The Impact of Eye Loss and Prosthetic Eye Wear on Recreational, Occupational and Social Areas of Functioning

Abstract

Background: This study aims to explore the impact of eye loss and
prosthetic eye wear on recreational, occupational and social areas of functioning.
Methods: Two hundred and seventeen anophthalmic patients who had worn
a prosthetic eye for at least two years and were older than 16 years responded
to an invitation to complete an anonymous questionnaire. Descriptive and
inferential statistics were used to investigate differences between variables.
Content analysis was used to analyse participants’ open responses.
Results: Participants reported a range of difficulties in occupational, social
and recreational areas of functioning. Those who experienced problems in these
areas reported stronger negative feelings and were more concerned about their
appearance and visual perception than those who had developed strategies to
overcome these problems.
Conclusion: This study identified recreational activities, social functioning
and workplace activities as the main areas where functional difficulties are
experienced by prosthetic eye wearers. The study (often using patients’ own
words) describes the impact of unilateral eye loss on these activities and
demonstrates how eye loss and prosthetic eye wear can negatively affect
anophthalmic patients’ behaviour and cognitive processing. It is important to
prepare patients for this and to provide coping strategies that address patients’
appearance and visual perception concerns due to their negative impact on
functioning.

Full text

Journal of Ophthalmology & Visual Sciences
Open Access
Citation: Pine NS, de Terte I and Pine KR. The Impact of Eye Loss and Prosthetic Eye Wear on Recreational,
Occupational and Social Areas of Functioning. J Ophthalmol & Vis Sci. 2017; 2(1): 1016.
J Ophthalmol & Vis Sci - Volume 2 Issue 1 - 2017
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Pine et al. © All rights are reserved
Abstract
Background: This study aims to explore the impact of eye loss and
prosthetic eye wear on recreational, occupational and social areas of functioning.
Methods: Two hundred and seventeen anophthalmic patients who had worn
a prosthetic eye for at least two years and were older than 16 years responded
to an invitation to complete an anonymous questionnaire. Descriptive and
inferential statistics were used to investigate differences between variables.
Content analysis was used to analyse participants’ open responses.
Results: Participants reported a range of difculties in occupational, social
and recreational areas of functioning. Those who experienced problems in these
areas reported stronger negative feelings and were more concerned about their
appearance and visual perception than those who had developed strategies to
overcome these problems.
Conclusion: This study identied recreational activities, social functioning
and workplace activities as the main areas where functional difculties are
experienced by prosthetic eye wearers. The study (often using patients’ own
words) describes the impact of unilateral eye loss on these activities and
demonstrates how eye loss and prosthetic eye wear can negatively affect
anophthalmic patients’ behaviour and cognitive processing. It is important to
prepare patients for this and to provide coping strategies that address patients’
appearance and visual perception concerns due to their negative impact on
functioning.
Keywords: Prosthetic eye wearers; Psychology; Functioning; Concerns;
Ocular prosthesis; Psychological difculties; Anophthalmia
Introduction
A prosthetic eye is used to replace a missing natural eye and
scleral shell prosthesis ts over a disgured non-functioning eye [1].
Previous research has established that losing an eye can negatively
impact one’s psychological wellbeing. In fact, McBain, Ezra, Rose
and New man [2] concluded that a patient’s adjustment to wearing
an ocular prosthesis was associated with psychological variables
rather than clinical or demographic factors. McBain, et al. [2] also
found that prosthetic eye wearers who had a pessimistic outlook,
negative self-image and a perceived lack of acceptance from society
had poorer psychological wellbeing. Another study investigated the
emotional experiences of individuals following eye loss and found
that 32% were preoccupied with hiding their disgurement ‘a great
deal’, 22.5% felt sad and 15% felt shy. At least 10% had ‘a great deal’ of
feelings of shame, insecurity, fear, inferiority and anger [3]. e most
common diculties of those with facial disgurement concern social
interactions, with aected individuals being subjected to intrusive
staring and comments [4].
Almost all the literature on the psychological adjustment of
patients living with a prosthetic eye has focused on appearance issues
[2,5,6], but when an eye is lost or disgured, there are also visual
Research Article
The Impact of Eye Loss and Prosthetic Eye Wear
on Recreational, Occupational and Social Areas of
Functioning
Pine NS1*, de Terte I2 and Pine KR2
1School of Psychology, Massey University, New Zealand
2School of Optometry and Vision Science, University of
Auckland, New Zealand
*Corresponding author: Pine NS, School of
Psychology, Massey University, New Zealand
Received: March 23, 2017; Accepted: April 20, 2017;
Published: April 28, 2017
perception changes such as impaired depth perception and restricted
visual range as well as a need to cope with the inconvenience of
wearing a prosthetic eye-in particular mucoid discharge from the eye
socket which is reported to aect 91% of anophthalmic patients [7].
Until now, the specic functional impact of eye loss or of wearing
an ocular prosthesis has received minimal research attention. is
study helps to address this by asking prosthetic eye wearers directly
about their experiences of occupational, social and/or recreational
diculties. It is expected that the greater the negative impact on
functioning, the greater the negative impact on psychological
wellbeing (and vice versa). e study covers current functional
impacts as well as those experienced in the past.
e ndings of this study will provide greater insight into the
practical implications of unilateral eye loss, which will hopefully lead
to more targeted psychological support and advice for current and
future prosthetic eye wearers.
Materials and Methods
Recruitment
Once the Massey University Human Ethics Committee granted
ethics approval, a questionnaire was mailed or emailed to potential

