Only Eye Study 5 (OnES 5): A Quantitative Study of Patient Experiences of Undergoing Surgery

doi:10.21203/rs.3.rs-3224275/v1

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Only Eye Study 5 (OnES 5): A Quantitative Study of Patient Experiences of Undergoing Surgery

https://doi.org/10.21203/rs.3.rs-3224275/v1

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Background/Objectives:

“Only Eye Surgery” can be a stressful experience for both surgeons and patients. Our study aimed to quantitatively explore the patient experience of having eye surgery on their remaining seeing eye.

Subjects/Methods:

A retrospective cohort study comparing monocular and binocular patients recruited from clinics in Brisbane, Australia. 107 patients (43 monocular, 64 binocular) completed a 12-item questionnaire regarding their experience.

Results

Multiple linear regression analysis identified that preoperative anxiety is greater in only eye surgery, (β=-13.99, 95%CI=-25.73 to -2.26, p < 0.05) and there were more worries about losing vision from surgery (β=-18.40, 95%CI=-32.31to -4.49, p < 0.05). The perceived level of support after surgery in binocular patients is influenced by their level of support from family or friends to discuss prior to surgery (r = 0.72), whereas in monocular patients, such level of support is influenced by patients’ level of trust in the surgeon (r = 0.50) and anaesthetist (r = 0.73).

Conclusions

Clinicians can provide support by acknowledging their patients’ anxieties related to loss of vision and its potential impact on lifestyle. By addressing these issues and providing the opportunity to discuss other aspects of the surgery preoperatively, further trust in the surgeon can be achieved. Postoperatively, the patient will feel more supported and enhance the recovery journey. In the advent of adverse outcome, the surgeon who has gained that higher level of trust, the patient will be more likely to feel reassured that everything was performed to the highest possible standard and more likely to accept the resulting level of vision.

Scientific community and society/Scientific community/Education

Health sciences/Diseases/Eye diseases/Eye abnormalities

“Only eye surgery” refers to eye surgery performed on the eyes of patients who are functionally blind in their other eye. While no set definition exists, a patient’s eye may be considered an “only eye” when the fellow eye is legally blind (visual acuity worse than 1.3 logMAR (3/60) or severe visual field loss) or the patient feels that loss of the fellow eye will reduce their ability to function independently such that it will have a life-changing impact on their quality of life. The circumstances surrounding the only eye can vary. In some cases, the only eye can be anatomically and functionally normal – with the fellow eye having dense amblyopia or been lost through trauma. Whereas in other cases, the only eye can have advanced disease (such as glaucoma) and/or has had multiple previous surgeries. The other eye may have been lost as a result of surgical complications, making the prospect of surgery in the remaining eye more distressing [1, 2, 3].

Only eye surgery is considered to have the same risk as eye surgery on binocular patients – with similar complication rates and comparable improvements in functional vision [4, 5, 6]. However, this does vary depending on the cause of vision loss in the fellow eye. As ophthalmic surgeons, we apply ourselves with total commitment to surgery in both monocular and binocular patients equally. However, there is a crucial difference in only eye surgery because the material risk if complications occur is one of lifelong blindness with complete loss of one of the most important senses, and consequent life-changing significant impact on independence and quality of life with increased risk of health harms for patients [7, 8, 9].

Due to the high-stakes-nature of only eye surgery, it is a stressful experience for both patients and surgeons. Previous studies have explored the experiences of surgeons performing only eye surgery, highlighting the unique challenges and considerations in training and supporting those surgeons [1, 3]. Few studies, however, have investigated the experiences of patients undergoing only eye surgery [2, 10, 11]. The Only Eye Study 2 by Jones et al. [2] explored the experience of only eye surgery patients by qualitative analysis of semi-structured interviews. It identified the significant emotional impact of surgery, fear of the potential burden of vision loss, the difficulty in coping with surgery and the need for individualised care.

This study aims to quantitatively explore the patient experience of only eye surgery, comparing the surgical experience between monocular and binocular patients and determine key elements to improve the patient journey.

