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Table 1.  

  All n = 210
Age (years) 46 (17-88)
Female/male 118/92
Ethnicity
White 170
Black African/Caribbean 9
South Asian 19
Other 12
Concomitant/incomitant 124/86
Classification a
Primary 35
Residual 33
Secondary 10
Secondary (Iatrogenic) 9
Consecutive 39
Neurogenic 47
Mechanical 37
Other 3
Disease duration (years) 24 (0-88)
Age of onset (years) 23 (0-76)
Previous surgery (yes/no) 98/112
Total no. of previous strabismus surgeries 1 (0-6)
Previous Botulinum toxin type A therapy (yes/no) 81/129
Previous prism therapy for diplopia (yes/no) 47/163
Worse eye visual acuity—LogMAR Conversionb 0.40 (-0.20-2.20)
Best eye visual acuity—LogMAR Conversionb - 0.06 (-0.20-0.80)
Deviation in primary position
Esotropia 59
Exotropia 78
Hypotropia and hypertropia 61
Other 12
Deviation in primary position 33.87 (2-90)
Diplopia/no diplopia 123/87
Mood (anxiety/depression)
Normal 123/172
Moderate 45/21
Caseness 42/18
AS-20 function/psychosocial
Below normal threshold 152/179
Above normal threshold 58/31

Table 1. Baseline characteristics of the sample.

aSecondary refers to a squint occurring following the loss or impairment of vision. Secondary (iatrogenic) refers to squint occurring secondary to sight saving surgery, eg retinal detachment surgery.
bVisual acuity. Vision acuity measured as Snellen's acuity but converter into LogMAR scale for statistical analysis. LogMAR values ranged between - 0.20 and 2.1. The score of 2.2 LogMAR being assigned to vision of counting fingers, hand movements, perception of light and non-perception of light.

Table 2.  

  Baseline 3 month 6 month Statistic
AS20 psychosocial 56.45 (1.62) 71.94 (1.75) a 74.65 (1.87) a F 2273.84 = 82.19, P <0.001
AS20 function 56.44 (1.44) 68.29 (1.57) a 69.42 (1.67) a F 2280.03 = 53.70, P<0.001
Depression 4.69 (0.23) 3.52 (0.25) a 3.21 (0.26) a F 2286.28 = 24.28, P <0.001
Anxiety 6.94 (0.26) 5.69 (0.28) a 5.79 (0.30) a F 2295.11 = 17.31, P <0.001
DAS24 39.29 (0.86) 34.66 (0.93) a 34.46 (0.98) a F 2242.42 = 24.03, P<0.001
IPQ-R personal control 2.51 (0.06) 2.46 (0.06) 2.43 (0.06) F2313.36 = 0.72, P = 0.49
IPQ-R consequences 2.99(0.06) 2.35(0.07) 2.23(0.07) F 2262.84 = 80.64, P <0.001
IPQ-R timeline 3.66 (0.07) 3.11 (0.07) 3.04 (0.07) F 2283.44 = 41.71, P <0.001
TRI treatment value 2.97 (0.04) 2.86 (0.05) 2.83 (0.05) a F 2314.04 = 3.99, P - 0.02
TRI treatment concerns 2.76 (0.05) 2.33 (0.06) a 2.19 (0.06) a F 2282.80 = 52.12, P <0.001
TRI decision satisfaction 3.97 (0.04) 4.13 (0.04) a 4.16 (0.04) a F 2295.88 = 11.86, P<0.001
TRI cure 3.61 (0.04) 3.27 (0.05) a 3.24 (0.05) a F 2348.88 = 26.66, P<0.001
FNE 37.11 (0.57) 35.60 (0.61) a 35.52 (0.64) a F 2272.66 = 7.19, P- 0.01
Perceived visibility 4.87 (0.12) 3.06 (0.13) a 2.79 (0.14) a F 2333.02 = 120.55, P <0.001
CARSAL 32.46 (0.42) 30.92 (0.46) a 31.03 (0.48) a F 2299.58 = 10.51, P<0.001
CARVAL 20.38 (0.49) 17.64 (0.54) a 17.41 (0.57) a F 2286.99 = 22.65, P<0.001
Social support—family 16.19 (0.23) 16.10 (0.25) 16.46 (0.26) F2309.33 = 1.56, P = 0.21
Social support—friends 16.00 (0.21) 16.02 (0.23) 16.04 (0.24) F2303.20= 0.02, P = 0.98
Social support—significant others 16.02 (0.27) 15.73 (0.30) 15.76 (0.31) F2292.73 =0.87, P=0.42
Anxiety
   Normal 123 (58.57) 131 (70.81) 115 (68.05) χ2 (2, n = 210) = 20.19, P <0.001
   Moderate 45 (21.43) 33 (17.84) 35 (20.71)  
   Caseness 42 (20.00) 21 (11.35) 19 (11.24)  
Depression
   Normal 172 (81.90) 165 (89.19) 151 (89.35) χ2 (2, n = 210) = 13.90, P = 0.001
   Moderate 21 (10.00) 11 (5.95) 11 (6.51)  
   Caseness 18 (8.57) 9 (4.86) 7 (4.14)  
AS20 psychosocial
   Below norm 179 (85.24) 124 (67.03) 116 (68.64) χ2 (2, n = 210) = 47.50, P = 0.001
   Above norm 31 (14.76) 61 (32.97) 53 (31.36)  
AS20 function
   Below norm 152 (72.38) 87 (47.03) 76 (44.97) χ2 (2, n = 210) = 55.93, P = 0.001
   Above norm 58 (27.62) 98 (52.97) 93 (55.03)  
AS20 psychosocial    
   Exceeded 95% LOAs 68 (36.76) 74 (43.79)
   Did not exceed 95% LOAs   117 (63.24) 95 (56.21)  
AS20 function    
   Exceeded 95% LOAs 61 (32.97) 64 (37.87)
   Did not exceed 95% LOAs   124 (67.03) 105 (62.13)  

