The aim of the present study was to explore the associations between visual outcomes of ocular injury patients in a tertiary hospital unit with clinical and demographic variables and to evaluate the psychosocial impact of the injury on the patients. An 18-month prospective study of 30 eye-injured adult patients was conducted in the General University Hospital of Heraklion, Crete, a tertiary referral hospital. All severe eye injury case information was prospectively collected between February 1, 2020 and August 31, 2021. Best corrected visual acuity (BCVA) was labelled not poor (>0.5/10 or >20/400 on the Snellen scale, <1.3 in LogMAR scale) and poor (≤0.5/10 or ≤20/400 on the Snellen scale, ≥1.3 on the LogMAR equivalent). Data regarding participants' perceived stress levels, by using Perceived Stress Scale 14 (PSS-14), were collected prospectively, one year after study end. Out of 30 ocular injury patients selected, 76.7% were men and most of them were self-employed and private or public sector workers (36.7%). Not poor final BCVA was related to not poor initial BCVA [odds ratio (OR) 1.714; P=0.006]. No statistical associations were found between visual outcome and demographic or clinical factors, but not poor final BCVA was associated with improved self-reported psychological condition of the sufferers, as examined by a questionnaire sheet developed to collect information for study purpose (8.36/10 vs. 6.40/10; P=0.011). No patient reported job loss or changed work status following the injury. Not poor initial BCVA was a significant predictor for not poor final visual outcomes (OR 1.714; P=0.006). Patients with not poor final BCVA expressed higher levels of positive psychology (8.36/10 vs. 6.40/10; P=0.011) and less fear of eye injury repetition (64.0 vs. 100.0%; P=0.286). Not poor final BCVA was associated with low PSS-14 scores one year after study end (77.3 vs. 0.0%, P=0.003). Collaboration between ophthalmologists, mental health professionals and primary care team may be important in order to help patients to cope with the psychosocial burden sequel to eye trauma.
Visual loss and impairment due to eye trauma are not only found to affect the visual acuity of patients, but also their quality of life, causing occupational and social dysfunctions (
Furthermore, Lax and Klein (
The majority of eye injuries refer to men as they tend to be more involved in high risk occupations compared with women (
The main goal of the present study was to explore factors associated with visual outcomes, in terms of clinical and psychosocial parameters, especially during the period of coronavirus disease 2019 (COVID-19), as restrictive measures of quarantine and commuting led to further access limitation.
Data of the present study were collected prospectively during an 18-month period between February 1, 2020 and August 31, 2021 from eye injury patients admitted to the General University Hospital of Heraklion Crete, Greece, the only tertiary care center of Crete. The present study included all adult patients that met the following inclusion criteria: i) >18 years, ii) with severe eye injuries presented to the emergency department of Ophthalmology, iii) hospitalized at the ophthalmology clinic either for specialized medical care or treated after surgical intervention. Patients included in the study sample were subjected to standard clinical practice. All socio-demographic information was collected via interview by the researchers during hospitalization. Clinical data were recorded in cooperation with a specialized ophthalmologist who examined each patient at the ophthalmology emergency department until their discharge from the hospital unit. Additionally, it was planned to prospectively record Perceived Stress Scale 14 (PSS-14) levels one year after study end in order to avoid acute phase distress bias and assess any long term effect.
Patients were age grouped between 18-40, 41-66 and ≥67 years. Education included elementary, secondary, high school and university level. A total of four occupation categories were used: Manual workers, farmers/livestock workers, self-employed and private-public sector workers and unemployed. Injuries were grouped into open and closed globe injuries, according to the Birmingham Eye Trauma Terminology (
Information on overall psychosocial status of the patients was assessed through a questionnaire sheet for data collection. Most questions were dichotomous (yes/no) while one question was scored by using a Likert scale of 1-10 points, (1, very bad; 5, moderate and 10, good) via telephone interview after a 6-month follow-up period. The same questionnaire collected information about patients' satisfaction regarding the medical service provision, the fear of incident repetition, patients' recovery from the eye trauma and changing work status.