Patients were recruited from two private practice ophthalmology clinics in Brisbane, Australia. The study included adult patients (age ≥ 18 years), who had undergone eye surgery on a ‘seeing eye’ and were more than 6 months post-surgery. The monocular cohort was comprised of patients who had one ‘seeing eye’ and one legally blind eye (visual acuity worse than 1.3 logMAR (3/60) or severe visual field loss) or the patient feels that loss of the ‘seeing eye’ will reduce their ability to function independently such that it will have a life-changing impact on their quality of life. The binocular cohort was comprised of patients with two ‘seeing eyes’. Patients were excluded from the study if they had medical conditions preventing them from completing the questionnaire (such as cognitive deficits). Ethical approval for this study was obtained from the Faculty of Medicine's Low/Negligible Risk Ethics Committee of The University of Queensland (Project ID: 2021/HE001721).

A 12-item Patient Only Eye Test (POET) questionnaire was developed, utilising the themes identified by Jones et al. [2] in Only Eye Study 2. Questionnaire items were all statements that could be scored along a visual analogue scale (VAS), with 0mm indicating the most negative feelings and 100mm indicating the most positive feelings. The questionnaire was developed and tested on 20 patients with feedback from two consultant ophthalmologists, who both regularly perform only eye surgeries and have conducted research on the experience of only eye surgery (GL and PS). The 12-item questionnaire is shown in Fig. 1.

All statistical analyses were performed using GraphPad Prism 9.3.1 software. Z-test was performed to compare baseline characteristics between monocular and binocular patients. Multiple linear regression analysis was performed for each questionnaire item, analysing the effect of monocularity against other potential confounders including sex, age, time since surgery and surgery type. Statistical significance was set at p < 0.05. Pearson correlation matrices were separately created for monocular patient data and binocular patient data. A moderate correlation was defined as 0.50 ≤ r < 0.70. A strong correlation was defined as r ≥ 0.70. Using results from the correlation matrices, flowchart frameworks of the patient surgery experience were developed, with direction of arrows on flowchart frameworks determined using a priori reasoning.

One hundred and thirteen patients (43 monocular, 70 binocular) (age range 41–90 years) were invited to complete the questionnaire. The participation rate was 100%. Data from six binocular patients was removed since no monocular patients with that type of surgery completed the questionnaire. Hence, data from 107 patients (43 (24M:19F) monocular, 64 (29M:35F) binocular) were included in the analysis. Average years of monocularity for the monocular cohort prior to surgery was 21 ± 3years (mean ± SEM) (Table 1).

Table 1

Demographic Data
		Monocular (n = 43)	Binocular (n = 64)	p-value
Sex [n(%)]	Male	24 (55.8%)	29 (45.3%)	0.29
Sex [n(%)]	Female	19 (44.2%)	35 (54.7%)	0.29
Age Range [n(%)]	41–50	2 (4.7%)	1 (1.6%)	0.34
	51–60	4 (9.3%)	6 (9.4%)	0.99
	61–70	9 (20.9%)	14 (21.9%)	0.91
	71–80	18 (41.9%)	30 (46.9%)	0.61
	81–90	10 (23.3%)	13 (20.3%)	0.72
Years of Monocularity [mean ± SEM]		20.98 ± 3.46	N/A	-
Time since surgery [n(%)]	< 1 year	16 (37.2%)	17 (26.6%)	0.24
	1 to 2 years	10 (23.3%)	20 (31.3%)	0.33
	2 to 3 years	0 (0%)	0 (0%)	-
	3 to 4 years	2 (4.7%)	9 (14.1%)	0.12
	4 to 5 years	3 (7.0%)	0 (0%)	< 0.05*
	> 5 years	12 (27.9%)	18 (28.1%)	0.98
Type of Surgery [n(%)]	Cataract	22 (51.2%)	34 (53.1%)	0.84
	Glaucoma	6 (14.0%)	6 (9.4%)	0.46
	Cataract + Glaucoma	11 (25.6%)	16 (25.0%)	0.95
	Cornea	2 (4.7%)	2 (3.1%)	0.68
	Retinal	2 (4.7%)	6 (9.4%)	0.36

Basic demographics showed no significant difference in sex or mean age between the groups (Table 1). In terms of time since surgery, the proportion of patients in the 4 to 5 years group was significantly different with 3 (7.0%) in the monocular group and 0 (0.0%) in the binocular group (p < 0.05; Table 1). There were no other significant differences in time since surgery between groups. Also, there were no significant differences in the type of surgery between the monocular and binocular patients (Table 1).

