grading system previously reported by Vaidya et al. [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e), and the score was defined as sum of the grades for the upper and lower eyelids (maximum score of 8). Meibomian gland loss was evaluated using a mobile pen-shaped meibography (Meibom Pen; Japan Focus Co., Ltd.; Tokyo; Japan) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ec). Gland dropout was graded according to the scale described by Arita et al. [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e), and the meibography score was defined as the sum of grades for the upper and lower eyelids (maximum score of 6).\u003c/p\u003e \u003cp\u003ePinch test was performed to assess the effect of horizontal eyelid laxity and subsequent lacrimal pump failure. The lower eyelid was gently pulled anteriorly away from the globe, and the distance from the lower eyelid margin to the ocular surface was measured using a caliper.\u003c/p\u003e\n\u003ch3\u003eStatistical Analyses\u003c/h3\u003e\n\u003cp\u003ePatient characteristics and measurement results were expressed as means\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviations. Pre- and postoperative measurement results were compared between the affected and unaffected sides using Student\u0026rsquo;s t-test or Mann-Whitney U test. Comparison between pre- and postoperative measurement results were carried out using the paired t-test or Wilcoxon signed-rank test.\u003c/p\u003e \u003cp\u003ePatients were classified into 2 groups: the improvement group included patients in whom both the DEQS score and 6-point self-evaluation scale either improved or remained unchanged postoperatively; and the deterioration group included patients who demonstrated postoperative worsening of the DEQS score and/or 6-point self-evaluation scale. Demographic characteristics and measurement outcomes were compared between the groups using Mann-Whitney U test, chi-square test, and Fisher\u0026rsquo;s exact test. Comparison of the preoperative measurement results between the groups was only carried out because disclosure of the risk factor of postoperative dry eye symptoms was the main purpose of this study. The multivariate logistic regression analysis was used to calculate the odds ratio (OR) with 95% confidence interval (CI) for the relationship between deterioration of dry eye symptoms and patient demographic and preoperative dry eye conditions. All statistical analyses were performed using SPSS\u0026trade; version 26 software (IBM Japan, Tokyo, Japan). Two-tailed \u003cem\u003eP\u003c/em\u003e values\u0026thinsp;\u0026lt;\u0026thinsp;0.05 were deemed to indicate statistical significance.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eData on patient characteristics are shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. This study included 50 patients with unilateral PANDO (8 males and 42 females; 21 right and 29 left; mean age, 68.2\u0026thinsp;\u0026plusmn;\u0026thinsp;13.8 years). Three patients were aged 50 years or younger (17, 42, and 49 years). All patients showed TFBUT of 5 s or shorter in the unaffected eyes (range, 0\u0026ndash;4 s), which corresponded to the diagnostic criteria of DED [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eData on patient characteristics and pinch test results. M, male; F, female; R, right, L left\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDeterioration\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eImprovement\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e68.2\u0026thinsp;\u0026plusmn;\u0026thinsp;13.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e71.7\u0026thinsp;\u0026plusmn;\u0026thinsp;10.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e66.7\u0026thinsp;\u0026plusmn;\u0026thinsp;15.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.313\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex (M/F)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8/42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5/10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3/32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.043\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSide (R/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21/29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7/8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14/21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePinch (mm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAffected side\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.2\u0026thinsp;\u0026plusmn;\u0026thinsp;1.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.5\u0026thinsp;\u0026plusmn;\u0026thinsp;1.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7.1\u0026thinsp;\u0026plusmn;\u0026thinsp;1.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.354\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnaffected side\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.1\u0026thinsp;\u0026plusmn;\u0026thinsp;1.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.3\u0026thinsp;\u0026plusmn;\u0026thinsp;1.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7.0\u0026thinsp;\u0026plusmn;\u0026thinsp;1.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.609\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eComparison of measurement outcomes between the affected and unaffected sides and between pre- and postoperative assessments are shown in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. Preoperatively, TFBUT and Schirmer test values were significantly longer on the affected side (P\u0026thinsp;=\u0026thinsp;0.008 and P\u0026thinsp;\u0026lt;\u0026thinsp;0.001, respectively). Both upper and lower TMH were also significantly higher on the affected side (both, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). No other preoperative parameters differed significantly between the two sides (P\u0026thinsp;\u0026gt;\u0026thinsp;0.050). Postoperatively, although lower TMH tended to be higher on the affected side, the difference did not reach statistical significance (P\u0026thinsp;=\u0026thinsp;0.098). All other postoperative parameters were not significantly different between the affected and unaffected sides (P\u0026thinsp;\u0026gt;\u0026thinsp;0.050).