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

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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
To link to this article: http://dx.doi.org/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 wearersinitial 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 participantsopen 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. Participantsinitial 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 patientsperso-
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 Zealands 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 participantscurrent 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
Participantsaverage 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, participantswere 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 interpretationof what the discharge
meant (18.5%) (Was my experience normal?), includ-
ing being worried about infectionand cleanliness (It
always seemed like I hadnt washed my eye). This was
followed by physical complaintscaused 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 participantsvisual perception con-
cerns were perception difficulties (36%), including
depth perception (Pouring hot water from the urn or
the teapothard 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 eyeand 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 participantsvisual 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 didnt want to talk about it), and being
teased (School teasing very badcalled cross-eyed;I
didnt 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
doesnt stress me out, but its just there. I am not
angry or upset;I accepted what happened a long
time ago;At my age it doesnt worry me what others
think. Im 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 peoples sense of identity or when self-
esteem is already established. For example, during teenage
years (1318 years), establishing ones 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 patientsnegative 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 individuals 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 truthwill 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
individualsinterpretation 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 patientsexperiences 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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... The loss of an eye is a major challenge for ones' mental health [1,2]. Besides psychological issues, sudden acquired monocular vision requires adaptation to impaired depth perception, reduced peripheral visual field, [3,4] mucoid discharge, tearing, foreign body sensation, pruritus, and irritation [5]. It is reported that wearing and maintaining a prosthetic eye can reinstate appearance, comfort, and daily routine [6]. ...
... Studies have also postulated that a well fabricated prosthesis, a positive experience from the previous prosthesis [9] and giving time to adjust and accept the prosthesis [10] help improve the concerns of anophthalmic patients. Pine, et al. [4], Korani, et al. [7] and Shapira, et al. [8] have reported commonly experienced concerns in populations wearing poly methyl methacrylate prosthetic eyes and Rokohl, et al. [9] have summarised common concerns in populations wearing glass prosthetic eyes. Pine, et al. [4] (New Zealand) and Rokohl, et al. [9] (Germany) emphasised concerns about the health of the good eye whereas Korani, et al. [7] emphasized concerns towards watering crusting, discharge in India and Shapira, et al. [8] reported particular concerns towards motility and discomfort in study populations in the United Kingdom (UK). ...
... Pine, et al. [4], Korani, et al. [7] and Shapira, et al. [8] have reported commonly experienced concerns in populations wearing poly methyl methacrylate prosthetic eyes and Rokohl, et al. [9] have summarised common concerns in populations wearing glass prosthetic eyes. Pine, et al. [4] (New Zealand) and Rokohl, et al. [9] (Germany) emphasised concerns about the health of the good eye whereas Korani, et al. [7] emphasized concerns towards watering crusting, discharge in India and Shapira, et al. [8] reported particular concerns towards motility and discomfort in study populations in the United Kingdom (UK). Concerns related to prosthesis fitting; general and prosthesis related appearance in all these countries reduced over time [5,[7][8][9]. ...
... The loss of an eye is a major challenge for ones' mental health [1,2]. Besides psychological issues, sudden acquired monocular vision requires adaptation to impaired depth perception, reduced peripheral visual field, [3,4] mucoid discharge, tearing, foreign body sensation, pruritus, and irritation [5]. It is reported that wearing and maintaining a prosthetic eye can reinstate appearance, comfort, and daily routine [6]. ...
... Studies have also postulated that a well fabricated prosthesis, a positive experience from the previous prosthesis [9] and giving time to adjust and accept the prosthesis [10] help improve the concerns of anophthalmic patients. Pine, et al. [4], Korani, et al. [7] and Shapira, et al. [8] have reported commonly experienced concerns in populations wearing poly methyl methacrylate prosthetic eyes and Rokohl, et al. [9] have summarised common concerns in populations wearing glass prosthetic eyes. Pine, et al. [4] (New Zealand) and Rokohl, et al. [9] (Germany) emphasised concerns about the health of the good eye whereas Korani, et al. [7] emphasized concerns towards watering crusting, discharge in India and Shapira, et al. [8] reported particular concerns towards motility and discomfort in study populations in the United Kingdom (UK). ...
