Psychological factors may impact quality of life after strabismus surgery

April 13, 2018

For most patients, health-related quality of life (HRQOL) improves dramatically following strabismus surgery. For some patients, however, HRQOL does not improve. Jonathan M. Holmes, M.D., and fellow researchers in Ophthalmology at Mayo Clinic's campus in Rochester, Minnesota, conducted a retrospective study between July 2012 and August 2016 to identify why.

"Previously, we have studied the associations with decreased HRQOL as measured at a single time point. We found depressive symptoms associated with reduced HRQOL, in addition to clinical factors such as worse diplopia and greater magnitude of deviation," says Dr. Holmes. "In this study we asked, 'What factors are associated with failure of the AS-20 scores to improve after eye muscle surgery?' "

The researchers enrolled 276 consecutive adult patients with strabismus undergoing strabismus surgery in the observational case series. Patients with all types of diplopic and nondiplopic strabismus were included, and previous strabismus surgery was allowed.

Participants completed the following four questionnaires, both preoperatively and six weeks postoperatively:

  • Adult Strabismus-20 (AS-20) HRQOL questionnaire, which measures HRQOL in four domains: Self-Perception, Interactions, Reading Function, General Function
  • Diplopia questionnaire, which allows patient reporting of diplopia severity in seven gaze positions
  • The Center for Epidemiologic Studies Depression Scale Revised (CESD-R), which measures current depressive symptoms
  • Type-D Scale 14 questionnaire, which assesses for type distressed (type-D) personality

Researchers then performed univariate and multiple logistic regression analyses to assess factors associated with failure of HRQOL to improve (no change in score or a decrease in score) in each of the four AS-20 domains. Analysis included only patients able to improve at least by the magnitude of previously defined 95 percent limits of agreement. Factors assessed include:

  • 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
  • Magnitude of ocular misalignment (as a vector)
  • Presence of esotropia
  • Presence of a vertical deviation
  • CESD-R scores
  • Type-D personality

"We found that poorer postoperative improvement in AS-20 scores is associated with depressive symptoms," says Dr. Holmes. "The finding that nonstrabismus factors, such as depressive symptoms, may also be associated with failure of AS-20 scores to improve postoperatively has important clinical implications, because there is increasing emphasis on using patient-reported outcomes for evaluating treatment effectiveness, and we need to understand the factors that might be influencing the patient's responses on these questionnaires."

Double vision

The researchers found that persistent double vision or new-onset double vision after surgery was also strongly associated with failure to improve AS-20 scores, both in functional vision domains such as Reading Function and General Function and in the Self-Perception domain. "Our results indicate that residual or new-onset double vision should be addressed by every means possible, such as providing prism in spectacles, or serious consideration of additional surgery," says Dr. Holmes.

Psychological factors

Researchers also found that psychological and personality factors were associated with failure of AS-20 scores to improve. Dr. Holmes notes: "Specifically, type-D personality was associated with failure to improve in the Self-Perception domain, and postoperative depressive symptoms were associated with failure to improve in the Interactions domain."

Facial anomalies

The presence of a coexistent noticeable anomaly affecting the face, such as a drooping eyelid (ptosis) was also associated with failure of AS-20 scores to improve on the AS-20 Interactions domain.

"We still see that the vast majority of adult patients with strabismus still have measurable improvement in HRQOL and functional vision following strabismus surgery," says Dr. Holmes. "However, our study highlights the need to consider psychological factors and personality parameters when interpreting patient-reported outcome measures such as HRQOL.

"The treating strabismus specialist should provide appropriate referral to psychiatry colleagues if the patient expresses depressive symptoms. These symptoms may coexist with strabismus, and although they may affect the patient's strabismus-related HRQOL and functional vision, they should be addressed directly, because they often have profound effects on the patient's well-being."

Study results were published in JAMA Ophthalmology in 2018.

For more information

Adult Strabismus-20 (AS-20) HRQOL questionnaire. Pediatric Eye Disease Investigator Group (PEDIG) — Public Web Site.

The Center for Epidemiologic Studies Depression Scale Revised (CESD-R).

Hatt SR, et al. Factors associated with failure of Adult Strabismus-20 questionnaire scores to improve following strabismus surgery. JAMA Ophthalmology. 2018;136:46.