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eStatistical comparison between the affected and unaffected sides and between pre- and postoperative ones.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003ePre-OP\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP value: Affected vs. unaffected sides\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003ePost-OP\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eP value: Affected vs. unaffected sides\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003eP value: Pre- vs. Post-OP\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAffected side\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUnaffected side\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAffected side\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUnaffected side\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAffected side\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eUnaffected side\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTFBUT (s)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.9\u0026thinsp;\u0026plusmn;\u0026thinsp;2.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.8\u0026thinsp;\u0026plusmn;\u0026thinsp;1.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.008\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.0\u0026thinsp;\u0026plusmn;\u0026thinsp;1.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.9\u0026thinsp;\u0026plusmn;\u0026thinsp;1.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.424\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.005\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.321\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTFBUP (area/line/spot/dimple/random)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1/36/13/0/0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1/37/10/0/2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.493\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1/30/19/0/1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1/33/14/0/2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.747\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.447\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.827\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eA score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.2\u0026thinsp;\u0026plusmn;\u0026thinsp;0.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.3\u0026thinsp;\u0026plusmn;\u0026thinsp;0.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.533\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.4\u0026thinsp;\u0026plusmn;\u0026thinsp;0.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.4\u0026thinsp;\u0026plusmn;\u0026thinsp;0.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.957\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.158\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.275\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eD score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.4\u0026thinsp;\u0026plusmn;\u0026thinsp;0.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.4\u0026thinsp;\u0026plusmn;\u0026thinsp;0.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.570\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.6\u0026thinsp;\u0026plusmn;\u0026thinsp;1.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.7\u0026thinsp;\u0026plusmn;\u0026thinsp;1.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.739\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.242\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.059\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSchirmer test (mm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13.5\u0026thinsp;\u0026plusmn;\u0026thinsp;8.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.3\u0026thinsp;\u0026plusmn;\u0026thinsp;6.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e9.8\u0026thinsp;\u0026plusmn;\u0026thinsp;7.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e8.8\u0026thinsp;\u0026plusmn;\u0026thinsp;6.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.473\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.003\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.054\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTMH (\u0026micro;m)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUpper\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e285.8\u0026thinsp;\u0026plusmn;\u0026thinsp;115.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e183.2\u0026thinsp;\u0026plusmn;\u0026thinsp;84.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e220.3\u0026thinsp;\u0026plusmn;\u0026thinsp;100.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e202.3\u0026thinsp;\u0026plusmn;\u0026thinsp;100.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.373\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.212\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLower\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e469.6\u0026thinsp;\u0026plusmn;\u0026thinsp;273.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e227.3\u0026thinsp;\u0026plusmn;\u0026thinsp;98.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e308.3\u0026thinsp;\u0026plusmn;\u0026thinsp;213.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e252.5\u0026thinsp;\u0026plusmn;\u0026thinsp;100.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.098\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.117\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDEQS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18.6\u0026thinsp;\u0026plusmn;\u0026thinsp;17.