Abstract
The aim of this study was to assess the improvement in psychosocial awareness of anophthalmic patients wearing ocular prostheses and its relationship with demographic characteristics, factors of loss/treatment, social activity, and relationship between professional and patient. Surveys including a form for evaluation of psychosocial pattern were conducted with 40 anophthalmic patients rehabilitated with ocular prosthesis at the Center of Oral Oncology in the authors’ dental school from January 1998 to November 2010. The improvement in psychosocial awareness was assessed by comparing the perception of some feelings reported in the period of eye loss and currently. Wilcoxon tests were applied for comparison of patients’ perception between the periods. χ 2 tests were used to assess the relationship between the improvement in psychosocial awareness and the variables of the study. In addition, the logistic regression model measured this relationship with the measure of odds ratio. The feelings of shame, shyness, preoccupation with hiding it, sadness, insecurity and fear were significant for improvement in psychosocial awareness. It was concluded that the anophthalmic patients wearing an ocular prosthesis has significant improvement in psychosocial awareness after rehabilitation.
The eye loss resulting from congenital malformation, tumour treatment, or trauma may lead to several social, familiar and psychiatric problems. The mutilated face can be a stigma for the patient and relatives. This may affect the individual’s self-esteem due to difficulty in establishing emotional ties, new life style, insecurity and rejection.
Alloplastic reconstruction aims to restore aesthetics, protect tissues and rehabilitate the patient for social reintegration. Some studies have evaluated the satisfaction and quality of life of anophthalmic patients rehabilitated with ocular prostheses. Pine et al. assessed the main concerns of patients wearing ocular prostheses and the modifications over time. Minor studies revealed the psychosocial status and adaptation of those patients after eye loss.
The changes experienced by the individual due to eye loss may establish a new psychosocial pattern. This study aimed to assess the improvement in psychosocial awareness of anophthalmic patients wearing ocular prostheses and its relationship with demographic characteristics, factors of loss/treatment, social activity, and the relationship between professional and patient.
Materials and methods
The records of all anophthalmic patients treated and rehabilitated with ocular prosthesis at the Center of Oral Oncology in the authors’ dental school from January 1998 to November 2010 were evaluated to select the individuals for this study. The inclusion criteria were: minimum of 2 years wearing ocular prosthesis (uni or bilaterally); eye loss resultant from pathology or trauma; and patients aged 10–90 years. The exclusion criteria were the presence of any type of psychosomatic disorder, local inflammatory or infectious disease, and ocular prostheses retained by implants.
After sample selection, the patients were contacted by telephone and invited to participate in the survey at the dental school. Of 52 patients interested in participating, 8 patients did not attend, reducing the number to 44 respondents. 40 patients were selected because 4 were unable to answer some questions. The patients were informed about the study and signed an informed consent form approved by the Human Research Ethics Committee (Process FOA/08-02375).
A form suggested by Nicodemo and Ferreira about the psychosocial profile of the anophthalmic patient rehabilitated with an ocular prosthesis was applied to the patients. The questionnaire used in this study has not been validated. Some questions suggested by Nicodemo and Ferreira were used in this study ( Fig. 1 ). The survey was conducted by the same operator in a quiet and comfortable environment and only the patient and the interviewer (LCB) remained in the room. The patient was seated in a comfortable chair during the procedure. The psychosocial awareness was evaluated regarding feelings of shame, shyness, blame, preoccupation with hiding it, sadness, insecurity, fear, inferiority and anger. Each feeling was recorded according to the following score of Nicodemo and Ferreira (0, none; 1, a little; 2, some; 3, a great deal). During the survey, the patients were asked to remember the way they felt when they lost their eyes and how such feelings remained. The improvement in psychosocial awareness was assessed by comparing the scores of the feelings of each patient between the two periods. A composed variable based on the improvement in the psychosocial awareness was obtained and defined as: no (no improvement in the psychosocial awareness), if improvement was observed for up to three feelings; and yes (improvement in the psychosocial awareness), if improvement in four or more feelings was reported. This composed variable was defined since there is no significance for comparison between different feelings and all feelings should be considered. In addition, the same level range was used for the scale (0, none; 1, a little; 2, some; 3, a great deal), which means that the scale was symmetric. At the end, the limit of three feelings was established based on the scores presented in Table 1 , showing that three feelings were not significantly different. Thus, it was considered that change up to this limit would not affect the psychosocial perception.
