- Email: [email protected]
Improved sensory status and quality-of-life measures in adult patients after strabismus surgery
Improved sensory status and quality-of-life measures in adult patients after strabismus surgery Anna Dickmann, MD,a Stefania Aliberti, MD,a Maria Teresa Rebecchi, CO,a Irene Aprile, PhD,b Annabella Salerni, MD,a Sergio Petroni, MD,a,b Rosa Parrilla, MD,a,b Vittoria Perrotta, MD,a Emiliana Di Nardo, CO,a and Emilio Balestrazzi, MDa PURPOSE METHODS
RESULTS
CONCLUSIONS
To evaluate the change in sensory status and quality-of-life measures in adults with longstanding childhood-onset constant strabismus. Consecutive patients with childhood-onset, long-term constant strabismus were enrolled. Sensory status was examined with Bagolini striated glasses test and Worth 4-dot test. Stereopsis was tested with the Lang and TNO stereopsis tests. Quality of life was studied with 2 different questionnaires (Short Form Health Survey [SF-36] and the Amblyopia and Strabismus Questionnaire [A&SQ]), which patients completed before and 3 months after strabismus surgery. A total of 20 patients (age range, 18-63 years) were included, 10 of whom were esotropic and 10 of whom were exotropic. Of these, 13 obtained a satisfactory postoperative alignment and demonstrated an increase of sensory status with Bagolini striated glasses. Six patients who demonstrated suppression preoperatively achieved fusion and stereopsis postoperatively. The mean score in all domains of the A&SQ improved significantly, particularly with regard to social contact and cosmesis (P 5 0.00067), distance estimation (P 5 0.000312), and visual disorientation (P 5 0.004777). Similarly, the mean score in 7 of 8 areas in the SF-36 improved significantly, particularly with regard to physical function (P 5 0.000564), general health (P 5 0.002296), vitality (P 5 0.002891), social function (P 5 0.004234), and mental health (P 5 0.000334). The overall mean score of both questionnaires improved in all patients with a satisfactory postoperative alignment and increase of sensory status. Surgical treatment of strabismus in adults with long-standing childhood-onset constant strabismus can result in patients feeling that their quality of life has improved and can restore binocular sensory function. ( J AAPOS 2013;17:25-28)
S
trabismus can affect many aspects of a patient’s quality of life, including psychosocial functioning and employment.1 It can lead to poor self-image, emotional problems, and social anxiety.2 The goal in treating strabismus in adults is to realign the visual axes to eliminate diplopia (when present), achieve or restore binocular function (if possible), and restore normal anatomic appearance.3 In several studies, the functional benefits of strabismus surgery in adults have been demonstrated4-8: expansion of visual fields, increase in sensory status with the Bagolini striated glasses, and a postoperative improvement in peripheral fusion assessed by Worth 4-dot test. Author affiliations: aInstitute of Ophthalmology, Catholic University, Rome, Italy; bDon Carlo Gnocchi Onlus Foundation, Italy Submitted May 6, 2012. Revision accepted September 14, 2012. Published online January 28, 2013. Correspondence: Sergio Petroni, MD, Institute of Ophthalmology, Catholic University, Largo F. Vito, 1 00168 Rome, Italy (email: [email protected]). Copyright Ó 2013 by the American Association for Pediatric Ophthalmology and Strabismus. 1091-8531/$36.00 http://dx.doi.org/10.1016/j.jaapos.2012.09.017
Journal of AAPOS
Although the treatment of strabismus in adults without binocular potential often has been considered merely “cosmetic,”9 in several studies authors have shown that, even when there is no hope of improving binocular function, strabismus surgery in adults positively affects self-image, leading to significant improvement in quality of life.10-12 A number of validated disease-specific instruments have been developed and applied in ophthalmology to assess changes in quality of life, such as Short Form Health Survey (SF-36),13 the Amblyopia and Strabismus Questionnaire (A&SQ),14-16 the Visual Function Index, the National Eye Institute Visual Function Questionnaire (51- and 25-item questionnaires), the Impact of Visual Impairment, and the Activities of Daily Vision Scale.17 The purpose of the present study was to evaluate postoperative changes in both sensory status and quality of life as measured by both SF-36 and A&SQ questionnaires in adults with long-standing childhood-onset constant strabismus.
