Anxiety and depression in patients wearing prosthetic eyes

Assessment of Anxiety, Depression, Self-Esteem, and Quality-of-Life in Patients Undergoing Surgical Removal of an Eye

Objectives

The objective of this study was to compare anxiety, depression, self-esteem, and quality of life in patients who underwent surgical removal of an eye with those of controls as well as to test the correlations of these variables in both groups.

Methods

Beck anxiety inventory (BAI), Beck depression inventory (BDI), 36-item short-form health survey (SF-36), and Rosenberg self-esteem scale were administered to 29 patients with surgical removal of an eye and 30 control subjects.

Results

The patient group had significantly lower scores on physical functioning, role limitations due to physical and emotional problems, pain, and general health perception domains of SF-36, as well as significantly higher BDI (p=0.004) scores as compared to controls. The study groups did not differ significantly with respect to BAI scores and energy/vitality, mental health, and social functioning domain scores of SF-36 (p>0.05).

Conclusion

This population of monocular patients had similar mental health-related and Beck's Anxiety Inventory scores equivalent to the control group despite the surgical removal of one eye. However, lower scores for some SF-36 domains and higher depression levels in this patient group suggest that psychiatric rehabilitation should be considered after eye removal to improve the psychological outcomes and quality of life in these patients.

Living with an artificial eye: qualitative insights into patient and family member experiences

PURPOSE

Artificial eye users (AEUs) can experience a negative impact on psychological and emotional wellbeing, including reduced social functioning, which may be a consequence of living with one eye removed, and/or of having a prosthetic eye. This may have wider consequences for their families. We aimed to explore what it means to live with a prosthetic eye, for both AEUs and their families-and how any quality of life (QoL) issues impact on their day-to-day functioning.

METHODS

A subset of AEUs and their family members taking part in a feasibility randomised controlled trial comparing hand-painted to digitally printed artificial eyes were invited for semi-structured interviews. Transcripts were analysed using reflexive thematic analysis. Qualitative results related to trial participation are covered elsewhere. Here, we focus on QoL and day-to-day functioning.

RESULTS

Twelve AEUs (eight males) and five spouses (one male) who had worn artificial eyes for 2-65 years took part, and four themes were identified. (1) Impact on day-to-day life: AEUs and their spouses have to adapt to (partial) sight loss, reduced levels of confidence, and social withdrawal. (2) Impact on psychological and emotional wellbeing: distress among AEUs and their spouses can be severe and prolonged, highlight unmet support needs. (3) Challenges with treatment experiences: AEUs experienced negative impact of fragmentation of care and long waiting times. (4) Worries about the future: AEUs mentioned fragility of remaining sight, and concerns around potential need for further treatment.

CONCLUSION

Patients and their family members experience negative impact of being an AEU on their everyday lives and quality of life. There is a potential role for psychosocial support services in supporting AEUs and their families even long after eye loss.

First-in-Human Whole-Eye Transplantation: Ensuring an Ethical Approach to Surgical Innovation

As innovations in the field of vascular composite allotransplantation (VCA) progress, whole-eye transplantation (WET) is poised to transition from non-human mammalian models to living human recipients. Present treatment options for vision loss are generally considered suboptimal, and attendant concerns ranging from aesthetics and prosthesis maintenance to social stigma may be mitigated by WET. Potential benefits to WET recipients may also include partial vision restoration, psychosocial benefits related to identity and social integration, improvements in physical comfort and function, and reduced surgical risk associated with a biologic eye compared to a prosthesis. Perioperative and postoperative risks of WET are expected to be comparable to those of facial transplantation (FT), and may be similarly mitigated by immunosuppressive protocols, adequate psychosocial support, and a thorough selection process for both the recipient and donor. To minimize the risks associated with immunosuppressive medications, the first attempts in human recipients will likely be performed in conjunction with a FT. If first-in-human attempts at combined FT-WET prove successful and the biologic eye survives, this opens the door for further advancement in the field of vision restoration by means of a viable surgical option. This analysis integrates recent innovations in WET research with the existing discourse on the ethics of surgical innovation and offers preliminary guidance to VCA programs considering undertaking WET in human recipients.

