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

Abstract

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.

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An investigation into discharge, visual perception,
and appearance concerns of prosthetic eye
wearers
Nicola S. Pine, Ian de Terte & Keith R. Pine
To cite this article: Nicola S. Pine, Ian de Terte & Keith R. Pine (2017): An investigation into
discharge, visual perception, and appearance concerns of prosthetic eye wearers, Orbit, DOI:
10.1080/01676830.2017.1337201
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ORIGINAL ARTICLE
An investigation into discharge, visual perception, and appearance concerns of
prosthetic eye wearers
Nicola S. Pine
a
, Ian de Terte
a
, and Keith R. Pine
b
a
School of Psychology, Massey University, Wellington, New Zealand;
b
School of Optometry and Vision Science, University of Auckland,
Auckland, New Zealand
ABSTRACT
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 partici-
pants. 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 interpreta-
tion 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’perso-
nal experience of eye loss.
ARTICLE HISTORY
Received 2 December 2016
Accepted 28 May 2017
KEYWORDS
Concerns; ocular prosthesis;
prosthetic eye wearers;
psychological impact
Introduction
Previous research investigating the psychological adjust-
ment of patients living with an ocular prosthesis has
focused on appearance-related issues.
1-3
The research, as
far as the authors are aware, has not yet addressed the
psychological impact of other important issues, such as
visual perception changes brought about by acquired
monocular vision and coping with mucoid discharge
from the eye socket. However, at least one investigation
has suggested these areas of concern are of significance to
experienced prosthetic eye wearers.
4
This study aims to further investigate the concerns of
prosthetic eye wearers to determine which concern
(appearance, discharge experience, or visual perception)
is more important than the others and to report on the
reasons given for these concerns.
Methods
Recruitment
Participants were over 16 years old and had worn an
ocular prosthesis for more than 2 years. Once the
Massey University Human Ethics Committee
granted ethics approval, the New Zealand
ProstheticEyeService(aprivatepracticewith
clinics throughout New Zealand’s North Island)
invited potential participants to complete an online
or hard-copy questionnaire. If questions raised psy-
chological difficulties for participants, contact
details of psychological support organizations were
provided. The questionnaire was completed by 217
participants (40% response rate).
CONTACT Nicola S. Pine pine.nikki@gmail.com School of Psychology, Massey University, Wallace Street, Mt Cook, Wellington 6021, New Zealand.
Supplemental data for this article can be accessed at https://doi.org/10.1080/01676830.2017.1337201.
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Questionnaire
The questionnaire contained 29 questions and five psy-
chological scales across four main categories (demo-
graphics, concerns, feelings and problems,
psychological scales). This article covers the first two
sections of the questionnaire (see the online supple-
mentary material).
Data analysis
Quantitative data were analysed using the Statistical
Package for the Social Sciences for Mac (version 23).
One-way analyses of variance investigated differences
between both initial and current concerns, reasons for
discharge and appearance concerns, and discharge con-
cerns relative to discharge frequency. Paired-samples
t-tests investigated differences between initial and cur-
rent levels of concern, and independent-samples t-tests
explored differences between concerns according to
gender and reasons for visual perception concerns.
Pearson correlations investigated relationships
between concern levels and participants’current age
and age at time of eye loss. A linear regression analysis
determined the relationship between discharge volume
and current discharge concerns.
Qualitative responses were subject to content analy-
sis to identify descriptive themes within the data and
their frequencies.
5,6
Results
Participants
Participants’average age was 58 years and their average
prosthetic eye wearing time was 27 years. The majority
were male (67%), and ethnicities were New Zealand
European (76%), Maori (13%), other (7%), Asian
(3%), and Pacific Islander (1%).
Concerns
There were no significant differences in levels of con-
cern for discharge, visual perception, and appearance
during the initial period following eye loss or after at
least 2 years. Over time, concerns about discharge,
visual perception, and appearance decreased signifi-
cantly (Table 1).
Demographic variables and concerns
The older participants were when they lost their eye,
the lower was their current concern about appearance
(r=–0.19, p= 0.007), and the greater was their initial
concern about visual perception (r= 0.22, p= 0.003).
Table 1. Differences between initial and current concerns of prosthetic eye wearers, including gender differences between initial and current mean levels of concern.
Mean level of
concern
Mean
difference Significance
Initial mean level of
concern
Initial mean
difference Significance
Current mean level of
concern
Current mean
difference Significance
Discharge Initial 2.52 .583 .000* Female 2.65 .212 .191 2.22 .425 .003*
Current 1.92 Male 2.44 1.80
Appearance Initial 2.52 .497 .000* Female 2.66 .203 .251 2.25 .330 .025*
Current 2.03 Male 2.45 1.92
Visual perception Initial 2.32 .377 .000* Female 2.32 .023 .892 1.94 .031 .824
Current 1.91 Male 2.30 1.91
*The mean difference is significant at the 0.05 level.
