Quality of Life After Ocular Trauma: A Prospective, Longitudinal, Questionnaire- Based Study in a Tertiary Hospital in the Philippines
Jose Carlo M. Artiaga, MD and Ruben Lim Bon Siong, MD
Department of Ophthalmology and Visual Sciences
University of the Philippines – Philippine General Hospital
Taft Avenue, Ermita, Manila, 1000, Philippines
Correspondence: Jose Carlo M. Artiaga, MD
Department of Ophthalmology and Visual Sciences
University of the Philippines – Philippine General Hospital
Taft Avenue, Ermita, Manila, 1000, Philippines
Disclosure: No financial support. No conflicting relationship exists for any of the authors. All authors have no proprietary interest in any of the materials, medicines, or equipment mentioned in this study.
Ocular trauma remains to be an important cause of low vision and blindness leading to handicap and disability. An estimated 2.4 million eye injuries occur annually, potentially leading to permanent visual impairment and disability.1 In 1998, around 3.9 million people were reported to have either low vision or blindness bilaterally, and 19 million more having low vision or blindness in one eye due to ocular trauma.2
The impact of ocular trauma is widely described in literature in terms of its clinical characteristics, visual outcome, and prognostic factors.1,3-9 Its effect on quality of life (QOL), however, has been limited to a few studies. QOL is defined as a broad multidimensional concept that usually includes subjective evaluations of both positive and negative aspects of life which include health, culture, and values, among others.10 Health-related quality of life (HRQoL) is how an individual perceives his/ her physical and mental health, and encompasses aspects such as functional status, social support, and socioeconomic status. Self-rated health is a predictor of both morbidity and mortality, suggesting that the determination of QOL is important in cases of eye injuries.11,12
The Ocular Trauma Score (OTS) is a scoring system developed to predict visual outcomes of patients after open globe ocular trauma at 6 months after injury.6 It is calculated based on the visual acuity and presence of various clinical characteristics upon initial examination. The probability of having a final visual acuity of 20/50 or worse at six months for patients with ocular trauma scores of 1, 2, and 3 was determined to be at 99%, 85%, and 59%, respectively.6 A positive correlation between OTS score and final visual acuity has been achieved in studies testing its applicability in different settings, including the Philippines.5-9
In 2007, the group of Van Beeck et al. developed a common core of health status measures by which disabilities from different types of injuries are assessed and reported.13 The combination of 2 tools, Health Utilities Index Mark III (HUI3) and the three-level EuroQol-5D (EQ-5D-3L), was recommended for use in all injury-related disability studies over all other tools evaluated. However, the absence of previous studies and validation of the HUI3 in the Philippine setting led us to use only the updated version of the EQ-5D-3L questionnaire, the EQ-5D-5L.
The EuroQol five-dimensional five-level (EQ- 5D-5L) questionnaire addresses 5 dimensions of daily living, namely: mobility, self-care, usual activities, pain/discomfort, and anxiety/depression.14 The responses of the patient for each dimension are recorded in 5 levels of severity: no problems (Level 1), slight problems (Level 2), moderate problems (Level 3), severe problems (Level 4), and extreme problems (Level 5). The EQ-5D-5L has been validated in a diverse patient population in 6 countries, including 8 patient groups with chronic conditions and a student cohort.15 The Tagalog translation of its earlier version, the EQ-5D-3L, has been validated for use in the Philippine setting.16 In a systematic review comparing the 2 versions of the questionnaire, the EQ-5D-5L was found to be better than the former version.17 Advantages of the use of the EQ-5D-5L questionnaire over similar QOL tools include a more accurate estimation of more severe injuries and a more valid utility scoring system.18
Current available literature described QOL measures in subsets of ocular trauma patients, mostly among open globe injuries.19-21 In all of these studies, QOL was measured months to years after the injury. To the best of our knowledge, an attempt to describe QOL trends prospectively among patients has not yet been made previously.
