The psychosocial impact of living with an ocular prosthesis

Global, psychological, and visual quality of life after evisceration/enucleation surgery (QOLAE study): A descriptive case series

PURPOSE

To describe the early health-related quality of life (HRQoL) of patients who have undergone an eye removal surgery.

METHODS

A descriptive monocentric study was conducted. Patients with a surgical indication of eye amputation were enrolled. Three standardized surveys were given to each patient 1-3 months after the surgery. The following standardized questionnaires were used: National Eye Institute Visual Function Questionnaire 25 (NEI VFQ-25) (range: 0-100), Short Form-36 (SF-36) (range: 0-100), and Perceived Stress Scale (PSS-10) (range: 0-40).

RESULTS

Between January 2021 and January 2022, in the Ophthalmology Department of the University Hospital of Besançon (France), 20 patients who were going to undergo an eye removal surgery were included. The population comprised a majority of men (12 men vs. 8 women) with a mean age of 70 (±16.2) years. The underlying conditions leading to the eye amputation were varied: three infections (15%), three retinal detachments (15%), three chronic uveitis (15%), 11 traumas (55%), three tumors (15%), and five chronic high intraocular pressures (25%). The surgical procedure consisted of an evisceration in 15 cases (75%) or an enucleation in five cases (25%). On average, the composite NEI VFQ-25 scored 68.7 (±22.4). Regarding the SF-36 score, the physical composite score was 63.1 (±15.4), and the mental composite score was 64.7 (±14.4). The overall PSS-10 score was 12.3 (±8.7).

CONCLUSION

The patients who had undergone an eye amputation had an early reduction in their HRQoL in all its domains, especially in the vision, mental, and physical specific quality of life. These patients need personalized preparation before the surgery. These findings need to be assessed in the long term.

A cross-over, randomised feasibility study of digitally-printed versus hand-painted artificial eyes in adults: PERSONAL-EYE-S

BACKGROUND/OBJECTIVES

Over 60,000 patients in the United Kingdom are estimated to have artificial eyes. Manufacturing and hand-painting of artificial eyes have not changed significantly since 1948. Delays and colour-matching issues may severely impact a patient's rehabilitation pathway. Technology advances mean alternatives are now possible. This cross-over, randomised feasibility trial aimed to determine the feasibility of conducting a full-scale trial of the effectiveness and cost-effectiveness of digitally-printed artificial eyes compared to hand-painted.

SUBJECTS/METHODS

Patients aged ≥18 years who were longstanding artificial eye users requiring a replacement were randomised to receive either a hand-painted or digitally-printed eye first followed by the other type of eye. Participants were asked to approach a close contact (CC) willing to participate alongside them. A subset of participants, their CCs, and staff were interviewed about their opinions on trial procedures, artificial eyes, delivery times and satisfaction.

RESULTS

Thirty-five participants were randomised and 10 CCs consented. Participant retention at final follow-up was 85.7%. Outcome data completion rates ranged from 91-100%. EQ-5D-5L completion ranged from 83-97%. Resource-use completion ranged from 0-94% with total costs at £347 for hand-painted and £404 for digitally-printed eye. There were two adverse events. Twelve participants, five CCs, and five staff were interviewed. There were positive and negative features of both types of eyes. We identified that social and psychological wellbeing is affected, often for many years after eye removal. Participation in the feasibility study was well accepted.

CONCLUSIONS

The feasibility study outcomes indicate that a full trial is achievable.

TRIAL REGISTRATION NUMBER

ISRCTN85921622.

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.

Vascularized Composite Allograft Versus Prosthetic for Reconstruction After Facial and Hand Trauma: Comparing Cost, Complications, and Long-term Outcome

ABSTRACT

In the past decade, vascularized composite allotransplantation (VCA) has become clinical reality for reconstruction after face and hand trauma. It offers patients the unique opportunity to regain form and function in a way that had only been achieved with traditional reconstruction or with the use of prostheses. On the other hand, prostheses for facial and hand reconstruction have continued to evolve over the years and, in many cases, represent the primary option for patients after hand and face trauma. We compared the cost, associated complications, and long-term outcomes of VCA with prostheses for reconstruction of the face and hand/upper extremity. Ultimately, VCA and prostheses represent 2 different reconstructive options with distinct benefit profiles and associated limitations and should ideally not be perceived as competing choices. Our work adds a valuable component to the general framework guiding the decision to offer VCA or prostheses for reconstruction after face and upper extremity trauma.

A cross-over, randomised feasibility study of digitally printed versus hand-painted artificial eyes in adults: PERSONAL-EYE-S - a study protocol

Background/objective

Around 11,500 artificial eyes are required yearly for new and existing patients. Artificial eyes have been manufactured and hand-painted at the National Artificial Eye Service (NAES) since 1948, in conjunction with approximately 30 local artificial eye services throughout the country. With the current scale of demand, services are under significant pressure. Manufacturing delays as well as necessary repainting to obtain adequate colour matching, may severely impact a patient's rehabilitation pathway to a normal home, social and work life. However, advances in technology mean alternatives are now possible. The aim of this study is to establish the feasibility of conducting a large-scale study of the effectiveness and cost-effectiveness of digitally printed artificial eyes compared to hand-painted eyes.

