Both episcleritis and scleritis affect individuals in a multitude of ways. Apart from the clinical symptoms the patients suffer, the general lifestyle, well-being and the psychological impacts caused by the entirety is frequently neglected. These impacts are however equally essential to be noted and analyzed for a complete assessment of patient well-being.
Widely used clinical measures of vision provide information regarding the disease process but they may not capture all the important aspects of visual function from the patient's perspective and the effect of treatment on the person as a whole [7]. Other researches regarding vision function assessment have shown issues with recognizing individuals/faces (both near and distance), with mobility (walking/running, driving, using public transport), reading, and light-related sensitivity issues, such as glare and difficulties with night driving [8, 9]. Perceptions of vision in a variety of diseases are now used in clinical trials to evaluate the efficacy of medical or surgical interventions.
Herein, for the first time in Nepal, the vision-related quality of life was assessed in the Nepalese episcleritis and scleritis patients in terms of general function (GF), psychosocial impact (PI) and visual symptoms (VS). And we found that the patients with episcleritis had statistically significant improvement in GF score (p < 0.05) using paired t-test. The effect size showed medium improvement (approximately 0.5). Whereas there was no statistically significant change in PI score, VS scoring and the total score (p < 0.05) using paired t-test. The effect size showed no improvement for PI and total score and small improvement for VS score.
Patients with scleritis had significant improvement in GF score, VS scoring and the total score (p < 0.05). The effect size showed medium improvement (approximately 0.5) for GF score and total score. However, the effect size showed only a small improvement (approximately 0.2) for PI score. Though PI score showed improvement following treatment but the change was not statistically significant (p > 0.05). This could be related to the fear in patients regarding recurrences in the future and gradual improvement throughout treatment.
Hoeksema and Los et al. [10] reported lower scores on vision-specific social functioning, vision-specific mental health, vision-specific role difficulties, and vision-specific dependency in patients undergoing treatment for uveitis or related ophthalmic complications. This implies these patients are more stressed and disappointed by their vision and they require more help given their visual perception [10].
Arvind V et al. in 2008 they reported significant improvement in VR-QOL (Vision-Related Quality of life) in all scales following treatment for uveitis (p < 0.001)[5]. Another similar study by Gamal et al. in 2016 in the similar setting concluded anterior uveitis and posterior uveitis patients had significant improvement (p ≤ 0.001) in all 3 scales but panuveitis and intermediate uveitis had significant improvement (p < 0.05) in only 2 scales [11]. The effect size showed small to large change in all 3 scales. However, there were no available past literature based upon changes in visual functions and quality of life among episcleritis and scleritis cases of Nepal.
Niemeyer et al concluded using IND-VFQ scores, on average, over its 6 months study period (p = 0.0001) [13]. They observed a decreased mental component summary score (p = 0.04) and decreased vitality subscale (p = 0.001), while the SF-36 physical component summary score did not significantly differ throughout the trial. Although uveitis treatment was related to better vision and vision-related personal satisfaction, patient-reported physical health showed no change throughout a half year of treatment, with decreased psychological wellness.
Sugar et al. [14] conducted a similar longitudinal study comparing individuals with non-infectious uveitis treated with fluocinolone acetonide implant with those treated with systemic corticosteroid. Patients in both treatment groups displayed comparative improvement in NEI-VFQ-25 scores after 3 years of follow-up. People giving more terrible visual acuity and visual fields at first were observed to be related to lower NEI-VFQ-25 scores for both treatment categories.
Kempen et al had evaluated the risks along with quality of life outcomes associated with fluocinolone acetonide implant versus systemic therapy with corticosteroids and immunosuppression in cases of intermediate, posterior and panuveitis. This in its entirety was a part of the Multicenter Uveitis Steroid Treatment (MUST) trial and follow-up Study [14]. Self-detailed QOL measures at first supported implant-treated patients. Later with time, the QOL measures for both the groups were assessed and narrowed down to a favourable score.
Kaleemunnisha et al. [7] reported a greater effect size along with statistically significant betterment in the composite score, at follow-up, (p = 0.004; effect size = 1.03). They observed improvement in the QOL scores corresponding to reduced inflammation and improved visual acuity, with the initiation of immunosuppressives.
Such a study of quantitatively measuring the impact of the disease and treatment using vision-related quality of life has not yet been done in patients of episcleritis and scleritis. Though these individuals are not affected visually compared to other ocular diseases, accompanying keratitis and uveitis as well as posterior scleritis with macular oedema or exudative retinal detachment do have visual deterioration. Psychological problems emerged as a concern with longstanding redness which may or may not be associated with pain and the fear of multiple recurrences.
Vision-Related Quality of Life of patients with scleritis showed significant improvement following treatment unlike episcleritis indicating scleritis more adversely affecting psychosocial well-being.