Perceived Stress Scale 14 (PSS-14) is a 14-item tool created by Cohen
All variables were summarized using descriptive statistics. For each variable the number of counts and the respective percentage was presented. Univariate analyses were performed using Fisher's exact test (for binary variables) and Pearson's Chi-square test with Yate's continuity correction (in case of non-binary categorical variables). Means with standard deviation were based on independent samples T-test for the question ‘How well do you currently feel in psychological terms?’, a 10 Likert scale rating. Odds ratios were calculated using simple logistic regression models with final BCVA (not poor vs. poor) as dependent variable. The statistical software used was SPSS version 24 (IBM Corp.). P<0.05 was considered to indicate a statistically significant difference.
The present study covered 30 patients, most of whom were men (76.7%) aged between 41-66 years (56.7%). The majority of participants were Greek (83.3%), had received elementary education (40.0%) and were married (86.7%). As to their occupation, 20.0% were manual workers, 26.7% farmers/livestock workers, while 36.7% were self-employed/private/public sector workers (
The present study compared patients according to their final BCVA (not poor vs. poor). All patients in both groups reported being satisfied with the health care services (100% in both groups). Patients with not poor final BCVA reported significantly improved feelings in terms of psychological status, compared with patients with poor final BCVA (8.36 vs. 6.40; P=0.011).
Patients with not poor final BCVA reported fear of incident repetition to a lesser extent compared with participants with poor final BCVA. The majority of patients (68%) with not poor final BCVA reported recovery from trauma compared with no (0%) patient in the poor final BVCA group (P=0.009).
Hospitalization for eight days or more was more frequent in patients with poor final BCVA compared with patients in the not poor final BCVA group (60 vs. 24%; P=0.143). No patients reported changing their work status and the days of absence from work were similar in both groups.
Patients in the poor final BCVA group reported paying more money in personal expenses (P=0.019) and reported limiting their social activities to a higher extent (100 vs. 52.9%; P=0.050). Finally, the reported PSS-14 scores were significantly higher in patients in the poor final BCVA group (P=0.003;
To the to the best of the authors' knowledge, the present study is the first to explore the psychological status of eye injury patients with visual outcomes in the geographical region of Crete, Greece and there are few published studies on this subject worldwide (
A number of studies proved that the type of injury (
The present study also showed that there was a significant association between initial BCVA and not poor final visual outcomes, in line with other studies (
As shown in
The findings of the present study indicated that PSS-14 scores were significantly higher in patients with poor final BCVA one year after the study end. To the best of the authors' knowledge, there are limited studies that explore similar associations. However, individuals with dry eye disease (DED) had higher level of perceived stress as measured by PSS (4-item version) in comparison with a non-DED group (
There is a need to stress that all patients with not poor or poor final BCVA reported being satisfied from healthcare services provision during hospitalization and follow-up, but this association was not significant. To the best of the authors' knowledge, there is limited research regarding patients' satisfaction from healthcare facilities and the way that this satisfaction interact with their feelings in terms of recovery from a severe eye injury and the psychological status during hospitalization or after discharge. Further research should be conducted to cast more light on this issue using appropriately designed tools. The' psychological impact of severe eye injuries should be evaluated and behavioral interventions could be initiated to help sufferers cope with all possible difficulties arisen. The multilevel effect of eye injuries to the patients is clear and should be taken into consideration by policy makers and health providers during the rehabilitation process.
