Research Article - Journal of Clinical Ophthalmology (2023) Volume 7, Issue 1

Effectiveness of illustration for alleviating preoperative stress in elderly patients undergoing first-time cataract surgery: A single-blinded quasi-randomized controlled trial

Yi Ching Chiang^1*, Hsiang Ping Wang², Dong Chen Shieh², Hui Ju Lin³

¹Department of Nursing, China Medical University Hospital, Taichung, Taiwan

²Department of Nursing, University of Hungkuang, Taichung, Taiwan

³Department of Ophthalmology and Medical Genetics, China Medical University Hospital, Taichung, Taiwan

Corresponding Author:

Dr. Yi Ching Chiang Department of Nursing Taichung Taiwan E-mail: Ann980914@gmail.com

Received: 14-July-2020, Manuscript No. AACOVS-20-15485; Editor assigned: 17-July-2020, PreQC No. AACOVS-20-15485 (PQ); Reviewed: 31-July-2020, QC No. AACOVS-20-15485; Revised: 30-November-2022, Manuscript No. AACOVS-20-15485 (R); Published: 28-December-2022, DOI: 10.35841/aacovs.6.5.566-573

Citation:Chiang YC, Wang HP, Shieh DC, et al. Effectiveness of illustration for alleviating preoperative stress in elderly patients undergoing first-time cataract surgery: A single-blinded quasi-randomized controlled trial. J Clin Ophthalmol 2022;6(5):566-573.

Abstract

Cataract is among the main causes of blindness and visual impairment in the world. According to global statistics, as of October 2019, it is estimated that at least 1 billion people have visual impairment or blindness, excluding refractive errors and presbyopia. The number of individuals with cataracts amounts to 65.2 million, which is much higher than that of people with glaucoma, corneal opacity, diabetic retinopathy, etc. Surgery is currently the only treatment that can save vision in people with cataracts and has been widely used. Most patients can complete surgery under local anesthesia, without hospitalization. Nevertheless, unclear procedures related to surgery and hospitalization, as well as an unfamiliar surgical environment and separation from family members increase the anxiety and stress of elderly patients undergoing cataract surgery, and some consequently even refuse surgical treatment. In addition, it has been reported that the preoperative stress levels of outpatients are higher than that of inpatients, possibly due to insufficient preoperative information: The concise health education guidelines can be a source of preoperative stress. This stress triggers the sympathetic nervous system, resulting in tachycardia, increased blood pressure, and arterial blood vessel contraction, which reduces blood supply to the eye and causes delayed wound healing; it also reduces the function of the immune system and thereby increases the risk of infection. Moreover, high preoperative stress can cause a sudden increase in systolic blood pressure, which causes a transient increase in intraocular pressure; such high intraocular pressure may cause severe complications during surgery.

Abstract

Cataract is among the main causes of blindness and visual impairment in the world. According to global statistics, as of October 2019, it is estimated that at least 1 billion people have visual impairment or blindness, excluding refractive errors and presbyopia. The number of individuals with cataracts amounts to 65.2 million, which is much higher than that of people with glaucoma, corneal opacity, diabetic retinopathy, etc. Surgery is currently the only treatment that can save vision in people with cataracts and has been widely used. Most patients can complete surgery under local anesthesia, without hospitalization. Nevertheless, unclear procedures related to surgery and hospitalization, as well as an unfamiliar surgical environment and separation from family members increase the anxiety and stress of elderly patients undergoing cataract surgery, and some consequently even refuse surgical treatment. In addition, it has been reported that the preoperative stress levels of outpatients are higher than that of inpatients, possibly due to insufficient preoperative information: The concise health education guidelines can be a source of preoperative stress. This stress triggers the sympathetic nervous system, resulting in tachycardia, increased blood pressure, and arterial blood vessel contraction, which reduces blood supply to the eye and causes delayed wound healing; it also reduces the function of the immune system and thereby increases the risk of infection. Moreover, high preoperative stress can cause a sudden increase in systolic blood pressure, which causes a transient increase in intraocular pressure; such high intraocular pressure may cause severe complications during surgery.

