Responsiveness of health-related quality-of-life questionnaires in adults undergoing Strabismus surgery

Patient perspectives on their outcomes from strabismus surgery undertaken for psychosocial reasons

BACKGROUND

Strabismus surgery undertaken for psychosocial reasons aims to align the eyes in a straighter position, reduce the psychosocial symptoms experienced and improve health related quality of life (HRQoL). Greater evidence of the postoperative outcomes in adults undergoing strabismus surgery for psychosocial reasons is required to inform funding and commissioning decisions about strabismus surgery.

METHODS

Semi-structured interviews were conducted with adults who had previously undergone strabismus surgery for psychosocial reasons to explore their perceptions of their postoperative outcomes. Maximum variation sampling was used to recruit males and females, younger and older participants. Interviews were transcribed and analysed using thematic analysis following the principles of grounded theory.

RESULTS

Thirteen adults were recruited and interviewed, mean 12.2 months postoperatively (range 4.5-20 months). Participants reported a range of improvements in vision, task performance, physical symptoms and confidence and emotions. Some worsening of physical symptoms was reported.

CONCLUSION

Despite undergoing strabismus surgery for psychosocial reasons, a range of improvements in vision, task performance and physical symptoms were reported by adult patients postoperatively, in addition to the expected improvements in confidence and emotions.

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.

Strabismus and Health Related Quality of Life in a pediatric Portuguese population

Introduction: Strabismus is a common condition among children, and its psychosocial impact has been demonstrated in recent years. The interest in a more comprehensive approach was enhanced by the recognition of health as a four-dimensional concept, arising the term Health-related Quality of Life. Therefore, we aim to evaluate the influence of strabismus in Health-Related Quality of Life of a Portuguese pediatric population. Material and Methods: Case-control prospective transversal study enrolling children between 5 and 12 years old. All had a complete orthoptic and ophthalmological evaluation, followed by an interview with a legal representative to answer the Pediatric Quality-of-Life Inventory 4.0, proxy-version. Results: Seventy-one children were included, 35 in the control group (CG) and 36 in the strabismus group (SG). In the SG, 30 (83.3%) patients had esotropia, 20 (55.6%) had more than 10 prismatic diopters and 26 (72.2%) were already surgically treated. Overall, SG was not statistically different from the CG, showing only mild inferior performance (p > .05). Furthermore, children with exotropia, higher deviations, none or gross stereoacuity and treatment-naïve, scored worse, especially in emotional, social, educational and psychosocial scores although not statistically significant (p > .05). Conclusion: This is the first prospective study addressing HRQoL and strabismus in a pediatric Portuguese population. It would be relevant to further address this issue in order to delineate more effective and global treatment strategies, not only considering ophthalmological goals but also the well-being of both children and guardians.

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.

Translation and transcultural adaptation of the AS-20 scale to measure quality of life in adults with strabismus in Colombia, a pilot study

BACKGROUND

Strabismus generates a negative psychosocial impact on adult patients, affecting aspects such as self-perception and quality of life. There is no scale in Colombian Spanish that measures these impacts.

OBJECTIVE

To carry out the translation and cross-cultural adaptation of the AS-20 instrument into Colombian Spanish.

MATERIALS AND METHODS

Pilot test of a cross-sectional Study for the translation, reverse translation, and cross-cultural the AS-20 instrument from its original language, English, to Colombian Spanish, in adult patients with strabismus in Bogotá, Colombia.

RESULTS

16 patients were assessed. The age range was between 18 and 68 years with a mean age of 41 years. The scale was answered in an average time of 10.62min. Difficulty was reported in three individuals for understanding two items (questions 8 and 14), which were resolved.

CONCLUSION

The translation and pilot test of AS-20 scale into Colombian Spanish was carried out, identifying and solving translational difficulties. Is the first step in the cross-cultural adaptation process. Based on the results, the validation and cross-cultural adaptation can be completed in a future study.

Health-Related Quality of Life in Adult Patients with Strabismus-Translation and Psychometric Testing of the Adult Strabismus Questionnaire (AS-20) into Finnish

(1) Strabismus has an impact on individuals' health-related quality of life. The impact should be assessed with valid patient-reported outcome measures such as the Adult Strabismus Questionnaire (AS-20). The AS-20 was further refined using a Rasch analysis for the American population. The aims of the study were to translate and culturally adapt the AS-20 into Finnish and to evaluate the psychometric properties of the Finnish AS-20. (2) The guidelines of the Professional Society for Health Economics and Outcomes Research steered the process and four items were added from the original data as Finnish additions. The construct and convergent validity and internal consistency were evaluated via psychometric testing for three potential Finnish AS-20 structures. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist was applied. (3) The participants (n = 137) reported that the translation was clear and understandable. All structures showed high reliability and internal consistency as measured using Cronbach alpha values. The convergent validity assessed using Spearman's correlation coefficients between the structures and one item of Satisfaction with Life Scale indicated very low to moderate positive correlations. The construct validity evaluated using a confirmatory factor analysis revealed the refined AS-20 structure to be satisfactory. (4) The refined AS-20 can be used in clinical practice and research, but further validation is recommended.

Botulinum Toxin A Injection for Convergence Insufficiency

PURPOSE

To evaluate the effects of botulinum toxin A injection in one or both lateral rectus muscles in patients with convergence insufficiency previously managed with non-surgical and/or surgical options other than botulinum toxin A injection.

METHODS

All patients with symptomatic convergence insufficiency treated with botulinum toxin A injection to one or both lateral rectus muscles from 2013 to 2018 at the Department of Ophthalmology, Rigshospitalet-Glostrup, Copenhagen University Hospital were retrospectively reviewed. All patients had near symptoms and were previously treated with a combination of convergence exercises, prisms, and/or surgery. Patients with previous botulinum toxin A injection in an extraocular muscle were excluded. Reading symptoms and deviation at near and distance were recorded at baseline and after 1 and 6 months.

RESULTS

Twenty-three patients with convergence insufficiency were included (8 men and 15 women). Follow-up was conducted after a median of 47 days (interquartile range [IQR]: 31.5 to 72.5 days) and 174 days (IQR: 139 to 267 days). At baseline, median near angle of deviation was 18 PD of exophoria (IQR: 13 to 21 PD). The near deviation was reduced to 10 PD of exophoria (IQR: 7 to 17 PD) at first follow-up visit and 14 PD of exophoria (IQR: 12 to 18 PD) at last follow-up visit. Thirteen of 23 patients (57%) and 3 of 13 patients (23%) reported improvement in reading symptoms at first and last follow-up visit, respectively, compared to baseline.

