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Clinical science
Effects of corrective surgery on social phobia, psychological distress, disease-related disability and quality of life in adult strabismus patients Gokay Alpak,1 Erol Coskun,2 Ibrahim Erbagci,2 Yasin Bez,3 Seydi Okumus,2 Burak Oren,2 Bulent Gurler2 1
Faculty of Medicine, Department of Psychiatry, Gaziantep University, Gaziantep, Turkey 2 Faculty of Medicine, Department of Opthalmology, Gaziantep University, Gaziantep, Turkey 3 Faculty of Medicine, Department of Psychiatry, Marmara University, Istanbul, Turkey Correspondence to Erol Coskun, Faculty of Medicine, Department of Opthalmology, Gaziantep University, 27310 Şahinbey, Gaziantep, Turkey; [email protected] Received 13 January 2014 Accepted 17 February 2014 Published Online First 13 March 2014
ABSTRACT Background Corrective surgery is done for ocular alignment and disrupted facial expression in some cases of adult strabismus patients. The effects of corrective surgery on the presence of social phobia (SP) diagnosis, the severity of social anxiety symptoms, the disease-related disability and the quality of life (QoL) among strabismus patients have not been thoroughly studied yet. Methods The study sample was composed of patients who had undergone corrective surgery for strabismus. Preoperative and postoperative evaluations made by using standardised measures of social phobia diagnosis (DSM-IV-TR) and severity (Liebowitz Social Anxiety Scale (LSAS)), anxiety and depression (Hospital Anxiety and Depression Scale (HADS)), disability (Sheehan Disability Scale) and quality of life (short form-36). Results Preoperatively, SP diagnosis was detected in 17 of 31 (54.8%) patients, whereas postoperatively 6 of 31 (19.4%) patients had SP ( p=0.001). Participants showed a significant decrease in all subscale scores and total score of both LSAS and HADS compared with their preoperative scores. Significant improvements were observed in QoL and disability scores as well. Conclusions Adult strabismus patients seem to gain benefits from corrective surgery not only for their ocular misalignment but also for social anxiety levels that may be associated with improvements in their QoL and disability levels.
INTRODUCTION
To cite: Alpak G, Coskun E, Erbagci I, et al. Br J Ophthalmol 2014;98: 876–879. 876
Strabismus is relatively common in the adult population and its prevalence is estimated to be around 4% in the USA.1 Purposes of surgical treatment of strabismus may be correction of ocular alignment, obtaining binocular vision, increasing visual field in patients with esotropia and correction of diplopia. If a patient does not have the ability of binocular vision and consequently has diplopia, then correcting the ocular alignment and disrupted facial expression is the purpose of surgical treatment.2 Ocular alignment is an important factor for normal socialisation process; therefore, strabismus may impair that of affected individuals.3–7 In a research, strabismus patients have reported problems in maintaining eye contact, a tendency to hide themselves, low self-esteem and avoidance from eye-contacting activities.8 It might be important to note that these symptoms are also shared by patients with social phobia (SP) diagnosis. SP can be defined as the fear of being ashamed or humiliated in various social settings, such as speaking in
public or participating with a group of unfamiliar people.9 SP secondary to various disfiguring or disabling physical conditions, such as essential tremor, stuttering, spasmodic torticollis, acne vulgaris and strabismus, has been studied in recent years.10–15 In some studies, improvements in self-esteem, ability to meet with new people, social relations and employment rates of strabismus patients have been reported after their surgical treatment.3 8 16 17 The effects of corrective surgery on the presence of SP diagnosis, the severity of social anxiety symptoms, the level of psychological distress, the disease-related disability and the quality of life (QoL) among strabismus patients have not been thoroughly studied yet. In an attempt to fill this gap in the literature, a group of adult strabismus patients were interviewed before and after their surgical correction to determine SP diagnosis, severity of social anxiety, psychological distress, disease-related disability and their healthrelated QoL.