Methods Consecutive patients examined in the Pediatric Ophthalmology and Strabismus Unit at the Catholic University of Rome were
25
26
Dickmann et al
enrolled in the study. All patients presented with concomitant horizontal strabismus and had a history of strabismus since childhood and a constant tropia at distance and near. Patients with normal binocular vision before strabismus surgery, organic eye disease, cataract, glaucoma, retinal or optic nerve disorder, laser treatment, or previous intraocular surgery were excluded. Patients presenting with a risk of postoperative diplopia also were excluded. All patients underwent surgical treatment. We defined a satisfactory outcome as postoperative deviation of #10D and the absence of diplopia. This study followed the tenets of the Declaration of Helsinki, and signed informed consent was obtained from each patient. Full ophthalmologic and orthoptic examinations were performed at baseline and 3 months after surgery, including ocular motility assessment, cycloplegic refraction, and dilated fundus examination. Patients underwent orthoptic examination while wearing their appropriate refractive correction. The deviation was measured before and after surgery by prism and cover test at distance and at near. The risk of postoperative diplopia was assessed by means of prismatic full correction of angle deviation. Sensory status was assessed pre- and postoperatively with Bagolini striated glasses and the Worth 4-dot test. Stereoacuity was tested by means of the Lang and TNO stereopsis tests. Functional recovery was defined as at least anomalous retinal correspondence and recovery of stereopsis. At baseline and 3 months after surgery, 2 questionnaires (SF-36 and the A&SQ) were administered in random order to all patients to assess the affects of strabismus on quality of life. Patients were provided with written instructions and allowed to complete the questionnaires in private. The Italian version of the validated A&SQ,14,15 translated from the English version, was used.16 The A&SQ contains 26 questions formulated within 5 areas: fear of losing the better eye, distance estimation, visual disorientation, diplopia, and social contact and cosmetic problems. All responses are graded on Likert-type scales. For the purpose of scoring, the rating scales are assumed to be linear and run from 0 to 100, where 0 corresponds to the least favorable score and 100 corresponds to the most favorable. A 5-option item thus has possible scores of 0, 25, 50, 75, and 100. The A&SQ total score, defined as the mean of all item scores, corresponds to overall quality of life. The SF-36 questionnaire, a widely used and well-validated generic quality of life instrument, comprises 36 items with 2 to 6 response options according to an ordinal scale. The SF-36 assesses 8 physical and mental health areas: physical function, role limitations due to physical health problems, bodily pain, general health, vitality, social function, role limitations due to emotional problems, and mental health. Raw scores were transformed to standardized scores on a scale from 0 to 100, with a greater score indicating better health-related quality of life.13 The t test was used for statistical analysis and the differences were considered significant if the P value was \0.05.
Results A total of 20 consecutive patients (10 males; mean age, 47 years; age range, 18-63 years) were included. Preoperative
Volume 17 Number 1 / February 2013 and 3-month postoperative amount of deviation, changes of sensory status, and stereoscopic test findings are presented in Table 1. In 11 patients strabismus emerged within the first year of life; in 9 patients between the first and the fifth year. Sensory Responses Of the 20 patients, 13 achieved a satisfactory postoperative alignment and all showed an increase of binocular fusion with Bagolini striated glasses. In particular, 4 patients with total suppression preoperatively achieved partial suppression and 9 patients anomalous retinal correspondence. Of the 13 patients with a satisfactory postoperative alignment and with improvement in sensory status with Bagolini striated glasses, 6 also improved to anomalous fusion and showed a gross stereoscopic response. The 7 patients with unsatisfactory postoperative alignment showed no improvement of sensory status nor recovery of stereopsis. With respect to type of strabismus, 9 of the 13 patients with a satisfactory postoperative alignment and improved sensory status were diagnosed within the first year of life (3 with esotropia and 6 with exotropia), and 4 were diagnosed between the first and the fifth year of life (3 with esotropia and 1 with exotropia). Of the 6 patients with esotropia, all showed anomalous binocular response with Bagolini striated glasses, and 2 achieved fusion (Worth 4-dot test) and demonstrated a gross stereopsis. The 7 patients with exotropia showed an anomalous binocular response with Bagolini striated glasses, and 4 achieved anomalous fusion (Worth 4-dot test) and gross stereopsis. Quality of Life For the 13 patients with satisfactory outcomes, the overall mean score with both questionnaires improved. For the 7 patients with unsatisfactory outcomes, the overall mean score remained unchanged with both questionnaires. With the A&SQ, 3 months after surgery the overall mean score improved by 19% (preoperative score, 63; postoperative score, 77; P 5 0.001). A lower overall mean score occurred only in 1 case. The mean score improved significantly in all areas (Figure 1), particularly with respect to contact and cosmesis (preoperative, 46; postoperative, 61; P 5 0.00067), distance estimation (preoperative, 72; postoperative, 88; P 5 0.000312), and visual disorientation (preoperative, 62; postoperative, 80; P 5 0.004777). With the SF-36 questionnaire, 3 months after surgery the overall mean score improved by 15% (preoperative, 73; postoperative, 85: P 5 0.000163). The mean score improved significantly in 7 of 8 areas (Figure 2), particularly with respect to physical function (preoperative, 82; postoperative, 96; P 5 0.000564), general health (preoperative, 70; postoperative, 79; P 5 0.002296), vitality (preoperative, 64; postoperative, 75; P 5 0.002891), social function (preoperative, 74, postoperative, 87; P 5 0.004234), and mental health domain (preoperative, 69; postoperative, 82; P 5 0.000334). With respect to bodily pain, improvement of the mean score was not statistically significant.