Keywords

Cataract surgery, Elderly patients, Illustration, Preoperative stress.

Introduction

In theory, to prevent the occurrence of surgical complications caused by preoperative stress, it is also necessary to provide appropriate and understandable preoperative information related to cataract surgery to such individuals [1]. In addition, providing such information preoperatively can also increase the cooperation of patients during surgery, as the importance of positioning, maintaining a fixed eye position, and maintaining a stable mood can be conveyed to subjects as key points for the successful completion of the operation [2]. According to the preoperative patient care standards, some subjects, such as the elderly, children, and high risk patients, require special attention and adequate preoperative preparation and information [3]. Therefore, in addition to assessing and understanding the relevant preoperative stress factors for individuals undergoing cataract surgery, and particularly for the elderly, it is necessary to use suitable preoperative surgical education methods, in addition to evaluating and understanding the relevant preoperative stress factors, in order to reduce the psychological burden on these individuals during surgery [4].

Individuals undergoing cataract surgery are typically elderly [5]. The teaching methods preferred by the elderly are narrative, practical operation, and discussion, and as learning styles, they typically prefer participative learning and cooperative learning [6]. In addition to considering the individual backgrounds of elderly people, it is necessary to meet their learning needs when providing them with education.

Older people's preferred teaching methods are combined with the real environment, and the learning results can be enhanced by real experience [7]. Additionally, direct interaction between learners and the real environment, and learning in context, can promote the construction of knowledge and problem solving, as well as application of the learned knowledge to the relevant situation [8].

The main objective of this study was to use illustration as an intervention for preoperative preparation of elderly patients scheduled for cataract surgery [9]. We compared this approach with the routine education approach, to obtain evidence on the effectiveness of illustration supported information to alleviate preoperative stress in elderly patients undergoing first time cataract surgery. The Transactional Model of Stress and Coping was used as the theoretical framework for this research [10].

Materials and Methods

Study design

A randomized controlled clinical with a quasi-experimental design was employed via purposive sampling between January 2018 to April 2019 [11]. The research process was divided into a preliminary period and a formal implementation period. GPower 3.0.10 (Heinrich Heine Universitat, Dusseldorf, Germany) was used to estimate the sample size, based on a medium effect size (0.5), p<0.05 and a power of 0.8. This indicated that a minimum of 128 participants needed to be included in this study, but considering that the subjects were elderly individuals, with highly heterogeneous personalities, and represented a vulnerable population, the sample size of this study adjusted the number of participants recruited [12].

Individuals were randomly assigned to receive information by illustration or by standard means, using allocation concealment. Individuals were included if they were elderly persons aged 65 years and over, undergoing their first cataract surgery, using only local anesthesia, if they were individuals with clear consciousness who were able to communicate, agreed to participate in the research and signed the consent form [13]. The following individuals were excluded:

• Those suffering from dysautonomia, such as hypertension, heart disease, asthma, adrenal disease, such as cushing's syndrome, addison's disease, or diabetes mellitus, and mental illness.

• Those who used mood stabilizers and hypnotic drugs.

• Those with severe oral disease or who chewed betel nuts, as these may affect analysis of saliva cortisol [14].

Participants

The study recruited participants from the department of ophthalmology of a medical center, identified through electronic medical records. Seventy-two participants were invited to participate in the study by conversation, including 60 who were undergoing their first cataract surgery and 12 healthy elderly who were not undergoing cataract surgery, who provided a baseline for objective measurements [15]. During the research, some participants in the illustration group and the control group canceled the surgery during the case collection period; consequently 5 more subjects were invited to participate. Finally, 72 participants completed the entire study, without further dropouts [16].

Intervention

The preliminary period: After elaborating on the purpose of the study and obtaining consent, 12 ophthalmology outpatients over 65 years of age, who had not undergone eye surgery, and did not have glaucoma or other diseases, were recruited to obtain baseline measurements for intraocular pressure, blood pressure, pulse rate, and saliva cortisol [17]. These values were used to compare the objective signs of stress of individuals in the illustration and control groups collected during the implementation period [18].