Time of admission or delay is an important factor for the final BCVA and the recovery of the patient, according to a recent retrospective study (
The main strength of the present study was that all data were prospectively selected, thus the information was accurate and complete concerning psychosocial outcomes, even after a long period from the eye injury. On the other hand, there were certain limitations to the present study. A number of eye injuries might not be included in the present study as they could have been managed by private ophthalmologists, local secondary or first aid units due to COVID-19 transportation restrictions. However, it is considered that the present study managed to collect more severe injuries as they required specialized treatment at a tertiary University Hospital. In addition, the study sample was limited during the study period and may not be representative for all eye injuries throughout the geographical region of Crete, as there were suspensions of work, again due to COVID-19 protective measures. As concluded by Liang
Further studies should be conducted throughout Greece, focusing on special geo-epidemiological features to identify factors related to visual outcomes and the psychological impact on the overall health of patients. Eye care practitioners should pay attention to the psychological needs of the patients, especially those severely injured, and help them cope with implications subsequent to the injury. Referral pathways and collaboration with other professionals could be established to address the needs of patients holistically. Moreover, a system of social interventions should be initiated, in terms of protective strategies and rehabilitation of visual impaired or disabled patients.
In conclusion, not poor initial BCVA was significantly associated with not poor final visual outcomes. Self-employed and workers of private-public sector had increased risk of experiencing an eye injury, despite the non-significant association. Patients with not poor final BCVA had significantly increased levels of positive psychology and low levels of perceived stress. Not poor final BCVA was also correlated to a reduced fear of incident repetition, while all patients with not poor or poor final visual acuity were satisfied from healthcare services provision, with no significant trend. Collaboration between ophthalmologists and mental health professionals is considered important in order to help patients to eliminate the psychological burden that eye injury entails.
Not applicable.
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.
EK, ED and ES conceived and designed the present study, interpreted the data and drafted the manuscript. EK performed data collection. AB performed data analysis and interpretation and drafted the manuscript. GM contributed to data analysis, data synthesis and interpretation and writing the manuscript. NT contributed organizational support, informational input and contributed to writing the manuscript. PV performed literature review, data synthesis and contributed to writing and revision of the manuscript. DS revised the manuscript and contributed intellectual input with meaningful content suggestions. ES and ED provided theoretical and intellectual input for implementation of the present study, manuscript drafting and critical revision. EK and NT confirm the authenticity of all the raw data. All authors read and approved the final manuscript.
All data was collected according to Declaration of Helsinki guidelines to assure confidentiality. The present study was also approved by the Scientific Council of the 7th Health District of Crete (protocol no. 17/30-10-2019) and the Scientific Ethics and Deontology Committee of the University of Crete (protocol no. 28/07-02-2020). Verbal and written informed consent was obtained from the patients.
Not applicable.
DS is the Editor-in-Chief for the journal, but had no personal involvement in the reviewing process, or any influence in terms of adjudicating on the final decision, for this article. Another member of the editorial board handled the manuscript as editor. The other authors declare that they have no competing interests.
Socio-demographic characteristics of eye injuries (n=30).
Characteristic | n | % |
---|---|---|
Sex | ||
Male | 23 | 76.7 |
Female | 7 | 23.3 |
Age, years | ||
18-40 | 10 | 33.3 |
41-66 | 17 | 56.7 |
66+ | 3 | 10.0 |
Mean ± standard deviation (min, max) | ||
48.3±15.2 (21,78) | ||
Education | ||
Elementary | 12 | 40.0 |
Secondary | 6 | 20.0 |
Higher | 9 | 30.0 |
University | 3 | 10.0 |
Family status | ||
Married | 26 | 86.7 |
Unmarried, divorced, widowed | 4 | 13.3 |
Nationality | ||
Greek | 25 | 83.3 |
Other | 5 | 16.7 |
Occupation | ||
Manual workers | 6 | 20.0 |
Farmers/livestock workers | 8 | 26.7 |
Self-employed/private-public sector employees | 11 | 36.7 |
Unemployed | 5 | 16.7 |
Insurance status | ||
Public insurance | 0 | 0 |
Private insurance | 15 | 50.0 |
Agricultural insurance | 10 | 33.3 |
Social security/self-employment insurance | 3 | 10.0 |
Uninsured | 2 | 36.7 |
Factors associated with visual outcomes (n=30).