Our purpose was to determine the HRQoL of patients sustaining potentially visually-disabling ocular injuries. We aimed to compare the QOL of patients with different types of ocular injuries and OTS over 4 months after injury. By correlating clinical and diagnostic characteristics with QOL indices, we hoped to identify patient-related factors that potentially impact the QOL of ocular trauma patients to guide clinicians in the holistic management of their patients.
The study is a prospective, longitudinal questionnaire-based HRQoL study done in the Philippine General Hospital, Manila, Philippines. Institutional review board approval was obtained. Written informed consent was secured from the study participants. Patients sustaining ocular injuries admitted at the ophthalmology ward from December 1, 2017 to August 1, 2018 were screened for inclusion to the study.
Patients aged 18 years old and above who were able to speak in conversant Filipino and was recently diagnosed with ocular trauma with OTS 1 to 3 were included in the study. Exclusion criteria were previous diagnosis of other ophthalmologic conditions, a positive history of previous surgery on affected eye, and decreased sensorium.
Collection of baseline data was done within 48 hours upon admission at the ophthalmology ward. These included age, sex, civil status, educational attainment, employment status, monthly income, membership in social services, presenting visual acuity, type of injury, and ocular trauma score. The Tagalog translation of the EuroQol five-dimensional five-level (EQ-5D-5L) questionnaire was administered by the primary investigator via face-to-face interview during the same encounter.22 Classification of injury was done according to the Birmingham Eye Trauma Terminology (BETT) System.23
Study participants were advised 3 follow-up visits on the 1st, 2nd and 4th month after recruitment wherein clinical and demographic data were collected and the EQ-5D-5L questionnaire readministered. The clinical course and changes from baseline were noted.
The primary outcome of the study was self-rated QOL measured by the EQ-5D-5L tool. Results were reported as an EQ-5D-5L index value to describe overall health profile and EQ visual analog scale (EQ VAS) as a measure of overall self-rated health status. Value sets for Thailand were used in computation of the EQ index.18 The highest possible score is a report of “no problems” for all dimensions and equivalent to an index score of 1.000, while the lowest possible score is a report of “extreme problems” in all dimensions and is equivalent to -0.452. Secondary outcomes included correlation of baseline characteristics to QOL indices at baseline.
The software used for statistical analysis was STATE/SE 14.1 (StataCorp, Lakeway Drive, College Station, Texas, USA). Descriptive statistics including frequencies, percentages, means, medians, and standard deviations were used to summarize the demographic and clinical characteristics of the patients. Kruskal-Wallis test was used to compare baseline QOL indices across trauma scores and types of injury. Univariate regression analysis was done to correlate baseline characteristics with QOL indices. QOL indices were compared across different visits
using the Mann-Whitney U test. Spearman correlation was used to determine the relationship between visual acuity and QOL indices at 4 different hospital visits. For all inferential analyses, a p-value of less than 0.05 was considered significant.
Study participants included 33 patients admitted at the ophthalmology ward for various forms of ocular trauma. Baseline characteristics are summarized in Table 1. The median age of study participants on admission was 35 years old (range: 19-59 years old). Thirty-one (31) out of 33 (93.9%) participants were males. The patients were admitted at a median of 4 days from injury. Thirty-one (31 or 93.9%) participants sustained open globe injuries, with 14 (42%) being penetrating lacerations and 10 (30%) classified as having intraocular foreign bodies (IOFB). Study participants were equally distributed by OTS with 11 each being classified among OTS 1, OTS 2, and OTS 3. Most patients (57.6%) presented with a visual acuity of light perception or hand motion. The most common clinical characteristic identified was a relative afferent pupillary defect (63.6%).
IOFB = intraocular foreign body, LP/HM = light perception or hand movement, NLP = no light perception, VAS = visual analog scale, SD = standard deviation
Thirteen patients (13 or 39%) returned for the recommended first follow-up visit (1 month from baseline), 17 (51%) returned for the second visit (2 months from baseline) while 15 (45%) returned for the third visit (4 months from baseline). The median length from baseline of the follow-up visits were 30 days, 63 days, and 130 days, respectively.