The implementation period: It took about 30 minutes to explain the research purpose and research method. The subjects who agreed to participate in the research, after confirming that there were no other problems, signed consent to participate in the research. Information was conveyed to the patients by using a research kit including a pen, ophthalmic anesthetic solution, small cotton swab, tonometer pen, tonometer sleeve, paper cup, microcentrifuge tube, 1 cc empty needle, self-adhesive label sticker for collection intraocular pressure and salivary [19]. Patients were told that the collection procedure would take about 15 minutes. The subjects who refused to participate in the study were provided routine education. After the education process was completed, the psychological burden of the research subject after participating in the intervention was investigated(Figure 1) [20].

Figure 1: Flowchart of the participants.

Ilustration supported information: The education content of the illustration was divided into 4 parts. The first part (preparation before arrival at the hospital) included the following: You can eat, but not too much; do not wear makeup, bring the consent form, as well as an indication of the direction of the operating room [21]. The second part (entering the operating preparation room) included the following: Measurement of ear temperature, wearing a surgical cap, do not tie the hair, wear a surgical gown, pupil dilation and entering the eye surgery room in a wheelchair. The third part (pre-operative preparation process) included the following: Taking on the supine position, surgery being performed with a microscope, measurement of blood pressure and pulse rate, wearing an oxygen mask, topical eyedrops of antibiotics, anesthetic, mydriatics and practicing looking at the microscope light. The last part (perceived information during the operation) included the following: Only the eye undergoing surgery will be exposed, but both eyes need to look at the microscope light together, eyes will feel wet due to surgical fluid, not blood, breath normally, do not hold the breath, the sounds of the surgical device will be heard and you are allowed to communicate important information, for example, about pain or other discomfort during the operation, but do not shake your head or move your body [22].

Data collection

The Impact of Events Scale-Revised (IES-R) was adopted for assessment of preoperative stress on cataract surgery, and the following objective parameters were measured: Intraocular pressure, blood pressure, pulse rate, and salivary cortisol [23].

The data were obtained at pretest and posttest, while intraoperative blood pressure and heart rate were also recorded.

Moreover, patients completed the psychological burden questionnaire after the whole procedure was completed. To maintain the consistency of the samples, data were collected before 12 noon [24].

Impact of events scale-revised: The IES-R is used to detect stress related feelings caused by the impact of specific events in the past 7 days. We revised the structural factors of the IESR with 3 facets, namely intrusion: 8 questions, avoidance: 8 questions and hyperarousal: 6 questions [25]. Cronbach's alpha of each facet was verified to be above 70 in previous studies.

The higher the score, the higher the stress feeling. Two studies used firefighters as research subjects and used the IES-R to explore the pressure and impact of disaster relief events. A score ≥ 25 points represents a significant level of psychological impact. The results published in the above 2 studies provided a cut-off point for this study at pretest and posttest [26].

Salivary cortisol: Before saliva sampling, the subject's oral condition was monitored. If there were wounds, such as mucous membrane wounds after tooth extraction, samples were not taken [27]. The subject was asked to rinse their mouths with cold water 10 minutes before collection, after which at least 0.5 c.c of saliva was collected and stored at 4°C and then frozen in the laboratory (-20°C) within the day.

Samples were collected on the day of making the surgery appointment, and 1 hour before surgery [28].

Intraocular pressure: The contact tonometer was calibrated monthly, and the stability of the tonometer was confirmed before measurement to ensure the quality of values obtained.

Glaucoma patients were excluded from the study. Intraocular pressure was measured in both eyes. The measurement position was at the center of the pupil; the average of 2 measurements was used for analysis. Measurements were taken on the day that the surgery appointment was made, as well as 1 h before surgery [29].

Vital signs monitoring: A blood pressure cuff was secured to the arm on the side of the non-operative eye. In addition to before and after measurement, blood pressure and pulse values were also collected during the operation. The average cataract operation time has a duration of 20 minutes (from the first wound to the end of the examination), and measurements were taken every 5 minutes. Thus, including the measurements made on the day of surgery appointment and 1 hour before surgery, 6 data measurements were obtained [30].

