TNOA Journal of Ophthalmic Science and Research

: 2022  |  Volume : 60  |  Issue : 3  |  Page : 227--231

Quality of life among prosthetic shell users – Questionnaire based

Pratheeba D Nivean1, Chitra Padavettan2, N Kheerthana2, Anshika Shah2, M Nivean1,  
1 MN Eye Hospital, Tondiarpet, Chennai, Tamil Nadu, India
2 Dr. M N College of Optometry (Affiliated to Tamil Nadu Dr. M. G. R. Medical University), Tondiarpet, Chennai, Tamil Nadu, India

Correspondence Address:
Chitra Padavettan
Dr. M N College of Optometry (Affiliated to Tamil Nadu Dr. M. G. R. Medical University), 779, Thiruvottiyur High Rd, Tondiarpet, Chennai - 600 021, Tamil Nadu


Purpose: The aim is to determine the psychological factor, driving capability, and the influence of the device among working professionals based on questionnaire. Methods: A qualitative questionnaire-based cross-sectional study was conducted among participants of a tertiary eye care center in Chennai from March 2020 to August 2020. The questionnaire consisted of participant demographics, psychological care, driving, and prosthetic support and maintenance-related questions. The responses were recorded over telephone and analysed using SPSS Statistics. Result: About 30 participants of age 9 years and above were included after obtaining consent. The average age was found to be 38.8 ± 12.7 years with 46.7% (n = 14) males and 53.3% (n = 16) females. Anophthalmic participants exhibit a substantial change in psychological feelings following ocular prosthesis. Participants found to be motivated after the cosmetic change brought about by prosthesis, and therefore had a higher output on work factor. In terms of driving, 90% of the subjects were comfortable using protective devices for safety measures. They found greater satisfaction in customised manually built prosthesis than computerised prosthesis. The former had smooth edge finish with reduced prosthetic motility, which has made the patient gain satisfaction, improving care and maintenance, and the handling of ocular prosthesis. Conclusion: The use of ocular prosthesis was found to decrease depression, insecurity, inferiority complex with minimal difficulty in activities of daily living, and no difficulty in driving with prosthesis. The quality of life improved with the use of customised prosthetic shells.

How to cite this article:
Nivean PD, Padavettan C, Kheerthana N, Shah A, Nivean M. Quality of life among prosthetic shell users – Questionnaire based.TNOA J Ophthalmic Sci Res 2022;60:227-231

How to cite this URL:
Nivean PD, Padavettan C, Kheerthana N, Shah A, Nivean M. Quality of life among prosthetic shell users – Questionnaire based. TNOA J Ophthalmic Sci Res [serial online] 2022 [cited 2022 Dec 10 ];60:227-231
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The sensory organs play a significant role in our daily lives and in particular, eyes help for communication and physical attractiveness.[1] Loss of an eye or a deformed eye has an expensive effect on an individual mind. Anophthalmia and microphthalmia are characterised, respectively, as the lack of ocular tissue within the orbit that includes the mean size of the eyes and it can be influenced by one or both eyes.[2],[3] The etiology of inherent ocular deformities could be because of[4] hereditary changes, maternal nourishment deficiency mainly vitamin A, and maternal contamination during pregnancy.[2],[4],[5] Restorative recovery of such people with specially designed ocular prosthesis gives proficient and social acknowledgment, reduces issues, and also has a huge improvement in psychosocial activities.[6],[7],[8],[9] Besides the psychosocial improvement, anophthalmic patients have trouble associated with the general well-being, issues associated with employment, maintenance of the prosthesis, and concerns associated with monocular statuses such as depth perception and reduced visual field.[10],[11],[12] These elements can potentially influence the patient's satisfaction. The frequent complication faced by ocular prosthetic users is lagophthalmos, watering, mucous discharge, and reduced motility of prosthesis.[13],[14],[15],[16] Surgeon satisfaction does not always translate into patient satisfaction because of the aesthetic nature of orbital implant surgery.[17] Hence, the objective of the hospital-based study is to determine the psychological feelings and satisfaction of patients based on questionnaire among prosthetic shell wearers.