Management of traumatic globe subluxation with optic nerve and extraocular muscle transection

A care algorithm for partial globe subluxation cases with optic nerve and at least one extraocular muscle (EOM) transection is presented after a literature review was performed using key term variations of globe, ocular, subluxation, optic nerve evulsion or transection, and trauma. Partial globe subluxation cases with transection of the optic nerve and at least 1 EOM were included. Exclusion criteria included globe rupture, complete enucleation defined by a globe without at least 1 EOM attachment, or unclear details confirming optic nerve transection. Including the patient presented herein, a total of 24 patients with 26 eyes were analyzed. About 73.08% of cases underwent initial repositioning (n = 19), with 11.54% of those requiring secondary enucleation or evisceration (n = 3). Of the secondarily managed cases, 2 of the 3 cases listed pain (n = 2) and inadequate cosmesis (n = 1) as rationale. We found that 26.92% of cases underwent initial enucleation (n = 7), citing lack of visual potential and limiting later complications. Most cases favored repositioning, which was typically sustainable. Initial repositioning can improve cosmetic outcome and psychological impact. Given the low risk of later management, cases of traumatic partial subluxation with EOM and optic nerve transections should attempt initial repositioning.

Workflow and treatment results for computer-aided design and 3D-printed conformer therapy of congenital anophthalmia and microphthalmia

BACKGROUND/AIMS

To evaluate treatment with custom, three-dimensional (3D) printed conformers for socket expansion in congenital microphthalmia and anophthalmia (MICA).

METHODS

Retrospective analysis of prospective cohort from 2016 to 2020. All children received custom-made 3D-printed conformers increasing in size. We measured height, width, thickness, surface and volume of first and consecutive conformers, as well as horizontal palpebral fissure length (HPF) at start and follow-up visits. We analysed these parameters for severely (<45%) and moderately (>45%-75%) affected children, based on affected axial length on ultrasonography.

RESULTS

We included 18 cases (9 severe, 9 moderate) with a total of 174 conformers (88 severe, 86 moderate) and a mean follow-up of 2.8 years (range 1.3-4.8). The mean relative HPF increased from 77% to 93% with 16/17 cases reaching >80%, and 12/17 cases >90% symmetry. Horizontal and vertical conformer dimensions increased up to 10 months of treatment, with a steeper slope for the severe group (10.5% vs 5.5% for height and 9.0% vs 6.1% for width gain per treatment month, for severe and moderate MICA, respectively). After 10 months of treatment conformer height and width increased only slightly. No serious complications were observed.

CONCLUSION

3D-design and printing of solid conformers results in highly acceptable horizontal eyelid symmetry in the treatment of congenital MICA. The mean increase in conformer height and width in the first 10 months should be about 170% for moderate and about 200% for severe MICA. The presented conformer size formulas can aid ophthalmologists and ocularists to plan conformer treatment.

Anxiety and Depression after Traumatic Open-Globe Injury

Introduction

This cross-sectional interview-based study aimed to assess the prevalence and severity of probable anxiety and depression in patients with traumatic open-globe injury and to identify factors associated with anxiety and depression following open-globe injury.

Methods

Two hundred and twenty-five patients with open-globe injury were identified at the UC Davis Medical Center between 2008 and 2019. Prisoners and patients under 18 at the time of recruitment were excluded from the study. One hundred and twenty-four patients provided consent to participate in the study, which involved a phone interview and chart review. The interview consisted of a section on sociodemographic data and potential associations followed by the Hospital Anxiety and Depression Scale, a standardized 14-question survey that has been validated in previous studies as an excellent predictor of anxiety and depression. A score of 8 for anxiety or depression was considered a positive test, and patients with a positive test in either category were advised to seek further evaluation with their primary care doctors. The prevalence of probable anxiety and depression was calculated, and linear regression was used to identify factors associated with anxiety and depression.