Methods

A cross-over, randomised feasibility study evaluating a digitally-printed artificial eye with a hand-painted eye, in patients aged ≥18 years with a current artificial eye. Participants will be identified in clinic, via ophthalmology clinic databases and two charity websites. Qualitative interviews will be conducted in the later phases of the study and focus on opinions on trial procedures, the different artificial eyes, delivery times, and patient satisfaction.

Discussion

Findings will inform the feasibility, and design, of a larger fully powered randomised controlled trial. The long-term aim is to create a more life-like artificial eye in order to improve patients' initial rehabilitation pathway, long term quality of life, and service experience. This will allow the transition of research findings into benefit to patients locally in the short term and National Health Service wide in the medium to long term.

ISRCTN registration

ISRCTN85921622 (prospectively registered on 17/06/2021).

Psychosocial distress and psychological adjustment in patients with ocular loss: a framework analysis

BACKGROUND

Patients with ocular loss tend to have physical and psychosocial difficulties. Maxillofacial prosthetic specialists involved in the treatment should be trained with competence to manage psychological complications. However, due to the multifactorial origin of the psychosocial distress, designing such training activities can be challenging. This research aimed to construct a conceptual framework illustrating the effects of ocular loss on patients' physical and psychosocial well-being and their coping strategies, to propose the learning content of training sessions.

METHODS

A semi-structured interview and a topic guide were employed to explore the perceptions from patients who were receiving their first custom ocular prosthesis, fabricated by maxillofacial prosthodontists. The participants were selected using a purposeful sampling up until data saturation. The data were analyzed using framework analysis.

RESULTS

Twelve patients participated in this research. Four main themes emerged from the data analysis: (1) Impact of ocular loss, (2) Factors influencing psychosocial distress, (3) Psychological adjustment, and (4) Expected treatment outcomes. Each theme appeared to have influence on the other, rather than presenting itself independently. Although patients with ocular loss experienced both physical and psychosocial difficulties, psychological distress was greatly influenced by self-perceived disfigurement, etiology, and social status. Therefore, they needed to develop their coping strategies including rehabilitation with ocular prosthesis.

CONCLUSION

Various forms of psychological adjustments were necessary in these patients with ocular loss to resume their daily lives. The specialist involved in the treatment should also partake in patients' psychological adjustment and should be competent in psychological management skills, such as supporting patients to meet their expectations.

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.

Motility of the Ocular Prosthesis in Anophthalmic Patients: Objective and Patient-perceived Findings

AIM

To study the impact of the prosthesis motility on the Quality of Life (QoL) in anophthalmic patients.

METHODS

Cross-sectional, observational study of 100 anophthalmic patients, of whom 64% had an acryl implant, 6% an Allen implant, 1% a hydroxyapatite implant, 4% a dermis fat graft, 16% no implant, and 9% an unknown implant. We quantitatively assessed the motility of the prosthesis with Kestenbaum glasses and the QoL with a validated questionnaire covering five domains: General functional abilities and care, wearing comfort, physical appearance, psychological and social functioning. Associations between measured prosthetic eye motility, patient-perceived motility, and satisfaction were made.

RESULTS

Motility of the prosthesis was impaired with an average loss of 76%, and correlated with Cosmetic satisfaction (adduction P = .02, abduction P = .008, elevation P = .04) and Social satisfaction (adduction P = .03, abduction P = .003). The patient-perceived motility of the prosthesis correlated with General functioning abilities (horizontal P = .0004, vertical P = .0004), Comfort (horizontal P = .001, vertical P = .003), Cosmetic satisfaction (horizontal P = .0002, vertical P = .0002), Psychological satisfaction (horizontal P = .001, vertical P = .001), and Social satisfaction (horizontal P = .002, vertical P = .003).

CONCLUSIONS

Ocular prosthetic motility has a significant impact on patient-perceived satisfaction and physical appearance, and predicts coping with the prosthetic condition on the psychosocial level. This highlights the need of introducing patient-reported outcome measures in the prosthetic rehabilitation of the anophthalmic patient.

Psychological aspects of living with an artificial eye

PURPOSE

Artificial eye clinics address physical and aesthetic aspects of orbital prostheses, but psychological effects may not be formally addressed. In general, without effective coping mechanisms, stress can lead to anxiety and depression. This study aims to determine, in the context of having an artificial eye, whether coping strategies, as well as perception of illness and other demographic and clinical variables are associated with anxiety or depression.

METHODS

Consecutive patients attending two artificial eye clinics were invited to participate in this audit. Participants completed questionnaires: HADS, Brief IPQ and Brief COPE. Variables with a correlation coefficient of ≥0.2 with anxiety or depression were included in regression modeling. The extent to which the participants' emotional and cognitive representations of their artificial eye related to feelings of anxiety and depression was determined.

