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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 29  |  Issue : 2  |  Page : 102-107

Barriers responsible for delay in surgical correction of strabismus: A study among adults undergoing strabismus surgery at a tertiary care center in Kerala


Department of Ophthalmology, Little Flower Hospital and Research Centre, Angamaly, Kerala, India

Date of Web Publication10-Aug-2017

Correspondence Address:
Sanitha Sathyan
Department of Ophthalmology, Little Flower Hospital and Research Centre, Angamaly, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/kjo.kjo_42_17

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  Abstract 


Aim: The aim of this study is to analyze the factors responsible for delay in surgical treatment among adults with strabismus.
Materials and Methods: A validated questionnaire-based study on fifty adult strabismic patients, enrolled through simple random sampling, who underwent surgical correction of strabismus at the strabismus clinic of a tertiary care eye hospital.
Results: A total of fifty patients in the age group 18– 45 years, including 28 males (56%) and 22 females (44%) were studied. 24% were students, 22% were professionals, 18% were skilled laborers, and 18% were homemakers. Strabismus had significant psychological impact on the quality of life of the patient and 50% suffered from low self-esteem attributable to squint 32% reported peer pressure and bullying. Lack of awareness about surgery (32%), fear of surgery (24%), and nonaffordability were the most common reasons reported by patients for delayed the surgical correction. The reasons for seeking surgical treatment in adulthood were for improving self-esteem and quality of life (32%) and due to pressure from family and friends (24%).
Conclusion: Social factors predominate as obstacles for timely correction of strabismus. Economic factors and lack of awareness among medical communities also contribute toward delay in treatment.

Keywords: Adult strabismus, barriers for stabismus surgery, delay in strabismus surgery, Kerala


How to cite this article:
Sathyan S, Jose J. Barriers responsible for delay in surgical correction of strabismus: A study among adults undergoing strabismus surgery at a tertiary care center in Kerala. Kerala J Ophthalmol 2017;29:102-7

How to cite this URL:
Sathyan S, Jose J. Barriers responsible for delay in surgical correction of strabismus: A study among adults undergoing strabismus surgery at a tertiary care center in Kerala. Kerala J Ophthalmol [serial online] 2017 [cited 2019 Jun 25];29:102-7. Available from: http://www.kjophthal.com/text.asp?2017/29/2/102/212752




  Introduction Top


In strabismic patients, favorable outcomes regarding visual acuity and binocular vision are obtained only when acceptable ocular realignment is established early in childhood and delay in surgery interferes with visual results.[1],[2],[3]

Strabismus is associated with significant psychosocial problems, and early surgery provides excellent prognosis in children with strabismus and improves their social well-being.[4] Reports state that bias and discrimination may develop against those affected by strabismus as early as 6 years of age,[5] there is a negative relationship between strabismus and formation of friendships, self-image, and a variety of other important psychosocial issues,[6] and these psychosocial problems were not only present in childhood but also persisted throughout adult life.[6] In addition, strabismic subjects were more likely to be perceived as less intelligent, less competent and found to have poorer communication skills than orthotropic subjects,[6] and there are considerable adverse vocational implications attributed to strabismus.[7]

Strabismic surgery significantly improves negative psychosocial issues associated with strabismus.[8] However, in clinical practice, it is commonly seen that many patients approach us during their adulthood for surgical correction of strabismus. Many of these adults with strabismus never had treatment in their childhood, while in many others, the condition had actually worsened with increasing age. Alternatively, some adults have had strabismus surgery as a child, but the eyes have begun to deviate again years later. This delay in undergoing strabismus surgery is presumed to be due to the common misconceptions about the success rates and complications, despite encouraging surgical results in the literature.[9],[10],[11],[12],[13],[14],[15]

In this study, we propose to analyze the factors responsible for delay in surgical correction of strabismus and outcomes of delayed correction in adults with strabismus, undergoing strabismus surgery at a tertiary care center in Kerala.

Aim

The aim of this study is to analyze the barriers responsible for delay in surgical treatment among adults with strabismus at a tertiary eye care center in Kerala.


