|Year : 2022 | Volume
| Issue : 2 | Page : 159-163
Strabismus and Quality of Life: The Impact of Surgical Intervention in Children and Adolescents in Colombia
Paola Pacheco1, Sarah Andrews2, Roberto Chaskel3
1 Department of Pediatrics and Mental Health Bogotá-, Colombia
2 Department of Psychiatry, University of Florida College of Medicine, Gainesville, FL, US
3 Departments of Pediatrics and Mental Health. Central Military Hospital, Bogotá-, Colombia
|Date of Submission||29-Jun-2022|
|Date of Decision||29-Jun-2022|
|Date of Acceptance||30-Jun-2022|
|Date of Web Publication||22-Aug-2022|
Dr. Paola Pacheco
Calle 103 #68a 54, Floresta II Sector, Casa, Bogota
Source of Support: None, Conflict of Interest: None
Introduction: Strabismus is a condition that impacts a variety of functional and psychosocial domains. One of the major areas of interest in the management of strabismus is improvement in the patient's quality of life (QOL), yet, the effect of surgical intervention on QOL is unclear, especially in pediatric populations. The aim of this study is to evaluate changes in the perception of QOL using the KIDSCREEN-52 questionnaire in a pediatric population both before and after surgical correction of strabismus. Methods: A prospective descriptive study was conducted in a sample of 8–17-year-old children and adolescents whose perception of QOL was evaluated using the KIDSCREEN-52 questionnaire. The questionnaire was administered prior to and 3 months after surgical correction and administered in two specialized institutions in Bogota, Colombia. Results: Twenty seven subjects were included, 59.3% (n = 16) were male with a mean age of 11.5 years. The etiology of strabismus was identified as congenital in 66.7% (n = 18) and bilateral in 59.3% (n = 16), while esotropia was the most common type (55.6%). The QOL measure, KIDSCREEN-52, resulted a statistically significant positive effect in all dimensions, except for the Financial Resources dimension. Conclusion: Subjects who underwent surgical intervention perceived improvement in almost all areas of QOL. These results highlight the importance of early surgical intervention, with an added opportunity to improve the patient's mental and social wellbeing, secondary to surgical correction of strabismus.
Keywords: Eye surgery, KIDSCREEN-52, ophthalmologic surgery, quality of life, strabismus
|How to cite this article:|
Pacheco P, Andrews S, Chaskel R. Strabismus and Quality of Life: The Impact of Surgical Intervention in Children and Adolescents in Colombia. World Soc Psychiatry 2022;4:159-63
| Introduction|| |
Strabismus is an ophthalmological condition with a prevalence of approximately 2%–5% in the pediatric population, with increased frequency in certain subgroups, prevalent up to 44%., Strabismus is characterized by ocular misalignment, due to neuromuscular or ocular mobility/movement anomalies, where the foveae of both eyes are not simultaneously aligned with object of focus. Therefore, strabismus can be classified as concomitant, paralytic, restrictive, sensory or syndromic. In the clinical setting, strabismus is described by the direction of the deviation: inward (eso), outward (exo), vertical (hypo/hyper), tortional; and any associated change with gaze: Comitant, incomitant and alternating/intermittent.,
Medical and surgical interventions are available in the management of strabismus. A variety of modalities can be utilized by the physician, including occlusion therapy, corrective lenses, orthoptic therapy and botulinum toxin. If results from nonsurgical measures are unsatisfactory, the physician can perform surgical manipulation of the extraocular muscles through an incision in the conjunctival cul-de-sac. In specialized facilities, this procedure can be performed in an average of 30–90 min, with the clinical objective of enabling binocular vision.,,
The complications of strabismus include amblyopia, diplopia and contractures of extraocular muscles, with a negative impact on academic and psychosocial environments. One of the first studies evaluating the psychological impacts of strabismus was published in 1987 by Eustis and Smith, who found that 41% of parents recognize the negative impact of strabismus on their child's psychological development and/or self-esteem. Similarly, other authors have demonstrated the possible association between strabismus and isolation from peers, being bullied, increased anxiety and feelings of sadness, low self-esteem, preoccupation with hiding their appearance, among others.