Final visual acuity (LogMar scale) | ||||
---|---|---|---|---|
Factors | Not poor (%) | Poor (%) | Odds ratio | P-value |
Initial visual acuity (LogMar scale) | 1.714 (1.063-2.765) | 0.006 | ||
Not poor | 18 (72.0) | 0 (0.0) | ||
Poor | 7 (28.0) | 5 (100.0) | ||
Type of injury | 1.313 (0.921-1.871) | 0.157 | ||
Closed globe injury | 15 (60.0) | 1 (20.0) | ||
Opened globe injury | 10 (40.0) | 4 (80.0) | ||
Occupation | 0.981 | |||
Manual workers | 5 (20.0) | 1 (20.0) | Reference group | |
Farmers/livestock workers | 7 (28.0) | 1 (20.0) | 0.714 (0.036-14.347) | 0.826 |
Self-employed/private-public sector employees | 9 (36.0) | 2 (40.0) | 1.111 (0.079-15.534) | 0.938 |
Unemployed | 4 (16.0) | 1 (20.0) | 1.250 (0.058-26.869) | 0.887 |
Residence distance from hospital (km) | 0.206 | |||
0-20 | 14 (56.0) | 2 (40.0) | Reference group | |
21-60 | 0 (0.0) | 1 (20.0) | 1.131 (0.010-11.235) | 0.143 |
61+ | 11 (44.0) | 2 (40.0) | 1.273 (0.154-10.530) | 0.823 |
Time of admittance to hospital | 1.185 (0.823-1.708) | 0.364 | ||
≤2 h | 16 (64.0) | 2 (40.0) | ||
>2 h | 9 (36.0) | 3 (60.0) | ||
Surgical intervention | 1.500 (1.049-2.145) | 0.042 | ||
No | 15 (60.0) | 0 (0.0) | ||
Yes | 10 (40.0) | 5 (100.0) |
Psycho-social determinants in not poor/poor final visual acuity groups (n=30).
Final visual acuity (LogMar scale) | ||||
---|---|---|---|---|
Psycho-social determinant | Not poor | Poor | Odds ratio | P-value |
Were you overall satisfied from health care services received? (Yes/No; number of positive answers) |
25 (100%) | 5 (100%) | - | |
How well do you currently feel in psychological terms? [from 1-10; Likert scale (1=very bad, 5=moderate, 10=very good)] |
8.36 (1.47) | 6.40 (1.52) | 0.449 (0.22-0.94) | 0.011 |
Do you feel fear of similar incident repetition in the future? (Yes/No; number of positive answers) |
16 (64.0%) | 5 (100.0%) | 0.762 (0.60-0.97) | 0.286 |
Have you already recovered from your ophthalmic trauma? (Yes/No; number of positive answers) |
17 (68.0%) | 0 (0.0%) | 1.625 (1.06-2.45) | 0.009 |
How many days of hospitalization did you spend? |
4.750 (0.64-35.5) | 0.143 | ||
0-7 days | 19 (76.0%) | 2 (40.0%) | ||
8+ days | 6 (24.0%) | 3 (60.0%) | ||
Did you change your work status due to your ophthalmic trauma? (Yes/No; number of positive answers) |
0 (0.0%) | 0 (0.0%) | - | |
How many days of sick leave did you get? |
1.375 (0.84-2.20) | 0.208 | ||
0-7 days | 19 (76.0%) | 2 (40.0%) | ||
8+ days | 6 (24.0%) | 3 (60.0%) | ||
What were your personal expenses (euros) due to your ophthalmic trauma? |
50 (0-300;55) | 80 (0-4000;340) | 1.010 (1.00-1.02) | 0.019 |
Were your social activities restricted? (Yes/No; number of positive answers) |
9 (52.9%) | 5 (100.0%) | 1.556 (1.05-2.30) | 0.050 |
PSS-14 score levels |
0.003 | |||
Low (0-18) | 17 (77.3%) | 0 (0.0%) | ||
Moderate (19-37) | 5 (22.7%) | 4 (80.0%) | ||
High (38-56) | 0 (0.0%) | 1 (20.0%) |
aSix month follow up assessment.
bOdds ratios could not be produced.
cOne year follow-up after study end.