A questionnaire-based cross-sectional study was conducted among participants (n = 30) using prosthetic device for a minimum of 6 months with age group 9 years and above during a period of March 2020 to August 2020. The questionnaire was divided into four components that include patient's demographics, psychological-related care, driving-related care, and prosthesis-related care. The questionnaire framework was designed with selective blocks from visual function questionnaire (National Eye Institute Visual Functioning Questionnaire-25 (NEI VFQ-25) validated version 2000)[18] and other previous literature.[19] Furthermore, the modified version was given for expert review. Back translation was done by a team of three translators to assess the quality and accuracy into Tamil language. The first part of the questionnaire consisted of demographic data that includes 1) age, 2) gender, 3) occupation, 4) educational status, 5) household income, 6) residence, and 7) marital status. The second part includes quality of life that contains psychological-related care 1) removal of eyeball, 2) reason for eye loss, 3) psychological feeling, 4) work influence, 5) relationship with friends/families, 6) present ocular complaints, 7) reaction of other people on losing an eye, 8) difficulty while going steps or curbs or dim light condition, and 9) Trouble faced while going out on meetings and gatherings. The third part consists of driving-related care that includes 1) currently driving, 2) not driving, 3) reason for gave up driving, and 4) difficulty while driving currently. The final part consist of prosthesis and its related care that consist of 1) Use of prosthesis before, 2) Adaptation of first prosthesis, 3) removal of prosthesis, 4) wearing full frame Glasses, 5) current prosthesis fit, 6) prosthesis material and type, 7) cleaning of ocular prosthesis, 8) method of cleaning, and 9) Nocturnal wear of ocular prosthesis.

Because of the pandemic circumstances, the optometrist addressed the questions to the participants over phone and responses were recorded and noted in the pre-designed Proforma. Informed consent was taken from each subject telephonically. The study was explained in detail and participants were free to withdraw from the study at any time and assured that there are no risks in participating. The study adhered to the tenets of the Declaration of Helsinki and ethical approval obtained from the institutional research committee. All patients who fulfilled inclusion criteria and willing to participate were recruited in the study.

The primary outcome is to rate the psychological feeling and influence of work before and after prosthetic shell wear and to study the impact of this device on driving. Secondary measures include comfort, cleanliness, and adaptation, nocturnal wear of ocular prosthesis, care and maintenance of these variables also assessed in this study.

Psychological feeling

Psychological-related concern were assessed on the basis of NEI VFQ-25) version 2000[18] and questionnaire developed by Nicodemo and Ferreira.[19] Four-point Likert scale ranging from 0 (None) to 3 (Severe). Higher the grading, greater the severity.

Work-influenced factor

Work factor was assessed on the basis of NEI VFQ-25 version 2000[18] with minimal changes grading ranging from 1 (No effect) to 5 (Huge impact). Higher the scale, greater the impact.

Driving-related care

Driving-related responses were assessed based on NEI VFQ-25 version 2000[18] with minimal changes. Initially the grading starts with 1 (Yes) and 2 (No) whether driving or not. Driving difficulty graded on 4-point Likert scale ranging from (0) No difficulty to (3) Extreme difficulty. Higher grading indicates extreme difficulty faced by patients while driving.

Prosthesis-related care

Prosthesis care assessment done based on study by Nicodemo and Ferreira.[19] Previous use of prosthesis and adaptation of initial prosthesis grading ranging from 0 (well) to 3 (bad); higher score indicates poor adaptation of ocular prosthesis. Removal and cleaning of prosthesis grading as (1) daily, (2) weekly, and (3) monthly; wearing full frame glasses 1 (Yes) or 2 (No); current prosthesis fit satisfied (1) or unsatisfied (2); prosthesis type and material, method of cleaning, and nocturnal wear of ocular prosthesis based on 3-scale grading (1) Yes, (2) No, and (3) Sometimes.

Statistical analysis

The patient responses were entered in Microsoft Excel (2015). Analyses using SPSS Statistics for Windows, Version 16.0 (SPSS Inc., Chicago, Ill., USA). Continuous variables were expressed as mean with standard deviation (SD) and categorical variables were presented as percentage. Wilcoxon signed rank test was done for psychological concerns and ocular complaints. Determination of the influence of work factor after prosthetic device was done using McNemar's test. All P values less than 0.05 were considered statistically significant.