The Tukey box and whisker plot (Fig. 2) demonstrates the generalised trends and distribution for each questionnaire item between cohorts. Most questionnaire items were skewed such that the majority of patients in both cohorts answered with higher VAS scores. This suggests that the overall experience of patients throughout the surgery journey was positive. However, there were questionnaire items where responses were less positive in both cohorts. There were lower VAS scores with wider distributions for thoughts prior to surgery (Q1) and worries about losing vision from surgery (Q3). Further, there was a wider distribution of VAS scores for level of worry during the surgery (Q8), level of coping after the surgery (Q9) and level of worry about the surgical complications (Q11).

Multiple linear regression analysis was performed for each questionnaire item to analyse the effects of monocularity as well as other potential confounding factors (sex, age, time since surgery and surgery types). Monocularity contributed to more negative thoughts prior to surgery (Q1) (β=-13.99, 95%CI=-25.73 to -2.26, p < 0.05) and more worries about losing vision from surgery (Q3) (β=-18.40, 95%CI=-32.31to -4.49, p < 0.05). The analysis also noted other factors that influenced the patient surgery journey. Thoughts prior to surgery (Q1) was more positive for 3 to 4 years since surgery (β = 32.00, 95%CI = 9.63 to 54.36, p < 0.01) and > 5 years since surgery (β = 17.86, 95%CI = 2.59 to 33.13, p < 0.05). Male patients felt they had a higher level of support after the surgery (Q10) (β = 7.21, 95%CI = 0.28 to 14.15, p < 0.05) and better feelings about the surgical outcome (Q12) (β = 8.57, 95%CI = 0.16 to 16.98, p < 0.05).

Age also had an impact on some questionnaire items. When comparing to patients aged 41–50 years, a higher level of support from family or friends to discuss with prior to surgery (Q4) was identified in the other patient groups aged 51–90 years. Similarly compared to patients aged 41–50 years, more positive feelings about the surgical outcome (Q12) was identified in the other patient groups aged 51–90 years. Surgery type had an impact on some questionnaire items. Level of trust in the surgeon (Q5) was slightly lower in patients that underwent Cataract + Glaucoma surgery (β=-3.03, 95%CI=-5.89 to -0.16, p < 0.05). Level of coping after the surgery (Q9) was lower in patients undergoing retinal surgery (β=-26.12, 95%CI=-41.98 to -10.26, p < 0.01).

It should be noted that in both monocular and binocular patient frameworks, the level of worry about losing vision from surgery (Q3) has a carry-on effect into the intraoperative and postoperative patient experiences (Figs. 3C & 4C). Additionally, there is an interrelationship between level of trust in the surgeon (Q5), level of trust in the anaesthetist (Q6) and level of trust in the surgical team (Q7), (Figs. 3B & 4B). For monocular patients, the level of support after surgery (Q10) was influenced by the level of trust in the surgeon (Q5) (r = 0.50) and the level of trust in the anaesthetist (Q6) (r = 0.73; Fig. 3B). However, in binocular patients such level of support after surgery (Q10) was influenced by the level of support from family or friends to discuss with prior to surgery (Q4) (r = 0.72; Fig. 4B).

Through quantitatively exploring the patient experience of undergoing only eye surgery, this study was able to identify key areas where improvements can be made to the patient journey. The positive responses to the questionnaire items (Fig. 2) suggested that eye surgery is generally well-received by patients, which is consistent with the literature [12]. However, there were lower VAS scores with wider distributions for thoughts prior to surgery (Q1), worries about losing vision from surgery (Q3), level of worry during the surgery (Q8), level of coping after the surgery (Q9) and worries about the surgical complications (Q11) (Fig. 2). This suggests a degree of anxiety and worry about poorer surgical outcomes throughout the surgery journey, especially in the monocular patients.

