Quantifying Diplopia with a Questionnaire

Abstract

Purpose To report a diplopia questionnaire (DQ) with a data-driven scoring algorithm. Design Cross-sectional study. Participants To optimize questionnaire scoring: 147 adults with diplopic strabismus completed both the DQ and the Adult Strabismus-20 (AS-20) health-related quality of life (HRQOL) questionnaire. To assess test-retest reliability: 117 adults with diplopic strabismus. To assess responsiveness to surgery: 42 adults (46 surgeries). Methods The 10-item AS-20 function subscale score (scored 0 to 100) was defined as the gold standard for severity. A range of weights was assigned to the responses and to the gaze positions (from equal weighting to greater weighting of primary and reading). Combining all response option weights with all gaze position weights yielded 382,848 scoring algorithms. We then calculated 382,848 Spearman rank correlation coefficients comparing each algorithm with the AS-20 function subscale score. Main outcome measures To optimize scoring, Spearman rank correlation coefficients (measuring agreement) between DQ scores and AS-20 function subscale scores. For test-retest reliability, 95% limits of agreement, and intraclass correlation coefficient (ICC). For responsiveness, change in DQ score. Results For the 382,848 possible scoring algorithms, correlations with AS-20 function subscale score ranged from −0.64 (best correlated) to −0.55. The best-correlated algorithm had response option weights of 5 for rarely, 50 for sometimes, and 75 for often, and gaze position weights of 40 for straight ahead in the distance, 40 for reading, 1 for up, 8 for down, 4 for right, 4 for left, and 3 for other, totaling 100. There was excellent test-retest reliability with an ICC of 0.89 (95% confidence interval 0.84 to 0.92) and 95% limits of agreement were 30.9 points. The DQ score was responsive to surgery with a mean change of 51 ± 34 (p<0.001). Conclusions We have developed a data-driven scoring algorithm for the diplopia questionnaire, rating diplopia symptoms from 0 to 100. Based on correlations with HRQOL, straight ahead and reading positions should be highly weighted. The DQ has excellent test-retest reliability and responsiveness, and may be useful in both clinical and research settings.

Improvement in specific function-related quality-of-life concerns after strabismus surgery in nondiplopic adults

“…Patients with intermittent strabismus or oculomotor, trochlear, or abducens nerve palsies were excluded. For inclusion, absence of diplopia was required at both the pre- and postoperative visits and was either recorded by the patient using the diplopia questionnaire 11 (diplopia rated as “never” or “rarely” in all gaze positions), or taken from the history documented in the patient’s medical record.…”

Depressive Symptoms Associated with Poor Health-Related Quality of Life in Adults with Strabismus

“…Consecutive adult strabismus patients were prospectively enrolled and completed four questionnaires: 1) Adult Strabismus-20 (AS-20) HRQOL questionnaire 2 with four, separately scored domains (Self-Perception, Interactions, Reading Function and General Function: scored 0 [worst] to 100 [best] HRQOL); 2) DS-14 distressed personality questionnaire 3 (classified: Yes/No); 3) Center for Epidemiologic Studies Depression Scale – Revised (CESD-R) depression screening questionnaire, 4 (scored 0–80; ≥ 16 subnormal); 4) Diplopia Questionnaire 5 rating diplopia severity (scored 0 [no diplopia] to 100 [constant diplopia]). Clinical data collected were: direction of deviation, magnitude of deviation, diplopia questionnaire score, best-eye visual acuity (LogMAR), and presence/absence of visually obtrusive co-morbidity.…”

One- Versus Two-Muscle Surgery for Presumed Unilateral Fourth Nerve Palsy Associated With Moderate Angle Hyperdeviations

“…14, 15 In this particular condition, one could argue that the presence and severity of diplopia should be used as the primary outcome measure, because in contrast to most other types of strabismus, a residual large-angle deviation without diplopia is rare. In the present study we used the patient-reported Diplopia Questionnaire 10 data when available, or patient history if Diplopia Questionnaire data were unavailable, and we defined diplopia success as no diplopia (or only rare) for straight ahead distance and for reading. Using only diplopia criteria to define success we found no significant difference between one- and two-muscle procedures overall.…”

“…We did not evaluate these parameters in the present study since there were insufficient data regarding head posture, limited follow-up after 1 year, and reoperation rate could be influenced by the individual surgeon’s preferences and coexisting neurologic conditions. In addition, we did not have standardized Diplopia Questionnaire 10 data on all patients and quantification of diplopia frequency may have been less accurate based on review of the history alone. Our motor outcome was based on primary position measurements and did not consider alignment in down or lateral gaze positions.…”

“…For some patients, diplopia had been formally assessed using the Diplopia Questionnaire, 10 providing a patient-reported rating of diplopia as present either “never,” “rarely,” “sometimes,” “often,” or “always” in specific positions of gaze. For patients who had not completed the Diplopia Questionnaire, assessment of diplopia frequency was based on the history recorded in the medical record.…”