Therefore, it is essential to discuss improvement in quality of life (QOL) in patients with strabismus, as one of the fundamental objectives of medical intervention. According to the World Health Organization, QOL is defined as “individual's perceptions of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns.” Within this broad construct is the Health-Related QOL (HRQoL), defined as the value assigned to life according to the modification due to disability, invalidity and social opportunities, affected by illnesses and diseases.,
Some studies have utilized QOL scales with adequate psychometric characteristics in the pediatric population with strabismus., These studies have shown a lower score in QOL reported by parents of children with strabismus, compared to subjects without the condition, especially in subscales measuring relationship with peers. As for the effects of surgical correction, Chew-Ean et al. found an improvement in QOL after surgical correction of exotropia in a sample of children and adolescents aged 8–17 years in Malaysia.
Nonetheless, there are no known studies that replicate the effects of surgical intervention on QOL, nor has this been evaluated in the Latin American population. Thus, this study aims to identify whether there is a change in the perception of QOL after surgical correction of strabismus in pediatric patients in an outpatient ophthalmology clinic in Bogotá, Colombia.
We included subjects between ages 8 and 17, patients from the ophthalmology service, who were diagnosed with strabismus and underwent surgical correction at the Central Military Hospital between August 1, 2015 and September 30, 2016 or at the Simón Bolívar Hospital between May 1, 2016 and October 1, 2016, in the City of Bogotá D. C, Colombia. We excluded patients whose parents did not provide informed consent to participate in this study, patients who did not complete the required measures, and patients with moderate to severe intellectual disability, cerebral palsy, or Downs syndrome since these conditions couldinterfere with subject's ability to complete the questionnaires.
| Methods|| |
This is a longitudinal, descriptive, observational study of all patients between 8 and 17 years of age who were admitted for surgical correction of strabismus and met the aforementioned selection criteria. After signed informed consent was obtained from the child's legal guardian, a survey was administered to acquire details about the subject's sociodemographic, socioeconomic and social networks, along with a self-administered, KIDSCREEN-52 QOL questionnaire. These forms were completed in 60–90 min, in the presence of a principal investigator within the institution's outpatient exam rooms, ensuring a quiet environment with adequate privacy. The variables of each group, at the time of entry into the study, are described below:
- Sociodemographic and socioeconomic: age, sex, educational level (at the time of entry into the study) and housing type (socioeconomic status)
- Social support: those living in the same home as the subject (both parents, single father, single mother, one or both parents and siblings, other relatives or shelters) and other close contacts of the subject (siblings, neighbors, classmates, cousins orno one)
- Clinical characteristics of strabismus: etiology of strabismus (congenital, paralytic, restrictive or secondary), type of strabismus (esotropia, exotropia, vertical strabismus or paralytic) and previous treatments (medical, surgical or both)
- Development and school performance: delay in motor development and school difficulties (repeated grades)
- KIDSCREEN-52 Quality of Life scale: This is a self-administered multidimensional questionnaire, designed by Aymerich et al. for children between 8 and 12 years that evaluates ten HRQoL dimensions: Psychological Well-being, Physical well-being, Moods and Emotions, Self-Perception, Autonomy, Parent Relations and Home Life, Social Support and Peers, School Environment, Social Acceptance (Bullying), and Financial Resources. This is a Likert-type scale with 52 items. The Spanish version of KIDSCREEN-52 has been culturally adapted and validated in Colombian children and adolescents, ages 8–18 years, by Valencia et al., who documented an adequate internal consistency and reliability in each of the different dimensions. Furthermore, this instrument is already widely utilized clinically with Colombian child and adolescent populations.,
Three months after surgery, in addition to the routine outpatient ophthalmologic follow up evaluation, each subject completed the QOL questionnaire under similar conditions as the initial visit.
This study follows the national guidelines for human research as outlined in the 1993 version of Resolution Number 8430, issued by the Ministry of Health and Social Protection of the Republic of Colombia and in the 2013 Law 1581, which ensures that personal details of each subject remain anonymous., Also, internationally recognized ethical principles were followed as outlined in the Declaration of Helsinki– Fortaleza and in the Belmont Report., Approvals were obtained from the Central Military Hospital's Ethics Committee in 2015 and from the Institutional Ethics Committee of Campo Abierto in 2016.