Results

The average age was 50.5 ± 19.2, and 75.8% of patients were male. The anxiety score was positive in 37.9% of patients and the depression score was positive in 28.2%. The mean anxiety and depression scores were 6.3 ± 4.7 and 5.5 ± 4.8, respectively. The P value of the linear regressions for anxiety score and depression score were both < 0.001, with R2 = 0.429 and 0.363, respectively. Younger age (P = 0.002) and unemployment at the time of the interview (P = 0.038) were associated with higher anxiety scores. Patients who were bothered by the appearance of their injured eye had higher anxiety scores (P < 0.001) and depression scores (P < 0.001). Patients without a high school diploma had higher depression scores (P < 0.001). Gender, enucleation status, number of people in support network, use of a prosthetic or scleral shell, final logMAR visual acuity, marital status, months since the initial injury, and presence of an intraocular foreign body were not significantly associated with anxiety or depression scores.

Conclusions

Traumatic open-globe injury is associated with a high prevalence of probable anxiety and depression. Dissatisfaction with the appearance of the injured eye was associated with higher anxiety and depression scores. Younger age and unemployment were associated with increased anxiety scores, and lack of a high school diploma was associated with higher depression scores.

Novel point-of-care biomarkers of the dry anophthalmic socket syndrome: tear film osmolarity and matrix metalloproteinase 9 immunoassay

PURPOSE

To compare tear film osmolarity (TFO) values and matrix metalloproteinase 9 (MMP-9) levels between anophthalmic sockets and healthy fellow eyes and to assess the use of the MMP-9 and TFO as objective biomarkers for the dry anophthalmic socket syndrome (DASS).

METHODS

In this prospective single-center study, the anophthalmic sockets and healthy fellow eyes of 98 unilateral anophthalmic patients were assessed using the ocular surface disease index (OSDI) questionnaire, InflammaDry® MMP-9 point-of-care immunoassay, TFO with TearLab™ Osmolarity System, and clinical conjunctival inflammation. MMP-9 concentration and conjunctival inflammation were graded semi-quantitatively. Differences between anophthalmic sockets and the healthy fellow eyes for OSDI scores, MMP-9, TFO values, clinical conjunctival inflammation, and eyelid abnormalities as well as the correlation between these factors and demographic data were evaluated.

RESULTS

Patients had significantly higher OSDI, MMP-9, and TFO values, as well as higher conjunctival inflammation on the anophthalmic side, compared to the healthy side (p ≤ 0.002, respectively). For anophthalmic sockets, there was a significant positive correlation between OSDI scores and TFO values (p = 0.007), between the grade of posterior blepharitis and TFO values (p = 0.026), and between the conjunctival inflammation and MMP-9 values (p < 0.001), as well as between MMP-9 levels and time since eye loss (p = 0.004).

CONCLUSIONS

Measuring MMP-9 and TFO may be helpful tools as efficient, quantifiable biomarkers, disease course parameters, or predictors for treatment response in the clinical management of patients with DASS or future therapy studies. Ophthalmologists should consider the updated diagnosis criteria including TFO and the definition for DASS proposed in this study.

[Evisceration, enucleation and exenteration-Indications, techniques, and postoperative care]

Various surgical techniques are available for the extirpation of an eye, depending on the underlying disease. Typical indications encompass tumors, inflammatory and infectious processes, glaucoma, trauma as well as congenital malformations. Surgical procedures include evisceration (resection of the intraocular space with preservation of the sclera), enucleation (extirpation of the entire eyeball including sclera and cornea) and exenteration (resection of the complete orbital soft tissue). The early detection of postoperatively manifesting complications, such as implant extrusion, conjunctivitis, postenucleation socket syndrome as well as the development of enophthalmus or ptosis, is of particular relevance in the context of postoperative care regarding functional, esthetic and social outcome. Special attention must be paid to ensuring a complication-free rehabilitation process, including the supply of a suitable, precisely fitting prosthesis or epithesis. This ensures the patient's psychosocial reintegration, in which an integrated interdisciplinary cooperation with ocularists and psychologists is essential. The latter play a particularly important role, as the psychological stress resulting from the procedure is often associated with a considerable reduction in the quality of life.

Health Literacy in Patients Wearing Prosthetic Eyes: A Prospective Cross-Sectional Study

PURPOSE

To investigate general and electronic health literacy (HL) levels in prosthetic eye wearing patients, to define factors associated with reduced HL, and to identify a potential healthcare gap.