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participants from the database of the New Zealand Prosthetic Eye
Service, a private practice with six clinics spread across the North
Island of New Zealand. Of the 540 potential participants contacted
about the research (181 via email), 217 completed the questionnaire
(40% response rate). All participants were at least 16 years old and
had worn an ocular prosthesis for at least 2 years.
Questionnaire
e questionnaire included 29 questions and 5 psychological
scales across 4 main categories (demographics, concerns, feelings
and problems, psychological scales). is study covers the problems
section of the questionnaire, which asked participants if they had
any problems in social, occupational and recreational areas of
functioning either currently or in the past. is study also draws
upon demographic information gathered (age, gender, education,
ethnicity, relationship status, occupation, age when eye lost, etiology,
duration of prosthesis wear) and participants’ concerns regarding
appearance, mucoid discharge and visual perception.
Data analysis
e Statistical Package for the Social Sciences for Mac (version
23) was used to analyze the quantitative data. Independent t-tests
were used to analyze dierences between: the presence of functional
problems (employment, social, recreational) and levels of concern
(discharge, appearance, visual perception) and the age at time of eye
loss and the presence of functional problems.
Participants’ open responses regarding the functional impacts
of eye loss were analyzed using content analysis. is identied
descriptive themes within the data and their frequencies [8]. e
percentage of responses within each category was computed,
with the most commonly occurring responses being viewed as the
most important [9]. For this reason, only categories that obtained
percentages over 10% were reported in the results.
Results
Participants
e majority of participants were New Zealand European (76%),
followed by Maori (13%), other (7%), Asian (3%) and Pacic Islander
(1%). Participants’ average age was 58 years. ey had worn a
prosthetic eye for 27 years on average and 67% were male.
e gender ratio on 67% men in the study population roughly
aligns with the 59% men in a larger survey of prosthetic eye wearers
in New Zealand [10]. e representation of New Zealand Europeans
(76%) and Pacic Islanders (1%) aligns with that in the general
population (75% and 0.08% respectively) [11]. however, there is an
under representation of Maori (13%) and Asian (3%) ethnicities
compared to the general population (16% and 12% respectively) [11],
possibly because it was an English language questionnaire.
Demographic effects
On average, participants with social problems lost their eye
at a younger age (M = 20.4, SD = 18.74) than those without social
problems (M = 32.3, SD = 21.31, p< .001). is may be due to the
developmental period of younger people and the importance of
belonging to social groups and forming intimate relationships
during this time [12]. Participants with social diculties were also
younger at the time of the study (M = 54.2, SD = 13.82) compared
to those without diculties (M = 60.7, SD = 13.83, p = .001). ere
were no signicant relationships between social problems and other
demographic measures or with any demographic measures and
occupational or recreational problems (p> 0.05).
Functional difculties of unilateral eye loss
e most common functional diculties reported by participants
were experienced with recreational activities (57%), social functioning
(40%) and employment or workplace activities (32.4%).
Recreational activities
Of those participants whose free comments identied problems
with recreational activities, 30.5% had stopped playing, or had
particular diculties with ball sports (“Used to play tennis and
squash, still possible but very dierent level, no longer fun for me”),
non-ball sports such as swimming and mountain biking, or contact
sports(“Would not play rugby in case of further injury”). Twenty six
percent commented that their recreational activities were aected by
monocular limitations (i.e., reduced peripheral vision and impaired
distance perception) (“I am not brilliant anymore at coordination
and catching a ball is only average”, “Can’t judge a moving ball”,
“Playing pool has become very dicult - judging distance and angles
has become very handicapping”). Monocular vision also impacted on
other sports or activities (e.g., “I would love to learn to dance, but
scared my sight would make me look silly trying to turn etc and not
seeing on my right side”, “Horse riding judging speed and distance,
also some balance problems”, “Minor problems skiing - have to
constantly look to my right to avoid other skiers”).Nineteen percent
commented that their recreational activities were aected by fear
of their prosthetic eye falling out (e.g., during swimming, surng,
diving, water skiing) and sixteen percent commented that they had
successfully adapted to initial diculties.
Successful adaption’s mentioned by this group included how they
developed strategies or used aids to compensate for problems (“Afraid
that if I came o my water-ski the eye may pop out. So I wear an
eye patch”, “I was scared my eye would fall out in the waves…I have
RECREATIONAL
Concern items Problems No problems Mean difference Sig.
Mucoid discharge 2 1.79 0.21 0.128
Appearance 2.15 1.85 0.3 .035*
Visual perception 2.11 1.64 0.47 .000*
EMPLOYMENT
Concern items Problems No problems Mean difference Sig.
Mucoid discharge 2.02 1.86 0.16 0.309
Appearance 2.39 1.87 0.53 .001*
Visual perception 2.07 1.71 0.36 .015*
SOCIAL
Concern items Problems No problems Mean difference Sig.
Mucoid discharge 2.2 1.75 0.45 .001*
Appearance 2.48 1.72 0.76 .000*
Visual perception 2.14 1.74 0.4 .003*
Table 1: Differences in mean level of concern items according to the presence or
absence of recreational, employment and social problems.
*The mean difference is signicant at the 0.05 level.