... Pine, et al. [4], Korani, et al. [7] and Shapira, et al. [8] have reported commonly experienced concerns in populations wearing poly methyl methacrylate prosthetic eyes and Rokohl, et al. [9] have summarised common concerns in populations wearing glass prosthetic eyes. Pine, et al. [4] (New Zealand) and Rokohl, et al. [9] (Germany) emphasised concerns about the health of the good eye whereas Korani, et al. [7] emphasized concerns towards watering crusting, discharge in India and Shapira, et al. [8] reported particular concerns towards motility and discomfort in study populations in the United Kingdom (UK). Concerns related to prosthesis fitting; general and prosthesis related appearance in all these countries reduced over time [5,[7][8][9]. ...
Article
Full-text available
Anophthalmic patients face many issues relating to general appearance and concerns related to prosthesis fitting and appearance. This issue has been studied extensively in several countries including India. Most of the concerns identified are similar globally, but some concerns are different when compared to India. This short commentary discusses possible reasons why these concerns differ between countries.
... Nevertheless, little has been published regarding functional and/or vision-related QOL aspects in these patients [4]. Furthermore, in the published research into the impact of an AE on the psychosocial well-being and QOL of the wearer, the measurement tools varied by way of multiple types of questionnaires and scales utilised. ...
... The chief visual function problems in acquired monocular vision are reduced visual field and compromised depth perception [4,9]. These have implications on daily activities such as sports and driving, as well as occupational ramifications, consequently affecting the quality of life and emotional well-being. ...
... Satisfaction among artificial eye wearers was linked amongst various factors to the ability to disguise disfigurement [4,17]. In this study, the self-rated better appearance of the artificial eye was predictive of better QOL scores. ...
Article
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To report associations with visual function and quality of life (QOL) in artificial eye wearers. 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. 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. 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.
... [22][23][24][25][26][27][28][29] However, studies on the relationship between sociodemographic factors, cause of loss, and type of surgery with the acceptance of and adaptation to the use of ocular prostheses are sparse. 30 Studies have evaluated the quality of life, stress, and anxiety of individuals after eye amputation, [6][7][8][9] as well as studies on adaptation difficulties faced by individuals receiving ocular prostheses and associated factors. [3][4][5][30][31][32][33][34][35][36][37][38][39][40][41][42][43] However, most of these studies have been retrospective or transversal. ...
... 30 Studies have evaluated the quality of life, stress, and anxiety of individuals after eye amputation, [6][7][8][9] as well as studies on adaptation difficulties faced by individuals receiving ocular prostheses and associated factors. [3][4][5][30][31][32][33][34][35][36][37][38][39][40][41][42][43] However, most of these studies have been retrospective or transversal. Thus, longitudinal studies should be performed to assess short-, medium-and long-term user needs, as well as the impact of prosthetic rehabilitation on the anophthalmic socket to identify requirements for public sector financing. ...
... The most frequent concerns of users of ocular prostheses are the esthetic appearance of the prosthesis in relation to the remaining eye. 28,30,[34][35][36]37 In this study, 7.70% complained about the esthetics of the prosthesis in that its size was excessive or deficient when compared with the size of the remaining eye. Despite the advantages of maintaining the ocular bulb or the presence of an orbital implant, excessive tissue limits the space to fit the ocular prosthesis, 13,14,20,29 complicating prosthesis fabrication and satisfactory esthetics. ...