METHODS

In this prospective cross-sectional study 148 prosthetic eye wearers were screened using the 16-item European Health Literacy Survey Questionnaire (HLS-EU-Q16) and the 8-item electronic Health Literacy Scale (eHEALS). HLS-EU-16 and eHEALS scores were correlated to health levels, vision functioning, and sociodemographic factors.

RESULTS

A total of 85 patients (57%) had adequate, 38 (26%) problematic, and 9 (6%) inadequate general HL, while 16 (11%) had no valid HLS-EU-Q16 score. General HL was positively correlated with physical health (p = 0.009) and negatively with a migration background (p = 0.023). There was a positive correlation between electronic HL and educational level (p < 0.001), social status (p = 0.048), and mental health (p = 0.013). Higher age was associated with lower electronic HL (p < 0.001).

CONCLUSIONS

More than 30% of the prosthetic eye wearers had problematic or even inadequate general HL, suggesting a significant health care gap. To identify patients with reduced HL, a standardized screening tool should be implemented as part of routine clinical care. Within integrated care, patients with insufficient HL should be offered barrier-free advisory services and information brochures in various languages.

Psychosocial factors among patients undergoing orbital exenteration

CLINICAL RELEVANCE

Patients undergoing exenteration have significant anxiety and depression, and lower quality of life that worsens after surgery. Therefore, counselling by an eye health-care provider along with the team of psychologist and psychiatrist could be provided pre-operatively to assess baseline psychosocial status and be continued post-operatively to look for any deterioration.

BACKGROUND

Orbital exenteration comes with psychological trauma of disfigurement of face. The study aimed to evaluate the quality of life, anxiety and depression in patients undergoing orbital exenteration, before and after the procedure; and also compared the same with patients previously rehabilitated by spectacle-mounted prosthesis after exenteration.

METHODS

It was a prospective cohort study. Group I included patients who were planned to undergo orbital exenteration, and group II were those already using spectacle-mounted prosthesis post orbital exenteration for at least 3 months. Level of depression was assessed using Patient Health Questionnaire-9(PHQ-9), anxiety using Generalised Anxiety and Depression scale-7(GAD-7), and quality of life was assessed using Functional Assessment of Cancer Therapy- General (FACT-G) score.

RESULTS

A total of 19 patients were recruited in group I and 10 patients in group II. The baseline demographic factors were comparable. The scores for PHQ-9 and GAD-7 were significantly higher at 3-month post-exenteration follow-up, indicating significantly higher levels of anxiety and depression after orbital exenteration in group I. Both these scores were significantly lower in group II compared to group I (3 months follow-up), indicating lower levels of anxiety and depression after rehabilitation with prosthesis. The FACT-G and its subscores were all significantly higher in group II patients compared to post-operative scores of group I patients, indicating higher overall quality of life after rehabilitation with prosthesis.

CONCLUSIONS

Patients undergoing exenteration have a significant level of anxiety and depression, and lower quality of life that worsens after orbital exenteration.

Post-enucleation socket syndrome-a novel pathophysiological definition

BACKGROUND

The last definition of the post-enucleation socket syndrome (PESS) by Tyers and Collin-formulated almost 40 years ago in 1982-is predominantly based on the clinical characteristics and does not include the insights of newer studies into the pathophysiological mechanism of the PESS.

METHODS

A systematic PubMed literature review regarding the pathophysiological mechanism of the PESS was performed, and results were comprised to give an overview of the current knowledge of the PESS including the exact pathophysiological mechanism.

RESULTS

The primarily postulated pathophysiological mechanism of the PESS was the atrophy of orbital tissues, especially of fat, resulting in variable clinical findings. Newer studies using high-resolution computed tomography and magnetic resonance imaging or performing histopathological analyses found no orbital fat atrophy but rather a rotatory displacement of the orbital tissues from superior to posterior and from posterior to inferior together with the retraction of the extraocular muscles and a possible volume loss of the orbital implant by resorption if it is manufactured from hydroxyapatite. PESS results in a backward tilt of the superior fornix, a deep superior sulcus, a pseudo-ptosis, a lower eyelid elongation and laxity, a shallower inferior fornix, as well as enophthalmos and may lead to an inability of wearing ocular prostheses.

CONCLUSIONS

A novel and comprehensive definition of the PESS is proposed: PESS is a multifactorial and variable syndrome caused by a rotatory displacement of orbital contents together with the retraction of the extraocular muscles and possible resorption of the orbital implant if it is manufactured from hydroxyapatite.