| Feelings | Eyes loss ‡ | Currently ‡ | P value † | ||||||
|---|---|---|---|---|---|---|---|---|---|
| None | A little | Some | A great deal | None | A little | Some | A great deal | ||
| 1. Shame | 19 (47.5) | 15 (37.5) | 2 (5.0) | 4 (10.0) | 33 (82.5) | 5 (12.5) | 1 (2.5) | 1 (2.5) | <0.001 * |
| 2. Shyness | 22 (55.0) | 9 (22.5) | 3 (7.5) | 6 (15.0) | 33 (82.5) | 4 (10.0) | 2 (5.0) | 1 (2.5) | 0.002 * |
| 3. Blame | 33 (82.5) | 5 (12.5) | 1 (2.5) | 1 (2.5) | 38 (95.0) | 1 (2.5) | 0 (0.0) | 1 (2.5) | 0.106 ns |
| 4. Preoccupation with hiding it | 17 (42.5) | 6 (15.0) | 4 (10.0) | 13 (32.5) | 24 (60.0) | 9 (22.5) | 1 (2.5) | 6 (15.0) | 0.015 * |
| 5. Sadness | 17 (42.5) | 10 (25.0) | 4 (10.0) | 9 (22.5) | 32 (80.0) | 7 (17.5) | 0 (0.0) | 1 (2.5) | <0.001 * |
| 6. Insecurity | 16 (40.0) | 14 (35.0) | 5 (12.5) | 5 (12.5) | 34 (85.0) | 5 (12.5) | 0 (0.0) | 1 (2.5) | <0.001 * |
| 7. Fear | 20 (50.0) | 12 (30.0) | 4 (10.0) | 4 (10.0) | 35 (87.5) | 4 (10.0) | 0 (0.0) | 1 (2.5) | <0.001 * |
| 8. Inferiority | 24 (60.0) | 10 (25.0) | 2 (5.0) | 4 (10.0) | 30 (75.0) | 7 (17.5) | 0 (0.0) | 3 (7.5) | 0.091 ns |
| 9. Anger | 28 (70.0) | 5 (12.5) | 3 (7.5) | 4 (10.0) | 35 (87.5) | 3 (7.5) | 0 (0.0) | 2 (5.0) | 0.197 ns |
The survey also evaluated some variables ( Fig. 1 ) that may be related to psychosocial awareness. These factors were categorized as demographic characteristics, factors of loss/treatment, social activity of the individuals, and relationship between professional and patient. The answers were grouped to synthesize the information and facilitate the power of the tests. For the first category, data about gender (male or female), marital status (married or single/divorced/widowed), educational level (incomplete elementary grades, complete elementary grades, or more than complete elementary grades), and household income (<03 times Brazilian minimum wage or ≥03 times Brazilian minimum wage) were collected. Considering the factors of loss/treatment, the patients were asked about the age when they lost the eyes and the current age, to classify the variable of time (recent for those patients that lost the eyes 2 or 3 years ago, and late for a period longer than 3 years), reason for the loss (trauma or pathology), adaptation with the first prosthesis (well/normally or badly/horribly), any problems in the work related to prosthesis (yes or no), and some positive influence of the prosthesis on personal relationship (yes or no). The evaluation of social activity included information about current occupation (yes or no); type of help received from family and relatives about comfort, company during treatment, attention and dialogue/conversation (yes or no); and time for leisure activities (yes or no). For the relationship between professional and patient, the individuals were asked about the attention, patience, and interest in them from the professionals involved (ophthalmologist, surgeon, prosthetist, and support staff) from eye loss to rehabilitation. The answers were classified as great (excellent/good) or bad (normal/unsatisfactory).
Statistical analysis
Descriptive statistical analysis (distribution of frequency and percentage) was applied to all factors and answers. The scores obtained for each feeling in different periods were compared through the Wilcoxon test (paired). The χ 2 test was used to evaluate the relationship between the improvement in psychosocial awareness and other variables. A statistically significant difference was observed when the P value was less than 0.05.
The logistic regression model was estimated to evaluate the association between improvement in psychosocial awareness and the variables of the present study that were considered significant by the χ 2 test ( P < 0.05). The odds ratio (OR) was estimated to measure this association and the model fit was assessed using the Hosmer and Lemeshow goodness-of-fit test, considering a poor fit at P = 0.05. Statistical analysis was performed using SPSS version 19.0 statistical software (SPSS Inc., Chicago, USA).