CONCLUSIONS

Botulinum toxin A injection may be useful in patients with convergence insufficiency. However, some patients may require repeated injections. [J Pediatr Ophthalmol Strabismus. 20XX;X(X):XX-XX.].

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.

Psychometric properties of the Dutch version Adult Strabismus-20 Questionnaire (AS-20)

PURPOSE

Strabismus often has an impact on a patient's quality of life (QoL). The Adult Strabismus-20 questionnaire (AS-20) is an instrument developed to assess the strabismus-specific QoL. The aim was to investigate several psychometric properties of the Dutch-AS-20 among adult patients with strabismus.

METHODS

Patients with any type of strabismus completed the Dutch-AS-20, the EuroQol five-dimensional questionnaire (EQ-5D-5L) and the Amblyopia and Strabismus Questionnaire (A&SQ) (N = 286). Psychometric properties were evaluated with the use of item response theory (IRT) analysis (graded response model) and by determining the internal consistency, test-retest reliability after two weeks, targeting and measurement precision. Construct validity of the AS-20 was tested against the EQ-5D-5L and the A&SQ.

RESULTS

Principal component analysis indicated a psychosocial and function subscale. After collapsing underutilised response options for 10 items, subsequent fit analysis showed that the function subscale benefitted from removal of two items. Differential item functioning (DIF) was detected on four items for age and gender subgroups, but with minimal impact on the total score. Internal consistency (Cronbach's alpha 0.93 psychosocial and 0.87 function subscale) and test-retest reliability (ICC 0.91 psychosocial and 0.88 function subscale) were sufficient. Targeting and measurement precision of both subscales was appropriate for patients with low to moderate levels of visual and psychosocial functioning but suboptimal for patients with high levels of visual and psychosocial functioning. Correlations were between 0.4 and 0.7 for (subscales of) the Dutch-AS-20 and the A&SQ or EQ-5D-5L, confirming expected construct validity.

CONCLUSIONS

The 18-item Dutch-AS-20 has sound psychometric properties to assess the strabismus-specific QoL among Dutch adult patients with low to moderate levels of visual and psychosocial functioning. Care must be taken when interpreting the results due to lower measurement precision at the higher end of both subscales. In future longitudinal studies, properties to assess treatment effects should be evaluated.

Economizing strabismus surgery: Using half the double-armed suture for horizontal muscles

In a developing country like India, both availability and affordability of medical care are obstacles, leading to delay in seeking timely treatment. To reduce the cost incurred to the patients for strabismus surgery, we used half of a 6-0 polyglactin suture for performing common muscle weakening and strengthening procedures: a fixed and hang back recessions with plication and resection. We cut the 45-cm-long double-armed 6-0 polyglactin sutures in two halves, and with a modified approach, used one-half in each of two patients planned for monocular two horizontal muscles surgeries: fixed recession-plication and hang back recession-resection. By devising an intuitive manner of threading a single armed 22.5 cm suture we successfully carried out horizontal extraocular muscle surgeries on each of two patients of exotropia. We believe in the long run, this will reduce the cost to individual patients and sponsoring groups, and suggest that strabismus surgeons consider adopting this option.

Binocular Interference vs Diplopia in Patients With Epiretinal Membrane

Importance

Patients with epiretinal membrane (ERM) sometimes close 1 eye for improved vision, but associations have not been rigorously studied.

Objective

To evaluate associations with monocular eye closure in patients with ERM, and to report binocular interference (closing 1 eye to improve visual quality).

Design, Setting, and Participants

Retrospective medical record review of an adult strabismus clinic at a tertiary referral center. Patients with ERM referred from retina clinicians between June 2010 and October 2019 who completed the Adult Strabismus (AS)-20 questionnaire, including the question: "I cover or close one eye to see things better." Two groups were identified: (1) patients reporting eye closure sometimes or more, and (2) patients reporting no eye closure (as control patients).

Main Outcomes and Measures

Frequencies of (1) central-peripheral rivalry (CPR)-type diplopia (dragged fovea diplopia); (2) binocular interference (monocular eye closure but no diplopia or strabismus); and (3) other, associated with monocular eye closure. Visual acuity, metamorphopsia, aniseikonia, and AS-20 quality of life domain scores (self-perception, interactions, reading function, and general function) compared between binocular interference, CPR-type diplopia, and control patients.

Results

A total of 124 patients with ERM (58 of 124 were women [47%]; mean [SD] age, 70 [9] years) reported monocular eye closure. Associations were binocular interference in 36 (29%; 95% CI, 21%-38%), CPR-type diplopia in 34 (27%; 95% CI, 20%-36%), and other (primarily strabismus) in 54 (44%). Compared with control patients with ERM (n = 11), patients with ERM and binocular interference had worse quality of life on AS-20 reading function (95 vs 62; mean difference, 22 points; 95% CI, 7-27 points; P = .007) and general function (89 vs 68; mean difference, 23 points; 95% CI, 13-34 points; P = .01) domains. Compared with CPR-type diplopia, patients with binocular interference had poorer worst-eye visual acuity (median 0.50 vs 0.30 logMAR [20/63 vs 20/40]; mean difference, 0.13 logMAR; 95% CI, 0.00-0.25 logMAR [20/20 to 20/35]; P = .03), and a larger interocular difference (0.46 vs 0.19 logMAR [20/58 vs 20/30]; mean difference, 0.15 logMAR; 95% CI, 0.03-0.28 logMAR [20/21 to 20/38]; P = .004).

Conclusions and Relevance

Study findings suggest that binocular interference, manifesting as monocular eye closure (without diplopia or strabismus), is a distinct entity affecting quality of life in patients with epiretinal membrane.

The impact of strabismus on psychosocial heath and quality of life: a systematic review

Strabismus can hinder an individual's ability to perform daily functions and negatively affect their well-being. I examine the impact strabismus has on psychosocial health and quality of life in children and adults and evaluate the challenges confronted by parents of children with strabismus. Numerous misconceptions exist regarding the impact strabismus has on overall health. Negative attitudes persist toward those affected, resulting in difficulties with self-image. Individuals with strabismus are at increased risk for both visual system and psychiatric disorders. Misinformation regarding available treatment options for children and adults with strabismus continues to exist, resulting in decreased access to care. Improved education of health care providers can increase appropriate referrals and initiation of treatment. Treatment of strabismus is not merely cosmetic and has the potential to improve psychosocial health and quality of life for children and adults with and without diplopia.