Monocular patients are more fearful in the preoperative period, with worse thoughts prior to surgery (Q1) and more worries about losing vision from surgery (Q3). Studies by Marback et al. [10] and Li et al. [11] both identified increased preoperative anxiety in monocular patients compared to binocular patients undergoing cataract surgery. Similarly, the Only Eye Study 2 by Jones et al. [12] identified that patients had extremely negative thoughts prior to surgery, which was associated with fears of vision loss. Patients were distressed by such vision loss and its potential to impact on their ability to do everyday activities as well as the increased burden of medical appointments and reliance on informal caregivers for transport [2].

Interestingly, the increased negative feelings in monocular patients were not detected after the preoperative period. The lack of difference in the level of worry during surgery (Q8), which is consistent with the literature [13], may be due to the patients being under sedation. Of note, there were no significant difference between the monocular and binocular cohort in terms of level of coping after surgery (Q9), level of worry about the surgical complications (Q11) and feelings about the surgical outcome (Q12). In contrast, Jones et al. [2] found the postoperative period was particularly distressing for patients. This discrepancy may be because patients are only fearful in the immediate postoperative period, when their eye is patched and they are unable to see. Thereafter, when their eye is uncovered, that fear is alleviated. Hence, while the immediate postoperative period may be more stressful for only eye surgery patients, the later postoperative period is less of an issue.

Given that fear in the preoperative period of only eye surgery seems to be the most negatively impactful on the patient experience, such preoperative fears should be addressed. Jones et al. [2] proposed that ‘psychological prehabilitation' may be an effective means of doing so – whereby, patients are given preoperative psychological intervention to prepare them for the psychological stressors of only eye surgery. Such strategy is premised on the similar use of physical ‘prehabilitation’ before surgeries,¹⁴ which has been found to improve patient outcomes [15].

Several strategies should be considered as part of such ‘psychological prehabilitation’ regime. Simple non-pharmacological strategies such as massages and music have been found to effectively reduce preoperative anxiety in surgical patients [16]. Such strategies could be used to complement other methods that psychologically prepare patients for the surgery journey such as cognitive behavioural therapy, preoperative videos and patient education programs [16]. Effective patient communication is also important since a strong doctor-patient relationship and clear patient education about the disease and the surgery have been found to be important for reducing preoperative anxiety in cataract surgery patients [17, 18]. Further, given that optimism has been found to help patients cope with the stress of only eye surgery, encouraging patients to be optimistic may be beneficial.² Supporting this notion, a review by Sweeney and Andrews [19] identified that optimism grounded in reality, has been found to improve patient outcomes.

The results from this study, were used to develop a framework for a patient experience flowchart. Different aspects of the patient surgery journey were found to be interrelated. (Figs. 3 & 4). Validity of this model is demonstrated by the level of trust in the surgeon (Q5), level of trust in the anaesthetist (Q6) and level of trust in the surgical team (Q7) are all positively correlated (Figs. 3B & 4B). Analysing the patient flowchart framework, it was found that in both the monocular and binocular cohort, the level of worry about losing vision from surgery (Q3) has a carry-on effect on the intraoperative and postoperative patient experience (Figs. 3C & 4C). This reinforces the importance of reducing preoperative anxiety through the aforementioned ‘psychological prehabilitation’.

The patient flowchart framework also identified that in monocular patients, the level of support after the surgery (Q10) was correlated with trust in the surgeon (Q5) and anaesthetist (Q6) (Fig. 3), whereas in binocular patients, such level of support was correlated with level of support from family or friends to discuss with prior to surgery (Q4) (Fig. 4). This important role for the surgeon in helping to reassure and support patients has been identified by Jones et al. [2] in the Only Eye Study 2. Indeed, it was found that patients were better able to cope with the anxiety of surgery when they felt that their surgeon developed a good relationship with them, cared about them as individuals and provided transparent information about the surgery [2]. Conversely, patients felt that when their surgeon came across as unempathetic, unable to listen to the patients’ concerns and when the patient felt that they were not included in the decision-making process, the patient experience was negatively affected [2].