Article
Purpose This prospective study evaluated and correlated the impact of ocular prostheses on quality of life and stress with socioeconomic level and clinical characteristics. The clinical difficulties and perceptions of patients after ocular rehabilitation were evaluated. Methods Anophthalmic patients (at least 18 years of age) who were not users of ocular prostheses were recruited. The Medical Outcomes Short‐Form Health Survey (SF‐36) and Perceived Stress Scale (PSS‐10) questionnaires were administered before and after 3 and 6 months of prosthesis installation. Clinical characteristics, difficulties, and perceptions were evaluated by quantitative and descriptive analysis (7 days, 3 months, 6 months). Data were analyzed by the Friedman test and Pearson Correlation test (α = 0.05). Results The final sample consisted of 26 patients. Quality of life showed improvement in the “Bodily Pain” and “General Health” domains. Wearing the prosthesis did not influence perceived stress. The clinical evaluation showed clinical discharge over 6 months and presence of pain only at 7 days. A weak correlation occurred between sociodemographic characteristics and the categories ”Role‐Physical" (r = 0.423) and “General Health” (r = 0.494); cause of anophthalmia and “Role‐Physical” (r = ‐0.471); and type of surgery and “General Health” (r = ‐0.432). Conclusions According to the results of this study, the provision of ocular prostheses showed positive influence in 2 domains of quality of life and weak correlations with socioeconomic level, type of surgery, and cause of loss. Ocular rehabilitation did not influence stress. The use and care of the prostheses did not affect tissue inflammation, but the discharge was continuous. This article is protected by copyright. All rights reserved
... It requires adaption to monocular vision, including changes in perception due to the loss of binocular cues to depth and a reduction in visual field on the affected side [1]. In addition, there is a change in appearance, comfort and routine associated with wearing and maintaining an artificial eye [2]. Previous reports underscore the importance of keeping patients well informed regarding outcomes, cosmesis and proper management of the prosthesis [3][4][5]. ...
... A consensus appears to be building around a protocol for managing discharge proposed by Pine et al. [8][9][10] Nonetheless, available data are mostly based on small discrete surveys [3][4][5][11][12][13]. Furthermore, the effects of management and other aspects on the comfort levels experienced by patients has not been widely explored [2]. ...
... These patients were shown to have lower healthrelated QOL scores [3,13], with perceptions of their social relationships negatively affected, whilst being prone to suffer from anxiety and depression [13]. Nevertheless, little was published regarding functional and/or vision related QOL aspects in these patients [2]. ...
Article
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To report associations with comfort and with appearance satisfaction in artificial eye wearers. Multicentre, observational, cross-sectional study, nationwide within the National Health Service England. The National Artificial Eye Questionnaire (NAEQ) was completed by 951 respondents. Multiple regressions assessed associations between the experiences of artificial eye wearers, routine management, changes over time, baseline and demographic parameters and their reported comfort, satisfaction with appearance and prosthesis motility. Better comfort levels were associated with needing less lubrication (β = 0.24, p < 0.001), older age (β = 0.17, p = 0.014), less discharge (β = 0.16, p < 0.001), less frequent cleaning (β = 0.16, p = 0.043), and male gender (β = 0.06, p = 0.047). Greater satisfaction with the appearance of the artificial eye was associated with better perceived motility (β = 0.57, p < 0.001). Black ethnic origin predicted a lower satisfaction with the appearance (β = −0.17, p = 0.001). Greater satisfaction with the motility was associated with a better appearance rating (β = 0.51, p < 0.001), longer time of having an artificial eye (β = 0.13, p < 0.001), older age (β = 0.11, p = 0.042), and a shorter adjustment time (β = −0.07, p = 0.016). Of the testimonials concerning appearance aspects, the majority (21/45, 46.7%) were related to the effect on social interactions. The results suggest that more attention should be given to the “dry anophthalmic socket syndrome” as a key cause of discomfort. Young patients are concerned particularly about the motility of the artificial eye. Over time satisfaction with the artificial eye movement is likely to improve.
... In addition to the functional disability with vision and visual field loss, cosmetic and aesthetic aspects are one of the most important concerns after enucleation [1][2][3]. The PESS is one of the main reasons for a bad appearance with a prosthetic eye [1][2][3][4][5]. ...