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Table 1. Clinical data Deviation Preop
Bagolini striated glasses Postop
Preop
Stereopsis, arcseca
Worth 4-dot test
Postop
Preop
Postop
D
N
D
N
D
N
D
N
D
N
D
N
Preop
Postop
b
1
48 ET
55 ET
10 ET
6 ET
Sup
Sup
ARC/Sup
ARC
Sup
Sup
Sup
Sup
2b
45 ET
50 ET
2 ET
2 XT
Sup
Sup
ARC/Sup
ARC
Sup
Sup
Sup
Sup
3b
20 XT
18 XT
4 XT
2 XT
Sup
Sup
ARC
ARC
Sup
Sup
Sup
Sup
4b
35 XT
45 XT
10 XT
12 XT
Sup
Sup
ARC
ARC
Sup
Sup
Sup
Sup
5b
45 XT
50 XT
30 XT
40 XT
Sup
Sup
Sup
Sup.
Sup
Sup
Sup
Sup
6b
36 XT
38 XT
4 XT
6 XT
Sup
Sup
ARC
ARC
Sup
Sup
ARC
ARC
7b
25 XT
35 XT
2 XT
8 XT
Sup
Sup.
ARC
ARC
Sup
Sup
Sup
ARC
8c
50 ET
55 ET
10 ET
18 ET
Sup
Sup
Sup
Sup
Sup
Sup
Sup
Sup
9b
20 ET
25 ET
2 ET
6 ET
Sup
Sup
ARC
ARC
Sup
Sup
Sup
Sup
10b
40 XT
45 XT
2 XT
4 ET
Sup
Sup.
ARC
ARC
Sup
Sup
ARC
ARC
b
11
58 XT
65 XT
10 XT
8 XT
Sup
Sup
ARC
ARC
Sup
Sup
ARC
ARC
12b
45 ET
45 ET
30 ET
30 ET
Sup
Sup
Sup
Sup
Sup
Sup
Sup
Sup
13c
35 XT
30 XT
25 XT
20 XT
Sup
Sup
Sup
Sup
Sup
Sup
Sup
Sup
14c
50 XT
55 XT
10 XT
2 XT
Sup.
Sup
ARC
ARC
Sup
Sup
Sup
Sup
15c
35 XT
40 XT
20 XT
30 XT
Sup
Sup
Sup
Sup
Sup
Sup
Sup
Sup
16c
40 ET
50 ET
6 ET
10 ET
Sup
Sup
ARC
ARC
Sup
Sup
ARC
ARC
17c
35 ET
40 ET
2 ET
2 ET
Sup
Sup
ARC/Sup
ARC
Sup
Sup
ARC
ARC
18c
40 ET
40 ET
25 ET
25 ET
Sup
Sup
Sup
Sup
Sup
Sup
Sup
Sup
19c
20 ET
20 ET
2 ET
2 ET
Sup
Sup
ARC/Sup
ARC
Sup
Sup
Sup
Sup
20c
50 ET
50 ET
10 ET
16 ET
Sup
Sup
Sup
Sup
Sup
Sup
Sup
Sup
Lang TNO Lang TNO Lang TNO Lang TNO Lang TNO Lang TNO Lang TNO Lang TNO Lang TNO Lang TNO Lang TNO Lang TNO Lang TNO Lang TNO Lang TNO Lang TNO Lang TNO Lang TNO Lang TNO Lang TNO
Lang 1 TNO Lang TNO Lang TNO Lang TNO Lang TNO Lang 1 TNO 2400 Lang 1 TNO 4800 Lang TNO Lang TNO Lang 1 TNO 2400 Lang 1 TNO 1200 Lang TNO Lang TNO Lang TNO Lang TNO Lang 1 TNO 1200 Lang 1 TNO 1200 Lang TNO Lang TNO Lang TNO
Case
ARC, anomalous retinal correspondence; D, at distance; ET, esotropia; N, at near; Postop, postoperative; Preop, preoperative; Sup, suppression; XT, exotropia. a Complete, 1; absent, . b Strabismus emerged within the first year of life. c Strabismus emerged between the first and the fifth year of life.
Discussion An improvement of sensory status after strabismus surgery in adults with long-standing constant strabismus has been reported in the literature. Kushner and Morton6 reported an improvement in sensory status as determined by means of Bagolini striated glasses. Mets and colleagues4 reported that adults that show no potential for binocularity preoperatively can experience improved sensory status, including stereopsis. Wortham and Greenwald5 reported expansion of the visual field after surgery for esotropia. In this study we tested the sensory status of adults before and after strabismus surgery to investigate the relationship
Journal of AAPOS
between surgical outcomes and changes in quality of life assessments. We observed that all patients with satisfactory postoperative alignment achieved a form of anomalous binocular cooperation with Bagolini striated glasses (a nondissociating test), with 6 patients achieving fusion and recovering stereopsis. The surgical reduction of the angle of deviation could help the eyes to obtain a form of binocular cooperation with, in some cases, achievement of a gross stereopsis. We demonstrated gross stereoscopic responses in 6 subjects, in 4 of whom exotropia presented in the first year of life and in 2 of whom esotropia onset was between 1 and 5 years of age. We hypothesize that in these
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Dickmann et al
Volume 17 Number 1 / February 2013 mean score unvaried with both questionnaires. These findings suggest that surgical treatment in adults with strabismus, even when the restoration of binocular vision is unlikely, may significantly improve the health-related quality of life and, in many cases, binocular function.23 References
FIG 1. A&SQ mean scores in 5 major areas and overall. FLBE, fear of losing the better eye; DE, distance estimation; VD, visual disorientation; DV, double vision; CC, contact and cosmesis.
