Influence of socioeconomic factors on satisfaction with customized ocular prostheses

Dear Editor, We wish to report findings from our prospective observational study assessing the impact of socioeconomic status (SES) on patient satisfaction with customized ocular prosthesis (COPs), conducted at a tertiary-care center in Northern India. While COPs provide essential aesthetic and psychological rehabilitation following enucleation or evisceration, there is limited literature on how socioeconomic disparities influence access to and satisfaction with these prosthesis.[1–6] Ethical approval and written informed consent were taken. The study included both primary COP cases (prostheses fitted 6–8 weeks post-surgery; n = 18) and secondary COP cases (fitted months/years post-surgery; n = 23). SES was assessed using the Kuppuswamy scale, which considers education, occupation, and family income.[7] Satisfaction levels were measured post-COP fitting using a structured questionnaire [Appendix ‘A’] with Likert-scale responses ranging from one (very dissatisfied) to five (very satisfied). The assessment covered comfort, functional aspects (e.g., movement of the prosthesis), aesthetic appearance, and overall satisfaction. Follow-ups were done at one, three, and six months. A total of 41 patients were enrolled. The most common cause of eye loss was ocular trauma, followed by infections such as endophthalmitis and panophthalmitis [Table 1]. Among primary COP cases, 94.4% of patients had undergone evisceration with a ball implant, and one patient (5.6%) had enucleation with an implant. In the secondary COP group, 47.8% had undergone evisceration without a ball implant, and 52.2% underwent enucleation with or without an implant.Table 1: Demographic and clinical characteristics of patients and their satisfaction levelsThe median duration between surgery and COP fitting was 6.8 weeks for primary and 3.5 years for secondary cases. Reasons for delayed prosthetic fitting were non-availability of facilities (34.8%), financial constraints (26.1%), fear of infection (17.4%), lack of awareness (13%), and fear of mishandling (8.7%). Class III SES (lower middle class) comprised the largest proportion of patients (52.2%). Higher satisfaction levels were observed in patients from higher socioeconomic classes (P = 0.001) [Table 1]. Notably, all Class I patients were 100% “very satisfied, ” compared to 70% in Class II and 81% in Class III, and markedly lower in Class IV and V. Patients from urban areas reported higher satisfaction levels compared to rural patients, though the difference was not statistically significant (P = 0.387). The type of surgery also influenced satisfaction. Cases with enucleation and secondary evisceration with ball implants yielded the highest satisfaction rates (81.8%). Primary evisceration with ball implants resulted in 58.8% being “very satisfied,” while enucleation without implants had lower satisfaction levels. Younger patients were more likely to undergo evisceration, while older patients underwent evisceration without ball implants (P = 0.011). Fig. 1 shows results after fitting of primary or secondary COP in adults [Fig. 1a-e] and pediatric cases [Fig. 1f-h].Figure 1: Post-fitting outcomes with customized ocular prostheses in adult patients (a-e) showing well-matched prosthetic eyes; and in pediatric patients (f-h) showing restoration of facial symmetry and favorable cosmetic rehabilitationEvisceration was preferred over enucleation because the orbital anatomy is preserved for better motility and cosmesis, less manipulation, less inflammation, and subsequently minimal scaring.[8] Also with evisceration, larger implants can be accommodated with modern sclerotomy techniques. These factors turned into higher satisfaction, particularly when a ball implant was used. Our study confirms that SES significantly affects satisfaction with COPs. Patients from higher SES likely benefit from better health literacy, access to specialized services and improved compliance. Lower SES groups, in contrast, face barriers like affordability, accessibility, and lower awareness levels, contributing to lower satisfaction levels. Rural patients often face challenges such as long travel distances, limited availability of specialized surgeons, and a lack of follow-up care, which can negatively impact satisfaction. Strengthening rural healthcare infrastructure and implementing mobile surgical units or telemedicine services could help mitigate these disparities.[9–11] In our study, the non-availability of the facility and the financial burden involved in the procedure were the limiting factors for the patients to opt for the procedure. The satisfaction level was seen in many cases in our study. Many expressed satisfaction with the immediate disguise of their blemish using COP. The patients with painful blind eyes resulting from endophthalmitis/panophthalmitis were happy with the relief of pain and the COP in place of a painful eye. The patients/participants with anterior staphyloma preferred the new eye to the disfigured one. Strategies such as preoperative counseling, personalized postoperative care, and enhanced communication can help manage patient expectations and improve satisfaction. In addition, targeted policies such as subsidized healthcare, prosthetic rehabilitation programs, and community outreach initiatives may bridge the gap for underserved populations.[9,10] To conclude, addressing socioeconomic disparities, improving access to prosthetic rehabilitation, and enhancing patient-centered care can significantly improve satisfaction levels, particularly among disadvantaged populations.