The psychological burden: After the research process ended, 3 questions were posed to the participants: 1) Will participation in this research increase your psychological stress levels? 2) Do you know in advance whether the surgical preparation process increases your psychological pressure? 3) Do you thing the research intervention activities can help you reduce your psychological stress before the surgery? These questions were asked to investigate the psychological burden of participants in the intervention activities.

Data analysis

IBM SPSS (version 22.0) software were used research data archiving and analysis. Statistical significance was defined at p<0.05. Categorical variables were analyzed by using the Chisquared test, and continuous variables were analyzed using independent t-tests. Data were presented as frequency and percentages, or as mean and standard deviation. Inferential statistics included analysis of covariance, the Johnson-Neyman and Wilcoxon-signed ranks tests, and the Mann-Whitney U test. A generalized estimating equation was used to compare the preoperative subjective stress levels and the objective signs of stress between the illustration group and the control group.

The Kruskal-Wallis H test was used to compare the preoperative blood pressure and pulse rate of the illustration and control groups with the healthy control group.

Ethical considerations

The study was conducted under the standards and ethical criteria of the Helsinki declaration and was approved by the ethics review board of medicine (CMUH106-REC1-156) and written informed consent was obtained from all participants.

The saliva samples collected by the institute were destroyed immediately after the data analysis file was completed.

Results

Participant demographics

A total of 72 patients completed the study (intervention group, n=30; control group, n=30; healthy control group=12).

Demographic details of the 72 participants are shown in Table 1. In the 60 participants in the illustration and control groups, about 66% were females. The best-corrected visual acuity of both eyes of the illustration and control groups were similar, about LogMAR=0.4. The mean number of days from enrollment to surgery was 13.38 (SD 9.38) days. Education level was below college (71%). About 61% were their own primary caregiver. More than 3/4 in both groups had no experience of surgery and 1/4 had a history of surgery (including brain, abdomen, orthopedics, spine, breast, hemorrhoids, gynecology, heart, thyroid and sinusitis). The demographic variable was not significantly different between the two groups. In the healthy group, more males than females and their best-corrected visual acuity was better than that in both the illustration and the control groups.

Table 1. Baseline characteristics of the participants (n=72).

Preoperative stress

After intervention, the scores before and after the correction of IES-Rs did not reach the cut-off point (>25) in either the illustration or control group. There was a significant difference between the preoperative and postoperative stress measurements, with a mean score of pretest/posttest on the IES-R of 7.87 (SD 12.88)/5.67 (SD 9.46) in the illustration group (p=0.02). There was no significant difference between the illustration and control groups, and between pre and postvalues in the control group. We adjusted for pretest IES-R and group in an analysis of covariance. Although there were no significant differences between 2 groups, the adjusted IES-R posttest scores showed greater remission of the preoperative psychological stress levels in the illustration group, and an increase in stress levels in the control group, as compared to preoperative stress values (Table 2).

Table 2. Level of preoperative stress after the intervention.

Intraocular pressure

The regression line showed heterogeneity of intraocular pressure in bilateral eyes. Therefore, analysis was performed using the Johnson-Neyman technique. The regression equation for the right eye in the illustration group was y=16+0.06^*x and in the control group was: y=7.56+0.06^*x. The regression equation in the left eye of the illustration group was: y=9.74+0.15^*x and in the control group was y=8.19+0.55^*x.

The intersection point in the right eye was 15.75 mmHg, and in the left eye was 16.50 mmHg. These results showed that, when the intersection point is reached, both methods of health education can be used. However, when the intraocular pressure exceeded 19 mmHg (dissimilarity point), the effect of using conventional education was better than that of using illustration (Figure 2).

Figure 2: Johnson-Neyman analysis of intraocular pressure in both eyes.