RESULTS

In the cohort of 208, clinically significant anxiety was present in 29.5% and clinically significant depression was present in 8.4%. Perceptions of the impact of the artificial eye and self-blame as a coping strategy were correlated with anxiety. Depression levels were higher when participants believed that their artificial eye had a greater impact on their life, when they lived alone, and when they used substances as a coping strategy.

CONCLUSION

Significant levels of anxiety exist in those living with artificial eyes, with various coping strategies used. Addressing this and offering alternative coping strategies may improve patient well being and overall satisfaction.

The UK National Artificial Eye Questionnaire Study: predictors of artificial eye wearers' experience Part 2 - visual function and quality of life

OBJECTIVES

To report associations with visual function and quality of life (QOL) in artificial eye wearers.

METHODS

Multicentre, observational, cross-sectional, nationwide study, within the National Health Service England. Items were adopted from the National Eye Institute Visual Function Questionnaire, and incorporated in the National Artificial Eye Questionnaire (NAEQ). The NAEQ was completed by 951 respondents. Multiple regressions assessed associations between the QOL scores and the experiences of artificial eye wearers, their routine management, changes over time, baseline and demographic parameters.

RESULTS

Parameters predictive of a better QOL composite score included longer artificial eye wear (β = 0.18, p < 0.001), better appearance (β = 0.17, p < 0.001), better comfort (β = 0.14, p = 0.001), tumour-related anophthalmia (β = 0.13, p = 0.003), male gender (β = 0.13, p < 0.001), shorter period of adjustment to monocular vision (β = 0.12, p < 0.001) and use of soap for cleaning (β = 0.09, p = 0.046). The composite score continued to improve beyond 10 years of prosthesis wear (≤2 years mean 72.80 ± 1.65 versus >10 years mean 79.45 ± 0.70; p = 0.001). Both better prosthesis appearance (β = 0.14, p = 0.022) and improved motility (β = 0.13, p = 0.042) predicted a better dependency score. Use of lubricating ointment predicted a worse dependency score (β = 0.23, p = 0.003). Neither the frequency of removal, nor the cleaning frequency of the artificial eye correlated with QOL scales.

CONCLUSIONS

Multiple factors in the artificial eye experience were found to predict visual function and QOL aspects. This study underscores the need to generate a dedicated QOL questionnaire for use in anophthalmic patients.

Detecting Critical Functional Ingredients Group and Mechanism of Xuebijing Injection in Treating Sepsis

Sepsis is a systemic inflammatory reaction caused by various infectious or noninfectious factors, which can lead to shock, multiple organ dysfunction syndrome, and death. It is one of the common complications and a main cause of death in critically ill patients. At present, the treatments of sepsis are mainly focused on the controlling of inflammatory response and reduction of various organ function damage, including anti-infection, hormones, mechanical ventilation, nutritional support, and traditional Chinese medicine (TCM). Among them, Xuebijing injection (XBJI) is an important derivative of TCM, which is widely used in clinical research. However, the molecular mechanism of XBJI on sepsis is still not clear. The mechanism of treatment of "bacteria, poison and inflammation" and the effects of multi-ingredient, multi-target, and multi-pathway have still not been clarified. For solving this issue, we designed a new systems pharmacology strategy which combines target genes of XBJI and the pathogenetic genes of sepsis to construct functional response space (FRS). The key response proteins in the FRS were determined by using a novel node importance calculation method and were condensed by a dynamic programming strategy to conduct the critical functional ingredients group (CFIG). The results showed that enriched pathways of key response proteins selected from FRS could cover 95.83% of the enriched pathways of reference targets, which were defined as the intersections of ingredient targets and pathogenetic genes. The targets of the optimized CFIG with 60 ingredients could be enriched into 182 pathways which covered 81.58% of 152 pathways of 1,606 pathogenetic genes. The prediction of CFIG targets showed that the CFIG of XBJI could affect sepsis synergistically through genes such as TAK1, TNF-α, IL-1β, and MEK1 in the pathways of MAPK, NF-κB, PI3K-AKT, Toll-like receptor, and tumor necrosis factor signaling. Finally, the effects of apigenin, baicalein, and luteolin were evaluated by in vitro experiments and were proved to be effective in reducing the production of intracellular reactive oxygen species in lipopolysaccharide-stimulated RAW264.7 cells, significantly. These results indicate that the novel integrative model can promote reliability and accuracy on depicting the CFIGs in XBJI and figure out a methodological coordinate for simplicity, mechanism analysis, and secondary development of formulas in TCM.

The Ruptured Globe, Sympathetic Ophthalmia, and the 14-Day Rule

PURPOSE

Prophylactic enucleation of a ruptured globe with no light perception within 14 days of injury to prevent sympathetic ophthalmia (SO) has been an established dictum in academic teaching for more than 100 years. This treatment strategy was originally based on observation, speculation, and careful thought, but there was never any scientific proof. This review summarizes and updates the current state of our knowledge about globe rupture and SO, examines the origin and validity of the 14-day rule, and emphasizes the importance of trying to save the traumatized eye whenever possible.

METHODS

A comprehensive literature review of SO and globe rupture was performed.