Table 2. Changes over time, estimated marginal mean (SE).

aSignificant difference from baseline P <0.01.
Bold values are statistically significant.

Table 3.  

  β t P 95% CI for β
Lower bound Upper bound
Outcome: psychosocial quality of life (constant) 0.00 4.50 0.00 1.70 4.34
Age 0.00 −0.01 0.99 −0.01 0.01
Gender 0.03 0.70 0.48 −0.10 0.20
Ethnicity
Black 0.02 0.48 0.63 −0.28 0.47
South Asian −0.04 −0.98 0.32 −0.40 0.13
Other ethnicity 0.02 0.49 0.62 −0.23 0.38
Classification
Primary 0.03 0.62 0.54 −0.17 0.33
Residual 0.02 0.41 0.68 −0.24 0.37
Secondary −0.03 −0.71 0.48 −0.57 0.27
Secondary iatrogenic 0.05 1.18 0.24 −0.16 0.63
Consecutive 0.00 0.00 1.00 −0.31 0.31
Mechanical −0.04 −0.90 0.37 −0.35 0.13
Other classification 0.01 0.41 0.68 −0.46 0.71
Disease duration (years) −0.05 −0.61 0.54 −0.01 0.01
Age of onset (years) −0.10 −1.24 0.22 −0.01 0.00
Previous surgery (yes/no) −0.04 −0.61 0.54 −0.31 0.16
Total no. of previous strabismus surgeries −0.03 −0.50 0.62 −0.13 0.08
Previous Botulinum toxin type A therapy (yes/no) 0.01 0.24 0.81 −0.13 0.17
Previous prism therapy for diplopia (yes/no) −0.06 −1.32 0.19 −0.34 0.07
Worse eye visual acuity—LogMAR Conversiona −0.02 −0.43 0.67 −0.15 0.10
Best eye visual acuity—LogMAR conversiona 0.04 1.14 0.25 −0.24 0.91
Deviation in primary position 0.01 0.31 0.75 0.00 0.01
Esotropia −0.01 −0.17 0.87 −0.23 0.19
Hypertropia or hypotropia 0.01 0.13 0.90 −0.25 0.28
Other direction 0.01 0.26 0.79 −0.32 0.43
Diplopia 0.09 1.65 0.10 −0.03 0.38
IQP-R timeline −0.01 −0.28 0.78 −0.10 0.07
IQP-R consequences −0.18 −3.41 0.00 −0.32 −0.09
IQP-R personal control −0.02 −0.51 0.61 −0.10 0.06
TRI treatment value 0.01 0.30 0.77 −0.13 0.17
TRI treatment concerns −0.03 −0.63 0.53 −0.13 0.07
TRI decision satisfaction 0.00 −0.06 0.95 −0.18 0.17
TRI cure −0.02 −0.37 0.71 −0.19 0.13
FNE −0.06 −1.21 0.23 −0.02 0.00
ESSQ intimacy and appearance-related issues −0.05 −0.73 0.46 −0.28 0.13
ESSQ visual functioning 0.08 1.17 0.25 −0.09 0.36
ESSQ social functioning 0.02 0.40 0.69 −0.23 0.34
RSSQ intimacy and appearance-related issues −0.24 −3.57 0.00 −0.33 −0.09
RSSQ visual functioning 0.02 0.36 0.72 −0.09 0.13
RSSQ social functioning −0.06 −1.11 0.27 −0.19 0.05
DAS24 −0.25 −4.39 0.00 −0.03 −0.01
Appearance concern −0.08 −1.57 0.12 −0.40 0.04
Perceived visibility −0.26 −4.43 0.00 −0.19 −0.07
Salience −0.01 −0.11 0.91 −0.01 0.01
Valence 0.01 0.15 0.88 −0.01 0.01
Social support—family −0.05 −1.11 0.27 −0.04 0.01
Social support—friends 0.04 0.95 0.34 −0.01 0.04
Social support—significant others 0.05 1.20 0.23 −0.01 0.03