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e13.0\u0026thinsp;\u0026plusmn;\u0026thinsp;15.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.018\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSelf-evaluation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.7\u0026thinsp;\u0026plusmn;\u0026thinsp;1.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.2\u0026thinsp;\u0026plusmn;\u0026thinsp;0.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarx line score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10.5\u0026thinsp;\u0026plusmn;\u0026thinsp;4.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.2\u0026thinsp;\u0026plusmn;\u0026thinsp;4.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.117\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10.2\u0026thinsp;\u0026plusmn;\u0026thinsp;4.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e9.2\u0026thinsp;\u0026plusmn;\u0026thinsp;4.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.336\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.457\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.769\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMGD score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.8\u0026thinsp;\u0026plusmn;\u0026thinsp;1.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.8\u0026thinsp;\u0026plusmn;\u0026thinsp;1.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.885\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.9\u0026thinsp;\u0026plusmn;\u0026thinsp;1.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.9\u0026thinsp;\u0026plusmn;\u0026thinsp;1.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.863\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.160\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.143\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMeibum expression score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.5\u0026thinsp;\u0026plusmn;\u0026thinsp;2.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.1\u0026thinsp;\u0026plusmn;\u0026thinsp;2.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.321\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.1\u0026thinsp;\u0026plusmn;\u0026thinsp;2.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.0\u0026thinsp;\u0026plusmn;\u0026thinsp;2.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.701\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.037\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.466\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMeibography score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.0\u0026thinsp;\u0026plusmn;\u0026thinsp;2.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.1\u0026thinsp;\u0026plusmn;\u0026thinsp;2.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.852\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.7\u0026thinsp;\u0026plusmn;\u0026thinsp;1.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.1\u0026thinsp;\u0026plusmn;\u0026thinsp;1.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.257\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.005\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.782\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"9\"\u003eOP, operative; TFBUT, tear film break-up time; TFBUP, tear film break-up pattern; TMH, tear meniscus height; DEQS, dry eye-related quality of life score; MGD, meibomian gland dysfunction\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eOn the affected side, TFBUT (P\u0026thinsp;=\u0026thinsp;0.005) and Schirmer test values (P\u0026thinsp;=\u0026thinsp;0.003) decreased significantly after surgery. Upper and lower TMH also showed significant postoperative reductions (both, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). In contrast, meibom expression (P\u0026thinsp;=\u0026thinsp;0.037) and meibography scores (P\u0026thinsp;=\u0026thinsp;0.005) demonstrated significant improvement. Patient-reported outcomes also improved, with significant reductions in both the DEQS score (P\u0026thinsp;=\u0026thinsp;0.018) and 6-point-self-evaluation scale (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003eNo significant postoperative changes were observed in any measurement on the unaffected side (P\u0026thinsp;\u0026gt;\u0026thinsp;0.050).\u003c/p\u003e \u003cp\u003eComparison of preoperative measurements between the groups are presented in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e. Postoperative deterioration of dry eye symptoms was observed in 15 patients (30.0%). The deterioration group demonstrated significantly longer preoperative TFBUT on both the affected (P\u0026thinsp;=\u0026thinsp;0.005) and unaffected sides (P\u0026thinsp;=\u0026thinsp;0.031). Upper TMH on the affected side tended to be lower in the deterioration group (P\u0026thinsp;=\u0026thinsp;0.077). In addition, preoperative DEQS scores were significantly lower in the deterioration group (P\u0026thinsp;=\u0026thinsp;0.024). The other variables did not significantly differ between the groups (P\u0026thinsp;\u0026gt;\u0026thinsp;0.050).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eStatistical comparison between the groups.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003ePre-OP (affected side)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003ePre-OP (unaffected side)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDeterioration\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eImprovement\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eDeterioration\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eImprovement\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDEQS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11.2\u0026thinsp;\u0026plusmn;\u0026thinsp;11.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22.8\u0026thinsp;\u0026plusmn;\u0026thinsp;18.