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.

Psychosocial impacts of adult strabismus and strabismus surgery: a review of the literature

BACKGROUND

Patients with strabismus may suffer from both reduced visual functioning and the psychosocial effects of ocular misalignment. For adults with strabismus, there is a strong body of evidence supporting the advantages of surgical restoration of binocular visual function. However, even in the absence of binocular visual potential, patients may benefit from reconstructive surgery to restore an aesthetically acceptable ocular alignment.

OBJECTIVE

To review the psychosocial implications of strabismus in the adult population and to summarize the psychosocial impact of surgical correction.

METHODS

A Medline search (1946-2013) was conducted to identify the psychosocial implications of strabismus, its effects on employment, and the impact of surgical correction on strabismic adults using the following keywords: strabismus, surgery, quality of life, life style, employment/employability effects, job satisfaction, social support/social isolation/social marginalization, adaptation, stress, depression, family relations, interpersonal relations, friends, and peer group. The search was limited to patients older than 18 years and studies published in English. Of the initial 87 articles for which abstracts were reviewed, 20 studies were of sufficient relevance to be included in the review.

RESULTS

Eight studies examined the psychosocial impact of strabismus, 2 of which explored the effect of strabismus on finding partners, and 4 studies examined the effect of strabismus on employment. These studies examined perceptions of both patients with strabismus and the general population. Eight studies evaluated the impact of strabismus surgery. Strabismus was shown to have negative psychosocial functioning and employability in both patients' and the public's perceptions. Surgical correction was associated with long-lasting improvement in psychological and social functioning.

CONCLUSIONS

There is a fairly strong body of evidence in the literature to suggest that adult strabismus patients suffer significant social, psychological, and economic effects because of their condition. Surgery can be effective in improving these disadvantages. Clinicians should be aware of the importance of offering surgery to patients with significant strabismus, even in patients for whom it is not expected to improve visual function.

Factors influencing the self-reported sense of deviation in adults with successful surgical outcomes for strabismus

BACKGROUND

To determine whether a sense of deviation remains in adults with successful motor alignment who fulfil diplopia criteria after surgery and to examine the factors associated with this judgement.

METHODS

This was a retrospective study. Adult patients defined as having a successful outcome based on more than 1 year of post-operative follow-up visits were included in the study. The sense of deviation was determined at the last visit. Pre- and post-operative deviation and characteristics including age, gender, education level, occupation, diagnosis, size of deviation, extraocular movement (EOM), binocular function, and health-related quality of life (HRQOL) were recorded.

RESULTS

In total, 22 (24%) of the 91 adults with successful surgical outcomes reported a sense of deviation. No significant differences were noted between subjects with and without a sense of deviation regarding patient demographics, pre- and post-operative deviation, changes in deviation, sensory fusion or EOM. Subjects with a sense of deviation had an increased prevalence of and larger post-operative vertical deviation, poorer stereo function, and lower HRQOL scores than those with no sense of deviation. The presence of post-operative vertical deviation was associated with a sense of deviation.

CONCLUSIONS

Approximately one-fourth (24%) of adults defined as having successful surgical outcomes who still had a sense of deviation exhibited worse stereo function, higher vertical deviation size and lower HRQOL scores. The presence of 3 to 5 prism dioptres(pd) of vertical deviation would be the main factor associated with a sense of deviation post-operatively.

Non-surgical correction of diplopia after stroke- a strong impact factor on quality of life-minireview

One of the most frequent disorders accompanied by diplopia is represented by stroke. Beyond different symptoms of stroke, diplopia constitutes an important clinical factor in influencing the quality of life in surviving patients. In this paper we discuss the visual impairment associated with stroke location, types of diplopia, the clinical examination, and the nonsurgical treatment of diplopia. The purpose of diplopia treatment is to restore binocular vision and eliminate the double vision. The most used nonsurgical treatment for diplopia is the optical correction by the prisms. Another therapeutic option is the botulinum toxin injections. Key words: diplopia, stroke, visual rehabilitation, prism correction,

Diplopia after strabismus surgery for adults with nondiplopic childhood-onset strabismus

PURPOSE

To describe frequency of postoperative diplopia after strabismus surgery in nondiplopic adults with childhood-onset strabismus and to report health-related quality-of-life (HRQOL) outcomes.

METHODS

We prospectively enrolled 79 adults with no diplopia in any gaze who had childhood-onset strabismus and were scheduled for strabismus surgery. Diplopia was assessed preoperatively and at 6 weeks and 1 year postoperatively using a standardized diplopia questionnaire with 5 response options in 7 gaze positions. HRQOL was assessed using the Adult Strabismus-20 (AS-20) questionnaire, with self-perception, interactions, reading function, and general function domains.

RESULTS

Constant diplopia in straight-ahead distance and reading gaze occurred in 1 patient (1% [95% CI, 0%-7%] at 6 weeks and 2% [95% CI, 0%-10%] at 1 year). Regarding the rate of any diplopia (including rarely) in any gaze, 15 of 78 patients (19%) reported diplopia at 6 weeks, of whom 13 had diplopia in straight-ahead distance gaze; 8 (10%), in reading gaze. At 1 year, 8 of 51 patients (16%) reported any diplopia (including rarely) in any gaze, of whom 7 had diplopia in straight-ahead distance gaze and 4 (8%) in reading gaze. Mean AS-20 scores improved at 1 year overall (by 32, 19, 14, and 15 points, resp., per domain) and for the 8 diplopic patients (by 21, 13, 16, and 11 points).

CONCLUSIONS

In adults with nondiplopic strabismus, constant postoperative diplopia is rare, although the rate of intermittent diplopia is higher. Even when postoperative diplopia occurs, HRQOL often improves.

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

Importance

Health-related quality of life (HRQOL) typically improves following strabismus surgery. Nevertheless, for some patients, HRQOL does not improve, and reasons for this are unknown.

Objective

To identify factors associated with failure of adult strabismus-20 (AS-20) HRQOL scores to improve following strabismus surgery.

Design, Setting, and Participants

Prospective observational case series at the Mayo Clinic, Rochester, Minnesota, comprising 276 adults, between July 2012 and August 2016.