Anxiety −0.03 −0.60 0.55 −0.03 0.02
Depression −0.01 −0.10 0.92 −0.03 0.03
Outcome: functional quality of life (constant) 0.00 4.66 0.00 2.35 5.76
Age −0.01 −0.12 0.91 −0.01 0.01
Gender 0.05 0.91 0.36 −0.11 0.29
Ethnicity
Black 0.05 0.97 0.33 −0.23 0.69
South Asian 0.06 1.12 0.26 −0.16 0.57
Other ethnicity 0.10 2.12 0.03 0.03 0.83
Classification a
Primary −0.05 −0.73 0.47 −0.45 0.21
Residual −0.01 −0.18 0.86 −0.44 0.36
Secondary 0.00 0.00 1.00 −0.56 0.56
Secondary iatrogenic −0.14 −2.62 0.01 −1.22 −0.17
Consecutive 0.08 0.92 0.36 −0.22 0.61
Mechanical −0.10 −1.58 0.11 −0.58 0.06
Other classification −0.06 −1.25 0.21 −1.25 0.28
Disease duration (years) −0.10 −0.96 0.34 −0.01 0.01
Age of onset (years) −0.09 −0.79 0.43 −0.01 0.01
Previous surgery (yes/no) −0.11 −1.34 0.18 −0.52 0.10
Total no. of previous strabismus surgeries 0.07 0.83 0.41 −0.08 0.19
Previous Botulinum toxin type A therapy (yes/no) 0.09 1.76 0.08 −0.02 0.38
Previous prism therapy for diplopia (yes/no) 0.08 1.41 0.16 −0.08 0.46
Worse eye visual acuity—LogMAR Conversionb 0.05 0.78 0.44 −0.10 0.23
Best eye visual acuity—LogMAR conversionb 0.01 0.28 0.78 −0.65 0.86
Deviation in primary position 0.01 0.10 0.92 −0.01 0.01
Esotropia 0.00 0.05 0.96 −0.27 0.29
Hypertropia or hypotropia 0.15 1.85 0.07 −0.02 0.68
Other direction 0.06 1.03 0.30 −0.23 0.75
Diplopia −0.10 −1.46 0.14 −0.48 0.07
IQP-R timeline −0.01 −0.21 0.83 −0.12 0.10
IQP-R consequences −0.28 −3.81 0.00 −0.45 −0.14
IQP-R personal control 0.04 0.88 0.38 −0.06 0.16
TRI treatment value −0.03 −0.52 0.60 −0.25 0.15
TRI treatment concerns −0.15 −2.49 0.01 −0.30 −0.04
TRI decision satisfaction −0.05 −0.78 0.44 −0.31 0.14
TRI cure −0.02 −0.26 0.80 −0.24 0.18
FNE −0.06 −0.85 0.39 −0.02 0.01
ESSQ intimacy and appearance-related issues 0.15 1.68 0.10 −0.04 0.51
ESSQ visual functioning −0.17 −2.04 0.04 −0.54 −0.01
ESSQ social functioning −0.02 −0.31 0.76 −0.43 0.31
RSSQ intimacy and appearance-related issues 0.11 1.26 0.21 −0.05 0.25
RSSQ visual functioning −0.20 2.42 0.02 −0.33 −0.03
RSSQ social functioning 0.00 −0.06 0.96 −0.16 0.15
DAS24 −0.21 −2.78 0.01 −0.03 0.00
Appearance concern 0.00 0.01 0.99 −0.29 0.29
Perceived visibility 0.05 0.60 0.55 −0.05 0.10
Salience −0.07 −1.09 0.27 −0.03 0.01
Valence 0.00 −0.06 0.95 −0.02 0.02
Social support—family −0.06 −0.85 0.40 −0.05 0.02
Social support—friends 0.05 0.72 0.47 −0.02 0.05
Social support—significant others −0.08 −1.32 0.19 −0.04 0.01
Anxiety −0.06 −0.92 0.36 −0.04 0.02
Depression −0.14 −1.94 0.05 −0.07 0.00