Not only is trust important for making the patient feel supported, but it has been found by Black et al [20] to improve patient safety in hip replacement, knee replacement and groin hernia repairs. Hence, it is clear that clinicians need to consider how they can strengthen their relationship with patients to gain their trust. While there is limited evidence for interventions to improve patient trust [21], several factors have been identified, such as perceived kindness and compassion from the surgeon, as well as having good bedside manner. These interpersonal skills are even valued higher than technical ability of the surgeon [22, 23]. Patients also trust clinicians more when they feel the clinician listens carefully to the patient and is thorough [22, 23]. The way clinicians interact with their clinical team is also important for developing trust; there is greater trust for teams that appear stronger and where the clinician has a strong working relationship with other members of the team [22]. Additionally, ophthalmology patients may have a religious-based value system, so that acknowledging their value system is another means by which patient trust can be built [24]. In only eye surgery patients this is especially important to consider since religious faith has been found to help patients cope with only eye surgery [2].

While the study’s major findings pertained to how monocular patients’ experience can be improved, it is important to note that our study uncovered other patient groups where their eye surgery experience could be improved. Specifically, female patients had lower level of support after the surgery (Q10) and worse feelings about the surgical outcome (Q12). The youngest patient group (aged 41–50 years) had lower level of support from family or friends to discuss with prior to surgery (Q4) and more negative feelings about the surgical outcome (Q12) than all older age groups. The level of coping after the surgery (Q9) was lower in patients undergoing retinal surgery, which may be due to the prolonged recovery time, with delayed recovery of useful vision due to the tamponade agents (gas or oil if used) and postoperative positioning. By noting where these groups are susceptible to a worse experience throughout the eye surgery journey, conscious efforts to alleviate these negative experiences can be undertaken.

There were several limitations to the findings of this study. In terms of retrospective collection of data, multiple linear regression analysis did not identify an effect of time since surgery on questionnaire item responses – except on thoughts prior to surgery (Q1), which was more positive for > 3 years since surgery. This could be the result of recall bias. Also, there may have been some sampling bias since the study only included patients whose surgery was outside the postoperative recovery period. This could potentially lead to a more positive recount of only eye surgery. Further, since study participants were recruited from two ophthalmology clinics with a predominantly Caucasian well-educated background and treated privately, the results are not generalisable to other populations undergoing only eye surgery patients. Hence, further studies on other patient groups are needed.

In summary, through quantitatively exploring the patient experience of only eye surgery, we have identified two key lessons for clinicians conducting these procedures. Firstly, the preoperative period is of great importance for the rest of the patient’s surgery experience, yet it is most negatively impacted by only eye surgery. Hence, efforts should be directed to alleviating patient fear in that period, potentially through ‘psychological prehabilitation’. Secondly, patients’ feeling of support after surgery is uniquely related to their trust in their surgeon and anaesthetist. This higher level of trust can be a significant factor. When the outcome of surgery is adverse, patients will be more likely to accept a poorer visual outcome, if they feel despite the best intentions, the surgeon and team performed at the highest possible level.

Acknowledgements: nil

Author Contribution Statement: EN was responsible for designing the protocol, extracting and analysing data, interpreting results and writing manuscript. GL was responsible for designing the protocol, development of questionnaire, recruiting and administering surveys, extracting and analysing data, interpreting results and writing manuscript. SG was responsible for recruiting and administering surveys, analysing data, interpreting results and providing feedback on manuscript. JL was responsible for providing feedback on manuscript. PS was responsible for development of questionnaire and providing feedback on manuscript.

Conflicts of interest: The authors declare no conflict of interest.

Funding: There were no sources of funding for this study.

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Only Eye Study 5 (OnES 5): A Quantitative Study of Patient Experiences of Undergoing Surgery

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INTRODUCTION

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