Factors Associated With Failure of Adult Strabismus-20 Questionnaire Scores to Improve Following Strabismus Surgery

Strabismus Surgery for Psychosocial Reasons-A Literature Review

Introduction

Strabismus surgery may be undertaken for visual benefit, to improve or eliminate diplopia symptoms, or to restore or improve binocular single vision (BSV). In patients without visual symptoms or expected visual benefit, strabismus surgery may still be undertaken if the presence of strabismus causes the patient psychosocial symptoms. To evaluate strabismus surgery undertaken for psychosocial reasons, evidence of postoperative outcomes in this specific cohort is needed.

Methods

A systematic search of the literature was conducted (1946-2023) to identify evidence where postoperative outcomes were reported for adult patients (age 18 years and above) who had undergone strabismus surgery for psychosocial reasons.

Results

Sixty-nine papers were included in the literature review. Most sources of evidence included patients within heterogeneous cohorts of strabismus surgery outcomes, with a range of symptoms and differing surgical aims.

Discussion

In adults who underwent strabismus surgery for psychosocial reasons, improved postoperative ocular alignment and/or improved health related quality of life (HRQoL) were common. Strabismus surgery outcomes appeared to be measured satisfactorily at three months postoperatively. Additional surgical outcomes, including an expanded field of vision, unexpected BSV, improved binocular summation, improved task performance and improved eye movements have been reported, but not fully investigated. There was a lack of consensus on how postoperative success should be defined and measured. A core outcome set for strabismus has been suggested and there is potential to add to the available evidence by investigating which outcome measures are most relevant to those with strabismus and psychosocial symptoms. There is a growing need for robust evidence in this specific subgroup of patients due to a lack of evidence specifically reporting postoperative outcomes in adults with strabismus and psychosocial symptoms.

Correlation of Strabismus Surgical Outcomes Graded by Goal-Determined Metric With Patient Satisfaction Survey

PURPOSE

Although strabismus surgery outcomes can be objectively measured, patient perception of results may differ. We present surgical outcomes graded by a prospective, "goal-determined metric" and compare these outcomes to results of a patient satisfaction survey.

DESIGN

Validity analysis comparing a clinical "goal-determined metric" to patient satisfaction.

METHODS

Goal-determined metric outcomes (2018-2021) for 2 surgeons treating esotropia or exotropia for diplopia control or reconstructive goals were collected. Inclusion required completion of postoperative examination 2-6 months after surgery and a satisfaction survey.

RESULTS

Record review identified 275 patients; 228 (median age 41 years [interquartile range 13-59]) met inclusion criteria. For the entire cohort, 87% were graded as "excellent" outcomes, and 78% of patients were overall "very satisfied." Agreement between patients' and surgeons' grading was 75% to 79% for all reconstructive surgery and for treatment of diplopia from esotropia. Agreement was lower, although not statistically different, for treatment of diplopia from exotropia (64%, 95% CI 43%-80%; P = .184). Preoperative risk factors, concurrent vertical or oblique surgery, and sex did not affect outcomes or satisfaction. Performance of activities requiring distance viewing improved more than performance of activities at near after esotropia-diplopia surgery (odds ratio 3.0, 95% CI 1.5-6.4; P = .004). For reconstructive cases achieving "much better" eye alignment, 62% and 72% (previously esotropic and exotropic) reported enhanced self-confidence.

CONCLUSIONS

Outcomes graded by goal-determined metric correlated well with many aspects of patient satisfaction. Patient-perceived improvement in appearance was important regardless of goal. Greater improvement in performance of activities requiring distance rather than near viewing characterized treatment of diplopia from esotropia.

Binocular Summation With Quantitative Contrast Sensitivity Function: A Novel Parameter to Evaluate Binocular Function in Intermittent Exotropia

Purpose

Intermittent exotropia (IXT) is the most common form of strabismus. Surgery can potentially improve binocular function in patients with IXT. We aimed to evaluate binocular function using a novel parameter-binocular summation ratio (BSR), measured using quantitative contrast sensitivity function (CSF) in patients with IXT before and after surgery.

Methods

Prospective study of 63 patients with IXT and 41 healthy controls were consecutively enrolled and underwent quantitative CSF testing binocularly and monocularly. BSR was calculated by dividing the CSF of the binocular value by the better monocular value. Forty-eight patients with IXT underwent strabismus surgery. BSR, stereoacuity, fusion ability, and strabismus questionnaires were assessed pre-operatively and 2 months postoperatively.