Table 3. Baseline predictors of change in psychosocial and functional quality of life.

aSecondary refers to a squint occurring following the loss or impairment of vision. Secondary (iatrogenic) refers to squint occurring secondary to sight saving surgery, for example retinal detachment surgery.
bVisual acuity measured as Snellens acuity but converted into LogMAR scale for statistical analysis. LogMAR values ranged between −0.20 and 2.1. The score of 2.2 LogMAR being assigned to vision of counting fingers, hand movements, perception of light and non perception of light. Bold values are statistically significant (P<0.05).

Table 4.  

  β t P 95% CI for β
Lower bound Upper bound
Outcome: psychosocial quality of life (constant) 0.00 0.39 0.69 −0.08 0.12
Success
Partial success −0.03 −0.78 0.44 −0.22 0.09
Unsuccessful 0.00 −0.13 0.90 −0.27 0.24
Change in IPQ-R timeline 0.00 0.04 0.97 −0.08 0.08
Change in IPQ-R consequences −0.16 −3.09 0.00 −0.26 −0.06
Change in IPQ-R personal control −0.01 −0.15 0.88 −0.08 0.07
Change in TRI treatment value 0.02 0.48 0.63 −0.07 0.12
Change in TRI treatment concerns −0.03 −0.78 0.43 −0.11 0.05
Change in TRI decision satisfaction −0.02 −0.40 0.69 −0.10 0.07
Change in TRI cure −0.04 −0.77 0.44 −0.14 0.06
Change in FNE −0.04 −0.85 0.39 −0.14 0.06
Change in salience −0.11 −2.33 0.02 −0.20 −0.02
Change in DAS24 −0.31 −5.42 0.00 −0.41 −0.19
Change in valence −0.05 −0.93 0.35 −0.14 0.05
Change in perceived visibility −0.42 −8.68 0.00 −0.51 −0.32
Change in social support—significant others 0.07 1.53 0.13 −0.02 0.16
Change in social support—family −0.06 −1.20 0.23 −0.16 0.04
Change in social support—friends 0.02 0.38 0.70 −0.07 0.11
Change in anxiety −0.06 −1.13 0.26 −0.16 0.04
Change in depression 0.04 0.73 0.47 −0.07 0.14
Outcome: functional quality of life (constant) 0.00 −0.36 0.72 −0.17 0.12
Success
Partial success 0.01 0.22 0.83 −0.21 0.26
Unsuccessful 0.00 0.01 0.99 −0.36 0.36
Change in IPQ-R timeline 0.01 0.15 0.88 −0.11 0.13
Change in IPQ-R consequences −0.38 −4.83 0.00 −0.51 −0.22
Change in IPQ-R personal control 0.06 1.06 0.29 −0.05 0.16
Change in TRI treatment value −0.09 −1.20 0.23 −0.22 0.05
Change in TRI treatment concerns −0.12 −1.97 0.05 −0.24 0.00
Change in TRI decision satisfaction −0.06 −0.94 0.35 −0.19 0.07
Change in TRI cure 0.05 0.64 0.52 −0.10 0.19
Change in FNE 0.02 0.29 0.77 −0.12 0.16
Change in DAS24 −0.07 −0.82 0.41 −0.22 0.09
Change in salience 0.01 0.08 0.94 −0.13 0.14
Change in valence −0.02 −0.26 0.79 −0.16 0.12
Change in perceived visibility 0.23 3.28 0.00 0.09 0.36
Change in social support—significant others −0.13 −2.07 0.04 −0.26 −0.01
Change in social support—family −0.02 −0.29 0.77 −0.16 0.12
Change in social support—friends 0.09 1.30 0.19 −0.04 0.22
Change in anxiety −0.05 −0.60 0.55 −0.19 0.10
Change in depression −0.34 −4.39 0.00 −0.49 −0.19

Table 4. Changes in clinical and psychosocial variables that predict change in psychosocial and functional quality of life.