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.024\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSelf-evaluation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.7\u0026thinsp;\u0026plusmn;\u0026thinsp;1.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.8\u0026thinsp;\u0026plusmn;\u0026thinsp;1.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.610\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTFBUT (s)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.9\u0026thinsp;\u0026plusmn;\u0026thinsp;2.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.4\u0026thinsp;\u0026plusmn;\u0026thinsp;2.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.005\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.3\u0026thinsp;\u0026plusmn;\u0026thinsp;1.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.6\u0026thinsp;\u0026plusmn;\u0026thinsp;0.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.031\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTFBUP (area/line/spot/dimple/random)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0/13/2/0/0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1/23/11/0/0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.827\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0/13/1/0/1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1/24/9/0/1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.390\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eA score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.1\u0026thinsp;\u0026plusmn;\u0026thinsp;0.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.3\u0026thinsp;\u0026plusmn;\u0026thinsp;0.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.324\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.1\u0026thinsp;\u0026plusmn;\u0026thinsp;0.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.3\u0026thinsp;\u0026plusmn;\u0026thinsp;0.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.134\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eD score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.2\u0026thinsp;\u0026plusmn;\u0026thinsp;0.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.5\u0026thinsp;\u0026plusmn;\u0026thinsp;0.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.327\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.2\u0026thinsp;\u0026plusmn;\u0026thinsp;0.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.5\u0026thinsp;\u0026plusmn;\u0026thinsp;0.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.151\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSchirmer test (mm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14.8\u0026thinsp;\u0026plusmn;\u0026thinsp;9.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13.0\u0026thinsp;\u0026plusmn;\u0026thinsp;8.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.538\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5.5\u0026thinsp;\u0026plusmn;\u0026thinsp;4.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e7.9\u0026thinsp;\u0026plusmn;\u0026thinsp;6.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.208\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTMH (\u0026micro;m)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUpper\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e248.7\u0026thinsp;\u0026plusmn;\u0026thinsp;100.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e301.7\u0026thinsp;\u0026plusmn;\u0026thinsp;119.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.077\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e175.4\u0026thinsp;\u0026plusmn;\u0026thinsp;65.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e186.6\u0026thinsp;\u0026plusmn;\u0026thinsp;92.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.719\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLower\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e444.7\u0026thinsp;\u0026plusmn;\u0026thinsp;257.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e480.2\u0026thinsp;\u0026plusmn;\u0026thinsp;282.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.597\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e234.3\u0026thinsp;\u0026plusmn;\u0026thinsp;100.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e224.3\u0026thinsp;\u0026plusmn;\u0026thinsp;99.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.775\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarx line score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10.9\u0026thinsp;\u0026plusmn;\u0026thinsp;2.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.4\u0026thinsp;\u0026plusmn;\u0026thinsp;4.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.873\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8.7\u0026thinsp;\u0026plusmn;\u0026thinsp;3.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e9.4\u0026thinsp;\u0026plusmn;\u0026thinsp;4.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.559\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMGD score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.1\u0026thinsp;\u0026plusmn;\u0026thinsp;1.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.7\u0026thinsp;\u0026plusmn;\u0026thinsp;1.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.351\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.2\u0026thinsp;\u0026plusmn;\u0026thinsp;1.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.6\u0026thinsp;\u0026plusmn;\u0026thinsp;1.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.227\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMeibum expression score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.3\u0026thinsp;\u0026plusmn;\u0026thinsp;2.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.6\u0026thinsp;\u0026plusmn;\u0026thinsp;2.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.602\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.1\u0026thinsp;\u0026plusmn;\u0026thinsp;2.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.1\u0026thinsp;\u0026plusmn;\u0026thinsp;2.