Quality of Life
Baseline median EQ index score among all patients was 0.476 (range -0.082 to 1.000) and baseline median EQ VAS score was 60 (range 0 to 100). Those with an OTS of 1 had lower EQ index score (median 0.447, range -0.082 to 0.060) and EQ VAS score (median 56, range 0 to 90) (Table 2). Globe rupture was associated with the lowest median EQ VAS score (56, range 0 to 90) compared to other types of injury, while presence of an IOFB was associated with the lowest median EQ index score (0.442, range 0.040 to 0.780, p=0.4358) (Table 3). Patients with globe contusions (EQ index 0.523, p=0.4358; EQ VAS 73, p=0.8821) and penetrating lacerations (EQ index 0.651, p=0.4358; and EQ VAS 61, p=0.8821) had higher self-rated health status than the median value across all participants, while those having globe ruptures (EQ index 0.448, p=0.4358; and EQ VAS 56, p=0.8821) and IOFB (EQ index 0.442, p=0.4358; and EQ VAS 61.5, p=0.8821) have lower values (Table 3). However, none of these findings were statistically significant (EQ index p=0.4358, EQ VAS p=0.8821) (Table 3).
Descriptive QOL among all patients at presentation is shown in Figure 1. More than half of patients consistently reported problems in three dimensions: usual activities (69.70%), pain and discomfort (81.82%), and anxiety and depression (69.70%). More patients with an OTS of 1 reported having problems in usual activities and having anxiety and depression (81.82%), while pain and discomfort were reported equally across trauma scores (81.82%) (Table 4). A larger percentage of patients with globe rupture reported having anxiety and depression (85.71%) than any other type of injury, while a larger percentage of patients with IOFB reported problems in performing usual activities (80%) (Table 5).
EQ index scores (Figure 2) and VAS (Figure 3) were lowest upon initial presentation. A statistically significant increase in EQ VAS (p=0.01) was seen between baseline measurement and the first month follow-up visit. An increasing trend was noted in EQ index scores in subsequent follow-up visits (Figure 2).
Using univariate linear regression analysis comparing baseline patient characteristics with EQ index and EQ VAS, none of the baseline characteristics were found to have significant predictive value of QOL indices (Table 6). A summary of visual acuity scores and QOL indices are presented in Table 7. Using Spearman’s rank correlation coefficient to compare EQ index scores and EQ VAS scores with visual acuity (in LogMAR) in all four clinic visits, no statistically significant association was identified (Table 8).
Patient demographics in this study are similar to other studies on ocular trauma. Young adult males make up majority of our study population. The proposed explanation consistently given for this observation was that majority of eye trauma occurs in the workplace particularly in the construction industry, in which young adult males comprise most of the workforce.3-4,24-27 In our study, 94% of patients were classified to have open globe injuries. There were only 2 patients with closed globe injuries: 1 with traumatic optic neuropathy and 1 with both ruptured lens and retinal detachment. Two studies on ocular trauma in Singapore24-25 reported the prevalence of open globe injuries to be less than 5% only, a number that is much less than that identified in our study. We attribute this observation to the use of the ocular trauma scores and admission to the hospital ward as inclusion criteria which, in effect, selected patients who had poor visual prognoses. The diagnosis of open globe injury itself is an indicator of poor visual outcome.26 The results of the study will, therefore, be more applicable to patients with open globe injuries despite our attempt to also represent the closed globe type of injury in our study population. The presence of poor visual acuity and relative afferent pupillary defect at baseline in more than half of all patients was expected, as both these factors were reported to be indicators of poor visual outcome.3-4,8-9,27
To the best of our knowledge, this is the first study to describe QOL of eye trauma patients shortly after the injury. In our study, we were able to identify that majority of patients with varying trauma scores and types of injury presented with pain and discomfort, problems in usual activities, and anxiety and depression. Adequate pain control, psychosocial evaluation and occupational rehabilitation are, therefore, suggested to be included in the management of eye trauma patients to address these problems.