Collected data was organized using Microsoft Excel®. Statistical analysis was performed using SPSS Statistics version 21, designed by IBM in New York City, Unite States of America, in 2012 having an institutional license. For the univariate analysis, descriptive statistics were performed, using measures of central tendency and dispersion for the continuous quantitative variables. For categorical variables, absolute and relative frequency tables were used.
To perform the bivariate analysis, the distribution of the continuous quantitative variables was evaluated using the nonparametric Shapiro–Wilk test. Depending on the results, if the null hypothesis was rejected, the Wilcoxon sign test, a nonparametric statistical measure was implemented, while the Student's t-test, a parametric statistical measure, was used if the null hypothesis was not rejected. To determine differences between subgroups for categorical variables, Chi-squared or Fisher's exact tests were used after ensuring compliance with statistical test assumptions
| Results|| |
Between August 1, 2015 and September 30, 2016, 27 patients met the study inclusion criteria and completed the surveys [Table 1]. Of these, 59.3% (n = 16) of the subjects were male, with a mean age of 11.5 years (standard deviation: ±2.74 years), with ages ranging from 8 to 17 years. Regarding the subject's gender, there were nostatistically significant differences in age, school dysfunction or psychomotor retardation (P > 0.05).
Regarding other characteristics, 59.3% of the subjects resided in middle class housing. At the time of the survey, most subjects reported living with one or both parents and siblings, all subjects were in school, with the majority enrolled in secondary education. Academic difficulties leading to repeated school years were reported by 33.3% of subjects.
Esotropia was the most frequent type of strabismus in the sample, present in 55.6% of cases. Regarding the etiology of strabismus, the most frequent was congenital, occurring in 66.7% of cases, followed by paralytic in 18.5%, with bilateral involvement in 59.3% of the cases. All subjects had previously received treatment for strabismus: 11.1% received surgical intervention, 74.1% medical intervention, and the rest received a combination of medical and surgical interventions.
The KIDSCREEN-52 questionnaire was completed by the 27 participants both prior to and 3 months after the surgical correction of strabismus. None of the subjects expressed difficulties in completing the questionnaire, nor were any subjects lost to follow-up. The results of KIDSCREEN-52 questionnaire performed after surgical intervention demonstrated a statistically significant improvement in all dimensions, except in Financial Resources (P = 0.1), when compared with results from the initial KIDSCREEN questionnaire [Table 2].
| Discussion|| |
This is one of the first known studies to evaluate changes in the perception of QOL in children and adolescents with strabismus before and after surgical correction of strabismus and is the first of its kind in Latin America. The 27 subjects who met inclusion criteria were recruited from ophthalmology services within two institutions in the city of Bogotá.
Perception of QOL was quantified by using the KIDSCREEN-52 self-administered questionnaire, resulting a positive impact in all of its dimensions, except for the financial resources dimension. This is an expected finding given that this dimension gauges the financial resources in the subject's family of origin. The overall results suggest that surgical correction of strabismus could have a positive impact on the perception of QOL in minors. Yet, additional research is required to evaluate other associated factors and to better identify patients who would have added benefit from surgical intervention.
The results of this study support previous publications that demonstrate a lower perceived QOL in minors with strabismus.,,, Moreover, similar to previous studies, there is evidence of improvement both in peer relations and social acceptance after corrective intervention. In a study by Schuster et al., implementing the KiGGS scale in 3–17-year-old German children with strabismus versus controls, differences in the “friends” subscale were statistically significant. Similar results were documented in a study by Hatt et al. who found that American children with strabismus had lower levels of social functionality when compared to controls.
Regarding the impact of surgical intervention, a study of 34 Malaysian children with exotropia, aged 8–17 years, demonstrated statistically significant improvement in the functional and psychosocial subscales of the Intermittent Exotropia Questionnaire after surgical intervention. They also found that improvement was more substantial in girls than in boys. On the other hand, using the KIDSCREEN-52 in a sample of 27 Colombian children with strabismus, this study demonstrates improvement in all QOL dimensions after surgical intervention, with the exception of financial resources. It is important to highlight that this study included different types of strabismus, with a majority of subjects with esotropia, without statistically significant gender differences. This indicates that these findings are not limited to a single type of strabismus and that a diverse population of children and adolescents with strabismus could benefit from surgical intervention.