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learnt to turn my back on the waves more and close my eyes hard”, “I
returned to playing rugby 4 months aer I lost my eye, taught myself
to catch the high ball, which was a re-aligning problem”). Others
avoided the activity, removed their eye, or used aids like underwater
goggles.
Participants with recreational diculties reported signicantly
stronger negative feelings (M = .70, SD = .92) than those without
diculties (M = .41, SD = .79, p< 0.001). ose with recreational
problems were also signicantly more concerned about their
appearance and visual perception (Table 1).
Social functioning
Of the 40% of participants who had experienced problems in their
social lives, 28% reported that this was due to other peoples’ reactions
or behavior, 23% to social interactions, 18% to appearance concerns
and 12.6% to meeting new people.
Other peoples’ reactions mainly included other people staring,
name-calling or making hurtful comments and asking questions
(“At school some teasing, remarks, unkindness”, “Passing snide and
judging comments”, “My partner le me. My family thought it was a
joke. e amount of people that make jokes about ‘where’s ya parrot’
really hurt”).
Social interactions brought on negative feelings such as shyness,
inferiority, embarrassment, insecurity, feeling scared, self-conscious,
dierent from others or less of a person, or lacking condence.
One participant explained that “for a while, confrontations about
the prosthetic eye tended to be quite intimidating and would evoke
feelings of inferiority as I felt less of a person, in turn this lead to
jealousy and pushing people away from me…”.
Worries about appearance included disguisability of their
prosthetic eye such as the movement of the prosthesis, drooping
eyelid, discharge, pupil dilation and feeling unattractive (“e
awareness that I look dierent from others rarely leaves me…”, “It
makes you very conscious and always fretting about whether the eye
looks close to normal”).
Meeting new people or having romantic relationships was cited
as another social diculty (“I took a very long time to move in a social
setting. I regarded the fact that I had only one eye was a drawback in
mixing socially. My mates actively sought female company whereas
I was quite reclusive”, “e moment I wore it and socialized with
friends, it was obvious they were aware of my wearing something
articial that did not seem natural and that in turn made me very
aware…it oen led to my lacking condence, avoiding meeting
people and generally staying away from meeting friends”).
Prosthetic eye wearers who reported experiencing social
problems had signicantly stronger negative feelings (M = .91, SD
= 1.01) than those without (M = .32, SD = .67, p< 0.001). ose with
social diculties also had signicantly higher discharge, appearance
and visual perception concerns than those without (Table 1).
Employment and workplace activities
Of those participants who experienced problems with
employment and workplace activities, 35% reported that this was
because of other peoples’ reactions and 35% reported that monocular
limitations negatively impacted their work.
Other peoples’ reactions included negative responses or
comments, employers’ doubts, jobs not being oered and others’ not
knowing how to respond (“Name-calling”, “Employers are always
doubtful about me having one eye only. Mostly I get declined for the
position that I am applying for. at makes me feel very low”, “I have
been turned down for a job because my eye would be ‘o putting’ to
customers in a front line role”, “People do not know how to meet
your eyes when talking directly to you”, “Workplace bullying”).
Monocular limitations negatively impacted participants’ work
(“Lack of distance and perception of surfaces cost me my employment
as a head green keeper and made some other employments problematic
until I made adjustments”, “Worked in electrical industry working
amongst live overhead wire. Handicapped by peripheral vision
and still have instances with that blind spot”). ere was also some
concern about safety due to monocular vision (“Nail guns and aim”,
“Driving forklis and working at heights”).
Prosthetic eye wearers who have experienced employment
problems reported having signicantly stronger negative emotions
(M = .83, SD = .97) than those with no employment problems (M =
.39, SD = .74, p< 0.001). ey were also signicantly more concerned
about appearance and visual perception than those without
employment problems (Table 1).
Discussion
e nding that prosthetic eye wearers with occupational,
social and/or recreational diculties experienced stronger negative
emotions is consistent with the idea that when a problem negatively
impacts on functioning, its severity typically increases and its impact
on mood intensies [13].
Participants with employment and recreational diculties
were particularly concerned with visual perception and specically
reported monocular limitations as being a reason for these diculties.
is is especially relevant to occupations or recreational activities
that have high visual demand and require sucient depth perception
and eld of vision, both of which are negatively impacted following
acquired monocular vision [14]. It is important therefore to inform
prosthetic eye wearers that there are strategies available to help them
compensate for these limitations (e.g., turning their head more
towards the side of the lost eye, positioning others on their sighted
side when walking or sitting, placing mirrors on their blindside on
their work desk or in their car [1]).
Participants with recreational, social and occupational diculties
were particularly concerned about appearance, as well as visual
perception. Other peoples’ reactions were also a common source of
stress for these participants. A number of studies have investigated
diculties in social settings for those with facial disgurement. It is
important to note the signicant role eyes have in communication and
‘perceived physical attractiveness’ and in turn, the understandable
impact that damage to them could have on ones social interactions.
In fact, this population typically has high levels of social anxiety and
avoidance of social situations [4,2], which we can now link to not only
appearance concerns but also to the practical impacts of acquired
monocular vision and mucoid discharge. e ndings of the current
study were consistent with previous research, which suggested that
monocular patients experienced social functioning impairment and