Main Outcomes and Measures

Participants completed the AS-20 HRQOL questionnaire, diplopia questionnaire, Center for Epidemiologic Studies Depression Scale-Revised (CESD-R) (depressive symptoms), and Type-D Scale 14 questionnaire (type-Distressed [type-D] personality) both preoperatively and 6 weeks postoperatively. To assess factors associated with failure of HRQOL to improve (no change or decrease in score), univariate and multiple logistic regression analyses were performed. Each of the 4 AS-20 domains (self-perception, interactions, reading function, and general function) were analyzed separately including only patients able to improve at least by the magnitude of previously defined 95% limits of agreement. Factors assessed were age (at onset and at surgery), sex, number of previous surgeries, presence of visually obtrusive facial anomaly, visual acuity, preoperative and postoperative diplopia questionnaire scores, alignment (as a vector), presence of esotropia, presence of a vertical deviation, CESD-R scores, and type-D personality. Stepwise multiple logistic regression analyses were performed to assess factors associated with failure of AS-20 scores to improve for each domain.

Results

Of the 276 participants, the median age was 57 years (range, 18-91 years), 153 were women (55%), and 266 were white (96%). Failure to improve was associated with worse diplopia postoperatively on the self-perception (adjusted risk ratio [RR], 1.01; 95% CI, 1.00-1.02), reading function (adjusted RR, 1.02; 95% CI, 1.01-1.03), and general function domains (adjusted RR, 1.02; 95% CI, 1.01-1.03). In addition, failure to improve on the self-perception domain was associated with type-D personality postoperatively (adjusted RR, 4.26; 95% CI, 1.90-9.57) and failure to improve on the interactions domain was associated with postoperative depressive symptoms (adjusted RR, 1.04; 95% CI, 1.02-1.06) and coexisting visually obtrusive anomaly (adjusted RR, 2.12; 95% CI, 1.04-4.32).

Conclusions and Relevance

Postoperative diplopia, depressive symptoms, type-D personality, and visually obtrusive facial anomalies were associated with failure of AS-20 scores to improve (remaining the same or worsening) following strabismus surgery. The association of nonstrabismus factors may have implications for patient treatment and is worthy of continued study.

Factors Associated With Health-Related Quality of Life in Medically and Surgically Treated Patients With Glaucoma

Importance

Health-related quality of life (HRQOL) is often reduced with glaucoma, but associated factors are poorly understood.

Objective

To determine factors associated with reduced HRQOL in medically and surgically treated patients with glaucoma.

Design, Setting, and Participants

Prospective cohort study at a tertiary referral glaucoma practice, with 160 consecutive, prospectively enrolled medically or surgically treated adult patients with glaucoma.

Main Outcome and Measures

All patients completed 2 HRQOL questionnaires (the 25-item National Eye Institute Visual Function Questionnaire and the Adult Strabismus-20 questionnaire [AS-20]). Thirty-six patients had undergone glaucoma drainage device surgery, 51 underwent trabeculectomy, and 73 were medically treated. Factors considered for association with HRQOL in multiple regression analyses were age, sex, best-eye and worst-eye mean deviation on Humphrey visual fields, treatment modality, best-eye and worst-eye visual acuity, and diplopia.

Results

The mean (SD) age of participants was 69 (13) years, 63% were female, 97% were white, 93% were not Hispanic, and the mean deviation (SD) was -13 (10) dB. Reduced HRQOL was associated with worse diplopia (Diplopia Questionnaire score) on 6 subscales (range of partial r2 [rp2], 0.207-0.069). Reduced HRQOL was associated with lower best-eye mean deviation on 5 of 6 subscales (rp2 range, 0.379-0.027), lower worst-eye mean deviation on 4 of 6 (rp2 range, 0.242-0.046), treatment group on 3 of 6 (rp2 range, 0.190-0.025), lower worst-eye visual acuity on 5 of 6 (rp2 range, 0.063-0.025), lower best-eye visual acuity on 2 of 6 (rp2 range, 0.032-0.017), and younger age on 2 of 6 (rp2 range, 0.021-0.014). In adjusted analyses, glaucoma drainage device was associated with worse HRQOL in 3 AS-20 subscales compared with trabeculectomy and 2 AS-20 subscales compared with medical. Differences ranged from -14.7 to -7.4, with half the absolute magnitude of the full range of the 95% CI ranging from 9.2 to 5.7.

Conclusions and Relevance

Our findings support the assertion that reduced HRQOL is common in surgically and medically treated patients with glaucoma. Overall, poor HRQOL in patients with glaucoma is moderately associated with worse diplopia, lower mean deviation on visual field testing in either eye, poorer visual acuity in either eye, treatment type, and younger age. Previous glaucoma drainage device surgery was specifically associated with poorer HRQOL compared with trabeculectomy or medical treatment. Psychosocial effects of glaucoma drainage device should be considered when counseling patients with glaucoma.

Does successful surgical correction of childhood large angle exotropia in adults make any difference to binocularity and quality of life?

Background/Aim: Strabismus surgery could achieve motor alignment and improve health-related quality of life (HRQOL) in adults with large angle exotropia, but whether it could improve binocularity and whether the binocularity is associated with HRQOL are unknown. The aim of this study is to evaluate the binocularity and HRQOL following successful surgical correction of childhood large angle exotropia in adults. Methods: Consecutive adults with childhood large angle exotropia (≥90 prism diopters) who underwent strabismus surgery in the Department of Ophthalmology and Vision Science, Eye and ENT Hospital, Shanghai Medical School, Fudan University were enrolled. Static and dynamic stereopsis tests were performed before surgery and 1 month after surgery. At the same time, Adult Strabismus-20 (AS-20), and Amblyopia and Strabismus questionnaire (A&SQ) were investigated. Results: A total of 29 adults achieved successful alignment: 18 intermittent exotropes (IXT) and 11 constant exotropes (CXT). One month after surgery, stereopsis was demonstrated better in all types of tests (p < .05 for all comparisons). Twelve patients gained normal stereopsis. More patients in IXT group gained normal stereopsis than in CXT group (x² = 7.62 p = .008). All HRQOL scores showed statistically significant improvement after surgery (p < .05 for all comparisons). IXT group had more changes of the composite score (t = 2.24, p = .03) and the functional score (t = 2.92, p = .007) of AS-20, and the functional score (t = 3.06, p= .005) of A&SQ than CXT group. Only the change of the functional score of A&SQ was demonstrated a statistically significant correlation with the normal stereopsis (t = 2.67, p = .02). Conclusions: The stereopsis and HRQOL in adults with childhood large angle exotropia can be improved after successful surgical correction. More patients in IXT group gained normal stereopsis correlated with better functional aspects of HRQOL.