RESULTS

SO is a rare disorder that may potentially occur following traumatic globe rupture as well as following a variety of other intraocular surgeries. Vitreoretinal surgery may be a more common cause than trauma according to some studies. SO may still occur despite having the eye removed within 14 days of the trauma. A variety of new medications including biologic agents are now available to treat SO with improved efficacy in suppressing the associated ocular inflammation and allowing retention of some useful vision. Removing the traumatized, blind eye may have other important psychological consequences associated with it that require consideration before eye removal is carried out. Retaining the blind, phthisical, disfigured eye avoids phantom vision and phantom pain associated with enucleation as well as providing a good platform to support and move an overlying prosthetic eye. Data on the occurrence of SO following evisceration and enucleation with and without predisposing factors confirms the exceedingly low risk.

CONCLUSION

Most civilian open globe injuries can be successfully repaired with modern, advanced microsurgical techniques currently available. Because of the exceedingly low risk of SO, even with the severity of open globe trauma during military conflicts being more devastating as a result of the blast and explosive injuries, today every attempt is made to primarily close the eye rather than primarily enucleate it, providing there is enough viable tissue to repair. The 14-day rule for eye removal after severe globe ruptures is not scientifically supported and does not always protect against SO, but the safe time period for prophylactic eye removal is not definitively known. In the exceptional cases where SO does occur, several new medications are now available that may help treat SO. We advocate saving the ruptured globe whenever possible and avoiding prophylactic enucleation to prevent the rare occurrence of SO. When an eye requires removal, evisceration is an acceptable alternative to enucleation in cases that do not harbor intraocular malignancy.

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.

Assessing the results of anophthalmic prostheses

Purpose

Anophthalmic sockets cause disfigurement that may result in emotional and social distress. The choice of procedure and implant is based upon the surgeon's experience. There remains no standardization of cosmetic result. We sought to identify quantifiable anatomical features and functional properties related to a successful cosmetic result in patients with ocular prosthesis and to determine correlations between self-reported and third-party assessment of cosmetic success.

Methods

This was a prospective observational study, which included 107 adult patients (50.1% female; age 53.08 ± 18.64 years, range 18-89) with acquired anophthalmia following prosthesis fitting. Patients completed a self-assessment questionnaire on self-perception of body image and ocular properties. Three independent examiners assessed cosmetic score. Assessed variables included prosthesis movement, eyelid symmetry, prosthesis stability, and socket fullness.

Results

The general cosmetic result was 8.1 ± 2.19 (on a predetermined scale of 1-10) as perceived by the patients and 7.2 ± 0.19 by the examiners. Interexaminer correlation was high for all variables (P < 0.05). A good cosmetic result was correlated with prosthesis movement (P = 0.02), eyelid symmetry (P = 0.001), and prosthesis stability (P = 0.01). Factors that correlated with a good cosmetic result on multivariate analysis were prosthesis movement (odds ratio [OR] 4.95, P = 0.004), eyelid symmetry (OR 4.51, P = 0.006), and socket fullness (OR 3.56, P = 0.005). No correlation was observed between patients' perceptions of the overall cosmetic result and those of the examiners.

Conclusion

The cosmetic result of prosthesis use among anophthalmic patients is generally good, as perceived by both patients and examiners. Good eyelid position and symmetry, orbital fullness, and prosthesis motility were associated with a better cosmetic result.

Digital photographic technique for the production of an artificial eye

The use of hand painting an iris button using oil paint remains the conventional method of artificial eye manufacturing. The authors found that replacing this technique with a digital photograph taken of a patient's unaffected eye offers several advantages over the conventional method but the process from capture to print must be standardised and colour accurate. The authors of this paper suggest a tried and tested formulated photographic process of capture and printing prior to polymerisation. It discusses issues that can arise and how these can be overcome in order to achieve a high-quality print that can be used to produce a 'life like' ocular prosthesis.

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.

The UK National Artificial Eye Questionnaire Study: comparisons between cosmetic shell and artificial eye users. Part 2: maintenance, management and quality of life

AIMS

To compare the unique experiences related to artificial eye (AE) versus cosmetic shell (CS) wear.

METHODS

In this observational, cross-sectional study, the National Artificial Eye Questionnaire was employed nationwide within the National Health Service England. This second part of the study assesses daily management and care experiences, as well as visual function and quality of life aspects.

RESULTS

Overall, 951 respondents wore an AE, while 238 wore a CS. Both AE and CS respondents rated a relatively high score for a beneficial effect of prosthesis polishing, with an average score of 80.08±0.87 versus 77.17±1.73 (p=0.13, respectively). CS respondents removed and cleaned their prosthesis more frequently than AE respondents (p<0.0001, p=0.002, respectively). CS respondents instilled lubrication more frequently than AE respondents (p=0.022) with 33.3% versus 43.7% of AE and CS wearers, respectively, lubricating on at least a daily basis. The overall QOL composite score was similar in both AE and CS groups (approximately 77%, p=0.74). Social functioning was similar, and relatively high in both groups (approximately 86%, p=0.77).

CONCLUSIONS

This study characterises unique aspects of CSs versus AEs in a large national cohort. The results should provide reinforcement to the gain in popularity of CSs.