  Materials and Methods Top


This was a questionnaire-based study conducted from April 2016 to September 2016 on fifty adult strabismic patients, enrolled through simple random sampling, who underwent surgical correction of strabismus at the Strabismus Clinic of Little Flower Hospital and Research Centre, Angamaly. The study was approved by the Institutional review board, and informed consent was obtained from all the participants before the commencement of the study. Those not willing to participate in the study and those from whom reliable information could not be obtained were excluded from the study.

All the patients underwent comprehensive ophthalmic examination, sensory and motor tests for strabismus before as a part of preoperative work up for strabismus surgery. A questionnaire regarding the psychosocial impact of strabismus was prepared and validated by subject experts [Appendix 1] [Additional file 1]. This validated questionnaire was administered by a single researcher (second author) through interview method. Data regarding demographic factors including age, sex, socioeconomic status, and profession were also collected. Demographic data and variables in the questionnaire were expressed as tables and pie diagrams.


  Results Top


A total of fifty patients in the age group 18– 45 years were included in this study. There were 28 males (56%) and 22 females (44%). Out of fifty patients, 45 were exotropes (90%), 4 were esotropes (8%), and one had hypertropia (2%). In 37 (74%) patients squinting was first noticed in early childhood and in 13 (26%) patients squinting was first noticed in the school going period. Out of fifty patients, 9 (18%) patients had positive family history of strabismus. Age distribution of the population is given in [Table 1].
Table 1: The age distribution of the study population

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Social class was assessed using modified Prasad's classification [16] system using an online assessment tool [17] following interview with the study participants. 96% (n = 48) of the study participants belonged to Prasad social Class I and 4% (n = 2) belonged to Prasad social Class II.

Highest educational status was assessed and classified as high school level, higher secondary school level, graduate level, and postgraduate level and above. [Table 2] shows the distribution of educational status among the study population, and [Figure 1] shows the corresponding pie diagram. Out of the fifty patients, 24% were students, 22% were professionals, 18% were skilled laborers, and 18% were homemakers. [Figure 2] shows the distribution based on the vocation.
Table 2: Educational status of the study population

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Figure 1: Pie diagram showing the distribution of educational status

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Figure 2: Distribution of patients based on the vocation

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Strabismus was detected in early childhood in 72% and during school period in 28%. There was no patient with first detection of strabismus beyond the school period. [Figure 3] shows the time of strabismus diagnosis in the population. In 46% of patients, strabismus was first detected by parents, in 26% by teachers, 16% by primary care physicians, and in 12% by acquaintances.
Figure 3: Time of the first diagnosis of strabismus in the study population

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Strabismus had a significant psychological impact on the quality of life of the patients in our study. 25 patients (50%) suffered from low self-esteem attributable to squint, 16 patients (32%) reported peer pressure and bullying due to due to misaligned eyes, and 9 (18%) had denial of opportunity or job due to strabismus. 84% of patients answered that they could have done better in life if they did not have strabismus. [Figure 4] demonstrates the psychological impact of strabismus in our study population.
Figure 4: Psychological impact of strabismus in the study population

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Most common reasons reported by patients for delaying the surgical correction of strabismus till adulthood include lack of awareness about surgery in 16 patients (32%), fear of surgery 12 patients (24%), nonaffordability in 12 patients (24%), and disbelief that surgery would improve their ocular alignment 6 patients (12%). Four patients (8%) were wrongly advised by the primary care doctors that strabismus surgery needs to be done at adulthood only. [Table 3] and [Figure 5] show the causes of delay in seeking surgical treatment.
Table 3: Causes of delay in seeking surgical treatment

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Figure 5: Causes of delay in seeking surgical treatment

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The reasons for seeking surgical treatment for strabismus in adulthood were for better self-esteem and quality of life in 16 patients (32%), pressure from family and friends in 12 patients (24%), for better marriage prospects in 8 patients (16%), for improving appearance in 7 patients (14%), and for better job opportunities in 7 patients (14%). [Table 4] and [Figure 6] show the reasons for undergoing surgical correction of strabismus as reported by our patients.
Table 4: Reasons for undergoing surgical correction of strabismus reported by the patients

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Figure 6: Reasons for undergoing surgical correction of strabismus

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  Discussion Top


This is the first study of its kind conducted among adults undergoing strabismus surgery in Kerala. Most of the patients in our study were in the 18– 22 years age group (38%), followed by 22– 26 years (26%) age group, and 26– 30 years (22%) age group. This indicates that factors such as appearance, peer pressure, and job opportunities could have a strong influence on the health-seeking behavior of these patients with strabismus. There was no significant gender difference among the patients seeking surgical correction, suggesting that gender did not have a bearing in determining the chances of undergoing strabismus surgery among adults in our setup.

