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Anxiety in cataract surgery: pilot study

Foggitt, Paul S∗,a,1

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Journal of Cataract & Refractive Surgery: October 2001 - Volume 27 - Issue 10 - p 1651-1655
doi: 10.1016/S0886-3350(01)00859-8
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Abstract

The routines and surgical techniques of cataract surgery have changed over time, and local anesthesia is now the preferred technique in most cases. There has been a change from retrobulbar or peribulbar injection to topical anesthesia, and these methods have proved satisfactory. Thus, it is unusual for patients to experience pain during surgery. However, the prospect of cataract surgery under local anesthesia might be expected to provoke anxiety because of concerns over the prospect of the operation, fear of the procedure itself, and worries about the outcome. Anxiety and stress are associated with systemic problems such as tachycardia, hypertension, and dysrhythmias.1,2 Increased preoperative anxiety has been correlated with increased postoperative pain, an increased analgesic requirement, and a prolonged hospital stay.1,3

This pilot study evaluated whether patients find the prospect and procedure of cataract treatment unduly anxiety provoking and whether any stage in the treatment causes more stress.

Patients and methods

One hundred eighteen patients were invited to participate in the study at Moorfields Eye Hospital; 10 declined. Of the 108 who agreed to participate, all provided informed written consent. Local ethics committee approval was also obtained.

To be included, patients had to be adults having planned cataract surgery under local anesthesia who were fluent English speakers or who could be interviewed through an interpreter. Children and adults having cataract surgery under general anesthesia were excluded.

The 108 patients were assigned to 1 of 3 groups by treatment stage: 38, preassessment (at clinic after consultation and listing); 36, operation day (at day ward on day of surgery before going to operating theater); 34, postoperative (first visit at clinic after surgery). The patients were not followed over time. However, if they were randomly encountered at a later treatment stage, they were invited to participate again. There were 22, 17, and 23 women and 16, 19, and 11 men in the preassessment, operation day, and postoperative groups, respectively. The age of the patients ranged from 43 to 91 years.

Three subgroups of patients were formed within each stage: patients having cataract treatment for the first time (first-surgery group), patients having cataract surgery a second time (second-surgery group), and a combination of the first- and second-surgery patients (combined group).

Anxiety was measured using the Hospital Anxiety and Depression (HAD) Scale4 and a Visual Analog Scale (VAS).5,6 Questionnaires were marked with a study number, treatment stage (preassessment, operation day, postoperative), and whether this was the first cataract operation. Patients in the first- and second-surgery groups were taken from the combined group. The patients' names and hospital numbers were kept separately and unnumbered.

The patients were first asked to complete the HAD scale, which assessed how they had been feeling over the past week. Patients were asked to read a statement (eg, “I can sit at ease and feel relaxed”) and underline the most appropriate of the following responses: definitely, usually, not often, or not at all. The responses were scored as 0, 1, 2, and 3, respectively. The interviewer read the questionnaire to patients who could not read it because of the cataract or because they had received dilating eyedrops (on the day ward).

The anxiety points for each question of the HAD scale were summed, giving an overall anxiety score. The HAD scale comprises 7 questions; thus, anxiety scores were out of 21. A HAD score of 0 to 7 indicated no anxiety; 8 to 10, doubtful cases; and 11 to 21, definite anxiety.

After they completed the HAD scale, patients were asked to complete a VAS as another indication of how they had been feeling over the past week. They scored their anxiety by making an X on a graded line ranging from 0 (no anxiety) to 10 (unbearable anxiety). A VAS score of 0 indicated no anxiety; 1 to 3, mild anxiety; 4 to 6, moderate anxiety; 7 to 9, severe anxiety; and 10, unbearable anxiety.

For statistical analysis, the distributions of the samples in each stage and group were checked for normality. In most cases, they were positively skewed for both the HAD and the VAS. The median was therefore selected as the most appropriate measure of central tendency, and the Mann-Whitney U test was used for the statistical analysis. The critical U value was approximated as follows7: U = [μ − 1.96σ − Symbol], for α = 5%; where μ = Symboln1n2 and σ = {Symboln1n2(n1 + n2 + 1)}Symbol. Calculations were conducted by hand, using a Texas Instruments TI80 graphics calculator.

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Results

The mean waiting time from preassessment to surgery was 27 days and from surgery to the first postoperative visit, 20 days.

Table 1 shows the median anxiety scores in the combined group at each treatment stage and Table 2, the Mann-Whitney U analysis and P values for differences in HAD scale and VAS anxiety scores between the preassessment and the operation day and between the operation day and the postoperative visit. There was a significant difference in HAD scale anxiety scores between the operation day and the postoperative visit (P < .05, Mann-Whitney U) but not between the preassessment and the operation day. There were no significant differences in VAS scores among the 3 treatment stages.

Table 1
Table 1:
Median anxiety scores in the combined group.
Table 2
Table 2:
Mann-Whitney U results for differences between treatment stages in the combined group.