Bold values are statistically significant (P<0.05).

CME

Does Strabismus Surgery Improve Quality and Mood, and What Factors Influence This?

  • Authors: Hayley B. McBain, PhD, CPsychol; Kelly A. MacKenzie, MSc, BSc (Hons); Joanne Hancox, BSc (Hons), FRCOphth; Daniel G. Ezra, MD, FRCOphth; Gillian G.W. Adams, FRCS(Ed), FRCOphth; Stanton P. Newman, PhD, CPsychol
  • CME Released: 4/29/2016
  • THIS ACTIVITY HAS EXPIRED
  • Valid for credit through: 4/29/2017
Start Activity


Target Audience and Goal Statement

This activity is intended for ophthalmologists and other clinicians caring for adults undergoing strabismus surgery.

The goal of this activity is to describe the clinical and psychosocial impact of adult strabismus surgery, predictors of outcomes, and potential interventions to improve quality of life after surgery, based on a surgical case series.

Upon completion of this activity, participants will be able to:

  1. Describe the clinical and psychosocial impact of adult strabismus surgery, based on a surgical case series
  2. Determine predictors of outcomes from adult strabismus surgery
  3. Evaluate potential interventions to improve quality of life after adult strabismus surgery


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  • Hayley B. McBain, PhD, CPsychol

    School of Health Sciences, City University London; Community Health Newham, East London Foundation Trust, London, United Kingdom

    Disclosures

    Disclosure: Hayley B. McBain, PhD, CPsychol, has disclosed no relevant financial relationships.

  • Kelly A. MacKenzie, MSc, BSc (Hons)

    Moorfields Eye Hospital NHS Foundation Trust, London, United Kingdom

    Disclosures

    Disclosure: Kelly A. MacKenzie, MSc, BSc (Hons), has disclosed no relevant financial relationships.

  • Joanne Hancox, BSc (Hons), FRCOphth

    Moorfields Eye Hospital NHS Foundation Trust, London, United Kingdom

    Disclosures

    Disclosure: Joanne Hancox, BSc (Hons), FRCOphth, has disclosed no relevant financial relationships.

  • Daniel G. Ezra, MD, FRCOphth

    Moorfields Eye Hospital NHS Foundation Trust; UCL Institute of Ophthalmology NIHR Biomedical Research Centre for Ophthalmology, London, United Kingdom

    Disclosures

    Disclosure: Daniel G. Ezra, MD, FRCOphth, has disclosed no relevant financial relationships.

  • Gillian G.W. Adams, FRCS(Ed), FRCOphth

    Moorfields Eye Hospital NHS Foundation Trust, London, United Kingdom

    Disclosures

    Disclosure: Gillian G.W. Adams, FRCS(Ed), FRCOphth, has disclosed no relevant financial relationships.

  • Stanton P. Newman, PhD, CPsychol

    School of Health Sciences, City University London, London, United Kingdom

    Disclosures

    Disclosure: Stanton P. Newman, PhD, CPsychol, has disclosed no relevant financial relationships.

Editor

  • Andrew J. Lotery, MD, FRCOphth

    Editor, Eye

    Disclosures

    Disclosure: Andrew J. Lotery, MD, FRCOphth, has disclosed the following relevant financial relationships:
    Served as an advisor or consultant for: Bayer HealthCare Pharmaceuticals; Roche
    Served as a speaker or a member of a speakers bureau for: Bayer HealthCare Pharmaceuticals

CME Author

  • Laurie Barclay, MD

    Freelance writer and reviewer, Medscape, LLC

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    Disclosure: Laurie Barclay, MD, has disclosed the following relevant financial relationships:
    Owns stock, stock options, or bonds from: Pfizer

CME Reviewer

  • Robert Morris, PharmD

    Associate CME Clinical Director, Medscape, LLC

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    Disclosure: Robert Morris, PharmD, has disclosed no relevant financial relationships.