Most of the patients belonged to Class I of Prasad social scale, indirectly pointing out that affordability was not the prime reason for delay in seeking surgical treatment. Neither was low educational status, as the minimum education was high school education, that too in a single patient.

The psychosocial [4] and vocational [7] aspects of strabismus in adults have been previously described in literature. Strabismus had significant psychological impact on the quality of life of the patients in our study also. Twenty-five patients (50%) suffered from low self-esteem attributable to squint, 16 patients (32%) reported peer pressure and bullying due to due to misaligned eyes, and 9 patients (18%) had history of denial of opportunity or job due to strabismus. Fifty percent of the patients suffered from low self-esteem due to strabismus and most wanted to improve their appearance to improve the marriage prospects. This indicates that social constructs such as appearance and marriage have a huge impact on the health-seeking behavior of patients in our area.

Although 72% detected strabismus during early childhood itself and 28% during school period, proper treatment was denied due to many factors. Most common reasons reported by patients for delaying the surgical correction of strabismus include lack of awareness about surgery (32%), economic reasons (24%), disbelief that surgery would improve their ocular alignment (12%), and fear of undergoing surgery (24%). Four patients (8%) were advised wrongly by the primary care physicians that strabismus surgery may be delayed till adulthood. Lack of awareness was the foremost cause for delay in surgery, followed by fear of surgery. This indicates that social misconceptions were the predominant reason for delay in strabismus surgery, and the community awareness regarding treatment facilities was low. That is why even when strabismus detection was done during early childhood/school period in all the patients, surgery was delayed till adulthood. This demonstrates a considerable gap between detection and treatment, pointing to a failure of service delivery among our patients. Community awareness and education have a long way to go to tackle these misconceptions about strabismus surgery and in improving the health-seeking behavior of our population.

A considerable delay of around 20 years between the initial diagnosis and surgical correction of strabismus has been described in studies from the United Kingdom [18] and France.[19] However, similar to our study, these were also targeted study of patients undergoing strabismus surgery in tertiary care centers and may have falsely estimated the true figures regarding surgical delay in the community. Population-based studies are needed for obtaining a true estimate of delay in strabismus surgery in the community.

Therefore, in all these patients, visual acuity and binocularity could not be restored due to the presence of amblyopia and what was gained was just cosmetic rehabilitation. A shocking fact is that this ignorance was present even among the primary care doctors also as 8% patients did not do surgery as they were advised to the contrary by their treating doctors. In the study by Coats et al. conducted in the United Kingdom,[18] wrong information passed on by the primary care physicians was cited as an important factor for delay in optimal correction of strabismus. Among the reasons cited for delay in care by their patients, one-third could have been avoided by better advice from the patient's eye specialist, who did not offer surgery, advised the patient that nothing could be done, or reportedly told the patient that he or she was too young for surgery.[9] Continuing medical education among primary care physicians about the surgical options for the correction of strabismus could substantially benefit our patients also, permitting them to live with freedom from physical and/or psychological problems associated with strabismus.

Economic reasons accounted for 24% of cases, which indicates that nonaffordability/lack of awareness about affordable treatment facilities also had a part to play in poor timing of strabismus correction. Economic reasons were not cited as interfering with timing of strabismus surgery in studies conducted in the West [18],[19] as they were covered by Government offered health insurance schemes, unlike our setup. Lack of public health insurance coverage for the entire population and the noninclusion of strabismus surgery for reimbursement in many private health insurance schemes in Kerala needs to be addressed to tackle this economic barrier.