Blood pressure and pulse rate

There was no significant difference in blood pressure or pulse rate before surgery between the 2 groups. We analyzed preoperative objective stress related parameters in the illustration group, the control group, and the healthy control group. The diastolic blood pressure of the illustration and the control groups was higher than that of the healthy control group (p<0.001). Blood pressure and pulse rate were collected at 5, 10, 15, 20 minutes after the start of the operation, and revealed that systolic and diastolic blood pressure, as well as pulse rate remained essentially stable throughout surgery in the illustration group. Table 3 shows that the systolic blood pressure in the illustration group decreased significantly, by 2.785 mmHg from starting to end (p=0.004). In terms of stability of systolic blood pressure during surgery, that in the illustration group was better than that in the control group (p=0.008). Although there was no statistically significant difference in pulse rate between the 2 groups, the pulse rate of the illustration group decreased significantly by 1.690 bpm from starting to end (p=0.001).

Salivary cortisol

The mean pretest and posttest salivary cortisol values in the illustration group was 6.94 (SD 8.80)/6.24 (SD 4.19), while that in the control group was 6.42 (SD 8.64)/6.21 (SD 3.68).

There was no significant difference between the 2 groups.

Psychological burden of the participants

Two subjects in the illustration group knew in advance that the surgical preparation process would increase their burden of psychological stress, and particularly the description of the intra-operative sensations. Four subjects in the control group felt that participating in the research activity would increase their psychological stress. As reason, they stated I will feel the atmosphere of the upcoming surgery early and feel nervous and stressed (Table 3).

Table 3. GEE analysis of blood pressure and pulse rate on the surgery period for the intervention group and control group.

Discussion

The mean of the IES-R score in the 60 subjects was 6.33 (SD 10.08), indicating that elderly patients undergoing cataract surgery had a low degree of subjective preoperative stress.

These results are consistent. Cataract surgery is a universal procedure. Precise preoperative assessment, examination procedures, and sufficient preoperative information (such as asking neighbors or family members who have undergone cataract surgery) may be the cause of the low level of stress before cataract surgery. In the illustration group, after receiving the operation environment illustration, the degree of preoperative stress levels decreased significantly, while the degree of preoperative stress in the control group increased.

The results obtained are similar to those of who also suggested that the education process should be adjusted according to the needs of the surgical patients, and that effective information retrieval for patients should be provided through appropriate health education teaching materials to reduce the psychological burden before surgery. Pre-operative education content can be supplemented with graphics to provide more complete preoperative preparation information. In our study, we organized pre-operational health education information into a systematic illustration, providing senior patients (aged 65 years or older) undergoing cataract surgery for the first time to understand the pre-operative preparation process, and found that their preoperative stress levels reduced.

The intraocular pressure of the eyes in this study was heterogeneous, because of the regression coefficients in the group. Using the Johnson Neyman correction method, we determined that, when the intraocular pressure of the eyes exceeded 19 mmHg, the ability of the patient to bear the information should be evaluated, and appropriate healthcare provided. The teaching content should be adapted to avoid adding pre-operative psychological stress. However, the postmeasurement value of intraocular pressure, taken 1 hour before surgery in this study, was higher than the value measured on the day of making the surgical appointment. This can reflect the cumulative effect of psychological load: That is, the more proximate the source of the stress is, may the more the intraocular pressure increases.

In terms of vital signs, the mean of the pretest diastolic blood pressure of the intervention group and the control group was 79.77 mmHg (SD 12.21) and 78.90 mmHg (SD 12.81), respectively, which was more than 10 mmHg higher than the 62.00 mmHg (SD 9.95) of the healthy group. It has been shown that acute stress events can stimulate an increase in the activity of the autonomic nervous system and affect the stability of hemodynamics. When faced with a source of stress, psychological pressure can affect muscle sympathetic nerve activity. The diastolic blood pressure reacts first, increasing rapidly, and individuals with more negative emotions showed a greater increase than those who had more positive emotions.