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role diculty (e.g., diculties with hobbies and job performance and
negative feelings towards social interpersonal relationships) [15-18].
e social impact of eye loss can aect both personal and professional
lives, particularly as this population typically has low self-esteem and
expectations about life chances in employment and relationships [4].
First meetings are also particularly dicult [19], as are forming long-
term friendships [20].
If an individual is repeatedly exposed to negative social events,
behaviour change such as avoidance of social situations (as well as
of recreational activities) can occur; however, it is important to
consider the role of the individual’s beliefs and behaviour during
social interactions. Research has found that in those with facial
disgurements, the expectation of a negative response from others
is sucient for them to report events dierently. at is, their
heightened sensitivity to their disgurement and idea of being treated
negatively leads to the misinterpretation of events or subtle changes
in their behaviour (e.g., poor eye contact, poor posture), which then
produce stronger reactions from the observers [4]. Sensitivity to the
disgurement and tendency to attribute all negative experiences to
appearance is commonly reported amongst the facially disgured
population [21].
Information processing biases have also been reported in that
aected individuals are selective in their interpretation of social
feedback, primarily focusing on information that supports their
internalized views of themselves and ignoring evidence that challenges
it [22]. ese particular beliefs and behaviours are important to
consider when planning psychological intervention. Having good
social skills has been found to be associated with successful adjustment
[23,24], which also highlights the importance of social skills training.
e results of this study demonstrate that eye loss and prosthetic
eye wear can negatively aect the behaviour and cognitive processing
of anophthalmic patients. is can lead to negative impacts on
important areas of functioning, thus increasing the likelihood
of greater psychological diculties. is highlights the need for
psychological support and strategies to be provided, particularly
during the early stages of eye loss and prosthetic eye wear, so to
reduce this potential negative impact and improve the psychological
wellbeing of prosthetic eye wearers.
Conclusion
is study identies recreational activities, social functioning
and employment or workplace activities as the main areas where
functional diculties are experienced by prosthetic eye wearers.
e study (oen using patients’ own words) describes the impact
of unilateral eye loss on these activities and demonstrates how eye
loss and prosthetic eye wear can negatively aect the behaviour and
cognitive processing of anophthalmic patients. It is important to
prepare patients for this and to provide coping strategies that address
patients’ appearance and visual perception concerns due to their
negative impact on functioning.
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