Demographic data

Mean ± SD age of the participants (n = 30) was 38.8 ± 12.7 years. About 46.7% were males (n = 14) and 53.3% females (n = 16). Furthermore, 56.7% (n = 17) were employed, 30% were not employed (n = 9), and 13.3% were students (n = 4). In accordance with educational status, 43.3% of the population had primary education (n = 13) and 56.7% of the population were undergraduates (n = 17). On the basis of income, they were grouped into two categories 1) <10,000 Rs/month and 2) 10,000–30,000 Rs/month and each group had 23.3% (n = 7) and 76.7% (n = 23), respectively. About 76.7% lived in urban areas (n = 23) and 23.3% lived in rural areas (n = 7). Concerning marital status, 10% (n = 3) were unmarried and 90% were married in this study (n = 27) [Table 1]. In this study, 53.3% participants had right eyeball removed and 46.6% had left eyeball removed. The reasons for eye loss were found to be trauma (56.67%), congenital factor among 33.33%, and blindness associated with pain in 10% of participants.{Table 1}

Psychological parameter

Significant improvement in psychological feelings was reported after wearing the ocular prosthesis. The ranking order and percentage of psychological feelings prior to prosthesis were depression (100%), fear (53.3%), insecurity (20%), anger (10%), shyness (6.67%), and inferiority complex (3.34%), and after wearing the prosthesis, it improved remarkably; the ranking order and percentage of psychological feelings were depression (23.34%), insecurity (13.34%), shyness (13.34%), anger (10%), inferiority complex (6.67%), and fear (3.34%) [Table 2].{Table 2}

Work influence

Participants who were not able to perform their work initially before the ocular prosthesis, cosmetically had enhanced improvement and a better performance level based on work factor. Patients who graded mild effect before ocular prosthesis (n = 9) subsequent to wearing ocular prosthesis they reported no effect (n = 3, 33.3%), little effect (n = 2, 22.2%), and mild effect (n = 4, 44.4%). Participants who reported a huge effect before ocular prosthesis (n = 14) subsequent to wearing ocular prosthesis had significant improvement exhibiting no impact 1 (7.14%), little effect 5 (35.71%), mild effect 6 (42.86%), and moderate effect 2 (14.29%) individually.

Ocular complaints

Wilcoxon signed rank test reported that discharge and watering were found to be significant (P = 0.000) despite the use of ocular prosthesis. These complaints seem to be most predominant factor. Other variables, such as irritation, ocular pain, and burning sensation, were found to be statistically insignificant (P-value > 0.05).

Daily living activities

In this study, 40.0% of people reported no difficulty while climbing stairs, 100% of people described little difficulty when other people react to their vision loss, and 60.0% of people felt little difficulty when going outside.

Driving-related care

Out of 30 patients, 10.0% (n = 3) gave up driving because of vision loss and 6.7% (n = 2) have fear and restriction of field of view and cosmetically appealing. After the use of prosthesis, only 10.0% (n = 3) have little difficulty while driving and others 90.0% (n = 27) have no difficulty.

Prosthesis and its related care

Most of the patients have not used prosthesis before. Regarding adaptation of prosthesis, initially 3.3% (n = 1) felt well, 56.7% (n = 17) felt normal, 33.3% (n = 10) felt not good, and 6.7% (n = 2) felt bad. With respect to the removal of prosthesis, 40% (n = 12) removed weekly and 60.0% (n = 18) removed monthly in this study. About 50.0% (n = 15) were using full frame glasses and 50.0% (n = 15) were not using full frame glasses and hence, the ratio of wearing full frame glasses based on protection is equivalent. Participants in this study were wearing customised prosthesis. Concerning the fit of prosthesis in this study, 90.0% (n = 27) were satisfied and 10.0% (n = 3) were unsatisfied. The cleaning of ocular prosthesis grouped into three groups: daily, weekly, and monthly and each group had 3.3% (n = 1), 56.7% (n = 17), and 40% (n = 12), respectively. About 83.3% (n = 25) participants prefer tap water and 16.7% (n = 5) used mild soap for cleaning the shell. Furthermore, 76.7% (n = 23) were using ocular prosthesis during night, 3.3% (n = 1) were not using, and 20.0% (n = 6) removed ocular prosthesis occasionally at night [Table 3].{Table 3}