FIG 2. SF-36 mean score in major 8 major areas and overall. PF, physical function; RP, role limitations due to physical health problems; BP, bodily pain (P . 0.05); GH, general health, VT, vitality; SF, social function; RE, role limitations due to emotional problems; MH, mental health.
2 patients the later onset of deviation allowed for development of some form of binocular cooperation. It is well known that exodeviations may become constant after a period of intermittency, so it is possible that our exotropic patients had an intermittent deviation in the first years of life. Several investigators18-23 have addressed the psychological impact of strabismus in adults by comparing preoperative and postoperative data by the use of standardized questionnaires relating surgical results and psychosocial outcomes. These studies have shown that strabismus is associated not only with functional deficits20 but also with psychosocial problems, a more negative selfimage, a lower quality of life,21 and increased anxiety and depression.22 Our analysis of postoperative A&SQ results showed a significant improvement of overall mean score and of mean score in all areas. We hypothesize that binocular vision is correlated to the distance estimation as well as to visual disorientation and that angle of strabismus is correlated with social contact and cosmesis results. Indeed, we found a significant improvement of mean score in these domains. The SF-36 questionnaire confirmed the postoperative improvement of overall mean score and of mean scores in 7 of 8 areas. All patients with satisfactory postoperative alignment displayed anomalous binocular responses and an increase of overall mean score with both questionnaires. Patients with an unsatisfactory postoperative alignment presented no changes of sensory status and an overall
1. Hatt SR, Leske DA, Kirgis PA, et al. The effects of strabismus on quality of life in adults. Am J Ophthalmol 2007;144:643-7. 2. Nelson BA, Gunton KB, Lasker JN, et al. The psychosocial aspect of strabismus in teenagers and adults and the impact of surgical correction. JAAPOS 2008;12:72-6. 3. Mills MD, Coats DK, Donahue SP, et al. Strabismus surgery for adults: A report by the American Academy of Ophthalmology. Ophthalmology 2004;111:1255-62. 4. Mets MB, Beauchamp C, Haldi BA. Binocularity following surgical correction of strabismus in adults. JAAPOS 2004;8:5435-8. 5. Wortham ED, Greenwald MJ. Expanded binocular peripheral visual fields following surgery for esotropia. J Pediatric Ophthalmol Strabismus 1989;26:109-12. 6. Kushner BJ, Morton GV. Post operative binocularity in adults with longstanding strabismus. Ophthalmology 1993;100:135-8. 7. Kushner BJ. Binocular field expansion in adults after surgery for esotropia. Arch Ophthalmol 1994;112:639-43. 8. Murray ADN, Orpen J, Calcutt C. Changes in the functional binocular status of older children and adults with previously untreated infantile esotropia following late surgical realignment. JAAPOS 2007;11:125-30. 9. Olitsky SE, Sudesch S, Graziano A, et al. The negative psychosocial impact of strabismus in adults. J AAPOS 1999;3:209-11. 10. Beauchamp GR, Black BC, Coats DK, et al. The management of strabismus in adults – III. The effects on disability. J AAPOS 2005;9:455-9. 11. Jackson S, Harrad RA, Morris M, et al. The psychosocial benefits of corrective surgery for adults with strabismus. Br J Ophthalmol 2006;90:883-8. 12. Edelman PM. Functional benefits of adult strabismus surgery. Am Orthopt J 2010;60:43-7. 13. Ware JE Jr, Sherbourne CD. The MOS 36-item short-form health survey (SF-36). Conceptual framework and item selection. Med Care 1992;30:473-83. 14. Van de Graaf ES, Van der Sterre GW, Polling JR, et al. Amblyopia & Strabismus Questionnaire: Design and initial validation. Strabismus 2004;12:181-93. 15. Van de Graaf ES, Felius J, van Kempen-du Saar H, et al. Construct validation of the Amblyopia and Strabismus Questionnaire (A&SQ) by factor analysis. Graefes Arch Clin Exp Ophthalmol 2009;247:1263-8. 16. Felius J, Beauchamp GR, Stager DR Sr, et al. The Amblyopia and Strabismus Questionnaire: English translation, validation, and subscales. Am J Ophthalmol 2007;143:305-10. 17. Carlton J, Kaltenthaler E. Health-related quality of life measures (HRQoL) in patients with amblyopia and strabismus: A systematic review. Br J Ophthalmol 2011;95:325-30. 18. Hatt SR, Leske DA, Bradley EA, et al. Comparison of quality of life instruments in adults with strabismus. Am J Ophthalmol 2009;148: 558-62. 19. Hatt SR, Leske DA, Holmes JM. Responsiveness of health-related quality-of-life questionnaires in adults undergoing strabismus surgery. Ophthalmology 2010;117:2322-8. 20. Lennerstrand G. Strabismus and eye muscle function. Acta Ophthalmol Scand 2007;85:711-23. 21. Menon V, Saha J, Tandon R, et al. Study of the psychosocial aspects of strabismus. J Pediatr Ophthalmol Strabismus 2002;39:203-8. 22. Satterfield D, Keltner JL, Morrison TL. Psychosocial aspects of strabismus study. Arch Ophthalmol 1993;111:1100-5. 23. Durnian JM, Noonan CP, Marsh IB. The psychosocial effects of adult strabismus: A review. Br J Ophthalmology 2011;95:450-53.