MATERIALS AND METHODS The study group was composed of patients who had undergone surgery for strabismus in an ophthalmology clinic of university hospital in Turkey. A complete ophthalmological examination and motility examination including prism cover test at distance and near primary position have been performed on all patients. Among them patients who were over 15 years of age and diagnosed with strabismus (over 25 prism dioptres (PD)) were included in the study. Patients with any facial deformity, any other physical disfiguring condition, any neurological disorders and with a residual strabismus showing a deviation of >10 were excluded from the study. The SP module of the Structured Clinical Interview for the DSM-IV Axis-I Disorders was administered by a senior psychiatrist (GA). As proposed by the other authors, we modified the DSM-IV criteria by ignoring criterion H (which excludes social anxiety due to a general medical condition) to permit a diagnosis of SP.10–15 The same psychiatrist administered the Liebowitz Social Anxiety Scale (LSAS) to assess the severity of SP. The patients completed a global measure of anxiety and depression (Hospital Anxiety and Depression Scale (HADS)), Sheehan Disability Scale (SDS) and shortform 36 (SF-36) scale. All patients were operated under general anaesthesia, and after surgery were prescribed topical moxifloxacin 0.5% and dexamethasone 0.1% eye drops to be applied five times daily for 1 month. Postoperative control examinations (a complete ophthalmic and motility
Alpak G, et al. Br J Ophthalmol 2014;98:876–879. doi:10.1136/bjophthalmol-2014-304888
Downloaded from http://bjo.bmj.com/ on March 29, 2015 - Published by group.bmj.com
Clinical science examination) of patients were performed, and all patients achieved normal ocular alignment after their controls. In this study, psychiatric clinical interviews were conducted with all patients and their forms were filled out 1 week prior to their surgery and 3 months after achieving orthophoria. SPSS software V.18.0 (SPSS for Windows software; SPSS, Inc, Chicago, Illinois, USA) was used for statistical analyses. Descriptive data were reported as frequency, percentage, mean ±SD or mode (min-max). The Kolmogorov–Smirnov test (K-S test) was performed to test the normal distribution of the variables. For continuous variables, paired samples t test was used if the variables showed normal distribution or its non-parametric equivalent Wilcoxon test was used where the variables were not distributed normally. Comparisons of categorical variables before and after surgery were performed by using the McNemar test. For all comparisons, p
Clinical science
Effects of corrective surgery on social phobia, psychological distress, disease-related disability and quality of life in adult strabismus patients Gokay Alpak,1 Erol Coskun,2 Ibrahim Erbagci,2 Yasin Bez,3 Seydi Okumus,2 Burak Oren,2 Bulent Gurler2 1
Faculty of Medicine, Department of Psychiatry, Gaziantep University, Gaziantep, Turkey 2 Faculty of Medicine, Department of Opthalmology, Gaziantep University, Gaziantep, Turkey 3 Faculty of Medicine, Department of Psychiatry, Marmara University, Istanbul, Turkey Correspondence to Erol Coskun, Faculty of Medicine, Department of Opthalmology, Gaziantep University, 27310 Şahinbey, Gaziantep, Turkey; [email protected] Received 13 January 2014 Accepted 17 February 2014 Published Online First 13 March 2014
ABSTRACT Background Corrective surgery is done for ocular alignment and disrupted facial expression in some cases of adult strabismus patients. The effects of corrective surgery on the presence of social phobia (SP) diagnosis, the severity of social anxiety symptoms, the disease-related disability and the quality of life (QoL) among strabismus patients have not been thoroughly studied yet. Methods The study sample was composed of patients who had undergone corrective surgery for strabismus. Preoperative and postoperative evaluations made by using standardised measures of social phobia diagnosis (DSM-IV-TR) and severity (Liebowitz Social Anxiety Scale (LSAS)), anxiety and depression (Hospital Anxiety and Depression Scale (HADS)), disability (Sheehan Disability Scale) and quality of life (short form-36). Results Preoperatively, SP diagnosis was detected in 17 of 31 (54.8%) patients, whereas postoperatively 6 of 31 (19.4%) patients had SP ( p=0.001). Participants showed a significant decrease in all subscale scores and total score of both LSAS and HADS compared with their preoperative scores. Significant improvements were observed in QoL and disability scores as well. Conclusions Adult strabismus patients seem to gain benefits from corrective surgery not only for their ocular misalignment but also for social anxiety levels that may be associated with improvements in their QoL and disability levels.