Results

Sixty-three patients with IXT (median age = 9 years) compared with 41 healthy controls showed a worse mean BSR based on all CSF metrics at baseline (the area under the log CSF [AULCSF], spatial frequency [SF] cutoff, and contrast sensitivity at 1.0-18.0 cpd SF). All 48 patients with IXT showed successful alignment after surgery, and there were significant improvements in BSR based on the AULCSF, SF cutoff, and contrast sensitivity at 6.0, 12.0, and 18.0 cpd SF, respectively. The distance stereoacuity and fusion ability also improved after surgery, and a better BSR was associated with better stereoacuity and fusion. For strabismus questionnaires, the psychosocial subscale scores improved postoperatively, whereas the functional subscale scores did not change.

Conclusions

BSR based on quantitative CSF can characterize binocular function across a range of spatial frequencies and can be used as a supplemental measurement for monitoring binocularity in patients with IXT in clinical settings.

Strabismus is more than a misalignment; a cross-sectional pilot study of HRQOL in Finnish strabismic adults referred to a university hospital

PURPOSE

To evaluate associations between the health-related quality of life (HRQOL) and demographic, self-reported strabismus-related and orthoptic status variables in Finnish strabismic adults.

METHODS

Participants (n = 137) of this study were adult patients who previously participated in the pilot study to translate and validate Adult Strabismus Questionnaire (AS-20) into Finnish. For this study, the participants' orthoptic status were collected among the previously obtained self-reported demographic and strabismus-related data. The refined AS-20 structure of 18 items and four subscales of self-perception, interaction, reading function and general function was used. Low scores on AS-20 indicate low HRQOL. The associations were evaluated with cross-tabulation and nonparametric methods of Mann-Whitney U and Kruskal-Wallis tests. Statistical significance was set at p < 0.05.

RESULTS

Interaction subscale scores were the highest of all subscale scores among the participants. Age had an association with HRQOL in self-perception and the youngest participants had the lowest scores. Importantly, participants who did not experience diplopia suffered from lower self-perception and interaction but reported higher scores on reading function and general function subscales compared to the participants who experienced diplopia. Exotropia with or without vertical strabismus were most common types among the participants. The education background was not associated with HRQOL.

CONCLUSION

Impacts of strabismus are similar in Finnish strabismic adults compared to international studies. Healthcare professionals and decision-makers should always consider the psychosocial impact of strabismus on patients without diplopia when making decisions on strabismus treatment and care processes.

Improvement in health-related quality of life with Botulinum toxin A injection in acquired superior oblique palsy

Purpose

This study aimed to investigate the outcomes of Botulinum toxin A (BTA) injection into the inferior oblique (IO) muscle for the management of unilateral acute acquired superior oblique palsy (SOP) and to evaluate changes in health-related quality of life post-injection using the Adult Strabismus-20 (AS-20) questionnaire.

Methods

A prospective cohort study was performed in patients with unilateral acute acquired SOP who received BTA injections. Four units of BTA were injected into the ipsilateral IO muscle. Ocular examinations were performed pre-and post-injection, including alignment, ocular movement, and cyclotorsion deviation. The patients' AS-20 questionnaire scores were analyzed.

Results

A total of 21 patients with acute acquired SOP were included. The initial median vertical deviation was 5 PD (range 1-16), which was improved to 0 PD (range 0-10) at both 1 and 6 months post-injection (p < 0.001 and p < 0.001, respectively). The median torsional deviation was 7° (range 2-18) at baseline and resolved to 0 degrees (range -3-5) at the 1-month and 0° (range -2-7) at the 6-month follow-up (p < 0.001 and p < 0.001, respectively). There were significant increases in the overall score (OAS), psychosocial subscale score (PSS), and functional subscale score (FSS) from baseline values at both the 1-month (p < 0.001, p < 0.001, and p = 0.001, respectively) and 6-month follow-up (all p < 0.001).

Conclusion

Injecting BTA into the ipsilateral IO muscle successfully resolved vertical and torsional deviations and significantly improved quality-of-life scores. Our findings show that BTA treatment, as an early treatment for acute acquired SOP, can help patients by significantly improving their quality of life.