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.625\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMeibography score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.0\u0026thinsp;\u0026plusmn;\u0026thinsp;2.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.0\u0026thinsp;\u0026plusmn;\u0026thinsp;2.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.983\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.3\u0026thinsp;\u0026plusmn;\u0026thinsp;2.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.0\u0026thinsp;\u0026plusmn;\u0026thinsp;1.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.689\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003eOP, operative; TFBUT, tear film break-up time; TFBUP, tear film break-up pattern; TMH, tear meniscus height; DEQS, dry eye-related quality of life score; MGD, meibomian gland dysfunction\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe results of the multivariate logistic regression analysis are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e. A higher upper TMH tended to decrease the risk of postoperative deterioration of dry eye symptom (OR, 0.984; 95% CI, 0.965\u0026ndash;1.003; P\u0026thinsp;=\u0026thinsp;0.099).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eResults of multivariate logistic regression analysis\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP values\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.120\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.917\u0026ndash;1.368\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.269\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTFBUT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAffected side\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.984\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.536\u0026ndash;1.803\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.957\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnaffected side\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.274\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.266\u0026ndash;6.106\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.762\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eA score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAffected side\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.093\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0-504.682\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.588\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnaffected side\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.030\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0-463.121\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.475\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eD score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAffected side\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.691\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.012-232.013\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.834\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnaffected side\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8.248\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.055-1241.062\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.409\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSchirmer test\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAffected side\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.200\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.945\u0026ndash;1.524\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.134\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnaffected side\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.841\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.626\u0026ndash;1.131\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.253\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUpper TMH\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAffected side\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.984\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.965\u0026ndash;1.003\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.099\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnaffected side\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.006\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.989\u0026ndash;1.022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.510\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLower TMH\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAffected side\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.997\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.984\u0026ndash;1.009\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.611\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnaffected side\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.997\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.977\u0026ndash;1.017\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.745\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarx line score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAffected side\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.857\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.492\u0026ndash;1.493\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.586\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnaffected side\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.706\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.370\u0026ndash;1.345\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.290\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMGD socre\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAffected side\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.340\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.028-187.898\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.229\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnaffected side\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7.324\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.449\u0026ndash;6.374\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.437\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMeibum expression score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAffected side\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.388\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.097\u0026ndash;1.551\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.181\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnaffected side\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.693\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.449\u0026ndash;6.374\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.437\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMeibography score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAffected side\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.506\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.116\u0026ndash;2.203\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.364\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnaffected side\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.954\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.643\u0026ndash;5.938\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.238\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePinch test\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAffected side\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.395\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.117\u0026ndash;16.715\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.793\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnaffected side\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.227\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.087\u0026ndash;17.370\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.880\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eTFBUT, tear film break-up time; TMH, tear meniscus height; MGD, meibomian gland dysfunction\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eIn this prospective observational study, we evaluated changes in ocular surface parameters and dry eye\u0026ndash;related symptoms following unilateral en-DCR for PANDO. Successful restoration of lacrimal drainage resulted in significant reductions in tear volume\u0026ndash;related parameters on the operated side, accompanied by improvements in meibomian gland function. Although dry eye\u0026ndash;related QOL improved in most patients, a substantial subset experienced postoperative worsening of dry eye symptoms.\u003c/p\u003e \u003cp\u003eEn-DCR significantly altered tear film and ocular surface parameters. In the present study, TFBUT and Schirmer test values decreased postoperatively. Consistent with previous reports, we also observed a reduction in TMH on the operated side following en-DCR [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], while the contralateral eye remained unchanged. These changes likely reflect normalization of tear retention after relief of nasolacrimal obstruction. However, they may also predispose a subset of patients to ocular surface instability. Previous studies reported subjective worsening of dry eye symptoms after DCR. Kang et al. demonstrated that approximately 27% of patients developed dry eye symptoms following successful en-DCR [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], and Kim et al. reported that 15% of patients with concomitant PANDO and DED experienced significant postoperative dry eye symptoms deterioration [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. In line with these observations, our study demonstrates not only subjective worsening in a subset of patients but also significant postoperative changes in objective parameters related to DED. These findings emphasize the close interaction between PANDO and the ocular surface and highlight the impact of lacrimal drainage restoration on tear film homeostasis.\u003c/p\u003e \u003cp\u003eMeibomian gland function was found to improve significantly following en-DCR. Although preoperative impairment of meibomian gland function on the affected side was not observed in our cohort, in contrast to findings reported in previous studies [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], both meibum expressibility and meibography scores improved significantly after surgery. These findings suggest a favorable effect of lacrimal drainage restoration on the lipid layer\u0026ndash;related components of the tear film. This improvement is consistent with the report by Goel et al., who demonstrated that DCR can reverse functional meibomian gland changes and improve tear film stability [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Although the underlying mechanism remains unclear, it is plausible that reduced tear stagnation and improved clearance of inflammatory mediators from the ocular surface and lacrimal system contribute to the observed improvement in meibomian gland function.\u003c/p\u003e \u003cp\u003eInterestingly, patients who experienced postoperative worsening of dry eye symptoms demonstrated longer preoperative TFBUT and lower DEQS scores, reflecting relatively mild subjective complaints and apparently stable tear film parameters prior to surgery. One possible explanation is that tear pooling secondary to NLDO masks underlying ocular surface vulnerability by increasing tear volume, thereby prolonging TFBUT and reducing symptom perception. Following restoration of lacrimal outflow, this compensatory effect may be lost, leading to the unmasking of subclinical or compensated DED. In addition, patients with mild preoperative symptoms may be more susceptible to noticeable postoperative deterioration due to a ceiling effect in symptom scoring, whereas those with more severe baseline symptoms have limited capacity for further worsening. These findings suggest that seemingly favorable preoperative tear film parameters and minimal subjective symptoms do not necessarily confer protection against postoperative dry eye deterioration and may, paradoxically, identify a subgroup at increased risk after en-DCR.