Anxiety and depression in patients wearing prosthetic eyes

PURPOSE

To investigate anxiety and depression levels in prosthetic eye-wearing patients using standardized psychometric instruments, to define factors associated with these psychological diseases, and to identify a potential healthcare gap.

METHODS

A total of 295 prosthetic eye wearers were screened using the 7-item generalized anxiety disorder scale (GAD-7) and the 9-item patient health questionnaire (PHQ-9). Scores of GAD-7 and PHQ-9 were correlated with scores of general physical and mental health functioning, vision-related quality of life, appearance-related distress, appearance-related social function, and further biosocial factors.

RESULTS

Five patients (2%) had a pre-diagnosed anxiety disorder, and 20 patients (7%) had a pre-diagnosed depression. However, our screening revealed 26 patients (9%) with anxiety symptoms, 31 patients (11%) with depression symptoms, and 40 patients (14%) suffering from both anxiety and depression symptoms. This underdiagnosing for both anxiety and depression disorders was significant (p < 0.001, respectively). Higher GAD-7 scores were significantly associated with higher PHQ-9 scores, lower appearance-related social function, lower mental health functioning, and female gender (p ≤ 0.021, respectively). Higher PHQ-9 scores were significantly associated with lower physical and mental health functioning, higher educational degree, and non-traumatic eye loss (p ≤ 0.038, respectively).

CONCLUSIONS

Anxiety and depression disorders seem to be underdiagnosed in prosthetic eye wearers and to have higher incidence compared with the general population. Therefore, a psychometric screening should be routinely implemented in the clinical care. For a successful long-term rehabilitation, integrated care by a multidisciplinary team including ophthalmic plastic surgeons, ophthalmologists, ocularists, general practitioners, and psychologists is essential.

Novel artificial eye service evaluation using patient reported outcome measures

BACKGROUND

This service evaluation explores patient reported outcomes from patients provided with high definition ocular prostheses (artificial eyes).

METHODS

Validated patient questionnaires (FACE-Q, DAS24 and HADS) were utilised to evaluate patient experiences of their new ocular prosthesis. 10 patients were included in the service evaluation, which was conducted between December 2018 and September 2019. Descriptive analysis of the mean and 95% CI was undertaken for all questionnaires. Statistical analysis was performed using SPSS 21 Principal Component Analysis (PCA) for FACE-Q questionnaires. Correlations were significant when factor loading is at α > 0.4.

RESULTS

A questionnaire response rate of 80% was achieved (n = 8). PCA analysis showed the number of variables tested could be reduced. Two principal components (PC1 and PC2) had very good to excellent internal consistency between variables with factor loading (α = 0.7-0.9). PC1 contained questionnaires 1-7, all of which were highly correlated. PC2 contained question number 8 with a factor loading of α = 0.8. This indicates good reliability, validity and responsiveness.

CONCLUSIONS

We hope to demonstrate the importance of service evaluations with respect to rapidly evolving technological advances in medical devices, pharmaceuticals and imaging modalities. Further feasibility and full clinical studies are required to confirm the positive results of the novel artificial eye service we have evaluated with respect to the traditional approach.

The prevalence of anophthalmic socket syndrome and its relation to patient quality of life

BACKGROUND

Following removal of the eye, soft tissue changes of the eyelids and orbit may develop into an anophthalmic socket (AS) syndrome, which is often attributed to orbital volume deficiency. While adequate primary orbital volume replacement is nowadays standard of care, patients may still present with facial asymmetry. The aim of this study is to provide insights into these changes and their impact on patient quality of life (QoL).

METHODS

Cross-sectional study of 59 patients with longstanding ocular prosthetic wear after enucleation or evisceration surgery. The alignment, function, and laxity of the eyelids of the anophthalmic side were compared to those of the fellow side. The QoL was assessed with a 4-item questionnaire specific for the prosthetic condition. The different aspects of AS syndrome were analysed in relation to disease-specific and prosthetic data and to the patient QoL scores.

RESULTS

Clinical AS syndrome was prevalent in 53% of patients with acquired anophthalmia. The anophthalmic side was statistically significantly different from the fellow side for the known AS syndrome features such as superior sulcus depression, margin reflex distance 1, and enophthalmia, but also for new features such as levator muscle function and lagophthalmia (P < 0.05). The difference was correlated with duration of prosthetic wear, prior orbital radiotherapy, and size of the prosthesis (P < 0.05). QoL scores were not correlated to the separate features of AS syndrome, except for a positive correlation between wearing comfort of the prosthesis and upper eyelid ptosis (P < 0.05).

CONCLUSION

Patients with an ocular prosthesis show a relatively high prevalence of one or more distinct clinical features of AS syndrome, which do not negatively affect patient QoL. These findings underscore the importance to tailor prosthetic and surgical treatment to the patient's perceived QoL rather than to the objective clinical findings.