The application of ocular prosthesis helps to overcome many psychosocial problems; however, there are various consequences and concerns connected to the use of ocular prosthesis.[11] This study showed reduction in depression followed by anxiety after the prosthetic wear. The reason for the higher prevalence of depression and anxiety in this sample could be attributed to the poor financial status of the participants, which may have created a great deal of confusion and apprehension for one's own health or future. In addition, interpersonal exclusion from the family contributed to anxiety and levels of loneliness proven by the reaction of the society towards their loss. Working professionals, particularly businesspersons and younger age groups, had a higher degree of depression. Goiato et al.[9] study showed that ocular prosthesis had a significant impact on the interpersonal relationships of patients that could be associated with emotional change and anthrophobia.[13] Female participants reported that this device plays a supportive role in the marriage context of women. A substantial change through increased social meeting in this study represents the fact that the presence of a prosthetic eye in a patient with anophthalmia gives confidence to individuals and to the community at large. It is analogous to the Dave et al.[20] research that patients who were open to public interaction are more likely to be anxious about their condition.

In terms of driving, initially, the patient had trouble in assessing distance and lack of visual perception, but able to easily overcome it with time. Driving with ocular prosthesis is dependent on driving authority. According to the Rokohl et al. study,[10] use of anti-reflective coatings can help minimise the reflection during the night, turn the head when driving To compensate for vision loss and to minimise disruptions, they can also use a bigger mirror winged lens, use protective measures such as audio control on the steering wheels and a hands-free mobile system for improved driver safety.[21] Halogen headlights that provide optimum illumination and brightness within one personal vehicle can be used as an aid in driving.

The most prevalent prosthetic-related issues were discharge accompanied by watering, which seems to be concurrent with previous studies.[10],[11] Profuse watering and discharge can be caused if the surfaces of the prosthesis are rough and the edges are sharp. Therefore, the patients should have a yearly check up of the prosthesis and polish the shell if needed. In the previous sample, they reported poor motility of prosthesis but in this research, none of the participants had issues with motility of prosthesis and felt relaxed and confident after fixation. Most participants use tap water to clean the prosthetic device and wear during night time.[22],[23] The choice of implant material depends mainly on three factors, i.e., the availability, cost, and experience of surgeons with different implant materials.[19] Four patients were not satisfied about the cosmesis in this study. They felt that the eyes were having a sunken look. It is mainly because of the superior sulcus deformity for which an option of fillers or autologous fat transfer was provided. However, none of them underwent further cosmetic correction as they were not much bothered to intervene further and they were happy with the results from what they had initially. In majority of the eye hospitals, custom prosthesis is not widely performed. The awareness among rural areas needs to be achieved by making it easily affordable. Typically, with good care, it lasts long; the less removed and cleaned, the better the longevity. The stock shell is readily available; however, custom prosthesis requires artistic touch by skilled individuals. There is a lack of trained optometrists in this procedure. There is a lot of scope in ocularistry, as it does not just stop with regular shell; it also includes orbital and faciomaxillary prosthesis, socket expanders, etc. Ophthalmologists and optometrists should work together to develop ocularistry industry and make this service available for the needy. It is also important to ensure that one-eyed patient have a fresh assessment regarding fitness for driving as that would be legally necessary.


This study concludes that after prosthetic wear, one-eyed patients feel better psychologically and physically. Although mild watering and discharge is a common complaint, most of them have been resolved, and the quality of life among users of prosthetic shell has improved. This specialty aims to provide fellow human beings who have lost of an eye with emotional and mental assistance.