Journal of AAPOS
RESULTS
CONCLUSIONS
To evaluate the change in sensory status and quality-of-life measures in adults with longstanding childhood-onset constant strabismus. Consecutive patients with childhood-onset, long-term constant strabismus were enrolled. Sensory status was examined with Bagolini striated glasses test and Worth 4-dot test. Stereopsis was tested with the Lang and TNO stereopsis tests. Quality of life was studied with 2 different questionnaires (Short Form Health Survey [SF-36] and the Amblyopia and Strabismus Questionnaire [A&SQ]), which patients completed before and 3 months after strabismus surgery. A total of 20 patients (age range, 18-63 years) were included, 10 of whom were esotropic and 10 of whom were exotropic. Of these, 13 obtained a satisfactory postoperative alignment and demonstrated an increase of sensory status with Bagolini striated glasses. Six patients who demonstrated suppression preoperatively achieved fusion and stereopsis postoperatively. The mean score in all domains of the A&SQ improved significantly, particularly with regard to social contact and cosmesis (P 5 0.00067), distance estimation (P 5 0.000312), and visual disorientation (P 5 0.004777). Similarly, the mean score in 7 of 8 areas in the SF-36 improved significantly, particularly with regard to physical function (P 5 0.000564), general health (P 5 0.002296), vitality (P 5 0.002891), social function (P 5 0.004234), and mental health (P 5 0.000334). The overall mean score of both questionnaires improved in all patients with a satisfactory postoperative alignment and increase of sensory status. Surgical treatment of strabismus in adults with long-standing childhood-onset constant strabismus can result in patients feeling that their quality of life has improved and can restore binocular sensory function. ( J AAPOS 2013;17:25-28)
S
trabismus can affect many aspects of a patient’s quality of life, including psychosocial functioning and employment.1 It can lead to poor self-image, emotional problems, and social anxiety.2 The goal in treating strabismus in adults is to realign the visual axes to eliminate diplopia (when present), achieve or restore binocular function (if possible), and restore normal anatomic appearance.3 In several studies, the functional benefits of strabismus surgery in adults have been demonstrated4-8: expansion of visual fields, increase in sensory status with the Bagolini striated glasses, and a postoperative improvement in peripheral fusion assessed by Worth 4-dot test. Author affiliations: aInstitute of Ophthalmology, Catholic University, Rome, Italy; bDon Carlo Gnocchi Onlus Foundation, Italy Submitted May 6, 2012. Revision accepted September 14, 2012. Published online January 28, 2013. Correspondence: Sergio Petroni, MD, Institute of Ophthalmology, Catholic University, Largo F. Vito, 1 00168 Rome, Italy (email: [email protected]). Copyright Ó 2013 by the American Association for Pediatric Ophthalmology and Strabismus. 1091-8531/$36.00 http://dx.doi.org/10.1016/j.jaapos.2012.09.017
Journal of AAPOS
Although the treatment of strabismus in adults without binocular potential often has been considered merely “cosmetic,”9 in several studies authors have shown that, even when there is no hope of improving binocular function, strabismus surgery in adults positively affects self-image, leading to significant improvement in quality of life.10-12 A number of validated disease-specific instruments have been developed and applied in ophthalmology to assess changes in quality of life, such as Short Form Health Survey (SF-36),13 the Amblyopia and Strabismus Questionnaire (A&SQ),14-16 the Visual Function Index, the National Eye Institute Visual Function Questionnaire (51- and 25-item questionnaires), the Impact of Visual Impairment, and the Activities of Daily Vision Scale.17 The purpose of the present study was to evaluate postoperative changes in both sensory status and quality of life as measured by both SF-36 and A&SQ questionnaires in adults with long-standing childhood-onset constant strabismus.