Custom ocular prosthesis-related concerns: patient feedback survey-based report vis-à-vis objective clinical grading scales

Purpose: To report the outcomes of a survey on patients' concerns and satisfaction with custom ocular prosthesis (COP) wear and compare with objective clinician grading scales.Methods: The questionnaire was answered by 156 participants. General social concerns and prosthesis-related concerns were plotted on a scale of 0 to 10, indicating least to maximum satisfaction and also not concerned to very concerned. Comparison between subjective patient and objective clinician scores was done.Results: The mean age at presentation was 27.53 ± 15.53 years (range 3-72 years).For patients that underwent a prior surgical procedure, mean satisfaction with the surgery was 9.42 ± 1.27. Mean satisfaction with the COP was 8.98 ± 1.75. The median satisfaction score for the primary surgery as well as for the outcome of the custom ocular prosthesis was 10. Commonest prosthesis-related concerns were reduced motility (mean 3 ± 2, median 3), watering, crusting and discharge (mean 2 ± 2, median 2), and difference in the size of the prosthetic eye relative to the other eye (mean 1 ± 2, median 1). Subjective patient concern responses and the objective clinician grading correlated strongly for movement of the prosthesis (r = -0.84, p < .0001), periocular fullness (r = 0.65, p < .0001), color of the prosthesis (r = -0.8, p < .0001) and size relative to the other eye (r = 0.7, p < .0001).Conclusion: Custom ocular prosthesis usage had a high satisfaction score with minimal concerns. Commonest prosthesis-related concerns correlated strongly with objective clinician grading.

Psychological symptoms in anophthalmic patients wearing ocular prosthesis and related factors

Anophthalmic patients not only cause obvious functional deficits and facial deformities, but lead to poor psychological outcomes, although prosthesis wearing can offer improvements in psychological well-being to some extent. The study aimed to comprehensively evaluate the psychological symptoms and analyze related factors in anophthalmic patients wearing ocular prosthesis.Total of 150 anophthalmic patients and 120 control subjects were included in this cross-sectional study. Baseline characteristics survey and the symptom checklist-90 scale were completed by all participants to assess the psychological symptoms and analyze their related factors by multivariate analysis.The anophthalmic patients exhibited the increased levels of somatization, depression, anxiety, and hostility compared with control subjects. The most prominent symptom was hostility with the median score of 1.20. Female patients presented with higher somatization, depression, anxiety, and hostility. Marital status single was positively associated with depression, anxiety, and hostility symptoms. Lower education and cause of enucleation were related to higher levels of hostility.Anophthalmic patients wearing ocular prosthesis presented with more prominent hostility and somatization besides its higher depression and anxiety symptoms. The findings suggest that for female single anophthalmic patients with low education, especially caused by trauma, timely psychological assessment and intervention should be provided to avoid undesirable consequences.

Depression, Anxiety and Stress Indicators for Prosthetic Eye Wearers

Background

This study explores the role of appearance, mucoid discharge, visual perception and functional problems as indicators for depression, anxiety and stress amongst prosthetic eye wearers.

Methods

A total of 217 anophthalmic patients who had worn a prosthetic eye for at least two years and were older than 16 years completed an anonymous questionnaire. Descriptive and inferential statistics were used to investigate differences and correlations between variables.

Results

The mean scores for depression, anxiety, and stress fell within the accepted normal ranges; however, 11% of participants experienced moderate depression, while 7% experienced severe or extremely severe levels. Ten percent were moderately anxious, and 7% were severely or extremely severely anxious. Five percent of participants were moderately stressed, while 7% were severely or extremely severely stressed.

Conclusion

Social settings are important predictors for depression, whereas anxiety and stress appear to derive more from appearance concerns and practical issues. Prosthetic eye wearers with employment, leisure and social functioning issues are at higher risk of depression, anxiety and stress, as well as appearance, anxiety and not feeling accepted by society. Older patients and those who feel accepted by society appear to suffer less anxiety and stress. It is recommended that psychologists be a part of an integrated team to address the needs of anophthalmic patients.

Prevalence of Meibomian Gland Dysfunction and Its Effect on Quality of Life and Ocular Discomfort in Patients with Prosthetic Eyes

Purpose: To evaluate the influence of ocular discomfort and meibomian gland dysfunction (MGD) on quality of life in patients with an ocular prosthesis. Methods: a prospective analysis was conducted on 18 patients with a unilateral ocular prosthesis. Evaluation of ocular discomfort symptoms, lid margin abnormalities (LMA), meibomian gland expression, meibography and a psychometric evaluation using the National Eye Institute Visual Function Questionnaire (NEI VFQ), Facial Appearance subscale of the Negative Physical Self Scale (NPSS-F), Hospital Anxiety and Depression Scale (HADS) and the DAS24 to evaluate anxiety and depression. Results: the statistically significant differences observed between normal and prosthetic eyes related to ocular symptoms and the meibography score (p = 0.0003). A negative correlation was reported between NEI VFQ score and meibography score (r = −0.509; p-value = 0.022). A positive correlation was detected with NPSS (r = 0.75; p-value < 0.0001), anxiety HADS score (r = 0.912; p-value = 0.001) and depression HADS score (r = 0.870; p-value > 0.0001). Conclusion: MGD represents the most common cause of evaporative dry eye disease, due to the reduction of the thickness of the lipid layer of the tear film. The occurrence of MGD in patients with prosthetic eyes is very common. Anxiety and depression were correlated to ocular discomfort and MGD, and this could affect the quality of life in patients with an ocular prosthesis.