Key message

Satisfaction and comfort of one-eyed patients depends on the improvement in the quality of life and activities of daily living among prosthetic shell wearers.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


1Raizada K, Rani D. Ocular prosthesis. Cont Lens Anterior Eye 2007;30:152-62.
2Verma AS, FitzPatrick DR. Anophthalmia and microphthalmia. Orphanet J Rare Dis 2007;2:47.
3Embryology, Eye Malformations-StatPearls-NCBI Bookshelf.
4Weber KA, Yang W, Carmichael SL, Shaw GM. Nutrient intake in women before conception and risks of anophthalmia and microphthalmia in their offspring. Birth Defects Res 2018;110:863-70.
5Dolk H, Busby A, Armstrong BG, Walls PH. Geographical variation in anophthalmia and microphthalmia in England, 1988-94. Br Med J 1998;317:905-10.
6Côas VR, Neves AC, Rode SD. Evaluation of the etiology of ocular globe atrophy or loss. Braz Dent J 2005;16:243-6.
7Chin K, Margolin CB, Finger PT. Early ocular prosthesis insertion improves quality of life after enucleation. Optometry 2006;77:71-5.
8Thakkar P, Patel JR, Sethuraman R, Nirmal N. Custom ocular prosthesis: A palliative approach. Indian J Palliat Care 2012;18:78-83.
9Goiato MC, Dos Santos DM, Bannwart LC, Moreno A, Pesqueira AA, Haddad MF, et al. Psychosocial impact on anophthalmic patients wearing ocular prosthesis. Int J Oral Maxillofac Surg 2013;42:113-9.
10Rokohl AC, Koch KR, Trester M, Trester W, Pine KR, Heindl LM. Concerns of anophthalmic patients wearing cryolite glass prosthetic eyes. Ophthal Plast Reconstr Surg 2018;34:369-74.
11Pine NS, de Terte I, Pine KR. An investigation into discharge, visual perception, and appearance concerns of prosthetic eye wearers. Orbit 2017;36:401-6.
12Pine K, Sloan B, Stewart J, Jacobs RJ. Concerns of anophthalmic patients wearing artificial eyes. Clin Exp Ophthalmol 2010;39:47-52.
13Ahn JM, Lee SY, Yoon JS. Health-related quality of life and emotional status of anophthalmic patients in Korea. Am J Ophthalmol 2010;149:1005-11.e1.
14Hatamleh MM, Abbariki M, Alqudah N, Cook AE. Survey of ocular prosthetics rehabilitation in the United Kingdom, Part 1: Anophthalmic patients' aetiology, opinions, and attitudes. J Craniofac Surg 2017;28:1293-6.
15Hatamleh MM, Alnazzawi AA, Abbariki M, Alqudah N, Cook AE. Survey of ocular prosthetics rehabilitation in the United Kingdom, Part 2: Anophthalmic patients' satisfaction and acceptance. J Craniofac Surg 2017;28:1297-301.
16Rasmussen ML. [Complications from eye prosthesis]. Ugeskr Laeger 2008;170:2456-8.
17Song JS, Oh J, Baek SH. A survey of satisfaction in anophthalmic patients wearing ocular prosthesis. Graefes Arch Clin Exp Ophthalmol 2006;244:330-5.
18Mangione CM, Lee PP, Gutierrez PR, Spritzer K, Berry S, Hays RD. Development of the 25-item National eye institute visual function questionnaire. Arch Ophthalmol 2001;119:1050-8.
19Nicodemo D, Ferreira LM. [Questionnaire of the psychosocial profile of the patient with anophthalmia with indication of ocular prosthesis]. Arq Bras Oftalmol 2006;69:463-70.
20Dave TV, Nayak A, Palo M, Goud Y, Tripuraneni D, Gupta S. Custom ocular prosthesis-related concerns: Patient feedback survey-based report vis-à-vis objective clinical grading scales. Orbit 2021;40:357-63.
21Los Angeles Prosthetic Eye Provider-Google Search.
22De Andrade Figueiredo LA, Sampaio AA, Souza SE, Ferreira FJ, Buzzá EP, Rizzatti-Barbosa CM. The role of prosthesis spacer for ocular prostheses. J Craniofac Surg 2017;28:e360-3.
23Pathak C, Pawah S, Singh G, Yadav I, Kundra S. Prosthetic rehabilitation of completely blind subject with bilateral customised ocular prosthesis: A case report. J Clin Diagnostic Res 2017;11:ZD06-8.