Diplopic versus nondiplopic strabismus: effects on functional vision and eye-related quality of life in adolescents

Twenty adolescents (12-17 years old) with diplopic strabismus and 20 with nondiplopic strabismus (matched to diplopic subjects for direction and magnitude of ocular deviation) completed the Pediatric Eye Questionnaire (PedEyeQ). Children completed the Child PedEyeQ, and one parent for each child completed the Proxy PedEyeQ and Parent PedEyeQ. PedEyeQ Rasch domain scores were calculated and converted to a scale of 0 (worst) to 100 (best). Distributions of domain scores were compared between diplopic and nondiplopic cohorts using Wilcoxon tests. Diplopic adolescents had significantly lower Child PedEyeQ scores on Functional Vision (72 vs 90; P = 0.008), Bothered by Eyes/Vision (65 vs 90; P = 0.009), and Frustration/Worry (53 vs 75; P < 0.001) domains. There was no difference on the Child Social domain (85 vs 90; P = 0.22). Proxy and Parent PedEyeQ scores were similar between diplopic and nondiplopic cohorts (P > 0.06 for each comparison). These findings highlight the importance of addressing diplopia when managing childhood strabismus.

Shared decision making and patients satisfaction with strabismus care-a pilot study

BACKGROUND

Strabismus is a complex disease that has various treatment approaches each with its own advantages and drawbacks. In this context, shared decisions making (SDM) is a communication process with the provider sharing all the relevant treatment alternatives, all the benefits, and risks of each procedure, while the patient shares all the preferences and values regarding his/her choices. In that way, SDM is a bidirectional process that goes beyond the typical informed consent. Therefore, it is known a little of the extent to which SDM influences the satisfaction with the treatment outcome along with strabismus patients. To study this correlation, an SDM-Q-9 questionnaire was provided within surgical consultations where treatment decisions were made; the SDM-Q-9 aims to assess the relationship between the post-operative patient's satisfaction and their SMD score.

METHODS

The study is considered a prospective observational pilot study. Eligible patients were adult patients diagnosed with strabismus, who had multiple treatment options, were given at the right of choice without being driven into a physician's preference. Ninety-three strabismus patients were asked to fill out the SDM-Q-9 questionnaire related to their perception of SDM during the entire period of strabismus treatment. After the treatment, patients were asked to rate their satisfaction level with the surgical outcome as excellent, good, fair, and poor. Descriptive statistics and the linear regression statistical tests (Spearman, Mann Whitney U, and Kriskal-Wallis) were used as analysis tools.

RESULTS

The average age of the participants was 24, where 50.6% were women. The mean SDM-Q-9 score among patients was 32 (IQR = 3). The postoperative patient satisfaction was rated as being excellent by 16 (17.2%) patients, good by 38 (40.9%), fair by 32 (34.4%), and poor by 7 patients (7.5%). Data analysis by linear regression statistical tests showed a positive correlation between the SDM-Q-9 score and the patient satisfaction related to the surgery outcome (B = 0.005, p < 0.001). Criteria in assessing patients' satisfaction were age, gender, and strabismus type. A positive correlation between SDM and real satisfaction (r = 0.834, p < 0.01) was found with age, and no significant relationship was found while taking into consideration the responder's gender and the strabismus type.

CONCLUSIONS

Assessing patient satisfaction after choosing a treatment for strabismus method helped us evaluate the gaps in constructive dialogue that would lead to a positive outcome for both patient and clinician. The correlation between the SDM process and the patients' satisfaction with surgery outcome, adjusted by age, has been established. These findings can serve as a springboard to further communicative improvements related to the SDM process and between patients and physicians, thereby consequently leading to patients' satisfaction raise in strabismus care. The study underlines the importance of further analysis and validation of on-ground interactions among the adolescent and adult patients and the clinicians across the strabismus management trajectory. A multicentral study and its validation will follow.

Measuring health-related quality of life in individuals with cyclodeviation using the Adult Strabismus 20 (AS-20) questionnaire

PURPOSE

To assess health-related quality of life (HRQoL) in patients diagnosed with cyclodeviation and to evaluate subjective change following surgical treatment using the Adult Strabismus-20 (AS-20) questionnaire.

METHODS

A prospective cohort study was performed from 2014 to 2019 on 29 adult patients with cyclodeviation and cyclodiplopia who were due to undergo corrective strabismus surgery by the same surgeon. The group was divided into two subgroups, according to the type of surgery required for fusion. All scores were analyzed for the whole sample and subgroups. Preoperative scores were compared with those of control patients.

RESULTS

Pre- and postoperative QoL scores were successfully collected from 26 patients (mean age, 56 years; 8 female) using the AS-20 questionnaire. Scores were significantly higher for control subjects than for patients in the cyclodeviation group (P = 0.0001). Postoperative scores for all 20 questionnaire questions were significantly improved for all patients (P = 0.002). There was a significant improvement in the functional subscale score (P = 0.001), but not in the psychosocial subscale score (P = 0.23). Results were enhanced by Rasch analysis.