Article
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Background The last definition of the post-enucleation socket syndrome (PESS) by Tyers and Collin—formulated almost 40 years ago in 1982—is predominantly based on the clinical characteristics and does not include the insights of newer studies into the pathophysiological mechanism of the PESS. Methods A systematic PubMed literature review regarding the pathophysiological mechanism of the PESS was performed, and results were comprised to give an overview of the current knowledge of the PESS including the exact pathophysiological mechanism. Results The primarily postulated pathophysiological mechanism of the PESS was the atrophy of orbital tissues, especially of fat, resulting in variable clinical findings. Newer studies using high-resolution computed tomography and magnetic resonance imaging or performing histopathological analyses found no orbital fat atrophy but rather a rotatory displacement of the orbital tissues from superior to posterior and from posterior to inferior together with the retraction of the extraocular muscles and a possible volume loss of the orbital implant by resorption if it is manufactured from hydroxyapatite. PESS results in a backward tilt of the superior fornix, a deep superior sulcus, a pseudo-ptosis, a lower eyelid elongation and laxity, a shallower inferior fornix, as well as enophthalmos and may lead to an inability of wearing ocular prostheses. Conclusions A novel and comprehensive definition of the PESS is proposed: PESS is a multifactorial and variable syndrome caused by a rotatory displacement of orbital contents together with the retraction of the extraocular muscles and possible resorption of the orbital implant if it is manufactured from hydroxyapatite.
... 12,13 Subjectively, previous analyses indicated that discharge was the principal concern related to prosthesis wearing, however more recent studies have focused the attention on the "dry anophthalmic socket syndrome" as a key cause of discomfort. 1,[14][15][16] Investigation on the psychosocial and QOL implications of prosthetic eye wearing have shown how patients' QOL is not influenced by the presence of discharge as much as by the degree of lubrication required. Thus, patients who use more lubrication report worse QOL, whereas the presence of discharge without associated discomfort does not influence patient's satisfaction equally. ...
Article
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Purpose To assess clinical and biomolecular changes of the conjunctival epithelium in anophthalmic patients wearing an ocular prosthesis. Methods Thirty-five unilateral anophthalmic patients were enrolled. Patients with blepharitis, lid abnormalities, and topical/systemic medication affecting the ocular surface were excluded. Symptom Assessment in Dry Eye (SANDE) questionnaire and tear function test (Schirmer Test Type I) were recorded. Conjunctival inflammation and meibomian gland dysfunction (MGD) were graded in the anophthalmic side and fellow eye. Impression cytology sampling of the upper, lower tarsal, and posterior/bulbar conjunctiva from the anophthalmic socket were collected and compared to healthy controls. Results Patients had significantly higher SANDE ( p < 0.001), Schirmer I test ( p = 0.004), conjunctival inflammation ( p < 0.001), and MGD scores ( p < 0.001) on the anophthalmic side compared to the fellow eye. Mucin 5AC, inflammatory markers (MMP-9, ICAM-1) expression ( p < 0.001), and response to oxidative stress (NRF2-KEAP1 signaling pathway) ( p < 0.05) were significantly upregulated in the posterior conjunctival surface in the anophthalmic socket. Conclusions Anophthalmic patients complained of more pronounced dry eye symptoms and presented more significant signs of inflammation and MGD on the anophthalmic side. The bulbar conjunctiva, behind the prosthesis, showed more significant hyperexpression of mucins, markers of inflammation, and increased response to oxidative stress compared to the tarsal conjunctiva. Patients wearing ocular prosthesis had signs of inflammation resembling dry eye disease.
... The existing generic questionnaires included: the World Health Organization QoL for general QoL; the 36-item Short Form (SF-36) Health Survey for eight health concepts; the Hospital Anxiety and Depression Scale (HADS) for mood; and the Derriford Appearance Scale (DAS24) for appearance-related social anxiety and avoidance (11). The existing condition-specific QoL questionnaires included the following: psychosocial impact of an OP (12), concerns and satisfaction with an OP (13,33), amblyopia and strabismus (14,15), orbitofacial prosthesis (1,6), and limb prosthesis (5). ...