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CME

Does Strabismus Surgery Improve Quality and Mood, and What Factors Influence This?: Results

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Results

Participants

Of the 335 patients who consented, 81.49% completed a baseline questionnaire. Of these, 210 completed either a3 (n = 41) or 6 month (n = 25) follow-up questionnaire or both (n = 144). Baseline characteristics of the sample can be found in Table 1 .

Impact of Surgery

Clinical Variables. The angle of deviation decreased significantly from baseline (mean difference (Md) = 30, range 2-90) to 3 months (Md = 10, range 0-90; z = -11.81, P<0.001, r = -0.57). There was a statistically significant reduction in the proportion of participants who experienced diplopia from prior (58.57%) to 3 months post surgery (40%; P <0.001). A small proportion (5.85%) experienced surgery induced diplopia at 3 months, 11 in the primary and downgaze position and 1 in another gaze.

Low levels of pain, swelling, scarring and redness were reported at both 3 and 6 months post surgery, with no significant changes in pain, swelling or scarring between these two follow-ups. Improvements in redness from 3 (Md = 1, range 0-10) to 6 months (Md = 0, range 0-10) post surgery were significant (z = -3.51, P = 0.001, r = -0.24).

Psychosocial Variables. Statistically significant improvements in psychosocial and functional quality of life, anxiety and depression, social anxiety and social avoidance, illness and treatment beliefs, fear of negative evaluation, perceived visibility, and salience and valance of appearance ( Table 2 ) were found from pre-surgery to 3 months and pre-surgery to 6 months. There were no significant changes from 3 to 6 months. Overtime the number of participants who were meeting moderate or 'caseness' levels of anxiety or depression, or scoring below normal in quality of life, reduced significantly from pre-surgery to 6 months post surgery, whereas the proportion of patients in the normal classification for mood and above normal in quality of life increased. There was no statistically significant difference in the proportion of participants who exceeded the 95% LOAs at 3 and 6 months post surgery (psychosocial quality of life: P = 0.33; functional quality of life P = 0.12).

Relationship Between Clinical Success and Quality of Life

According to clinical criteria, 110 (52.38%) participants experienced successful surgery, 20 (9.52%) failed and 80 (38.09%) were partial successes. Of these 80 partial successes, 10 (12.5%) were scheduled for further surgery, 43 (53.75%) had been discharged from the service, 13 (16.25%) had a scheduled follow-up appointment, 9 (11.25%) were receiving prism therapy and 5 (6.25%) botulinum toxin therapy. While there were no statistically significant differences between these three groups of patients on changes in functional quality of life from baseline to 6 months (F2207= 0.89, P = 0.42), there were differences in changes in psychosocial quality of life (F2207 = 4.22, P = 0.02, η2 = 0.04). Post-hoc comparison indicated that the mean residualised change score for those who experienced partial success (M = - 0.24, SD = 0.84) was significantly lower than those who experienced success (M = 0.18, SD = 1.05).

Satisfaction

Over 80% of patients did not regret having surgery, ~ 6% had some regret either at 3 or 6 months. Between 70 and 80% of the sample would go through the operation, only 1-4% would not.

Who Benefits Most From Surgery?

The final model for changes in psychosocial quality of life explained 85% of the total variance (F49 160 = 18.60, P<0.001). The statistically significant predictors were the IPQ-R consequences subscale, the intimacy and appearance-related issues subscale of the RSSQ, the DAS24 and perceived visibility at baseline ( Table 3 ). The final model for changes in functional quality of life explained 72% of the variance (F49 160 = 8.60, P <0.001). The statistically significant predictors were ethnicity, classification, the IPQ-R consequences subscale, the TRI treatment concern subscale, the visual functioning subscale of the ESSQ and RSSQ, and DAS24 at baseline ( Table 3 ).

Which Concepts Should Be Targeted in Order to Improve the Impact of Surgery?

The final model for changes in psychosocial quality of life accounted for 78% of the variance (F19 190 = 35.78, P<0.001). The statistically significant predictors were changes in; the IPQ-R consequences subscale, salience, DAS24 and in perceived visibility ( Table 4 ). The final model for changes in psychosocial quality of life accounted for 51% of the variance (F19 190 = 10.48, P<0.001). The statistically significant predictors were changes in; the IPQ-R consequences subscale, perceived visibility, social support from significant others and depression ( Table 4 ).