Methods Consecutive patients examined in the Pediatric Ophthalmology and Strabismus Unit at the Catholic University of Rome were
25
26
Dickmann et al
enrolled in the study. All patients presented with concomitant horizontal strabismus and had a history of strabismus since childhood and a constant tropia at distance and near. Patients with normal binocular vision before strabismus surgery, organic eye disease, cataract, glaucoma, retinal or optic nerve disorder, laser treatment, or previous intraocular surgery were excluded. Patients presenting with a risk of postoperative diplopia also were excluded. All patients underwent surgical treatment. We defined a satisfactory outcome as postoperative deviation of #10D and the absence of diplopia. This study followed the tenets of the Declaration of Helsinki, and signed informed consent was obtained from each patient. Full ophthalmologic and orthoptic examinations were performed at baseline and 3 months after surgery, including ocular motility assessment, cycloplegic refraction, and dilated fundus examination. Patients underwent orthoptic examination while wearing their appropriate refractive correction. The deviation was measured before and after surgery by prism and cover test at distance and at near. The risk of postoperative diplopia was assessed by means of prismatic full correction of angle deviation. Sensory status was assessed pre- and postoperatively with Bagolini striated glasses and the Worth 4-dot test. Stereoacuity was tested by means of the Lang and TNO stereopsis tests. Functional recovery was defined as at least anomalous retinal correspondence and recovery of stereopsis. At baseline and 3 months after surgery, 2 questionnaires (SF-36 and the A&SQ) were administered in random order to all patients to assess the affects of strabismus on quality of life. Patients were provided with written instructions and allowed to complete the questionnaires in private. The Italian version of the validated A&SQ,14,15 translated from the English version, was used.16 The A&SQ contains 26 questions formulated within 5 areas: fear of losing the better eye, distance estimation, visual disorientation, diplopia, and social contact and cosmetic problems. All responses are graded on Likert-type scales. For the purpose of scoring, the rating scales are assumed to be linear and run from 0 to 100, where 0 corresponds to the least favorable score and 100 corresponds to the most favorable. A 5-option item thus has possible scores of 0, 25, 50, 75, and 100. The A&SQ total score, defined as the mean of all item scores, corresponds to overall quality of life. The SF-36 questionnaire, a widely used and well-validated generic quality of life instrument, comprises 36 items with 2 to 6 response options according to an ordinal scale. The SF-36 assesses 8 physical and mental health areas: physical function, role limitations due to physical health problems, bodily pain, general health, vitality, social function, role limitations due to emotional problems, and mental health. Raw scores were transformed to standardized scores on a scale from 0 to 100, with a greater score indicating better health-related quality of life.13 The t test was used for statistical analysis and the differences were considered significant if the P value was \0.05.
Results A total of 20 consecutive patients (10 males; mean age, 47 years; age range, 18-63 years) were included. Preoperative
Volume 17 Number 1 / February 2013 and 3-month postoperative amount of deviation, changes of sensory status, and stereoscopic test findings are presented in Table 1. In 11 patients strabismus emerged within the first year of life; in 9 patients between the first and the fifth year. Sensory Responses Of the 20 patients, 13 achieved a satisfactory postoperative alignment and all showed an increase of binocular fusion with Bagolini striated glasses. In particular, 4 patients with total suppression preoperatively achieved partial suppression and 9 patients anomalous retinal correspondence. Of the 13 patients with a satisfactory postoperative alignment and with improvement in sensory status with Bagolini striated glasses, 6 also improved to anomalous fusion and showed a gross stereoscopic response. The 7 patients with unsatisfactory postoperative alignment showed no improvement of sensory status nor recovery of stereopsis. With respect to type of strabismus, 9 of the 13 patients with a satisfactory postoperative alignment and improved sensory status were diagnosed within the first year of life (3 with esotropia and 6 with exotropia), and 4 were diagnosed between the first and the fifth year of life (3 with esotropia and 1 with exotropia). Of the 6 patients with esotropia, all showed anomalous binocular response with Bagolini striated glasses, and 2 achieved fusion (Worth 4-dot test) and demonstrated a gross stereopsis. The 7 patients with exotropia showed an anomalous binocular response with Bagolini striated glasses, and 4 achieved anomalous fusion (Worth 4-dot test) and gross stereopsis. Quality of Life For the 13 patients with satisfactory outcomes, the overall mean score with both questionnaires improved. For the 7 patients with unsatisfactory outcomes, the overall mean score remained unchanged with both questionnaires. With the A&SQ, 3 months after surgery the overall mean score improved by 19% (preoperative score, 63; postoperative score, 77; P 5 0.001). A lower overall mean score occurred only in 1 case. The mean score improved significantly in all areas (Figure 1), particularly with respect to contact and cosmesis (preoperative, 46; postoperative, 61; P 5 0.00067), distance estimation (preoperative, 72; postoperative, 88; P 5 0.000312), and visual disorientation (preoperative, 62; postoperative, 80; P 5 0.004777). With the SF-36 questionnaire, 3 months after surgery the overall mean score improved by 15% (preoperative, 73; postoperative, 85: P 5 0.000163). The mean score improved significantly in 7 of 8 areas (Figure 2), particularly with respect to physical function (preoperative, 82; postoperative, 96; P 5 0.000564), general health (preoperative, 70; postoperative, 79; P 5 0.002296), vitality (preoperative, 64; postoperative, 75; P 5 0.002891), social function (preoperative, 74, postoperative, 87; P 5 0.004234), and mental health domain (preoperative, 69; postoperative, 82; P 5 0.000334). With respect to bodily pain, improvement of the mean score was not statistically significant.
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27
Table 1. Clinical data Deviation Preop
Bagolini striated glasses Postop
Preop
Stereopsis, arcseca
Worth 4-dot test
Postop
Preop
Postop
D
N
D
N
D
N
D
N
D
N
D
N
Preop
Postop
b
1
48 ET
55 ET
10 ET
6 ET
Sup
Sup
ARC/Sup
ARC
Sup
Sup
Sup
Sup
2b
45 ET
50 ET
2 ET
2 XT
Sup
Sup
ARC/Sup
ARC
Sup
Sup
Sup
Sup
3b
20 XT
18 XT
4 XT
2 XT
Sup
Sup
ARC
ARC
Sup
Sup
Sup
Sup
4b
35 XT
45 XT
10 XT
12 XT
Sup
Sup
ARC
ARC
Sup
Sup
Sup
Sup
5b
45 XT
50 XT
30 XT
40 XT
Sup
Sup
Sup
Sup.