Regarding the limitations of this study, the sample size was small despite having a long recruitment period, attributed to the low prevalence rate and barriers in the recruitment of minors into the study. Additionally, the KIDSCREEN-52 questionnaire was not designed to assess QOL explicitly in strabismus or with surgical interventions, and therefore does not evaluate areas specific to these conditions. Nevertheless, it has been utilized extensively in the assessment of QOL in this age group and has adequate psychometric properties to justify its use.
| Conclusion|| |
This study demonstrates an improvement in the perception of QOL in a group of Colombian children and adolescents with strabismus after corrective surgery. This result supports previously published literature and highlights the importance of a QOL assessment at the time of decision-making in the clinical setting and during postintervention follow-up. It is imperative to conduct new research to evaluate the interplay of contributing variables within this result.
At the same time, this investigation also brings up a need for more research on the impact of various physical/ medical and psychiatric disorders/ conditions and their impact on quality of life for children and youth. Such investigations need to be contextualized within different cultural/ national settings and can examine both the visibility (versus invisibility) of the condition as well as the stigma associated with that the disorder/condition in that cultural context.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Liu G, Ranka MP. Strabismus surgery for children with developmental delay. Curr Opin Ophthalmol 2014;25:417-23.
Camacho JC, Bravo ML. Strabismus and Amblyopia: Basic Concepts for Primary Care Physicians. MedUNAB 2011;14:106-20.
Gunton KB, Wasserman BN, DeBenedictis C. Strabismus. Prim Care 2015;42:393-407.
Kassem IS, Miller MT, Archer SM. One year of pediatric ophthalmology and strabismus research in review. Asia Pac J Ophthalmol (Phila) 2013;2:388-400.
Donahue SP. Clinical practice. Pediatric strabismus. N Engl J Med 2007;356:1040-7.
Eustis S, Smith DR. Parental understanding of strabismus. J Pediatr Ophthalmol Strabismus 1987;24:232-6.
Satterfield D, Keltner JL, Morrison TL. Psychosocial aspects of strabismus study. Arch Ophthalmol 1993;111:1100-5.
Development of the World Health Organization WHOQOL-BREF quality of life assessment. The WHOQOL Group. Psychol Med 1998;28:551-8.
Suárez MF, Sanchez R, Calvo JM. Validación de la escala Schizophrenia Quality Of Life Scale (SQLS) para medir la calidad de vida en pacientes con diagnóstico de esquizofrenia en Colombia. Rev Colomb Psiquiatr 2013;42:257-65.
Badia Llach X. What is health-related quality of life and how is it measured? Gastroenterol Hepatol 2004;27:2-6.
Hatt SR, Leske DA, Castañeda YS, Wernimont SM, Liebermann L, Cheng-Patel CS, et al
. Association of strabismus with functional vision and eye-related quality of life in children. JAMA Ophthalmol 2020;138:528-35.
Schuster AK, Elflein HM, Pokora R, Schlaud M, Baumgarten F, Urschitz MS. Health-related quality of life and mental health in children and adolescents with strabismus – Results of the representative population-based survey KiGGS. Health Qual Life Outcomes 2019;17:81.
Chew-Ean T, Ghani SA, Shatriah I. Infantile esotropia in Malaysian children: The impact of surgery on health-related quality of life assessment in patients and their parents. Med J Malaysia 2020;75:531-7.
Aymerich M, Berra S, Guillamón I, Herdman M, Alonso J, Ravens-Sieberer U, et al
. Development of the Spanish version of the KIDSCREEN, a health-related quality of life instrument for children and adolescents. Gac Sanit 2005;19:93-102.
World Medical Association. World Medical Association Declaration of Helsinki: Ethical Principles for Medical Research Involving Human Subjects. JAMA 2013;310:2191-4.
Departamento de Salud, Educación y Bienestar. Principioséticos y Pautas Para la Protección de los Sereshumanosen la Investigación; 1978.
IBM. IBM SPSS Stadistics. Nueva York: IBM; 2012.
[Table 1], [Table 2]