Development of a conceptual model regarding quality of life in Chinese adult patients with strabismus: a mixed method

Background

Substantial challenges have been reported in China in terms of the large number of adult patients with strabismus and their poor quality of life. Quality of life is a cultural concept that varies according to personal feelings and perceptions, and it is influenced by physical, psychological and social factors. However, to date, there has been no mixed-method research of the quality of life of Chinese adult patients with strabismus, and no conceptual model has been reported. This study aimed to utilize mixed methods to explore the influence of strabismus on health-related quality of life in Chinese adult patients and to develop a conceptual model.

Methods

Thirty adult patients with strabismus from three tertiary hospitals in China participated in the interview. In-depth one-to-one interviews were semi-structured and addressed strabismus-related symptoms and the impacts on the participants’ quality of life. Transcripts were analysed to identify themes. A self-designed questionnaire was distributed to 448 patients, 437 of whom returned valid questionnaires. Descriptive statistics and x² test were conducted.

Results

Five themes were revealed regarding the impact of strabismus on patient quality of life: appearance, daily activities, personal development, social interaction, and emotions. In the survey, the top three symptoms (n ≥ 70%) rated by the participants were monocular vision, eye fatigue and physical discomfort. Compared to those without diplopia, the patients who suffered diplopia more often reported experiencing the symptoms of blurred vision, monocular vision, physical discomfort, eye fatigue, cannot estimate depth well and increasing deviation size (all p < 0.05).

Conclusions

This study is the first to examine quality of life among Chinese strabismus patients using both qualitative and quantitative methods and proposing a conceptual model. Symptom burden and appearance were the two original reasons for the decreased quality of life, and they were also the triggers for strabismus patients to visit clinics and undergo surgery. The interventions to treat symptoms burden should be different between patients with and without diplopia.

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.

Health-Related Quality of Life (HRQoL) in Young Adults with Strabismus in India

INTRODUCTION

Strabismus has negative psycho-social and functional effects in adults. The impact can be minimised with surgery. However, in a low-income setting, it is important to evaluate the level of impact and prioritise the target population for intervention. The Adult Strabismus (AS-20) questionnaire is a reliable tool for assessment of Health-Related Quality of Life (HRQoL) in strabismic adults.

AIM

To assess the HRQoL in young adults with manifest strabismus through psychosocial and functional scores according to gender and direction of deviation using the AS-20 questionnaire.

MATERIALS AND METHODS

In this cross-sectional cohort study, 132 young adults who manifest horizontal strabismus were recruited and the AS-20 questionnaire was administered. Patient's demographic profile and type of strabismus were noted and compared with the overall mean scores of psycho-social and functional subscales. Data was analyzed using SPSS 21 and p-value less than 0.05 was considered statistically significant.

RESULTS

The participants comprised of 70 (53.03%) males and 62 (46.97%) females with a mean age of 24.5±3.57 years (range 18 to 38 years). The overall mean AS-20 score of young adults with strabismus was 61.62±12.61. The overall mean score for male and female were 65.54±13.53 and 57.68±13.46, respectively. Similarly, the mean scores for esotropes was 57.03±11.66 and 66.19±15.30 for exotropes. The overall mean scores were statistically significantly reduced (decreased QoL) in females as compared to males (CI 95%; p=0.002) and in esotropes as compared to exotropes (CI 95%; p=0.001). However, there was no significant difference between the psychosocial and functional score for all types of strabismus and genders (for all, p>0.05).

CONCLUSION

The Quality of Life (QoL) is affected through psychosocial and functional factors in adults with strabismus. Females and adults with esotropia faced greater difficulties in the QoL. We recommend clinicians to consider the impact on QoL while managing adult with strabismus.

Microvascular Decompression Versus Stereotactic Radiosurgery for Trigeminal Neuralgia: A Decision Analysis

INTRODUCTION

 Both microvascular decompression (MVD) and stereotactic radiosurgery (SRS) have been demonstrated to be effective in treating medically refractory trigeminal neuralgia. However, there is controversy over which one offers more durable pain relief and the patient selection for each treatment. We used a decision analysis model to calculate the health-related quality of life (QOL) for each treatment.

METHODS

 We searched PubMed and the Cochrane Database of Systematic Reviews for relevant articles on MVD or SRS for trigeminal neuralgia published between 2000 and 2015. Using data from these studies, we modeled pain relief and complication outcomes and assigned QOL values. A sensitivity analysis using a Monte Carlo simulation determined which procedure led to the greatest QOL.

RESULTS

MVD produced a significantly higher QOL than SRS at a seven-year follow-up. Additionally, MVD patients had a significantly higher rate of complete pain relief and a significantly lower rate of complications and recurrence.

CONCLUSIONS

With a decision-analytic model, we calculated that MVD provides more favorable outcomes than SRS for the treatment of trigeminal neuralgia.

Long-Term Quality of Life in Adult Patients with Strabismus after Corrective Surgery Compared to the General Population

PURPOSE

To evaluate the status of and factors associated with long-term health-related quality of life (HRQOL) in adult patients with strabismus following corrective surgery.

METHODS

Prospective cross-sectional study. A total of 122 adults who underwent corrective surgery and were followed up for at least 1 year were recruited. Pre- and post-operative HRQOL were evaluated using the Chinese version of the Adult Strabismus 20 (AS-20). Demographics and clinical characteristics were recorded. Eighty-nine age-matched, normal individuals without a history of strabismus were recruited as a control group.

RESULTS

AS-20 scores improved significantly in the psychosocial subscale and total scale after surgery for all122 patients, but not in the function subscale. HRQOL was better in the successful cases than in the non-successful cases (p<0.005). Subjects who recovered stereo function had better HRQOL than those who did not (p<0.01). Compared to the control population, the patients had poorer HRQOL post-operatively, with only approximately 30% of the subjects having scores within the normal threshold scores. The self-sense of a lack of ocular deviation and a successful surgical outcome were significant factors associated with post-operative HRQOL status.

CONCLUSIONS

HRQOL, as evaluated by AS-20 scores, improved in the patients after surgery but was worse than that in the general population. Successful surgical outcomes and a sense of good alignment were the main factors that correlated with increased post-operative HRQOL. Positive assessments of surgical results by patients may benefit post-operative HRQOL.