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Older participants were less concerned about their cur-
rent appearance (r=–0.32, p< 0.001), while females
were more concerned about current discharge and
appearance compared to males (Table 1).
Discharge concerns
Eighty percent of participants experienced discharge,
48% at a moderate to severe level. Those experien-
cing it hourly were significantly more concerned (M
= 3.05, SD = .85) than those experiencing it daily (M
= 2.05, SD = .927, p< 0.001) or weekly (M = 1.70,
SD = .83, p< 0.001). Greater discharge volume also
led to greater concerns about discharge (R
2
= 0.61, F
(1, 189)
=297,p<0.001).
At the present time, participants were equally con-
cerned about discharge drawing attention to their
prosthesis (M = 2.57, SD = 0.98), about having to
continually wipe their eye (M = 2.69, SD = 0.92),
and about discharge discomfort (M = 2.52, SD =
1.03) (p> 0.05).
Visual perception concerns
At the present time, participants’were equally con-
cerned about judging distance (M = 2.34, SD = 0.96)
and reduced peripheral vision (M = 2.45, SD = 0.88,
p>0.05).
Appearance concerns
Current levels of concern regarding appearance were
the look of prosthesis relative to good eye (M = 2.43,
SD = 0.94), how I appear to myself (M = 2.28, SD =
1.03), and how I appear to others (M=2.67, SD= 0.89).
Current concerns about how participants appeared to
others were greater compared with how they appeared
to themselves (mean difference = –0.39, p= 0.002)
Reasons for concerns
Discharge
The initial reason for discharge concerns was partici-
pants’“negative interpretation”of what the discharge
meant (18.5%) (“Was my experience normal?”), includ-
ing being “worried about infection”and cleanliness (“It
always seemed like I hadn’t washed my eye”). This was
followed by “physical complaints”caused by the dis-
charge (16.7%), including “pain around inner eyelid,”
“itchiness,”irritation from wiping the eye, and the
consequences of discharge on eye functioning (“With
the crusting, my eyelid would close”;“It stops my eye
blinking”). Lastly, 13% of participants indicated that
volume and frequency of discharge were reasons for
their concern.
Current reasons for discharge concerns were “phy-
sical complaints”(33%) (“Skin irritation”;“Gets really
tacky at times and hard to blink”), followed by “others
noticing the discharge”(13.3%) (“I notice people focus-
ing on my eye when I talk with them and I begin to
wonder if there is any discharge or crusting visible and
I feel uncomfortable”). Lastly, participants were con-
cerned about their eye rotating in the socket when
wiping discharge (10%) (“I am concerned if I rub my
eye that it will rotate in the socket, so I often use a
mirror or the selfie view on phone camera to check
alignment”).
Visual perception
Initial reasons for participants’visual perception con-
cerns were perception difficulties (36%), including
depth perception (“Pouring hot water from the urn or
the teapot—hard to judge the distance”), peripheral
vision (“I often hurt myself walking into open doors
or cupboards”), and cognitive factors (“Visual ‘ghost’
images from my lost eye”and “loss of 3D vision”).
Adaptive behavior (11.7%) referred to acceptance and
the development of compensatory strategies (“Getting
used to having to look around a lot more”;“If I am
walking with a new person, I let them know I need to
walk on the left side”). Functional impact (10.4%)
referred to the negative impact that visual perception
difficulties had on sport and work [“The loss of full
vision directly (and permanently) affected my work
prospects”;“Had a huge impact on any ball games I
could play as judgment of distances impaired”].
Current reasons for participants’visual perception
concerns were difficulties with depth perception and
peripheral vision (37%), followed by specific difficulties
regarding driving and/or nighttime vision (27.4%)
(“Have lost independence and no longer able to drive,
also night vision is not at all good”), and finally adap-
tive behavior (19.4%) (“Experience and time improves
ability”).
Appearance
Initial reasons for appearance concerns were about
disguisability (23%) (“Always worried the eye would
turn and be obvious to others”;“The pupil did not
dilate at night making the prosthesis more noticeable”;
“Looked obvious in photographs”). Some participants
were “fine with their appearance”(17%) because they
were either happy that the prosthesis matched their
companion eye (“An excellent match, so not a lot of
people realised it was prosthetic”) or believed their
prosthetic eye improved their appearance
(“Appearance has never been an issue in fact a great
change from my previously damaged eye”). “Others’
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responses”(15.6%) referred to other people staring (“I
was very self-conscious of people staring at me”), ask-
ing questions (“Having to answer questions early on
was hard as I didn’t want to talk about it”), and being
teased (“School teasing very bad—called cross-eyed”;“I
didn’t want to go out in public because I thought
people would say things about it and laugh, which
people did and still do”).