\u003c/p\u003e \u003cp\u003eLower preoperative upper TMH may represent a potential marker for postoperative deterioration of dry eye symptoms. Unlike lower TMH, which can be elevated by tear retention in NLDO, upper TMH is less influenced by tear pooling and may better reflect true basal tear volume. In this context, a relatively low upper TMH may indicate preexisting but masked aqueous tear deficiency despite apparently normal tear film parameters, such as prolonged TFBUT. Following restoration of lacrimal drainage, inferior tear pooling resolves, unmasking underlying tear insufficiency and predisposing these patients to postoperative ocular surface instability. These findings suggest that upper TMH may serve as a useful preoperative parameter for identifying patients at risk of dry eye deterioration after en-DCR.\u003c/p\u003e \u003cp\u003eThis study has several limitations. Although prospectively designed, it was conducted at a single center with a relatively limited sample size. The postoperative follow-up period was relatively short and may not fully reflect long-term tear film and ocular surface changes after en-DCR. In addition, inflammatory biomarkers and detailed lacrimal functional assessments were not included, which could have provided further insight into the underlying mechanisms.\u003c/p\u003e \u003cp\u003eIn conclusion, successful en-DCR was associated with significant postoperative changes in tear film and ocular surface parameters in the affected side. While several aqueous tear\u0026ndash;related indices declined after surgery, meibomian gland function improved significantly. Notably, a distinct deterioration group (30%) experienced worsening of dry eye symptoms despite favorable preoperative parameters, indicating that tear retention may mask underlying ocular surface vulnerability. These findings emphasize the complex interplay between PANDO, tear dynamics, and ocular surface health and support the need for careful preoperative dry eye evaluation and patient counseling before en-DCR.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e None.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions:\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eConceptualization\u003c/strong\u003e, YT; \u003cstrong\u003emethodology\u003c/strong\u003e, YT; \u003cstrong\u003edata curation\u003c/strong\u003e, MI, KS, and YT; \u003cstrong\u003evalidation\u003c/strong\u003e, YT; \u003cstrong\u003eformal analysis\u003c/strong\u003e, YT; \u003cstrong\u003einvestigation\u003c/strong\u003e, YT; \u003cstrong\u003ewriting-original draft preparation\u003c/strong\u003e, MA;\u003cstrong\u003e\u0026nbsp;writing-review and editing\u003c/strong\u003e, MI, KS, and YT; \u003cstrong\u003esupervision\u003c/strong\u003e, YT; \u003cstrong\u003eproject administration\u003c/strong\u003e, YT. All authors have read and agreed to the published version of the manuscript. No one contributed to the work who did not meet our authorship criteria.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMeeting Presentation:\u003c/strong\u003e None.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability statement:\u0026nbsp;\u003c/strong\u003eThe datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration of Generative AI in scientific writing:\u0026nbsp;\u003c/strong\u003eThe authors did not use generative AI and AI-assisted technologies in the writing process.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e: Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e: YT received speaker and consultant honoraria from Amgen Inc., Chugai Pharmaceutical Co., Ltd., Santen Pharmaceutical Co., Ltd., and Ono Pharmaceutical Co., Ltd. The other authors have no financial or conflicts of interest to disclose.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eShen GL, Ng JD, Ma XP (2016) Etiology, diagnosis, management and outcomes of epiphora referrals to an oculoplastic practice. Int J Ophthalmol 9:1751\u0026ndash;1755\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYu X, Wang K, Hu Y, Meng Z, Li J, Liu Y, Xiao L, Chen M, Li S, Shen Y, Chen R, Liang X (2024) Dry eye and decreased tear film stability in primary acquired nasolacrimal duct obstruction patients. Int Ophthalmol 44:277\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYoon S, Lee H, Baek S (2023) Meibomian gland dysfunction in primary acquired nasolacrimal duct obstruction. J Craniofac Surg 34:e395\u0026ndash;e398\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKim MH, Lee K, Chang M (2023) Dry eye assessment of patients undergoing endoscopic dacryocystorhinostomy for nasolacrimal duct obstruction combined with dry eye syndrome. Korean J Ophthalmol 37:395\u0026ndash;400\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKang TS, Cho J, Kim J, Sung JY, Kim JM, Kim KN, Lee SB (2021) Modified ocular surface disease index as a screening criteria for dry eye syndrome presenting after successful dacryocystorhinostomy. PLoS ONE 16:e0247168\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTıskaoğlu NS, Yazıcı A (2023) Reduced tear break-up time in the fellow eye of patients with unilateral primary acquired nasolacrimal duct obstruction. Int Ophthalmol 43:965\u0026ndash;971\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHamano T (2005) Lacrimal duct occlusion for the treatment of dry eye. Semin Ophthalmol 20:71\u0026ndash;74\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKamao T, Takahashi N, Zheng X, Shiraishi A (2020) Changes of visual symptoms and functions in patients with and without dry eye after lacrimal passage obstruction treatment. Curr Eye Res 