Primary replacement for the management of exposed orbital implant

Purpose: We present a series of primary orbital implant replacement for cases of implant exposure to describe our experience of this one-staged surgical approach. Methods: This study reports on a one-stage technique which involved the removal of the exposed implant or dermis fat graft (DFG) and insertion of a secondary (replacement) in the same procedure, with a variety of materials, including autologous tissue. Re-exposure in a socket where a DFG was placed was defined as a new defect in the newly epithelialized conjunctiva or dehiscence of the dermis-conjunctiva junction. All cases of primary replacement for the management of exposed orbital implant, porous and non-porous, were included, even when there were clinical signs suggestive of infection. The primary outcome was the rate of re-exposure, requiring additional surgical procedures. Infection following primary replacement was a secondary outcome. Results: Seventy-eight patients had primary replacement for the management of an exposed orbital implant. 6.4% had re-exposure at a mean follow-up of 49.7 months (9.1% for ball implants and 4.5% for DFG). The rate of exposure was higher in those with prior signs of infection than those without (8% vs. 3.6%). Re-exposure occurred in 4.5% of cases with DFG implantation, 4.3% of cases with non-porous implants and in 20% of cases with porous implants. Conclusion: Primary replacement for management of exposed orbital implant, porous and non-porous, has a high rate of successful outcome even in cases with presumed or confirmed infection.

Survey of Ocular Prosthetics Rehabilitation in the United Kingdom, Part 2: Anophthalmic Patients' Satisfaction and Acceptance

AIM

Ocular prostheses are integral for anophthalmic patients. Part 1 of this study reported that patients' aetiology, opinions, and attitudes significantly affected their prosthetic eyes experience. Part 2 investigates the patient satisfaction and acceptance in light of some of the aetiological demographics reported in Part 1.

METHODOLOGY

One hundred sixty questionnaires were delivered to anophthalmic patients attending oculoplastic clinic. Etiological aspects presented in the questionnaire were disseminated in part 1. Patient satisfaction was assessed through 8 closed-end statements reflecting aspects concerning patient's views on prosthesis comfort and appearance; patient's expectations, self-esteem, and perception; and cooperation with ocularist. Each statement had 3 categories as agree, moderately agree, and disagree. A total of 126 questionnaires were returned (response rate was 78.8%). Data was analyzed using SPSS software. Association coefficients and correlations between variables were also analyzed.

RESULTS

Total number of responses for the 8 statements was 888, averaging of 111 (expected 126) respondent per statement. Overall, 95.4% of our patients agreed with all satisfaction statements presented echoing very high satisfaction rate with their ocular prosthetics. Having an eye replacement that covers the defect is associated with high satisfaction among patients regardless of ocular prosthetic type. Patient acceptance of prosthesis in relation to employment status was high but not the same among the different categories (P > 0.05). High satisfaction with ocular prosthetics was prevalent among both genders, but there were no statistically significant differences in percentages of agreement in all statements (P > 0.05). Satisfaction and acceptance with ocular prosthetics was the same among all age groups of 12 to 85 years old (P > 0.05).

CONCLUSIONS

The patient satisfaction is associated with the interplay of different variables that is related to ocular prosthesis design and its ability to disguise disfigurement (ie, prosthesis shape, resemblance to existing contra-lateral eye, etc.); patients themselves (ie, gender, age, occupation, marital status, etc); and psychological well-being and social support provided. Anophthalmic patients of the north west of England are significantly happy with their ocular prosthetic rehabilitation and support they receive from their regional hospital. Ocular prosthetics enhances their psychological well-being and social interaction and factors like patients' sex, age, employment status, and type of ocular prosthesis have no effect on their acceptance and satisfaction.

An investigation into discharge, visual perception, and appearance concerns of prosthetic eye wearers

We investigate prosthetic eye wearers' initial and current concerns about mucoid discharge, visual perception, and appearance, and the reasons for their concerns. A retrospective, cross-sectional study of private practice patients was designed. Participants were 217 experienced prosthetic eye wearers, aged at least 16 years. An anonymous questionnaire was e-mailed or mailed to participants. Descriptive and inferential statistics were used to investigate differences or correlations between variables. Content analysis was used to analyze participants' open responses. Participants were equally concerned about discharge, visual perception, and appearance during the first three months following eye loss and at least 2 years later, even though their concerns decreased. Older participants were less concerned about appearance, while females were more concerned about current discharge and appearance. The greater the frequency and volume of discharge, the greater was the concern. Participants' initial discharge concern was due to a negative interpretation of what it meant, but later, it was due to discomfort from wiping, and how discharge looked to others. Loss of depth perception and reduced visual range were equally concerning. Initial appearance concerns related to disguisability of the prosthesis, but over time, changes to the socket and eyelids became more important. Loss of self-image is commonly considered to be the major concern of anophthalmic patients, but discharge and visual perception concerns are of equal importance. Reasons given for these concerns provide greater insight into patients' personal experience of eye loss.