Enucleation in pediatric open globe injuries: demographics and risk factors

PURPOSE

The purpose of this study is to report the demographics and risk factors for undergoing primary enucleation in the setting of acute open globe injury (OGI) in the pediatric population in the USA.

METHODS

This retrospective, cross-sectional study of pediatric patients with OGIs in the USA between 2002 and 2014 was conducted utilizing data from the National Inpatient Sample Database. Descriptive statistics, chi-square testing, and univariate and multivariable analyses were performed.

RESULTS

In the USA, 8944 cases of pediatric OGI were identified between 2002 and 2014 in the NIS Database, of which 344 underwent primary enucleation. Blacks and Asian/Pacific Islanders made up higher proportions of enucleated cases compared to non-enucleated cases. Older age, male sex, being Black or Asian/Pacific Islander, OGI with an intraocular foreign body, rupture type OGI, and concurrent endophthalmitis were identified as risk factors for undergoing enucleation. There was no significant difference in insurance status among enucleated versus non-enucleated cases. Mean length of hospital stay (in days) was almost 3 times higher in enucleated OGIs. By hospital's geographic location, the Midwest hospitals had a greater proportion of enucleated versus non-enucleated cases compared to other regions.

CONCLUSION

Significant demographic differences were identified in OGI patients that underwent primary enucleation versus repair with regard to age, sex, race, the geographic location of hospital admission, mean length of hospital stay, type of ocular injury, and other ocular complications. Most pediatric traumatic enucleations between 2002 and 2014 were reported in teenagers (16-20 age group), in males, and in Blacks.

Embryonic Development of the Orbit

The embryonic and fetal development of the orbit comprises a series of sequential events, starting with the fertilization of the ovum and extending until birth. Most of the publications dealing with orbital morphogenesis describe the sequential development of each germinal layer, the ectoderm with its neuroectoderm derivative and the mesoderm. This approach provides a clear understanding of the mode of development of each layer but does not give the reader a general picture of the structure of the orbit within any specified time frame. In order to enhance our understanding of the developmental anatomy of the orbit, the authors have summarized the recent developments in orbital morphogenesis, a temporally precise and morphogenetically intricate process. Understanding this multidimensional process of development in prenatal life, identifying and linking signaling cascades, as well as the regulatory genes linked to existing diseases, may pave the way for advanced molecular diagnostic testing, developing minimally invasive interventions, and the use of progenitor/stem cell and even regenerative therapy.

The prevalence of anxiety symptoms and disorders among ophthalmic disease patients

Background:

Progressive and irreversible vision loss has been shown to place a patient at risk of mental health problems such as anxiety. However, the reported prevalence of anxiety symptoms and disorders among eye disease patients vary across studies. Thus, this study aims to clarify the estimated prevalence of anxiety symptoms and disorders among ophthalmic disease patients.

Methods:

Relevant studies on the prevalence of anxiety symptoms and disorders among eye disease patients were collected through international databases, PubMed, Scopus, and Web of Science. A random-effects model was used to determine the pooled prevalence of anxiety symptoms and disorders among ophthalmic disease patients.

Results:

The 95 included studies yielded a pooled prevalence of 31.2% patients with anxiety symptoms and 19.0% with anxiety disorders among subjects with ophthalmic disease. Pediatric patients were more anxious (58.6%) than adults (29%). Anxiety symptoms were most prevalent in uveitis (53.5%), followed by dry eye disease (DED, 37.2%), retinitis pigmentosa (RP, 36.5%), diabetic retinopathy (DR, 31.3%), glaucoma (30.7%), myopia (24.7%), age-related macular degeneration (AMD, 21.6%), and cataract (21.2%) patients. Anxiety disorders were most prevalent in thyroid eye disease (TED, 28.9%), followed by glaucoma (22.2%) and DED (11.4%). When compared with healthy controls, there was a twofold increase on the prevalence of anxiety symptoms (OR = 1.912, 95% CI 1.463–2.5, p < 0.001) and anxiety disorders (OR = 2.281, 95% CI 1.168–4.454, p = 0.016).