45:1590\u0026ndash;1597\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYokoi N, Georgiev GA, Kato H, Komuro A, Sonomura Y, Sotozono C, Tsubota K, Kinoshita S (2017) Classification of fluorescein breakup patterns: a novel method of differential diagnosis for dry eye. Am J Ophthalmol 180:72\u0026ndash;85\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMiyata K, Amano S, Sawa M, Nishida T (2003) A novel grading method for superficial punctate keratopathy magnitude and its correlation with corneal epithelial permeability. Arch Ophthalmol 121:1537\u0026ndash;1539\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSakane Y, Yamaguchi M, Yokoi N, Uchino M, Dogru M, Oishi T, Ohashi Y (2013) Development and validation of the Dry Eye-Related Quality-of-Life Score questionnaire. JAMA Ophthalmol 131:1331\u0026ndash;1338\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYamaguchi M, Kutsuna M, Uno T, Zheng X, Kodama T, Ohashi Y (2006) Marx line: fluorescein staining line on the inner lid as indicator of meibomian gland function. Am J Ophthalmol 141:669\u0026ndash;675\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVaidya A, Kakizaki H, Takahashi Y (2020) Postoperative changes in status of meibomian gland dysfunction in patients with involutional entropion. Int Ophthalmol 40:1397\u0026ndash;1402\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eArita R, Itoh K, Maeda S, Maeda K, Furuta A, Fukuoka S, Tomidokoro A, Amano S (2009) Proposed diagnostic criteria for obstructive meibomian gland dysfunction. Ophthalmology 116:2058\u0026ndash;2063e1\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShimazaki J (2018) Definition and diagnostic criteria of dry eye disease: historical overview and future directions. Invest Ophthalmol Vis Sci 59:DES7\u0026ndash;DES12\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDoran MA, Ayintap E, Aytogan H (2024) Evaluation of the relationship between tear meniscus changes and quality of life outcomes after external dacryocystorhinostomy. Int Ophthalmol 44:105\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOhtomo K, Ueta T, Fukuda R, Usui T, Miyai T, Shirakawa R, Amano S, Nagahara M (2014) Tear meniscus volume changes in dacryocystorhinostomy evaluated with quantitative measurement using anterior segment optical coherence tomography. Invest Ophthalmol Vis Sci 55:2057\u0026ndash;2061\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang G, Jin H, Sheng Y, Ji F, Liu Y, Han L, Wang X, Chen Z, Ding H, Liu J, Fu Q (2024) Higher incidence of meibomian gland dysfunction in postmenopausal women with primary acquired nasolacrimal duct obstruction. Int Ophthalmol 44:70\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGoel R, Saini S, Golhait P, Shah S (2024) Association of primary chronic dacryocystitis and meibomian gland dysfunction. Indian J Ophthalmol 72:185\u0026ndash;189\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"epiphora, dry eye, dacryocystorhinostomy, nasolacrimal duct obstruction","lastPublishedDoi":"10.21203/rs.3.rs-8727321/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8727321/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose\u003c/strong\u003eTo evaluate postoperative changes in tear film, ocular surface, and meibomian gland parameters following successful endonasal dacryocystorhinostomy (en-DCR) and predictive factors in postoperative dry-eye symptom deterioration in patients with primary acquired nasolacrimal duct obstruction (PANDO).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003eThis prospective study included 50 patients with unilateral PANDO who underwent successful en-DCR. Tear film break-up time (TFBUT), Schirmer test, tear meniscus height (TMH), meibomian gland parameters, and dry eye–related symptoms were assessed preoperatively and 3 months postoperatively. Measurements were compared between affected and unaffected eyes, and between pre- and postoperative visits. Patients were categorized into unchanged/improvement or deterioration groups based on postoperative symptom changes. Multivariate logistic regression was performed to identify risk factors for postoperative deterioration.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e Postoperatively, the affected eyes demonstrated significant reductions in TFBUT, Schirmer values, and upper and lower TMH, while the fellow eyes remained unchanged. Meibomian gland function significantly improved after surgery. Subjective dry eye symptoms remained unchanged or improved in majority of the patients. However, 15 patients (30.0%) experienced postoperative symptom deterioration. Patients in the deterioration group had significantly longer preoperative TFBUT and lower DEQS scores. Multivariate analysis showed that lower preoperative upper TMH tended to be associated with an increased risk of postoperative symptom deterioration.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e Restoration of lacrimal drainage by en-DCR was associated with significant postoperative changes in tear film and ocular surface parameters, together with improvement in meibomian gland function. Lower preoperative upper TMH may be a potential risk factor for postoperative worsening of dry eye symptoms.\u003c/p\u003e","manuscriptTitle":"Dry Eye Outcomes after Endonasal Dacryocystorhinostomy: Tear Film Changes and Risk Factors for Symptom Deterioration","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-17 11:41:10","doi":"10.21203/rs.3.rs-8727321/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"243de497-590b-4ea9-aae7-ea99222e655f","owner":[],"postedDate":"February 17th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-04-14T16:10:21+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-17 11:41:10","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8727321","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8727321","identity":"rs-8727321","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}