Table 3 shows the median anxiety scores in the first-surgery group at each treatment stage and Table 4, the Mann-Whitney U analysis and P values for differences in HAD scale and VAS anxiety scores between the preassessment and the operation day and between the operation day and the postoperative visit. There was a significant difference in HAD scale anxiety scores between the operation day and the postoperative visit (P < .05, Mann-Whitney U) but not between the preassessment and the operation day. There were no significant differences in VAS scores among the 3 treatment stages.

Table 3
Table 3:
Median anxiety scores in the first-surgery group.
Table 4
Table 4:
Mann-Whitney U results for differences between treatment stages in the first-surgery group.

Table 5 shows the median anxiety scores in the second-surgery group at each treatment stage and Table 6, the Mann-Whitney U analysis and P values for differences in HAD scale and VAS anxiety scores between the preassessment and the operation day and between the operation day and the postoperative visit. There were no significant differences in the HAD or VAS scores among the 3 treatment stages.

Table 5
Table 5:
Median anxiety scores in the second-surgery group.
Table 6
Table 6:
Mann-Whitney U results for differences between treatment stages in the second-surgery group.

Discussion

The measurement scales for anxiety that were considered for use in this study design were the Hospital Anxiety and Depression (HAD) Scale,4 Psychiatric Symptom Frequency Scale,8 Amsterdam Preoperative Anxiety and Information Scale,9 Yale Preoperative Anxiety Scale,10 General Health Questionnaire,11 State-Trait Anxiety Inventory Questionnaire,12 and a Visual Analog Scale (VAS).5,6 The HAD scale was selected as the most appropriate measure as it has been cited as a reliable instrument in evaluating depression and anxiety in a hospital medical outpatient setting.4 In addition, HAD scale scores are not affected by physical illness, and the scale has separate scores for depression and anxiety.

The VAS was used as a comparison to the HAD scale and to encourage patients to directly reflect on their anxiety. The VAS was originally designed for use in the self-assessment of pain13; however, in this study, it was adapted to serve as a measure of anxiety. The VAS for anxiety has been validated.5,6 In addition, the VAS has been used more than the HAD scale in ophthalmology,14–17 albeit to measure pain.

In patients having cataract surgery for the first time, there was a difference in anxiety trends among the 3 treatment stages between the HAD scale and the VAS. The median HAD scale anxiety scores showed greatest anxiety on the day of surgery, whereas the median VAS scores found patients to be most anxious at the preassessment stage.

Patients did not act as their own controls as they were not followed over the course of their treatment. This may have resulted in bias. Digit preference may have occurred when patients were using the VAS; since the VAS was presented as a numerically graded line marked 0 to 7, patients may have selected their anxiety level according to whether the number on the VAS was odd or even, 2 and 4 being examples of commonly selected numbers. The HAD scale is not affected by digit preference as the numerical score assigned to each response was obstructed from the patient's view. Also, the HAD scale is standardized. There is a set format and instructions to the questionnaire, allowing comparison of this study's results to those in future ones. For these 2 reasons, the HAD scale is of preference, in the final analysis.

In the combined group of first- and second-surgery patients, the HAD scale showed that the preassessment stage was more anxiety provoking than the operation day or the postoperative visit. There was a statistically significant difference between anxiety on the operation day and that at the postoperative visit but not between the preassessment stage and operation day, suggesting that the anxiety scores between the 2 latter stages were similar. These results indicate that patients, regardless of whether they are having surgery for the first or second time, may be particularly anxious about hospitals.

In the first-surgery group, the operation day was the most anxiety provoking. As in the combined group, there was a statistically significant difference in anxiety between the operation day and the postoperative visit but not between the preassessment stage and operation day, suggesting that the anxiety scores between the 2 latter stages were similar. Because patients having cataract surgery for the first time do not have the benefit of experience, their greater anxiety preoperatively may be the result of uncertainty about what the operation involves and its success rate. This topic is worthy of further investigation; that is, is preoperative patient anxiety affected by the level of preparation and information obtained?

In the second-surgery group, the preassessment stage was the most anxiety provoking. There were no statistically significant differences among the 3 treatment stages, suggesting that anxiety levels among them were similar. These patients may have felt less anxious at the day ward because of the good nursing care they received and because of reassurances from the preassessment clinic nurses.

Conclusion

In this study, the average patient in all stages and groups had a HAD scale anxiety score of below 7 (ie, no significant anxiety). Furthermore, there were few statistically significant differences among stages in the HAD scale anxiety scores, indicating that the average cataract patient attending Moorfields Eye Hospital is not likely to be unduly anxious during the process of cataract surgery under local anesthesia.

It is surprising how little work has been done in this area despite the tremendous changes in clinical practice in the past 10 years. The approach to day care is still evolving, and this study provides a benchmark of the quality of care that Moorfields Eye Hospital provides, against which future developments can be judged.

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© 2001 by Lippincott Williams & Wilkins, Inc.