Gain beyond cosmesis: demonstration of psychosocial and functional gains following successful strabismus surgery using the adult strabismus questionnaire adult strabismus 20

Background:

Strabismus adversely affects psychosocial and functional aspects; while its correction impacts positively.

Aim:

The aim was to evaluate the gains in scores: Overall scores (OASs), psychosocial subscale scores (PSSs) and functional subscale scores (FSSs) following successful surgical alignment.

Settings and Design:

We evaluated changed scores in the adult strabismus 20 (AS-20) questionnaire, administered before and after successful surgery.

Materials and Methods:

Thirty adults horizontal strabismics, were administered the AS-20, at baseline, and at 6-week and 3-month. Group-wise analysis was carried out based on gender, strabismus type (esotropia [ET] or exotropia [XT]), back-ground and amblyopia.

Statistical Analysis:

We used Wilcoxon, and Mann-Whitney U-tests. Significance was set at P ≤ 0.05.

Results:

At baseline, there were no significant differences within the groups, except that those with amblyopia significantly scored less than nonamblyopes in OAS (median scores: 53.8 vs. 71.3; P = 0.009) and FSS (56.3 vs. 85.3; P = 0.009). OAS, PSS and FSS showed significant gains at 6-week and 3-month (all Wilcoxon P < 0.001). Compared with males, females showed significantly more gain at 3-month (OAS: 37.9 vs. 28.7; P = 0.02), on account of PSS gain (49.6 vs. 37.5; P = 0.01). The ET performed better than XT only on the FSS at 6-week (28.7 vs. 15.0; P = 0.02). Vis-à-vis the nonamblyopes, the amblyopes showed significantly more benefit at 6-week alone (OAS: 18.7 vs. 28.7; P = 0.04), largely due to gains in PSS.

Conclusions:

Successful strabismus surgery has demonstrated significant gains in psychosocial, functional and overall functions. There is some evidence that gains may be more in females; with a trend to better outcomes in ET and amblyopes up to 6-week.

Strabismus in Adults Older Than 60 Years

PURPOSE

To describe the epidemiology of adult strabismus, its etiology, and treatment methods in patients 60 years and older presenting to a tertiary care center.

METHODS

This retrospective chart review study of patients with strabismus was performed at the Ratner Eye Center, University of California-San Diego. Data collected included demographics, etiology of misalignment, alignment in the primary position, binocularity, previous surgical intervention, and treatment methods.

RESULTS

A total of 291 patients were included. The majority of patients (87.9%) had an acquired underlying etiology of misalignment (neurological, non-neurological, thyroid eye disease, or myotoxic). The most common presenting complaint was diplopia (77%). A total of 38.8% of patients had previous strabismus surgery. Surgical interventions were pursued in 32% of patients.

CONCLUSIONS

This article provides insight into the epidemiology of strabismus in patients older than 60 years. The characterization and greater understanding of strabismus in this age group can be used to enhance prevention, diagnosis, and treatment of these patients. [J Pediatr Ophthalmol Strabismus. 2016;53(6):365-368.].

Does strabismus surgery improve quality and mood, and what factors influence this?

AimsTo establish the impact of adult strabismus surgery on clinical and psychosocial well-being and determine who experiences the greatest benefit from surgery and how one could intervene to improve quality of life post-surgery.MethodsA longitudinal study, with measurements taken pre-surgery and at 3 and 6 months post-surgery. All participants completed the AS-20 a disease specific quality of life scale, along with measures of mood, strabismus and appearance-related beliefs and cognitions and perceived social support. Participants also underwent a full orthoptic assessment at their preoperative visit and again 3 months postoperatively. Clinical outcomes of surgery were classified as success, partial success or failure, using the largest angle of deviation, diplopia and requirement for further therapy.Results210 participants took part in the study. Strabismus surgery led to statistically significant improvements in psychosocial and functional quality of life. Those whose surgery was deemed a partial success did however experience a deterioration in quality of life. A combination of clinical variables, high expectations, and negative beliefs about the illness and appearance pre-surgery were significant predictors of change in quality of life from pre- to post-surgery.ConclusionsStrabismus surgery leads to significant improvements in quality of life up to 6 months postoperatively. There are however a group of patients who do not experience these benefits. A series of clinical and psychosocial factors have now been identified, which will enable clinicians to identify patients who may be vulnerable to poorer outcomes post-surgery and allow for the development of interventions to improve quality of life after surgery.

Incorporating Health-related Quality of Life Into the Assessment of Outcome Following Strabismus Surgery

PURPOSE

To evaluate changes in health-related quality of life (HRQOL) in adult strabismus patients classified as surgical failures by standard motor and diplopia criteria.

DESIGN

Prospective cohort study evaluating outcomes.

METHODS

Adults undergoing strabismus surgery in a single clinical practice, with preoperative and 1-year-postoperative Adult Strabismus-20 HRQOL questionnaires, were included. Motor and diplopia criteria were applied to classify outcomes (success, partial success, or failure). For those classified as failure, the medical record of the 1-year examination was reviewed to determine whether the patient reported subjective improvement. We evaluated improvement in HRQOL, defined as exceeding 95% limits of agreement on at least 1 of the 4 Adult Strabismus-20 domains. We compared proportions exceeding 95% limits of agreement in those reporting subjective improvement vs those who did not.

RESULTS

Forty of 227 patients (18%) were classified as failure by motor and diplopia criteria, with 39 of 40 able to exceed Adult Strabismus-20 95% limits of agreement. Overall, 21 of 39 (54%) showed improved HRQOL by exceeding 95% limits of agreement on at least 1 of the 4 Adult Strabismus-20 domains (54% vs predicted 10% by chance alone; P < .0001). Twenty-five patients (64%) reported subjective improvement, of whom 16 (64%) showed improved HRQOL exceeding 95% limits of agreement.

CONCLUSIONS

Many apparent surgical failures report subjective improvement, often reflected in improved HRQOL scores. We propose incorporating quantitative HRQOL criteria into the assessment of strabismus surgery outcomes, defining success as either meeting motor and diplopia criteria or showing improvement in HRQOL beyond test-retest variability.

Lookup Tables Versus Stacked Rasch Analysis in Comparing Pre- and Postintervention Adult Strabismus-20 Data

Purpose

We compare two methods of analysis for Rasch scoring pre- to postintervention data: Rasch lookup table versus de novo stacked Rasch analysis using the Adult Strabismus-20 (AS-20).