Comparing the QOL indices across different trauma scores, differences recorded failed to show statistical significance, suggesting that QOL may not differ significantly among patients with OTS of 1 to 3. The result may, however, be different among patients sustaining injuries with better visual prognosis, which warrants further investigation. The trend identified across types of injuries by EQ index was different from that by EQ VAS, and neither showed any statistically significant difference. This suggests that QOL across different types of injury may be comparable.
This study showed that the HRQoL improved over time following injury. The increase in QOL indices was greatest between initial presentation and the first month after injury, where it was found to be statistically significant. Possible reasons for this observation may be the alleviation of pain and perceived acute illness, adjustment to injury outcome and prognosis, and a positive result of treatment.
The results of this study add to our knowledge from previously published literature. Rofail et al. reported that patients sustaining open globe injuries have difficulties in reading, doing their favorite hobbies and performing their usual jobs as far as 12 years from injury.19 In our study, we have found that these problems in usual activities are already reported upon presentation. Yuksel et al. reported that all HRQoL aspects were decreased compared to control among patients sustaining ocular penetrating injuries at a mean of 8 months after injury.20 This suggests that despite an improving trend found in our study, QOL may not return to premorbid levels.
None of the baseline patient characteristics including age, sex, educational attainment, type of trauma, nor ocular trauma score were significantly associated with baseline QOL indices. This suggests that none of the clinical and demographic characteristics of eye trauma patients will be able to help predict or estimate their QOL upon initial consult with their physicians. In the Blue Mountains Eye Study involving 3,108 study participants in a general population, moderate to severe visual impairment was associated with poorer HRQoL.28 We sought a similar association between visual acuity and QOL indices in our study by using Spearman’s rank order correlation analysis comparing these across all four hospital visits but our results showed no statistically significant correlation between the two factors. Our results were more consistent with those of Yuksel et al. which did not report any correlation between visual acuity and health-related quality of life.20 The discrepancy between our results and that of the Blue Mountains Eye Study is likely attributable to the difference in study population.28 HRQoL may be correlated with visual acuity in the general population but not among ocular trauma patients. Clinicians should, therefore, be wary of estimating the QOL of eye trauma patients by their visual acuity.
The limitations of the study should be taken into account in interpreting our results. Patients who are admitted to the hospital ward belong to the low socioeconomic classes which may restrict the relevance of our results to similar subsets of the general population only. The use of the OTS as an inclusion criterion led to selection of mostly subjects with open-globe injuries. Our results, therefore, may not apply to other types of injuries that were not well represented in our study population (i.e. closed globe injuries and perforating lacerations). Recruitment of patients from the hospital ward instead of the emergency department also resulted to exclusion of most closed globe injuries which did not usually warrant ward admission. These factors also resulted into a small sample size. Poor adherence to the recommended follow-up schedule led to an even smaller data for analysis in subsequent visits. The short duration of the study did not allow for a description of the chronic phase of injury to compare directly with previously published results.
One advantage of using the EQ-5D-5L questionnaire is its utility in public health as the EQ index scores can be used in calculation of quality-adjusted life years (QALYs) for economic evaluation of health care. The data derived in our study may be used in future studies which aim to determine the economic aspects of eye injuries.
To address the limitations enumerated, we recommend that future studies expand the population and the study duration. If the ocular trauma scoring system will still be used to determine inclusion into the study, we expect that analyzing trauma with OTS of 4 and 5 will largely increase both the number of study participants and the representation of closed globe injuries. Likewise, a separate study on the quality of life of patients sustaining closed globe injuries may also be pursued.
In this study, we found that most patients sustaining potentially visually-disabling ocular injuries report pain and discomfort, problems in performing usual activities, and anxiety and depression upon initial presentation. There was no significant difference in health-related QOL indices identified across ocular trauma scores and types of injury. Across hospital visits, health-related QOL is at its lowest immediately after injury and improves significantly in the first month. None of the clinical characteristics at baseline were shown to predict quality of life indices. Visual acuity was also not found to be significantly correlated with QOL indices in any of the four hospital visits.
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