Conclusion:

Anxiety symptoms and disorders are common problems associated with ophthalmic disease patients. Thus, comprehensive and appropriate treatments are necessary for treating anxiety symptoms and disorders among ophthalmic disease patients.

The psychosocial impact of losing an eye through traumatic injury and living with prosthetic restoration: A thematic analysis

This study aims to explore the psychosocial factors and challenges affecting the lives of those who wear an ocular prosthesis following a traumatic eye injury. Thematic analysis of semi-structured interviews with eight individuals resulted in five themes: emotional devastation in the aftermath; moving forward; fear of negative social evaluation; keeping it normal - protecting self and close others; and threat of injury & blindness. Enucleation or evisceration of an eye causes significant emotional stress. Despite successful prosthetic restoration, many individuals continue to experience ongoing psychosocial challenges, as a consequence of their experiences of visible difference and visual impairment.

Anophthalmic Socket Syndrome: Prevalence, Impact and Management Strategies

Anophthalmic socket syndrome determines functional deficits and facial deformities, and may lead to poor psychological outcomes. This review aims to comprehensively evaluate the features of the syndrome, based on literature review and authors’ clinical and surgical experience. An electronic database (PubMed,MEDLINE and Google Scholar) search of all articles written in English and non-English language with abstract translated to English on anophthalmic socket syndrome was performed. Data reviewed included demographics, presentations, investigations, management, complications and outcomes. Different types of orbital implants were evaluated; the management of implant exposure was examined; different orbital volume enhancement procedures such as secondary implantation, subperiosteal implants and the use of fillers in anophthalmic patients were described; the problems related to socket contraction were outlined; the treatment options for chronic anophthalmic socket pain and phantom eye syndrome were assessed; the most recent advances in the management of congenital anophthalmia were described. Current clinical evidence does not support a specific orbital implant; late exposure of porous implants may be due to pegging, which currently is seldom used; filler absorption in the orbit appears to be faster than in the dermis, and repeated treatments could be a potential source of inflammation; socket contraction results in significant functional and psychological disability, and management is challenging. Patients affected by anophthalmic socket pain and phantom eye syndrome need specific counseling. It is auspicable to use a standardized protocol to treat children affected by clinical congenital anophthalmia; dermis fat graft is a suitable option in these patients as it helps continued socket expansion. Dermis fat graft can also address the volume deficit in case of explantation of exposed implants and in contracted sockets in both children and adults. Appropriate clinical care is essential, as adequate prosthesis wearing improves the quality of life of anophthalmic patients.

Measuring quality of care and life in patients with an ocular prosthesis

PURPOSE

In patients with an anophthalmic condition, the primary determinants of success of ocular prosthetic rehabilitation are satisfaction with care and quality of life (QoL). The aim of this study is to develop a condition-specific questionnaire as a patient-reported outcome measure for patients with an ocular prosthesis.

METHODS

Observational cross-sectional prospective study. We included 100 patients (52 female, 48 male, > 18 years old) with an anophthalmic and ocular prosthetic condition existing for 2 years or more. The patients completed a pre-tested 72-item questionnaire regarding their experience on living with an ocular prosthesis in four domains of QoL: single vision and care, wearing comfort, physical appearance and motility, and psychosocial functioning. Associations with demographic factors and condition- and prosthesis-related variables were investigated with multivariate analysis. The questionnaire was reduced with principal component analysis to obtain the Global Ocular Prosthesis Score (GOPS).

RESULTS

Satisfaction scores for each QoL domain were high with a mean visual analogue score between 7.2 and 7.6. Patients were generally satisfied with the physical appearance of the artificial eye and reported adequate psychosocial functioning. Patients described the reduced peripheral visual field and socket discharge as chief complaints. The test was reduced to a 20-item questionnaire. The mean GOPS was 70.87 (median 75.00).

CONCLUSIONS

Patients with longstanding ocular prosthetic wear are satisfied with their physical appearance and report adequate psychosocial functioning. A concise 20-item questionnaire for the anophthalmic condition is a valuable tool to quantitatively measure patient-reported outcome of ocular prosthetic rehabilitation.

TRIAL REGISTRATION NUMBER

NCT04321382, 03/2020, retrospectively registered.