Methods

One hundred forty-seven subjects completed the AS-20 questionnaire prior to surgery and 6 weeks postoperatively. Subjects were classified 6 weeks postoperatively as “success,” “partial success,” or “failure” based on angle and diplopia status. Postoperative change in AS-20 scores was compared for all four AS-20 domains (self-perception, interactions, reading function, and general function) overall and by success status using two methods: (1) applying historical Rasch threshold measures from lookup tables and (2) performing a stacked de novo Rasch analysis. Change was assessed by analyzing effect size, improvement exceeding 95% limits of agreement (LOA), and score distributions.

Results

Effect sizes were similar for all AS-20 domains whether obtained from lookup tables or stacked analysis. Similar proportions exceeded 95% LOAs using lookup tables versus stacked analysis. Improvement in median score was observed for all AS-20 domains using lookup tables and stacked analysis (P < 0.0001 for all comparisons).

Conclusions

The Rasch-scored AS-20 is a responsive and valid instrument designed to measure strabismus-specific health-related quality of life. When analyzing pre- to postoperative change in AS-20 scores, Rasch lookup tables and de novo stacked Rasch analysis yield essentially the same results.

Translational Relevance

We describe a practical application of lookup tables, allowing the clinician or researcher to score the Rasch-calibrated AS-20 questionnaire without specialized software.

Evaluation and validity of the Danish version of the Adult Strabismus Questionnaire AS-20

Purpose

Assessing health-related quality of life in patients with strabismus is important in evaluating the clinical benefits of strabismus treatment. The purpose of this study was to translate the Adult Strabismus Quality of Life Questionnaire (AS-20) into Danish and evaluate its reliability and validity in adult patients with strabismus in Denmark.

Methods

The AS-20 was translated into Danish in accordance with standard international adopted methods. We presented the questionnaire to 64 adults with strabismus and to 13 non-strabismic adult controls. We tested the reliability of the Danish version by reassuring test–retest reliability, estimated the internal consistency, and analyzed the validity (discriminatory power) of the questionnaire by comparing patient scores with scores from control individuals.

Results

The Danish AS-20 produced high level of internal consistency (Cronbach’s α values) for both subscales (psychosocial: 0.95 and functional: 0.85). We found good discriminatory power of the AS-20. The patients scored significantly lower not only on AS-20 composite score (median =63, interquartile range [IQR] =44–79) compared to healthy individuals (median =98, IQR =93–100) (P<0.0001) but also on all individual questions in both subscales (psychosocial: 1–10 and functional: 11–20).

Conclusion

The Danish version of AS-20 shows high reliability and validity, and in our opinion, AS-20 is therefore a suitable instrument for evaluating self-perceived psychosocial and functional influence of strabismus.

Measuring Health-Related Quality of Life in Strabismus: A Modification of the Adult Strabismus-20 (AS-20) Questionnaire Using Rasch Analysis

Purpose

To evaluate the psychometric properties of the Adult Strabismus-20 (AS-20)- a health-related quality of life (HRQoL) questionnaire in adults with strabismus, and if flawed, to revise the AS-20 and its subscales creating valid measurement scales.

Methods

584 adults (meanage, 27.5 years) with strabismus were recruited from an outpatient clinic at a South Indian tertiary eye care centre and were administered the AS-20 questionnaire.The AS-20 was translated and back translated into two Indian languages. The AS-20 and its two 10-item subscales – ‘psychosocial’ and ‘function’were assessed separately for fit to the Rasch model, including an assessment of the rating scale, unidimensionality (by principal components analysis), measurement precision by person separation reliability, PSR, targeting, and differential item functioning (DIF; notable > 1.0 logits).

Results

Response categories were not used as intended, thereby, required re-organization and reducing their number from 5 to 3. The AS-20 had adequate measurement precision (PSR = 0.87) but lacked unidimensionality; however, deletion of the six multi-dimensionality causing items and an additional three misfitting items resulted in 11-item unidimensional questionnaire (AS-11). Two items failed to satisfy the model expectations in the ‘psychosocial’ subscale and were deleted – resulting in an 8-item unidimensional scale with adequate PSR (0.81) and targeting (0.23 logits). One item misfit in the ‘function’ subscale and was deleted—resulting in a 9 item Rasch-revised unidimensional subscale with acceptable PSR (0.80) and targeting (0.97 logits).None of the items displayed notable DIF by age, gender and level of education.

Conclusions

The AS-11 and its two Rasch-revised subscales – 8-item psychosocial and 9-item function subscale may be more appropriate than the original AS-20 and its two 10-item subscales for use as unidimensional measures of HRQoL in adults with strabismus in India. Further work is required to establish the validity of the revised rating scale.

Comparison of the Adult Strabismus Quality of Life Questionnaire (AS-20) with the Amblyopia and Strabismus Questionnaire (ASQE) among adults with strabismus who seek medical care in China

BACKGROUND

The impact of strabismus on visual function, self-image, self-esteem, and social interactions might decrease health-related quality of life (HRQoL). This study aimed to evaluate the psychometric properties and clinical applications of two strabismus-specific HRQoL questionnaires in the cultural context of China.

METHODS

The Chinese versions of the Adult Strabismus Quality of Life Questionnaire (AS-20) and the Amblyopia and Strabismus Questionnaire (ASQE) were self-administered to 304 adults with strabismus. The Cronbach's α coefficient was calculated to assess the internal consistency reliability. The criterion-related validity was identified by exploring Spearman's correlation with the most widely used vision-specific quality of life questionnaire NEI-VFQ-25. One-way ANOVA was employed to examine the differences in the quality of life of strabismus patients with visually normal adults and with other eye diseases patients.

RESULTS

Significantly positive correlations with NEI-VFQ-25 were shown in both scales (r = 0.21 - 0.44, p <0.05, p <0.01). Both scales could distinguish individuals with strabismus from visually normal adults (p <0.001) and adults with other eye diseases (p <0.001). The overall Cronbach's α value were 0.91 for the AS-20 and 0.89 for the ASQE; and for the subscales, the α value ranged from 0.68 to 0.90.

CONCLUSION

This was the first cross-sectional study to compare the psychometric properties of two strabismus-targeted questionnaires, AS-20 and ASQE in the context of Chinese culture. Both AS-20 and ASQE showed satisfactory and comparable properties for measuring HRQoL in strabismus patients.