Sup
Sup
Sup
Sup
6b
36 XT
38 XT
4 XT
6 XT
Sup
Sup
ARC
ARC
Sup
Sup
ARC
ARC
7b
25 XT
35 XT
2 XT
8 XT
Sup
Sup.
ARC
ARC
Sup
Sup
Sup
ARC
8c
50 ET
55 ET
10 ET
18 ET
Sup
Sup
Sup
Sup
Sup
Sup
Sup
Sup
9b
20 ET
25 ET
2 ET
6 ET
Sup
Sup
ARC
ARC
Sup
Sup
Sup
Sup
10b
40 XT
45 XT
2 XT
4 ET
Sup
Sup.
ARC
ARC
Sup
Sup
ARC
ARC
b
11
58 XT
65 XT
10 XT
8 XT
Sup
Sup
ARC
ARC
Sup
Sup
ARC
ARC
12b
45 ET
45 ET
30 ET
30 ET
Sup
Sup
Sup
Sup
Sup
Sup
Sup
Sup
13c
35 XT
30 XT
25 XT
20 XT
Sup
Sup
Sup
Sup
Sup
Sup
Sup
Sup
14c
50 XT
55 XT
10 XT
2 XT
Sup.
Sup
ARC
ARC
Sup
Sup
Sup
Sup
15c
35 XT
40 XT
20 XT
30 XT
Sup
Sup
Sup
Sup
Sup
Sup
Sup
Sup
16c
40 ET
50 ET
6 ET
10 ET
Sup
Sup
ARC
ARC
Sup
Sup
ARC
ARC
17c
35 ET
40 ET
2 ET
2 ET
Sup
Sup
ARC/Sup
ARC
Sup
Sup
ARC
ARC
18c
40 ET
40 ET
25 ET
25 ET
Sup
Sup
Sup
Sup
Sup
Sup
Sup
Sup
19c
20 ET
20 ET
2 ET
2 ET
Sup
Sup
ARC/Sup
ARC
Sup
Sup
Sup
Sup
20c
50 ET
50 ET
10 ET
16 ET
Sup
Sup
Sup
Sup
Sup
Sup
Sup
Sup
Lang TNO Lang TNO Lang TNO Lang TNO Lang TNO Lang TNO Lang TNO Lang TNO Lang TNO Lang TNO Lang TNO Lang TNO Lang TNO Lang TNO Lang TNO Lang TNO Lang TNO Lang TNO Lang TNO Lang TNO
Lang 1 TNO Lang TNO Lang TNO Lang TNO Lang TNO Lang 1 TNO 2400 Lang 1 TNO 4800 Lang TNO Lang TNO Lang 1 TNO 2400 Lang 1 TNO 1200 Lang TNO Lang TNO Lang TNO Lang TNO Lang 1 TNO 1200 Lang 1 TNO 1200 Lang TNO Lang TNO Lang TNO
Case
ARC, anomalous retinal correspondence; D, at distance; ET, esotropia; N, at near; Postop, postoperative; Preop, preoperative; Sup, suppression; XT, exotropia. a Complete, 1; absent, . b Strabismus emerged within the first year of life. c Strabismus emerged between the first and the fifth year of life.
Discussion An improvement of sensory status after strabismus surgery in adults with long-standing constant strabismus has been reported in the literature. Kushner and Morton6 reported an improvement in sensory status as determined by means of Bagolini striated glasses. Mets and colleagues4 reported that adults that show no potential for binocularity preoperatively can experience improved sensory status, including stereopsis. Wortham and Greenwald5 reported expansion of the visual field after surgery for esotropia. In this study we tested the sensory status of adults before and after strabismus surgery to investigate the relationship
Journal of AAPOS
between surgical outcomes and changes in quality of life assessments. We observed that all patients with satisfactory postoperative alignment achieved a form of anomalous binocular cooperation with Bagolini striated glasses (a nondissociating test), with 6 patients achieving fusion and recovering stereopsis. The surgical reduction of the angle of deviation could help the eyes to obtain a form of binocular cooperation with, in some cases, achievement of a gross stereopsis. We demonstrated gross stereoscopic responses in 6 subjects, in 4 of whom exotropia presented in the first year of life and in 2 of whom esotropia onset was between 1 and 5 years of age. We hypothesize that in these
28
Dickmann et al
Volume 17 Number 1 / February 2013 mean score unvaried with both questionnaires. These findings suggest that surgical treatment in adults with strabismus, even when the restoration of binocular vision is unlikely, may significantly improve the health-related quality of life and, in many cases, binocular function.23 References
FIG 1. A&SQ mean scores in 5 major areas and overall. FLBE, fear of losing the better eye; DE, distance estimation; VD, visual disorientation; DV, double vision; CC, contact and cosmesis.
FIG 2. SF-36 mean score in major 8 major areas and overall. PF, physical function; RP, role limitations due to physical health problems; BP, bodily pain (P . 0.05); GH, general health, VT, vitality; SF, social function; RE, role limitations due to emotional problems; MH, mental health.
