Patient Factors, Postop Diplopia Tied to Dissatisfaction After Strabismus Surgery

By Marilynn Larkin

December 04, 2017

NEW YORK (Reuters Health) – Postoperative diplopia, depressive symptoms, "distressed" personality type, and visually obtrusive facial anomalies are associated with failure of strabismus surgery to improve patients' health-related quality of life (HRQOL), researchers say.

"It is important to include the patient’s perspective in evaluating the success or failure of any medical treatment," Dr. Jonathan Holmes of Mayo Clinic in Rochester, Minnesota, told Reuters Health.

"We previously developed the Adult Strabismus-20 (AS-20) HRQOL questionnaire ( to specifically evaluate how strabismus affects a patient’s everyday life, both in the areas of functional vision and quality of life - specifically, how ocular misalignment affects their self-perception and interactions," he said by email.

"In this study, we asked the question 'what factors are associated with failure of the AS-20 scores to improve after eye muscle surgery?'”

Dr. Holmes and colleagues prospectively enrolled 276 strabismus surgery patients (median age, 57; 55% women; 96% white) at Mayo Clinic. All completed the AS-20 HRQOL and clinical questionnaires on diplopia, depression, and type-D ("distressed") personality - both preoperatively and six weeks postoperatively.

Each of the four AS-20 domains (self-perception, interactions, reading function and general function) was analyzed separately and factors associated with failure of scores to improve postoperatively were identified.

As reported in JAMA Ophthalmology, online November 22, failure to improve on AS-20 HRQOL scores was associated with worse postoperative diplopia in the domains of self-perception, reading function, and general function.

Failure to improve in the self-perception domain was associated significantly with postoperative measures of type-D personality (adjusted risk ratio, 4.26); failure to improve in the interactions domain had significant associations with coexisting visually obtrusive anomaly (ARR, 2.12) and with depressive symptoms (ARR, 1.04).

"Not surprisingly, we found that double vision after surgery was strongly associated with failure to improve AS-20 scores, both in functional vision domains and in psychosocial domains," Dr. Holmes said. "Strabismus surgery is often performed to improve double vision, so if that effort fails, then patient-reported function and quality of life are less likely to improve."

"But importantly . . . our study highlights the need to consider psychological factors and personality parameters when interpreting patient-reported outcome measures such as HRQOL," he added. "Appropriate referral should be made by the treating strabismus specialist to our psychiatry colleagues if the patient expresses depressive symptoms."

Dr. Sean Donahue of the Vanderbilt Eye Institute in Nashville commented, "The sole outcome being measured in this study was improvement on a 20-question questionnaire about 'health-related quality of life.'"

"It should be noted that other outcomes - resolution of double vision, improvement in ocular alignment, improvement in visual function - were not addressed in this study," he told Reuters Health by email. "(Patients) may have had improvement in other indicators, but not in what is measured by this questionnaire."

"Nonetheless," he added, "the authors are to be congratulated on developing a questionnaire that helps to quantify the improvement obtained as a result of strabismus surgery, and to find characteristics . . . that predict lack of improvement."

"The strabismus surgeon needs to pay particular attention to identifying patients who are experiencing severe double vision, or who have pre-existing depression or visually significant facial anomalies, and ensure they are adequately informed that they are at risk of not feeling they have had improvement after surgery," Dr. Donohue concluded.


JAMA Ophthalmol 2017.


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