CONCLUSIONS

Cyclodeviation patients demonstrated significantly lower scores than controls. The functional scores were significantly lower than the psychosocial scores, in contrast to other forms of strabismus. Strabismus surgery had a significant effect on quality-of-life scores in this group of adults.

Satisfaction with strabismus surgery based on the opinion of expert surgeons

PURPOSE

To assess the perception of strabismus surgeons in Spain regarding patient satisfaction after surgery, by analysing the types of strabismus with the most satisfied patients, as well as the causes of dissatisfaction.

METHODS

A survey was carried out among the members of the Spanish Strabology Society who were over 50 years of age, active in Spain, with more than 20 years of surgical experience, and whose main surgical activity was strabismus. The questionnaire consisted of 18 questions about the perception of patient satisfaction according to the type of strabismus, patient age, as well as the most frequent cause of dissatisfaction after surgery.

RESULTS

The questionnaires were completed by a total of 29 surgeons, with a mean of 31 years of surgical experience. The most frequent cause of perceived dissatisfaction was residual strabismus. No differences were found in the satisfaction index between children and adults. The surgery that was considered to produce greater satisfaction was endotropia, followed by decompensated 4th nerve palsy, and exotropia, while 3rd nerve palsy was the cause of the most dissatisfaction.

CONCLUSIONS

According to strabismus surgeons, endotropia is the most satisfactory surgery for the patient, followed by exotropia, vertical strabismus, and traumatic paralysis of the 4th cranial nerve.

Improvement in psychiatric symptoms after strabismus surgery in adolescent patients in long-term follow-up

Aims

To assess the psychological effects of preoperative primary eye position and surgical correction of strabismus in adolescent patients.

Methods

Eighty-three adolescent patients with exotropia were included in this observational and prospective study. Patients with preoperative manifest exotropia formed the manifest exotropia group. Patients with intermittent exotropia that had orthophoria with overcorrecting minus lenses and recently increased frequency of manifest phase were indicated for surgery and formed the latent deviation group. All patients were scored with the Turkish version of the Social Appearance Anxiety Scale (SAAS), depression subscale of Hospital Anxiety and Depression Scale (HAD-D) Brief Fear of Negative Evaluation Scale (BFNE), state anxiety subscale of State-Trait Anxiety Inventory (STAI-S) and trait anxiety subscale of State-Trait Anxiety Inventory (STAI-T) before and 1 year after strabismus surgery.

Results

The mean preoperative scores of the HAD-D, SAAS, BFNE, STAI-S and STAI-T before strabismus surgery were significantly higher in the manifest exotropia group than in the latent deviation group (p≤0.001 for all). Surgical correction significantly improved the outcomes of all scales in the manifest exotropia group (p≤0.001 for all). Outcomes of the STAI-S and STAI-T significantly improved in the latent deviation group after the surgery (p=0.008, p=0.006, respectively), whereas outcomes of the HAD-D, SAAS and BFNE did not improve (p=0.079, p=0.071, p=0.127, respectively). The mean postoperative scores of all scales did not differ between the two groups (p>0.05 for all).

Conclusions

Strabismus has psychological consequences in adolescent patients, and the visible eye deviation caused by strabismus is a strong indicator of psychological distress.

Investigation of factors associated with the success of adult strabismus surgery from the patient's perspective

PURPOSE

To explore factors that influence the success of adult strabismus surgery based on health-related quality of life (HRQOL) criteria.

METHODS

The HRQOL aspect of strabismus surgery was assessed using the Adult Strabismus 20 (AS-20) questionnaire. Adult patients (≥16 years of age) undergoing strabismus surgery between 2014 and 2016 were identified using a treatment register. Pre- and postoperative AS-20 scores were calculated. HRQOL surgical success was defined as a pre- to postoperative change in AS-20 score exceeding previously published 95% limits of agreement. Any relationship between demographic factors (sex, age, and socioeconomic status), presence or absence of diplopia, type and magnitude of deviation, and change in deviation size with HRQOL success was investigated.

RESULTS

A total of 87 patients were included (mean age, 47 years; 53% female). Nondiplopic patients showed significantly lower pre- and postoperative scores on the AS-20 psychosocial subscale compared to diplopic patients. Of 87 surgeries, 54 (62%) were classified as successful based on HRQOL criteria. Multiple logistic regression analysis showed only lower socioeconomic status to be significantly associated with a higher rate of HRQOL success (P = 0.04).

CONCLUSIONS

Strabismic patients with a lower socioeconomic status are more likely to achieve HRQOL success following surgery. We also show that nondiplopic patients have more psychosocial concerns than those with diplopia and that this disparity persists even after strabismus surgery.