Social and emotional impact of strabismus surgery on quality of life in children

Health-related quality of life measures (HRQoL) in patients with amblyopia and strabismus: a systematic review

BACKGROUND/AIMS

Health-related quality of life (HRQoL) measures are used in healthcare to help inform clinical decision-making and policy-making decisions. A number of disease-specific or condition-specific measures have been developed and applied in ophthalmology; however, their use in the specific fields of amblyopia and strabismus are not as established. The purpose of this study is to identify and discuss specific HRQoL instruments that may be used in the investigation and management of patients with amblyopia and/or strabismus.

METHODS

A systematic literature review was undertaken in November 2009. The electronic databases of AMED (Allied and Complementary Medicine: 1985 to November 2009), the British Nursing Index and Archive (1985 to October 2009), Ovid Medline In-Process and Other Non-Indexed Citations and Ovid Medline (1950 to present) and PsycINFO (1806 to November Week 1 2009) were searched. No language restrictions were applied to the search.

RESULTS

Four instruments were identified: the Amblyopia and Strabismus Questionnaire (A&SQ), the Amblyopia Treatment Index (ATI), the Adult Strabismus Questionnaire (AS-20) and the Intermittent Exotropia Questionnaire (IXTQ).

CONCLUSION

The use of HRQoL measures in patients with amblyopia and/or strabismus is a developing area. Further research is necessary to determine the impact of issues such as diplopia and poor cosmesis upon patient groups, and to determine the influence of ethnicity and parental reporting in these patients.

Comparison of psychosocial and emotional consequences of childhood strabismus on the families from rural and urban India

Purpose:

To compare the psychosocial consequences of horizontal comitant strabismus in children between the families of urban and rural India.

Materials and Methods:

In this cohort study, an eight-question quality-of-life instrument was administered by trained staff to the guardians of strabismic children from rural and urban areas by a live interview.

Results:

This study included 93 strabismic-children aged 4-16 years of which 52 were females. Forty-one had esodeviation and 52 had exodeviation. Seventy per cent parents were extremely distressed due to squint, 65% were extremely distressed due to people's remarks, 65% were extremely worried, 55% children were extremely distressed due to people's remarks, 57% children were severely ostracized, 38% had severe difficulty in communication and 50% had difficulty to cope; 64% parents were not advised a corrective surgery. The difference between families from rural and urban areas, or whether a male child was affected or a female child or for an esodeviation or an exodeviation was statistically not significant. The questionnaire had a good internal consistency (Cronbach's Alpha = 0.71).

Conclusions:

There was a significant negative psychosocial and emotional impact of childhood strabismus that was not affected by the rural or urban location of the family or the gender of the strabismic child or type of the deviation. The quality-of-life instrument can be used as part of the clinical examination for strabismic children.

The psychosocial aspects of strabismus: correlation between the AS-20 and DAS59 quality-of-life questionnaires

PURPOSE

To compare two quality-of-life (QoL) scales and subscales: the Derriford Appearance Scale 59 (DAS59) and the Adult Strabismus-20 (AS-20) scale in a series of strabismic and nonstrabismic patients and to illustrate the differences in results between strabismic and nonstrabismic patients.

METHODS

The DAS59 is a self-report QoL questionnaire generating an assessment of distress caused by problems of appearance. The AS-20 is a newly developed strabismus specific QoL scale. A prospective, noninterventional study of a series of consecutive adult patients undergoing strabismus surgery and a control group was performed. Patients were given both questionnaires to complete before surgery. The underlying condition, previous number of surgeries, and deviation measurements were recorded.

RESULTS

Thirty-four patients and 30 controls correctly completed both questionnaires. In the strabismus group, the mean AS-20 score was 50.5. The mean DAS59 score was 122.5 (out of 269). There is strong correlation between the scales (r = -0.813; 95% CI, -0.90 to -0.66; p < 0.0001). In the control group, the AS-20 score was 98.8 and the DAS59, 84.4, with both showing significant differences to the strabismic group (t = 12.9 [p < 0.0001] and t = -4.642 [p < 0.0001], respectively).

CONCLUSIONS

The AS-20 shows strong correlation to the widely used DAS59. Strabismus patients show significantly more psychosocial distress than controls. The AS-20 is specific to strabismus patients and the result is not influenced by any other systemic factors that can impinge on the more general DAS59 scale.

Vision-Related Quality of Life and Emotional Impact in Children with Strabismus: A Prospective Study

The potential impact of the surgical correction of strabismus on vision-related quality of life (VRQOL) and the symptoms of anxiety and depression in children with strabismus remain unclear. The present study included 60 children with strabismus: 30 with heterophoria and 30 with heterotropia. A healthy age-and gender-matched control group ( n = 60) was also recruited. The psychological instruments that were used were the short-form 25-item National Eye Institute Visual Functioning Questionnaire (NEI-VFQ-25) and the Hospital Anxiety and Depression Scale (HADS). The results demonstrated that eight of the 12 NEI-VFQ-25 subscales were significantly impaired in children with strabismus compared with matched controls. Compared with pre-operative values, significant improvements were noted after surgery in the NEI-VFQ-25 summary score, and the anxiety and depression scores. This study demonstrated that the NEI-VFQ-25 instrument can be used in strabismus children and that surgical interventions can improve VRQOL, anxiety and depression in strabismus patients.

Adult strabismus and social phobia: a case-controlled study

PURPOSE

To determine the social phobia rate, social anxiety level, severity of depressive symptoms, and disease-related disability in adult strabismus patients.