Article
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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
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Purpose To evaluate morphological alterations of meibomian glands (MGs) in the dry anophthalmic socket syndrome (DASS). Methods Fifteen unilateral anophthalmic patients wearing cryolite glass prosthetic eyes were enrolled. All patients with clinical blepharitis or other significant eyelid abnormalities were excluded. In vivo laser scanning confocal microscopy (LSCM) of the MGs in the lower eyelids both on the anophthalmic side and the healthy fellow eye was performed to quantify acinar unit density, acinar unit diameter, acinar unit area, meibum secretion reflectivity, the inhomogeneous appearance of the glandular interstice, and inhomogeneous appearance of the acinar walls. Results The lower eyelids of the anophthalmic sockets revealed a significant reduction of the acinar unit density ( p = 0.003) as well as a significantly more inhomogeneous appearance of the periglandular interstices ( p = 0.018) and the acinar unit walls ( p = 0.015) than the healthy fellow eyelid. However, there were no significant differences regarding the acinar unit diameter, acinar unit area, and meibum secretion reflectivity of the MGs on the anophthalmic side compared to the healthy fellow eyelid ( p ≥ 0.05, respectively). Conclusions The eyelids of anophthalmic sockets without clinical blepharitis demonstrate a reduced density of MG acinar units and a more inhomogeneous appearance of the periglandular interstices and the acinar unit walls. This can cause meibomian gland dysfunction contributing to DASS and suggests early treatment of these symptomatic patients, even in the clinical absence of any blepharitis signs.
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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 (NAEQ) was employed nationwide within the National Health Service England. The proportions or mean values of the aetiology of sight or eye loss, demographics, length of prosthesis wear, reported adjustment time to the prosthesis, comfort, discharge and satisfaction of appearance were compared between AE and CS respondents. Results: Overall, 951 respondents wore an AE, while 238 wore a CS. In both, trauma was the leading cause for the prosthesis (47.6% and 44.1%, respectively); however, these groups differed in the proportions of the other aetiologies (p<0.0001). AE respondents were generally older (p=0.002) and had longer overall prosthesis wear (p<0.0001) compared with CS respondents. The overall comfort score was similarly, relatively high in both AE and CS respondents (80.4±0.73 vs 81.41±1.45; p=0.51). The discharge-related patient satisfaction ranking was relatively low, in both groups, with a small trend towards worse discharge scores among AE wearers (59.41±0.76 vs 62.26±1.52, p=0.094). Self-reported length of time that has taken to adjust to wearing the prosthesis was not significantly different (p=0.17). Appearance of the eye (p=0.032) and motility of the prosthesis (p<0.0001) were ranked superior by CS respondents compared with AE. Conclusions: This study characterises unique aspects of CS versus AE in a large national cohort. The results should provide reinforcement to the gain in popularity of CS.
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Objective: Many patients are satisfied with their ocular prosthesis, but some describe problems with social interactions, body image and self-esteem. Although both clinical practice and research suggest that the severity of a disfiguring condition does not predict distress, there has been little research with patients living with an ocular prosthesis. The objective was to explore the psychological impact of living with an artificial eye or cosmetic shell and determine the relationship between psychological well-being and clinical and psychosocial factors. Methods: A cross-sectional study between March and September 2008 at the ocular prosthesis clinic of Moorfields Eye Hospital, UK. The primary outcome measures were mood as measured by the Hospital Anxiety and Depression Scale (HADS) and appearance-related social anxiety and social avoidance, as measured by the Derriford Appearance Scale (DAS24). Results: Mean scores on the HADS and DAS24 were within normal range, but a considerable proportion of participants were experiencing significant levels of distress. Psychosocial adjustment was unrelated to most clinical and demographic variables, but was associated with a series of cognitive processes. Conclusions: Psychological variables, rather than clinical or demographic factors, are associated with how a patient adjusts to wearing an ocular prosthesis. Such factors might be amenable to change through psychosocial intervention.
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