Impact of strabismus surgery on health-related quality of life in adults

PURPOSE OF REVIEW

Adult strabismus can cause many symptoms, which have generally been divided into functional complaints and social complaints. The validity of surgical correction has historically been based on the restoration of functional improvement. In the absence of this expectation, surgery was labeled cosmetic. Yet, many studies have revealed the immense impact of ocular misalignment on psychosocial variables. The purpose of this article is to review the potential functional and psychosocial benefits of strabismus surgery and to summarize the development and status of questionnaires to help quantify these benefits.

RECENT FINDINGS

Functional benefits of strabismus surgery have been recently summarized with a meta-analysis. Several questionnaires have been evaluated to assess the functional and psychosocial factors in adult strabismus. Two strabismus-specific questionnaires, the Amblyopia and Strabismus Questionnaire and the Adult Strabismus-20, reveal improvements in adults following surgery. The appropriate patient population, impact of comorbidities on the scores, and the timing of the administration of the questionnaire postoperatively still need to be determined.

SUMMARY

Future studies of the impact of strabismus surgery in adults will need to report not only objective motor results, but also the impact on health-related quality of life to encompass all the benefits of strabismus surgery.

Successful treatment of diplopia with prism improves health-related quality of life

PURPOSE

To report change in strabismus-specific health-related quality of life (HRQOL) following treatment with prism.

DESIGN

Retrospective cross-sectional study.

METHODS

Thirty-four patients with diplopia (median age 63, range 14-84 years) completed the Adult Strabismus-20 questionnaire (100-0, best to worst HRQOL) and a diplopia questionnaire in a clinical practice before prism and in prism correction. Before prism, diplopia was "sometimes" or worse for reading and/or straight-ahead distance. Prism treatment success was defined as diplopia rated "never" or "rarely" on the diplopia questionnaire for reading and straight-ahead distance. Failure was defined as worsening or no change in diplopia. For both successes and failures, mean Adult Strabismus-20 scores were compared before prism and in prism correction. Each of the 4 Adult Strabismus-20 domains (self-perception, interactions, reading function, and general function) was analyzed separately.

RESULTS

Twenty-three of 34 (68%) were successes and 11 (32%) were failures. For successes, reading function improved from 57 ± 27 (SD) before prism to 69 ± 27 in-prism correction (difference 12 ± 20, 95% CI 3.2-20.8, P = .02) and general function improved from 66 ± 25 to 80 ± 18 (difference 14 ± 22, 95% CI 5.0-23.6, P = .003). Self-perception and interaction domains remained unchanged (P > .2). For failures there was no significant change in Adult Strabismus-20 score on any domain (P > .4).

CONCLUSIONS

Successful correction of diplopia with prism is associated with improvement in strabismus-specific HRQOL, specifically reading function and general function.

Improvement in specific function-related quality-of-life concerns after strabismus surgery in nondiplopic adults

BACKGROUND

We have previously reported improvement in psychosocial scores after strabismus surgery on the patient-derived health-related quality of life (HRQOL) Adult Strabismus 20 (AS-20) questionnaire in adults with nondiplopic strabismus. Unexpectedly, we also found improvement in the function domain. The aim of the present study was to identify which specific aspects of function-related quality of life improved postoperatively.

METHODS

We retrospectively identified non diplopic adult patients with a history of childhood onset strabismus who underwent surgery and who had preoperative and 1-year postoperative AS-20 questionnaires (scored from 0 [worst] to 100 [best]). Change in scores for each item was evaluated using signed-rank tests.

RESULTS

A total of 20 patients were included. Of the 10 function-related AS-20 items, 9 showed significant mean improvement postoperatively (improvement ranged from 12.5 to 32.5 points, all P < 0.05). Rasch-derived mean scores improved in both reading function and general function domains (71.0 to 86.5 and 66.4 to 87.5, respectively; both P < 0.0001). Specific areas of function-related benefit were concentration, depth perception, hobbies, strain, reading, stress, and worry.

CONCLUSIONS

We found specific function-related quality of life benefits after strabismus surgery in nondiplopic adult patients, particularly those with childhood onset strabismus.

Comparative effectiveness of treatment options for pediatric craniopharyngiomas

OBJECT

No clear treatment guidelines for pediatric craniopharyngiomas exist. The authors developed a decision analytical model to evaluate outcomes of 4 surgical approaches for craniopharyngiomas in children, including attempted gross-total resection (GTR), planned subtotal removal plus radiotherapy, biopsy plus radiotherapy, and endoscopic resections of all kinds.

METHODS

Pooled data, including the authors' own experience, were used to create evidence tables, from which incidence, relative risks, and summary outcomes in quality-adjusted life years (QALYs) were calculated for the 4 management strategies.

RESULTS

Quality-adjusted life years at the 5-year follow-up were 2.3 ± 0.1 for attempted GTR, 2.9 ± 0.2 for planned subtotal removal plus radiotherapy, 3.9 ± 0.2 for biopsy plus radiotherapy, and 3.7 ± 0.2 for endoscopic resection (F = 17,150, p < 0.001). Similarly, QALYs at 10-year follow-up were 4.5 ± 0.2 for attempted GTR, 5.7 ± 0.5 for planned subtotal removal plus radiotherapy, and 7.8 ± 0.5 for biopsy plus radiotherapy (F = 6,173, p < 0.001). On post hoc pairwise comparisons, the differences between all pairs compared were also highly significant (p < 0.001). Since follow-up data at 10 years are lacking for endoscopic cases, this category was excluded from 10-year comparisons.

CONCLUSIONS

Biopsy with subsequent radiotherapy is the preferred approach with respect to improved overall quality of life. While endoscopic approaches also show promise in preserving quality of life at five-year follow-up, there are not sufficient data to draw conclusions about this comparison at 10 years.

The impact of strabismus on quality of life in adults with and without diplopia: a systematic review

Strabismus affects approximately 4% of the adult population and can cause substantial physical disturbance and changes to appearance. This article aims to examine the impact of strabismus in adults both with and without diplopia, focusing primarily on quality of life (QoL). We highlight the value of measuring QoL, assess the ways in which it can be measured, and the impact the disease, diplopia, and surgery have on the patient. QoL differs for strabismus patients based on their diplopia status. Patients with diplopia tend to have more concerns relating to functional QoL, whereas patients without diplopia have primarily psychosocial concerns. Two diplopia-specific questionnaires have been designed to assess QoL and the perceived severity of symptoms. Further research is needed to identify the variables which influence QoL so that appropriate support can be given to all patients with strabismus to improve their QoL.