METHODS

Forty-nine strabismus patients and 46 control subjects from 15 to 65 years of age were evaluated. A psychiatric interview focusing on social phobia and the Liebowitz Social Anxiety Scale (LSAS) were administered to each participant. All participants completed the Hospital Anxiety and Depression Scale (HADS), a psychiatric symptom checklist (Symptom Checklist 90-Revised; SCL-90R), and the Sheehan Disability Scale.

RESULTS

Social phobia was diagnosed in 26 of the 49 strabismus patients and in 8 of the 46 control subjects (p < 0.001). Strabismus patients demonstrated significantly greater scores in all of the subscores and the total scores of LSAS. They were more disabled in social life, family life, and at work. They also showed greater interpersonal sensitivity scores compared with the control group. Compared with strabismus patients without social phobia, the strabismus patients with social phobia demonstrated significantly greater depression scores in HADS and also scored in all dimensions of LSAS. Their social life and family life scores in disability scale and all scores in SCL-90-R except somatization were better than strabismus patients without social phobia.

CONCLUSIONS

In adult strabismus patients, social phobia is a frequent psychiatric comorbidity. Adult patients with strabismus need to be carefully evaluated for social phobia for an appropriate referral and treatment.

Effect of amblyopia on self-esteem in children

PURPOSE

In an investigation of the psychosocial impact of amblyopia on children, the perceived self-esteem of children who had been treated for amblyopia was compared with that of age-matched controls. The influence of amblyopia condition or treatment factors that may impact self-perception scores was also explored.

METHODS

Children with a history of treatment for amblyopia (n = 47; age 9.2 +/- 1.3 years) and age-matched controls (n = 52; age 9.4 +/- 0.5 years) completed a standardized age-appropriate questionnaire based evaluation of perceived self-esteem (Harter Self Perception Profile for Children). Their vision characteristics and treatment regimen were also recorded. Bivariate correlation analysis was used to investigate the amblyopic characteristics and treatment factors that may have influenced self-perception scores in the amblyopic group.

RESULTS

Children treated for amblyopia had significantly lower social acceptance scores than age-matched control children. In other areas related to self-esteem, including scholastic competence, physical appearance, athletic competence, behavioral conduct and global self worth, amblyopic children gave scores similar to those of control children. Within the amblyopic group, a lower social acceptance score was significantly correlated with a history of treatment with patching but not with a history of strabismus or wearing of glasses.

CONCLUSIONS

Self-perception of social acceptance was lower in children treated for amblyopia compared with age-matched controls. A reduction in these scores was associated with a history of patching treatment but not with a history of strabismus or spectacle wear.

Strabismus: Background and Surgical Techniques

Through the process of evolution, the position of the eyes within the head has moved from lateral to frontal. Although reducing the panoramic view afforded by the lateral positioning, this new arrangement allowed stereopsis (depth perception) (Hubel and Wiesel 1965).

Redirecting Gaze to Improve the Cosmetic Appearance of Strabismus

PURPOSE

We studied a behavioral technique in which strabismics can reduce the detectability of their eye turn by appropriately redirecting their gaze. We tested the efficacy of this technique for various amounts of strabismus and different positions of gaze.

METHODS

We took digital images of a model gazing in different lateral directions and digitally edited them to simulate fixation with one eye on different lateral locations whereas the other eye was misaligned from the first by +/-0, 6, 12, 18, 24, and 30 Delta. Then we asked 22 lay observers to examine each of the images and to report whether or not they perceived eye contact and normal gaze.

RESULTS

The observers reported that our model appeared to look normal and gave them eye contact two-thirds of the time for up to 18 Delta of exotropia and 12 of esotropia when she looked half her prismatic deviation to the side opposite her eye turn.

CONCLUSION

By appropriately directing their gaze, both exotropes and esotropes can improve the cosmetic appearance of their strabismus and increase the perception that they are looking at the observer. This may be useful during job interviews and other social encounters where eye contact and a good impression are critical. A drawback is that large amounts of strabismus may require the gazer to look far to the side of the observer's head where it may be difficult to maintain gaze and the observer's facial expression may be hard to read. However, all patients may be counseled on which eye to look at when engaging in conversation, as looking at the appropriate rather than the inappropriate eye can reduce the perceived amount of their strabismus. Also, when their portrait is being taken, the full amount of eccentric gaze could easily be used.

The cost utility of strabismus surgery in adults

PURPOSE

Cost-utility analysis evaluates the cost of medical care in relation to the gain in quality-adjusted life years (QALYs). Our purpose was to develop a cost model for surgical care for adult strabismus, to estimate the mean cost per case, to determine the associated gain in QALYs, and to perform cost-utility analysis.

METHODS

A cost model incorporated surgery, pre- and postoperative care, and a mean of 1.5 procedures per patient. The gain in QALYs was based on the improvement of utility on a scale from 0 (death) to 1 (perfect health). Utility was measured through physician-conducted interviews employing a time tradeoff question (seeking to estimate the portion of life expectancy a patient would be willing to trade for being rid of disease and associated effects). The interviews were conducted before and 5 to 8 weeks after surgery in 35 strabismic patients (age 19-75 years).

RESULTS

The cost model resulted in an estimated total cost of 4,254 dollars per case. A significant improvement of utility was found: 0.96 +/- 0.11 postoperatively versus 0.85 +/- 0.20 preoperatively (p = 0.00008). Based on the mean life expectancy (36.0 years) of these patients, and discounting outcomes and costs by 3% annually, this resulted in a mean value gain of 2.61 QALYs after surgery and a cost-utility for strabismus surgery of 1,632 dollas/QALY.

CONCLUSIONS

In the United States, treatments <50,000 dollars/QALY are generally considered "very cost-effective." Strabismus surgery in adults falls well within this range.