Elsevier

Ophthalmology

Volume 121, Issue 4, April 2014, Pages 883-888
Ophthalmology

Original article
Associations between Health-Related Quality of Life and the Decision to Perform Surgery for Childhood Intermittent Exotropia

https://doi.org/10.1016/j.ophtha.2013.10.029Get rights and content

Objective

To assess associations between health-related quality of life (HRQOL) and the decision to perform strabismus surgery for children with intermittent exotropia.

Design

Retrospective chart review.

Participants

Children with intermittent exotropia.

Methods

Included subjects, identified in a clinical practice, had assessment of HRQOL using the intermittent exotropia questionnaire (IXTQ), comprising child, proxy, and parent components (parent domains: function, psychosocial, and surgery). The IXTQ scores were evaluated for association with surgery, along with standard clinical measures: prism and alternate cover test (PACT), stereoacuity, and control score (mean of the 3 most recent scores). Included data were from preoperative examination (surgical cohort) or from most recent follow-up examination (nonsurgical cohort). Univariate and multivariate logistic regression analyses were performed, and relative risk (RR) ratios were calculated. Spearman rank correlations were calculated to identify highly correlated items.

Main Outcome Measures

Association of individual factors with the decision to perform surgery, calculated using RR ratios.

Results

One hundred six children with intermittent exotropia (median age, 6 years; range, 2–16 years) were eligible for inclusion. Nineteen (18%) of 106 underwent surgery. Using all available data, the IXTQ proxy score, IXTQ parent function score, IXTQ parent psychosocial score, distance control score, near control score, near PACT, and Randot Preschool stereoacuity (Stereoptical Co, Inc, Chicago, IL) were associated with undergoing surgery (P<0.1). Sixty-nine of 106 patients had complete data on all factors identified in univariate analysis and were included in multivariate analyses. Fourteen (20%) of these 69 patients underwent surgery. In multivariate analyses, poor distance control score (RR, 1.83; 95% confidence interval [CI], 1.25–2.68) and reduced IXTQ parent function score (RR, 0.96; 95% CI, 0.92–0.99) were associated with surgical intervention. Repeat multivariate analyses retaining only 1 of the highly correlated items showed IXTQ proxy, IXTQ parent psychosocial, larger near PACT, and worse near control were also associated with surgery.

Conclusions

After accounting for poorer exodeviation control at distance, reduced parent and proxy HRQOL were associated with undergoing strabismus surgery for childhood intermittent exotropia. Recognizing reduced parental HRQOL may be important, with a possible role for educational or counselling interventions.

Section snippets

Methods

Institutional review board approval was obtained from the Institutional Review Board at Mayo Clinic, Rochester, Minnesota, and all procedures and data collection were conducted in a manner compliant with the Health Insurance Portability and Accountability Act. All research procedures adhered to the tenets of the Declaration of Helsinki.

Results

One hundred six children (median age, 6 years; range, 2–16 years) were included; 19 (18%) of 106 underwent surgery. Most patients had basic, pseudodivergence excess, or true divergence excess types of intermittent exotropia. Only 3 patients had convergence insufficiency-type intermittent exotropia. As required for eligibility, all 106 patients had completed at least one component of the IXTQ. The parent component was completed in all 106 patients, the proxy component was completed in 105 of 106

Discussion

In assessing factors that influence the decision to perform surgery in children with intermittent exotropia, poorer parental and proxy HRQOL were strongly associated with surgery, after accounting for poor control of the exodeviation at distance. Children with intermittent exotropia whose accompanying parent reported poorer HRQOL were more likely to undergo surgery than those whose parents reported better HRQOL.

The parent component of the IXTQ measures parental HRQOL specifically as it relates

References (18)

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    This confirms that, regardless of the methodology used to monitor postoperative motor alignment, binocular goals are harder to achieve. Prior publications31-33 have established that variable fusion and control of alignment in patients with intermittent exotropia, the dominant subpopulation, remains an outstanding clinical concern and reoperation is common. In addition to the methodology for monitoring motor alignment (SPCT vs APCT), fewer excellent outcomes for those seeking binocular goals may result from the narrower range of motor alignment, both at distance and at near, and the mandated sensory criteria for success.

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    The reduced parental HRQOL might cause parents to seek further interventions for their children. Recently, Hatt and colleagues21 found that reduced parental and proxy HRQOL are associated with the decision to perform surgery and that recognizing parental concerns as independent of clinical severity may be important for managing childhood intermittent exotropia. Therefore, it is important for physicians to recognize reduced parental HRQOL and to provide more suggestions for managing intermittent exotropia, perhaps by providing the parents with more information about the current status and development of their child’s exotropia or by discussing the possible interventions with the parents and helping optimize their decision.

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    Conversely, considering them not to have deteriorated might have biased against finding an effect of patching if these participants eventually would have deteriorated had they not started nonrandomized treatment. These cases reflected clinician and parental concern about possible worsening of the IXT, concerns that may have been influenced by knowledge of the treatment group and that are often key factors in the decision to proceed with IXT surgery.33 In the fourth case, also in the observation group, a participant's excellent stereoacuity did not support the diagnosis of constant exotropia.

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Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Supported by the National Institutes of Health, Bethesda, Maryland (grant no.: EY018810 [J.M.H.]); Research to Prevent Blindness, Inc, New York, New York (J.M.H. as Olga Keith Weiss Scholar and an unrestricted grant to the Department of Ophthalmology, Mayo Clinic); and the Mayo Foundation, Rochester, Minnesota. The funding organization had no role in the design or conduct of this research.

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