Prosthetics in Facial Reconstruction

Reconstruction of the head and neck can be a challenging undertaking owing to numerous considerations for successful rehabilitation. Although head and neck defects were once considered irretrievably morbid and associated with a poor quality of life, advances in surgical technique has immensely contributed to the well-being of these patients. However, all patients are not suitable surgical candidates and many have sought nonsurgical options for functional and cosmetic restoration. As such, the advent of prostheses has ameliorated those concerns and provided a viable alternative for select patient populations. Prosthetic reconstruction has evolved significantly over the past decade. Advances in biocompatible materials and imaging adjuncts have spurred further discovery and forward progress. A multidisciplinary approach to head and neck reconstruction focused on appropriate expectations and patient-centered goals is most successfully coordinated by a team of head and neck surgeons, maxillofacial surgeons, and prosthetic specialists. The aim of this article is to provide a comprehensive review of the current trends for prosthetic rehabilitation of head and neck defects, and further elaborate on the limitations and advancements in the field.

Questionnaire study to gain an insight into the manufacturing and fitting process of artificial eyes in children: an ocularist perspective

Purpose

To gain an insight into the manufacturing and fitting of artificial eyes in children and potential improvements to the process.

Method

An online qualitative survey was distributed to 39 ocularists/prosthetists in Europe and Canada. Participants were recruited through purposive sampling, specifically maximum variation sampling from the researcher’s contacts and an online search.

Results

The findings highlighted the current impression technique as being the most difficult yet most important part of the current process for both the ocularist and child patient. Negatively affecting obtaining a good impression, the child patients distress can be reduced by their parents by providing encouragement, reassurance, practicing the insertion and removal of the artificial eye and being matter of fact. Whilst improvements to the current process provided mixed views, the incorporation of current technology was perceived as not being able to meet the requirements to produce aesthetically pleasing artificial eyes.

Conclusion

The current artificial eye process can be seen as an interaction with its success being dependent on the child patient’s acceptance and adjustment which is dependent on the factors associated to the process. Investigation into the needs of the patient and whether technology can improve the process are the next steps in its advancement.

Orbital implants: State-of-the-art review with emphasis on biomaterials and recent advances

In the treatment of severe oculo-orbital traumas, intraocular malignancies or other life-threatening conditions it is sometimes necessary to surgically remove the patient's diseased eye. Following the removal of the eye, an orbital implant is inserted into the anophthalmic socket in order to provide satisfactory volume replacement and restore the aesthetic appearance of a normal eye. Over the last decades, the implant design and the criteria of materials selection evolved from simple non-porous polymeric sphere to devices with more complex shape and functionalities for ensuring better clinical outcomes in the long-term. Polymeric and ceramic porous implants have gained prominence since their highly interconnected porous architecture allows them to act as a passive framework for fibrovascular in-growth offering reduced complication rates and the possibility of pegging to enhance the motility of the artificial eye. However, there are still drawbacks to these materials. Some critical aspects of today's orbital implants include the risk of migration and extrusion, postoperative infections and low motility transmitted to the aesthetic ocular prosthesis. Hence, the development of novel biomaterials with enhanced functionalities (e.g. angiogenesis, antibacterial effect, in situ mouldability) which enable an improved outcome of eye replacement is more than ever desirable and represents one of the most challenging topics of research in the field of ocular implants. This review summarizes the evolution of orbital implants and provides an overview of the most recent advances in the field as well as some critical remarks for materials design, selection, characterization and translation to clinical applications.

Vision-Related Quality of Life and Appearance Concerns Are Associated with Anxiety and Depression after Eye Enucleation: A Cross-Sectional Study

Aims

To investigate the association of demographic, clinical and psychosocial variables with levels of anxiety and depression in participants wearing an ocular prosthesis after eye enucleation.

Methods

This cross-sectional study included 195 participants with an enucleated eye who were attending an ophthalmic clinic for prosthetic rehabilitation between July and November 2014. Demographic and clinical data, and self-reported feelings of shame, sadness and anger were collected. Participants also completed the National Eye Institute Visual Function Questionnaire, the Facial Appearance subscale of the Negative Physical Self Scale, and the Hospital Anxiety and Depression Scale. Regression models were used to identify the factors associated with anxiety and depression.

Results

The proportion of participants with clinical anxiety was 11.8% and clinical depression 13.8%. More anxiety and depression were associated with poorer vision-related quality of life and greater levels of appearance concerns. Younger age was related to greater levels of anxiety. Less educated participants and those feeling more angry about losing an eye are more prone to experience depression. Clinical variables were unrelated to anxiety or depression.

Conclusions

Anxiety and depression are more prevalent in eye-enucleated patients than the general population, which brings up the issues of psychiatric support in these patients. Psychosocial rather than clinical characteristics were associated with anxiety and depression. Longitudinal studies need to be conducted to further elucidate the direction of causality before interventions to improve mood states are developed.