Results
The frequencies of the patients’ answers for each feeling in both periods are shown in Table 1 . The Wilcoxon test revealed statistically significant difference ( P ≤ 0.015) in the psychosocial awareness for the feelings of shame, shyness, preoccupation with hiding it, sadness, insecurity and fear. For these feelings, the answers were negative (higher scores) at the moment of loss in comparison to the actual perception. This may indicate the importance of such feelings for evaluation of psychosocial awareness with more positive answers (reduction of score range, 3–0) which means improvement in psychosocial awareness ( Table 1 ). Among the 16 female patients, 12 (75%) presented improvement in psychosocial awareness in comparison to 8 (33.3%) of the 24 male patients ( Table 2 ). An association between gender and improvement in psychosocial awareness was observed ( χ 2 = 6.67, P = 0.01). The test also revealed the influence of household income ( χ 2 = 3.96, P = 0.047). It was not statistically significant ( P > 0.05) for the other demographic characteristic variables ( Table 2 ).
| Demographic characteristics | Improvement in psychosocial awareness | Total | P value † | ||||
|---|---|---|---|---|---|---|---|
| Yes | No | N | % b | ||||
| N | % a | N | % a | ||||
| Gender | |||||||
| Female | 12 | 75.0 | 4 | 25.0 | 16 | 40.0 | 0.010 * |
| Male | 8 | 33.3 | 16 | 66.7 | 24 | 60.0 | |
| Marital status | |||||||
| Married | 8 | 44.4 | 10 | 55.6 | 18 | 45.0 | 0.53 ns |
| Single/divorced/widower | 12 | 54.5 | 10 | 45.5 | 22 | 55.0 | |
| Educational level | |||||||
| Incomplete elementary grades | 7 | 43.8 | 9 | 56.3 | 16 | 40.0 | 0.60 ns |
| Complete elementary grades | 5 | 45.5 | 6 | 54.5 | 11 | 27.5 | |
| More than complete elementary grades | 8 | 61.5 | 5 | 38.5 | 13 | 32.5 | |
| Household income | |||||||
| <3 times Brazilian minimum wage | 10 | 71.4 | 4 | 28.6 | 14 | 35.0 | 0.047 * |
| ≥3 times Brazilian minimum wage | 10 | 38.5 | 16 | 61.5 | 26 | 65.0 | |
| Total | 20 | 50.0 | 20 | 50.0 | 40 | 100.0 | |
a Values in parentheses are expressed as percentage in line.
For the factors of loss/treatment, there was an association between reason for loss and improvement in psychosocial awareness ( χ 2 = 4.29, P = 0.038) ( Table 3 ). Considering some positive influence of the prostheses on personal relationships, 12 (30.0%) patients reported a negative answer and 28 (70.0%) a positive one ( χ 2 = 7.62, P = 0.006). There was no evidence of association between improvement in psychosocial awareness and other variables (time of loss, adaptation with the first prosthesis, and any problems in the work related to the prosthesis) ( P > 0.05) ( Table 3 ). Regarding the association between social activity and improvement in psychosocial awareness, it was revealed that of the 19 (47.5%) patients who received comfort from their family and relatives, 13 (68.4%) presented improvement in perception; which was a higher percentage than the 7 (33.3%) patients who did not receive such help ( χ 2 = 4.91, P = 0.027) ( Table 4 ). The remaining variables related to family help (company during treatment, attention and dialogue/conversation) did not have a significant association with the improvement in psychosocial awareness ( P > 0.05) ( Table 4 ). There was no significant difference in improvement for the patients reporting some type of leisure activity ( P > 0.05) ( Table 4 ).
| Factors of loss/treatment | Improvement in psychosocial awareness | Total | P value † | ||||
|---|---|---|---|---|---|---|---|
| Yes | No | N | % b | ||||
| N | % a | N | % a | ||||
| Time of loss | |||||||
| Recent | 9 | 69.2 | 4 | 30.8 | 13 | 32.5 | 0.09 ns |
| Late | 11 | 40.7 | 16 | 59.3 | 27 | 67.5 | |
| Reason for the loss | |||||||
| Trauma | 11 | 39.3 | 17 | 60.7 | 28 | 70.0 | 0.038 * |
| Pathology | 9 | 75.0 | 3 | 25.0 | 12 | 30.0 | |
| Adaptation with the first prosthesis | |||||||
| Well/normally | 11 | 47.8 | 12 | 52.2 | 23 | 57.5 | 0.75 ns |
| Badly/horribly | 9 | 52.9 | 8 | 47.1 | 17 | 42.5 | |
| Any problems in the work related to prosthesis | |||||||
| No | 14 | 53.8 | 12 | 46.2 | 26 | 65.0 | 0.51 ns |
| Yes | 6 | 42.9 | 8 | 57.1 | 14 | 35.0 | |
| Some positive influence of the prosthesis on the personal relationship | |||||||
| No | 2 | 16.7 | 10 | 83.3 | 12 | 30.0 | 0.006 * |
| Yes | 18 | 64.3 | 10 | 35.7 | 28 | 70.0 | |
| Total | 20 | 50.0 | 20 | 50.0 | 40 | 100.0 | |
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