  Conclusion Top


Our study indicates that social factors predominate as obstacles for timely correction of strabismus. Economic factors and lack of awareness among medical community also contribute toward delay in treatment. High education and reasonably good socioeconomic status did not improve health-seeking characteristics. These barriers hampering with the timely management of strabismus needs to be addressed through appropriate strategies.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Ing MR. Early surgical alignment for congenital esotropia. Ophthalmology 1983;90:132-5.  Back to cited text no. 1
    
2.
Birch EE, Wang J. Stereoacuity outcomes after treatment of infantile and accommodative esotropia. Optom Vis Sci 2009;86:647-52.  Back to cited text no. 2
    
3.
Kelkar JA, Gopal S, Shah RB, Kelkar AS. Intermittent exotropia: Surgical treatment strategies. Indian J Ophthalmol 2015;63:566-9.  Back to cited text no. 3
[PUBMED]  [Full text]  
4.
Satterfield D, Keltner JL, Morrison TL. Psychosocial aspects of strabismus study. Arch Ophthalmol 1993;111:1100-5.  Back to cited text no. 4
    
5.
Paysse EA, Steele EA, McCreery KM, Wilhelmus KR, Coats DK. Age of the emergence of negative attitudes toward strabismus. J AAPOS 2001;5:361-6.  Back to cited text no. 5
    
6.
Olitsky SE, Sudesh S, Graziano A, Hamblen J, Brooks SE, Shaha SH. The negative psychosocial impact of strabismus in adults. J AAPOS 1999;3:209-11.  Back to cited text no. 6
    
7.
Coats DK, Paysse EA, Towler AJ, Dipboye RL. Impact of large angle horizontal strabismus on ability to obtain employment. Ophthalmology 2000;107:402-5.  Back to cited text no. 7
    
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Burke JP, Leach CM, Davis H. Psychosocial implications of strabismus surgery in adults. J Pediatr Ophthalmol Strabismus 1997;34:159-64.  Back to cited text no. 8
    
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Scott WE, Kutschke PJ, Lee WR. 20th annual Frank Costenbader Lecture – Adult strabismus. J Pediatr Ophthalmol Strabismus 1995;32:348-52.  Back to cited text no. 9
    
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Kushner BJ, Morton GV. Postoperative binocularity in adults with longstanding strabismus. Ophthalmology 1992;99:316-9.  Back to cited text no. 10
    
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Hertle RW. Clinical characteristics of surgically treated adult strabismus. J Pediatr Ophthalmol Strabismus 1998;35:138-45.  Back to cited text no. 11
    
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Ball A, Drummond GT, Pearce WG. Unexpected stereoacuity following surgical correction of long-standing horizontal strabismus. Can J Ophthalmol 1993;28:217-20.  Back to cited text no. 12
    
13.
Morris RJ, Scott WE, Dickey CF. Fusion after surgical alignment of longstanding strabismus in adults. Ophthalmology 1993;100:135-8.  Back to cited text no. 13
    
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Wortham E 5th, Greenwald MJ. Expanded binocular peripheral visual fields following surgery for esotropia. J Pediatr Ophthalmol Strabismus 1989;26:109-12.  Back to cited text no. 14
    
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Kushner BJ. Binocular field expansion in adults after surgery for esotropia. Arch Ophthalmol 1994;112:639-43.  Back to cited text no. 15
    
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Sharma R. Revision of Prasad's social classification and provision of an online tool for real-time updating. South Asian J Cancer 2013;2:157.  Back to cited text no. 16
    
17.
Sharma R. Online Interactive Calculator for Real-time Update of the Prasad's Social Classification. Available from: http://www.prasadscaleupdate.weebly.com. [Last accessed on 2016 Oct 13].  Back to cited text no. 17
    
18.
Coats DK, Stager DR Sr., Beauchamp GR, Stager DR Jr., Mazow ML, Paysse EA, et al. Reasons for delay of surgical intervention in adult strabismus. Arch Ophthalmol 2005;123:497-9.  Back to cited text no. 18
    
19.
Spielmann AC, Spielman A. Oculomotor surgery in adult patients: Why is it so frequently rejected? In: Spiritus M, editor. Transactions of the 25th Meeting European Strabismological Association. Lisse, Netherlands: Aeolus Press Science Publisher; 2000. p. 186-91.  Back to cited text no. 19
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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