Current reasons for appearance concerns were ana-
tomical factors (29%) (“Eye socket sunk in”;“Eyelid
droop”), acceptance of their appearance (22%) (“It
doesn’t stress me out, but it’s just there. I am not
angry or upset”;“I accepted what happened a long
time ago”;“At my age it doesn’t worry me what others
think. I’m past catching women”) and disguisability
(14.6%) (“Biggest psychological barrier”).
Discussion
Loss of self-image is commonly considered to be the
major concern of anophthalmic patients, but this study
has found that discharge and visual perception con-
cerns are of equal importance. McBain et al.
1
acknowl-
edged this possibility when noting that their study was
limited to appearance factors only. Other investigators
have stressed the need for research into all aspects of
prosthetic eye wear, not just appearance.
7
The finding that older participants were less concerned
about their appearance is consistent with the idea that
older adults become more focused on physical function-
ing and although they experience body dissatisfaction
8
their priorities may move away from their outward
appearance.
9,10
It is also possible that eye loss impacts
less on older people’s sense of identity or when self-
esteem is already established. For example, during teenage
years (13–18 years), establishing one’s identity and fitting
into social groups is a key developmental task.
11
Women are more concerned about their appearance
than men
12
because society appears to judge them more
by their appearance.
13
This may account for the heigh-
tened concerns women expressed about appearance
and discharge in this study.
A high percentage of participants (80%) experienced
discharge, and it is not surprising that levels of concern
were correlated with frequency and volume of dis-
charge. However, the finding that many patients were
concerned about the meaning of the discharge (e.g., an
infection, poor hygiene, abnormal) suggests that clin-
icians should inform patients early on about the like-
lihood of socket discharge and explain its annoying
but essentially harmless nature. This would avoid unne-
cessary distress due to patients’negative interpretation
of discharge.
14
The primary deficits of acquired monocular vision
are reduced visual range and impaired depth
perception.
15
These deficits can cause problems with
daily activities such as sports and driving, as well as
the ability to perform in some work environments,
leading to distress. However, over time, participants
developed strategies to compensate for their deficits
and were able to resume previous work and daily activ-
ities. McLean
16
suggested that adaptation following
sudden eye loss normally takes one year or less.
Participants in this study were significantly more
concerned with how they appeared to others compared
with how they appeared to themselves. They identified
disguisability as an important factor that caused parti-
cular concern when their prosthesis did not move in
concert with or match their companion eye, or when
anatomical factors affected their facial symmetry. The
visibility of an individual’s condition can have a sig-
nificant psychological impact and create difficulties
with body image, self-esteem, and quality of life, as
well as social interactions.
17
The main function of a
prosthetic eye is to restore facial harmony, and when
this is ineffective, patients fear that the “truth”will be
discovered and they will be exposed to ridicule.
18
This
is the same for people with other visible
disfigurements.
19,20
A major source of stress for those with facial disfig-
urement is the unavoidability of having to share their
condition with others,
21,22
with the most common dif-
ficulties falling within the area of social interaction.
23
The finding that initial concerns about discharge,
visual perception, and appearance decrease signifi-
cantly over time is reassuring for patients who have
recently lost an eye. This decrease may be due to the
passage of time itself (adapting to a “new normal”)
and to the development of coping strategies.
24,25
Having good social skills is associated with success-
ful adjustment,
26,27
and such skills as educating
others, remaining calm, and assertively confronting
negative reactions
28
develop over time. It is the
individuals’interpretation of themselves, their disfig-
urement, and their interactions with others that
influences their adjustment process, and in turn
their level of distress associated with their
disfigurement.
29
Having a supportive family and
social environment is an important factor when cop-
ing with disfigurement.
30
Over time, wearers often develop individualized
cleaning routines to minimize the volume or frequency
of discharge, meaning less distress. Compensatory stra-
tegies and behaviors to cope with acquired monocular
vision take time to learn and put into practice, but once
these are perfected, the negative functional impact and
4N. S. PINE ET AL.
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associated concerns are likely to decrease. Over time,
prosthetic eye wearers naturally get older, which can
have an effect on coping ability, as older adults cope
better with their disfigurement compared to younger
adults.
29
The results of this study provide greater insights
into anophthalmic patients’experiences and feelings
when they receive their first prosthesis and over the
ensuing years. These insights help inform the advice
provided by clinicians and highlight areas for future
research, particularly regarding the impact of less
explored socket discharge and visual perception
concerns.
Disclosure statement
The participants in this study were recruited from the NZ
Prosthetic Eye Service, which is owned and operated by Keith
Pine.
Funding
This research was supported in part by funding from Massey
University.
ORCID
Ian de Terte http://orcid.org/0000-0001-8918-0965
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