This was in accordance with the pre-operative psychological stress and the diastolic blood pressure of the research subjects in our study. After the intervention, the blood pressure and pulse rate of the illustration group and the control group did not differ markedly between the 2 groups. These results were similar to those of Choi and Park, who found that intervention could reduce the subjective stress feelings of patients before surgery, but found that it did not affect blood pressure and pulse. However, after the intervention, the blood pressure and pulse rate during surgery was statistically significantly different between the groups in our study. The blood pressure and pulse rate of the illustration group decreased from beginning to end the operation, and remained fairly stable during surgery, indicating that the illustration message can stabilize patients. The patient’s mood during the operation stabilizes the hemodynamic response. Previous studies have explored the effects of interventions such as hand-held grips, massage therapy, and music therapy on the physiological indicators of patients undergoing cataract surgery; however, those studies only used pretest and posttest measurements, and did not discuss the stability of intraoperative physiological indicators or the effectiveness of their intervention thereon.

This suggests that future studies should investigate intervention measures used to reduce patients' intraoperative stress.

In terms of salivary cortisol levels, there was no significant difference between the 2 groups after the intervention, similar to the results. The subjects included in our study were healthy elderly patients who were undergoing cataract surgery for the first time and had no other concomitant medical diseases, such as hypertension, diabetes, heart disease, immune diseases, etc.

Considering that the secretion of salivary cortisol varies from morning to evening, the saliva collection was set to be completed before noon, but it was not easy to recruit cases under this screening condition. Consequently, samples of 19 subjects were taken after noon, and the pretest was not completely synchronized. This may be the reason for the lack of significant difference in salivary cortisol levels between the 2 groups after the intervention. Moon and Cho reported a study on a group of similar age and sample size as in the present study, and found similar results. However, the source of cortisol differed between the 2 studies. In addition, the results of our study are inconsistent with those of Park and Park, who performed cataract surgery in patients over 65 years old and took saliva samples before and after the operation; but did not report the time lag between collections. In our study, the mean of the time in saliva sample collection time before and after the test was 15.03 (SD 11.3) days in the illustration group, and 11.73 (SD 6.72) days in the control group. Whether the time interval between the collections of samples affected the lack of changes observed in salivary cortisol concentration needs to be further explored.

Conclusion

This study explored the effectiveness of illustration-supported information in reduction of preoperative stress in elderly individuals undergoing cataract surgery. We found that illustration-supported information led to a decrease in preoperative stress levels of elderly patients, and helped to stabilize the patients' autonomic nervous system responses during surgery. We also found that, if intraocular pressure exceeded 19 mmHg, the amount of information provided needs to be considered. Therefore, for elderly individuals undergoing cataract surgery for the first time, it is recommended that intraocular pressure be included in the assessment of the preoperative stress state of the subject. Before providing preoperative educational information, it is necessary to evaluate the patient's ability to accept information, in order to avoid providing excessive information, which can increase preoperative stress levels. The content and format of the illustration used can be formulated according to the clinical scope. In our study, considering that subjects undergoing cataract surgery need to undergo mydriasis before surgery, and that vision after mydriasis is restored to the original state only after 6-8 hours, we enlarged the size of the picture card to 42 cm in length and 30 cm in width, thereby assisting elderly individual's visual perception during illustration-supported education.

Acknowledgment

We are grateful to the patients and staff of the Department of Ophthalmology and the operating room who participated in this study.

Limitations

This study had a quasi-experimental design. Because the included study subjects were elderly patients ≥ 65 years of age, and considering that they constitute a vulnerable group, only 60 subjects were enrolled in the study process. Moreover, patients were limited to those recruited from a medical center in the central part of the country; thus, its effectiveness cannot be extended to all elderly patients undergoing first-time cataract surgery in other medical institutions. In addition, the recruitment of subjects in this study was limited to those from the outpatient clinic of an attending ophthalmologist; hence, it is impossible to compare the effectiveness of the illustration approach in patients, even of the same ethnic group, attended to by other doctors. Future studies should expand the sample size or should cooperate with other medical institutions in a multi-center study. Furthermore, the subjects of this study were elderly patients, and the degenerative physiological function related to memory of the illustration is a limitation of this study. Whether this influenced the effectiveness of the illustration intervention needs to be assessed in future studies.

Conflicts of Interest

None.

Funding

The work was supported by the Medical Research Department of the China Medical University Hospital (DMR-104-117).

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