INTRODUCTION
To cite: Alpak G, Coskun E, Erbagci I, et al. Br J Ophthalmol 2014;98: 876–879. 876
Strabismus is relatively common in the adult population and its prevalence is estimated to be around 4% in the USA.1 Purposes of surgical treatment of strabismus may be correction of ocular alignment, obtaining binocular vision, increasing visual field in patients with esotropia and correction of diplopia. If a patient does not have the ability of binocular vision and consequently has diplopia, then correcting the ocular alignment and disrupted facial expression is the purpose of surgical treatment.2 Ocular alignment is an important factor for normal socialisation process; therefore, strabismus may impair that of affected individuals.3–7 In a research, strabismus patients have reported problems in maintaining eye contact, a tendency to hide themselves, low self-esteem and avoidance from eye-contacting activities.8 It might be important to note that these symptoms are also shared by patients with social phobia (SP) diagnosis. SP can be defined as the fear of being ashamed or humiliated in various social settings, such as speaking in
public or participating with a group of unfamiliar people.9 SP secondary to various disfiguring or disabling physical conditions, such as essential tremor, stuttering, spasmodic torticollis, acne vulgaris and strabismus, has been studied in recent years.10–15 In some studies, improvements in self-esteem, ability to meet with new people, social relations and employment rates of strabismus patients have been reported after their surgical treatment.3 8 16 17 The effects of corrective surgery on the presence of SP diagnosis, the severity of social anxiety symptoms, the level of psychological distress, the disease-related disability and the quality of life (QoL) among strabismus patients have not been thoroughly studied yet. In an attempt to fill this gap in the literature, a group of adult strabismus patients were interviewed before and after their surgical correction to determine SP diagnosis, severity of social anxiety, psychological distress, disease-related disability and their healthrelated QoL.
MATERIALS AND METHODS The study group was composed of patients who had undergone surgery for strabismus in an ophthalmology clinic of university hospital in Turkey. A complete ophthalmological examination and motility examination including prism cover test at distance and near primary position have been performed on all patients. Among them patients who were over 15 years of age and diagnosed with strabismus (over 25 prism dioptres (PD)) were included in the study. Patients with any facial deformity, any other physical disfiguring condition, any neurological disorders and with a residual strabismus showing a deviation of >10 were excluded from the study. The SP module of the Structured Clinical Interview for the DSM-IV Axis-I Disorders was administered by a senior psychiatrist (GA). As proposed by the other authors, we modified the DSM-IV criteria by ignoring criterion H (which excludes social anxiety due to a general medical condition) to permit a diagnosis of SP.10–15 The same psychiatrist administered the Liebowitz Social Anxiety Scale (LSAS) to assess the severity of SP. The patients completed a global measure of anxiety and depression (Hospital Anxiety and Depression Scale (HADS)), Sheehan Disability Scale (SDS) and shortform 36 (SF-36) scale. All patients were operated under general anaesthesia, and after surgery were prescribed topical moxifloxacin 0.5% and dexamethasone 0.1% eye drops to be applied five times daily for 1 month. Postoperative control examinations (a complete ophthalmic and motility
Alpak G, et al. Br J Ophthalmol 2014;98:876–879. doi:10.1136/bjophthalmol-2014-304888
Downloaded from http://bjo.bmj.com/ on March 29, 2015 - Published by group.bmj.com
Clinical science examination) of patients were performed, and all patients achieved normal ocular alignment after their controls. In this study, psychiatric clinical interviews were conducted with all patients and their forms were filled out 1 week prior to their surgery and 3 months after achieving orthophoria. SPSS software V.18.0 (SPSS for Windows software; SPSS, Inc, Chicago, Illinois, USA) was used for statistical analyses. Descriptive data were reported as frequency, percentage, mean ±SD or mode (min-max). The Kolmogorov–Smirnov test (K-S test) was performed to test the normal distribution of the variables. For continuous variables, paired samples t test was used if the variables showed normal distribution or its non-parametric equivalent Wilcoxon test was used where the variables were not distributed normally. Comparisons of categorical variables before and after surgery were performed by using the McNemar test. For all comparisons, p