2 patients the later onset of deviation allowed for development of some form of binocular cooperation. It is well known that exodeviations may become constant after a period of intermittency, so it is possible that our exotropic patients had an intermittent deviation in the first years of life. Several investigators18-23 have addressed the psychological impact of strabismus in adults by comparing preoperative and postoperative data by the use of standardized questionnaires relating surgical results and psychosocial outcomes. These studies have shown that strabismus is associated not only with functional deficits20 but also with psychosocial problems, a more negative selfimage, a lower quality of life,21 and increased anxiety and depression.22 Our analysis of postoperative A&SQ results showed a significant improvement of overall mean score and of mean score in all areas. We hypothesize that binocular vision is correlated to the distance estimation as well as to visual disorientation and that angle of strabismus is correlated with social contact and cosmesis results. Indeed, we found a significant improvement of mean score in these domains. The SF-36 questionnaire confirmed the postoperative improvement of overall mean score and of mean scores in 7 of 8 areas. All patients with satisfactory postoperative alignment displayed anomalous binocular responses and an increase of overall mean score with both questionnaires. Patients with an unsatisfactory postoperative alignment presented no changes of sensory status and an overall
1. Hatt SR, Leske DA, Kirgis PA, et al. The effects of strabismus on quality of life in adults. Am J Ophthalmol 2007;144:643-7. 2. Nelson BA, Gunton KB, Lasker JN, et al. The psychosocial aspect of strabismus in teenagers and adults and the impact of surgical correction. JAAPOS 2008;12:72-6. 3. Mills MD, Coats DK, Donahue SP, et al. Strabismus surgery for adults: A report by the American Academy of Ophthalmology. Ophthalmology 2004;111:1255-62. 4. Mets MB, Beauchamp C, Haldi BA. Binocularity following surgical correction of strabismus in adults. JAAPOS 2004;8:5435-8. 5. Wortham ED, Greenwald MJ. Expanded binocular peripheral visual fields following surgery for esotropia. J Pediatric Ophthalmol Strabismus 1989;26:109-12. 6. Kushner BJ, Morton GV. Post operative binocularity in adults with longstanding strabismus. Ophthalmology 1993;100:135-8. 7. Kushner BJ. Binocular field expansion in adults after surgery for esotropia. Arch Ophthalmol 1994;112:639-43. 8. Murray ADN, Orpen J, Calcutt C. Changes in the functional binocular status of older children and adults with previously untreated infantile esotropia following late surgical realignment. JAAPOS 2007;11:125-30. 9. Olitsky SE, Sudesch S, Graziano A, et al. The negative psychosocial impact of strabismus in adults. J AAPOS 1999;3:209-11. 10. Beauchamp GR, Black BC, Coats DK, et al. The management of strabismus in adults – III. The effects on disability. J AAPOS 2005;9:455-9. 11. Jackson S, Harrad RA, Morris M, et al. The psychosocial benefits of corrective surgery for adults with strabismus. Br J Ophthalmol 2006;90:883-8. 12. Edelman PM. Functional benefits of adult strabismus surgery. Am Orthopt J 2010;60:43-7. 13. Ware JE Jr, Sherbourne CD. The MOS 36-item short-form health survey (SF-36). Conceptual framework and item selection. Med Care 1992;30:473-83. 14. Van de Graaf ES, Van der Sterre GW, Polling JR, et al. Amblyopia & Strabismus Questionnaire: Design and initial validation. Strabismus 2004;12:181-93. 15. Van de Graaf ES, Felius J, van Kempen-du Saar H, et al. Construct validation of the Amblyopia and Strabismus Questionnaire (A&SQ) by factor analysis. Graefes Arch Clin Exp Ophthalmol 2009;247:1263-8. 16. Felius J, Beauchamp GR, Stager DR Sr, et al. The Amblyopia and Strabismus Questionnaire: English translation, validation, and subscales. Am J Ophthalmol 2007;143:305-10. 17. Carlton J, Kaltenthaler E. Health-related quality of life measures (HRQoL) in patients with amblyopia and strabismus: A systematic review. Br J Ophthalmol 2011;95:325-30. 18. Hatt SR, Leske DA, Bradley EA, et al. Comparison of quality of life instruments in adults with strabismus. Am J Ophthalmol 2009;148: 558-62. 19. Hatt SR, Leske DA, Holmes JM. Responsiveness of health-related quality-of-life questionnaires in adults undergoing strabismus surgery. Ophthalmology 2010;117:2322-8. 20. Lennerstrand G. Strabismus and eye muscle function. Acta Ophthalmol Scand 2007;85:711-23. 21. Menon V, Saha J, Tandon R, et al. Study of the psychosocial aspects of strabismus. J Pediatr Ophthalmol Strabismus 2002;39:203-8. 22. Satterfield D, Keltner JL, Morrison TL. Psychosocial aspects of strabismus study. Arch Ophthalmol 1993;111:1100-5. 23. Durnian JM, Noonan CP, Marsh IB. The psychosocial effects of adult strabismus: A review. Br J Ophthalmology 2011;95:450-53.
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