Patient reported psychosocial functioning following successful ptosis surgery

Ptosis, the drooping of one or both eyelids, can be congenital or acquired (most commonly aponeurotic/age-related) and may lead to visual impairments (blurred vision, decreased visual fields, reduced ability to perform daily activities) and altered appearance. Prevalence increases with age, and screening for ptosis in patients over 60 has been suggested. Despite recognized psychosocial impacts in ophthalmic conditions (e.g., higher depression, anxiety, appearance-related distress and social avoidance relative to population norms), research on appearance aspects in adult ptosis is limited. Social perceptions of individuals with appearance-altering eye conditions can be negatively biased. Qualitative reports indicate psychosocial benefits after ptosis correction and blepharoplasty. Access to ptosis surgery within the NHS is inconsistent, with some CCGs classifying repairs as cosmetic; funding and commissioning decisions often require evidence of clinical and cost effectiveness. While objective measures of eyelid position are commonly reported, patient-reported psychosocial outcomes are rarely collected and may not align with objective measures. This study prospectively assesses changes in psychosocial functioning and HRQoL before and after clinically successful ptosis surgery using validated instruments.

Design: Prospective, pre- to post-operative evaluation of adult patients undergoing ptosis correction surgery, with follow-up limited to those with clinically successful outcomes. Participants: 61 adults provided informed consent and completed pre-operative measures. Inclusion at follow-up required clinically successful surgery, defined postoperatively by acceptable margin-reflex distance (MRD ≤1 mm asymmetry between eyes) and patient satisfaction at final discharge; seven (30%) had bilateral simultaneous correction. Follow-up Process: Follow-up questionnaires were mailed after final discharge to those with clinically successful outcomes; two patients had successful surgery but did not attend final discharge. Ten patients were lost to follow-up due to staffing issues over six months and were not sent follow-up measures. Ultimately, 23 participants returned completed follow-up measures (response rate 70%); average time from surgery to follow-up was 14 months (range 4–30 months). Measures: - Appearance-related social anxiety/distress: Derriford Appearance Scale (DAS24). - Anxiety and depression: Hospital Anxiety and Depression Scale (HADS). - Fear of negative evaluation: FNE scale. - Postoperative patient-reported benefit: Glasgow Benefit Inventory (GBI; total, general, social, physical subscales; scores range -100 to 100 with higher positive values indicating greater benefit, 0 = no change). Data Quality and Power: Data validity checks were performed; non-responders did not differ significantly from responders on preoperative measures, and missingness was consistent with MCAR. Power analysis (PASS; confirmed in Minitab) indicated n=23 paired evaluations provide ≥80% power to detect a repeated-measures standardized effect size of 0.6 (alpha=0.05, two-sided). Statistical Analysis: Paired samples t-tests assessed pre- to post-operative changes, with 95% confidence intervals for mean differences. Effect sizes (e.g., Cohen’s d) were calculated. Percentages transitioning between clinical thresholds on DAS24, HADS, and FNE were summarized. Ethics: Approved by relevant institutional and governance frameworks; informed consent obtained; ethical guidelines for human participants followed.

• Sample and follow-up: 61 consented and completed pre-op measures; 33 sent follow-up; 23 completed follow-up (70% response). Mean follow-up 14 months (4–30). Non-responders did not differ from responders on pre-op appearance concern, anxiety, depression, or fear of negative evaluation. - Appearance-related distress (DAS24): Significant improvement post-surgery: pre-op M = 30.4 (SD 9.5), post-op M = 23.7 (SD 7.9); t(17) = -3.64, 95% CI 2.81–11.7, p = 0.003; medium effect size (d = 0.66). - Anxiety (HADS-A): Significant reduction: pre-op M = 7.6, post-op M = 4.9; t(19) = 4.27, 95% CI 1.38–4.02, p < 0.001. - Depression (HADS-D): No significant change: pre-op M = 3.6; post-op M = 3.2; t(19) = 0.672, 95% CI -0.85 to 1.65, p = 0.510. - Fear of Negative Evaluation (FNE): Significant reduction: pre-op M = 34.79, post-op M = 31.26; t(18) = 2.47, 95% CI 0.52–6.53, p = 0.024; small-to-moderate effect. - Threshold changes: After surgery, 78% reported minimal appearance-related anxiety; no patients reported considerable appearance anxiety post-op vs 14% pre-op. Reductions observed in categories of anxiety and fear of negative evaluation. - Patient-reported benefit (GBI, n = 21): Total M = 20.5 (SD 16.1), range -6 to 58; 85% positive change, 5% no change, 10% negative. General subscale M = 30.9 (SD 24.2), -8 to 88 (85% positive). Social subscale M = 3.2 (SD 8.5), 0 to 33 (15% positive, 85% no change). Physical subscale M = -3.9 (SD 17.4), -67 to 17 (10% positive, 76% no change, 14% negative). - Overall: 85% of patients reported positive benefit to well-being following surgery.

The study addressed whether clinically successful ptosis surgery improves psychosocial functioning and HRQoL. Findings show significant reductions in appearance-related distress, general anxiety, and fear of negative evaluation, with no significant change in depression. Postoperatively, no patients reported considerable appearance-related anxiety, and most reported minimal concerns, indicating meaningful alleviation of psychosocial burdens associated with ptosis. The GBI results corroborate these improvements, with 85% reporting positive change in general well-being. These outcomes support considering psychosocial benefits, not only functional visual improvements, in decisions regarding ptosis surgery access and commissioning. The results align with prior reports in ophthalmic plastic surgery and ptosis populations, emphasizing that patient-reported outcomes capture benefits not reflected solely by objective eyelid measurements.

Ptosis surgery yields significant psychosocial benefits, including reduced appearance-related distress, lower general anxiety, and diminished fear of negative evaluation, with the majority of patients reporting overall improvements in well-being. These findings highlight that patient benefit extends beyond visual function to broader psychological and social domains. Future research should involve larger, multi-site, consecutively recruited cohorts, include patients with varied surgical outcomes, and standardize follow-up intervals to enhance generalizability and examine the durability of psychosocial gains.

• Single-site study with a relatively small sample. - Non-consecutive recruitment. - Follow-up restricted to patients with clinically successful surgery; patients with disengagement or objectively unsuccessful outcomes were not included, limiting generalizability. - Variable time to follow-up (4–30 months). - Potential response bias due to mailed follow-up and attrition; however, baseline comparisons suggested non-responders were similar to responders.