Saudi Children's Perception of Strabismus: A Hospital-Based Study.

PURPOSE: Children with strabismus may face difficulties interacting with their peers in elementary school. This study investigates the psychosocial effect of different types of strabismus on Saudi children's selection of a playmate.
METHODS: Photographs of orthotropic children were digitally modified to simulate various magnitudes of strabismus. Orthotropic children with normal visual acuity viewed 18 sets of paired photographs and were asked to choose a playmate from each pair. Parents were asked to fill out a questionnaire on their socioeconomic background and to determine whether surgery should be indicated in strabismic patients for psychosocial reasons. Parents were also asked to rate their perception of seven personal characteristics of two images of the same child (one orthotropic and one strabismic).
RESULTS: Two hundred and thirty-three children, aged 3-15 years (mean age: 9.94 [3.6] years), were studied. Children aged ≤6 years were significantly more likely not to distinguish between orthotropic children and those with strabismus (P < 0.001). Out of 233 participants, 69.6% were significantly in favor of orthotropic faces as opposed to 30.4% (P < 0.0001). Children perceived esotropia as less disturbing than exotropia and hypertropia (P < 0.001). Smaller magnitudes of strabismus were significantly preferred over larger angles (P < 0.001). Parents judged strabismic faces more negatively than orthotropic faces on all seven characteristics. Almost 88.4% of the adults thought that strabismic patients should undergo surgery for correction.
CONCLUSIONS: Our findings suggest that children with apparent strabismus are perceived negatively and might be subjected to social alienation at a young age. Therefore, there is a need for strategies to address negative social bias toward children with strabismus and to enhance their peer acceptance in our society. Copyright:

Introduction

Previous reports have suggested that strabismic children have difficulties interacting with their peers in elementary school,[12] and research on the psychological impact of strabismus showed that children as young as six exhibit negative attitudes toward strabismus.[3] While these observations were made of children interacting with strabismic dolls, a study conducted on college students demonstrated that observers also had a more negative attitude toward photographs of individuals with strabismus than toward those of orthotropic individuals.[4] Later work showed that teachers rated young strabismic students lower than nonstrabismic children in several personal characteristic categories.[2] In addition, teachers perceived strabismic children to be more likely to have social barriers than other children.

It is essential to discuss how strabismus affects a child's social acceptance when counseling parents about their child's condition. It may be necessary to perform surgery to correct strabismus and improve visual function. Strabismus surgery may provide sustainable control of alignment and symptomatic relief. Furthermore, corrective surgery may also provide psychosocial benefits for strabismic children.[56]

Although previous studies have provided insights into children's and teachers' behaviors toward children with strabismus,[23] no study has investigated parents' perception of strabismic children. In addition, no study has been conducted in the Middle East to determine whether strabismus influences children's preferences in the selection of playmates.

This study uses digital image manipulation of facial photographs to (i) ascertain the emergence of negative attitudes toward strabismus in young children, (ii) investigate the effect of strabismus on young Saudi children's playmate selection because it is well known that ethnicity affects people's perception of strabismus,[7] and (iii) explore the parents' perception of children with strabismus. It also indirectly explores whether surgery would be indicated in these patients at an earlier age to improve their psychosocial health.

Methods

Between July and October 2019, children visiting a tertiary hospital in Saudi Arabia were recruited to partake in this cross-sectional study. The children were all Saudi, aged 3–15 years, divided into three age groups: 3–6 years (n = 51), 7–12 years (n = 105), and 13–15 years (n = 77). The participants were different from the children recruited for photographing, and measures were taken to ensure that the children in the photographs were not related to any of the participants. All children were tested for visual acuity (VA) and had VA better than 20/40 with or without correction, were orthotropic on cover test, and had full extraocular motility.

Portrait photographs (from the shoulders up) of the children were taken with a digital camera positioned 1 m from them. The children were asked to look at targets straight ahead, 20 and 40 cm (or 20 and 50 cm) to the left, right, and above the camera. A digital imaging software was used to create a strabismic photograph by cutting the eye from one of the off-center gaze photographs and pasting it onto the photograph of the child looking straight at the camera. For each participant, a series of photographs was created to simulate different magnitudes of strabismus, including 20 and 40 prism diopters (PDs) of esotropia and exotropia and 15 PD and 30 PD hypertropia [Figure 1]. All legal guardians of the photographed children granted permission to the researchers to use the images for research purposes. Additional informed consent was obtained from the legal guardian of the participant for whom identifying information is included in this article. Children were included in the photographs, provided they had no physical flaw on the face, were of Saudi nationality, were aged between 3 and 16 years, and did not wear spectacles.

Figure 1

Examples of digitally altered photographs showing esotropia (a), exotropia (b), and hypertropia (c). Horizontal deviations are 20 and 40 prism diopters in magnitude and vertical deviations are 15 and 30 prism diopters in magnitude, increasing from left to right in each panel (top, middle, and bottom)

Participants were interviewed individually in the presence of their parents after granting written permissions. Each participant viewed 18-paired images in total, with the same person side by side. One of the images was strabismic and the other one was orthotropic or consisted of two different strabismus types. The children viewed a photograph with each magnitude and direction of strabismus at least once. After identifying which of the kids in the photographs they would like to play with, participants were then asked why they made that choice. Exclusion criteria included lack of cooperation or precision in response, side bias, or recognition of someone in the photograph due to potential bias.

In addition, parents were asked to fill out a questionnaire on their socioeconomic background. The parents were asked to assess the strabismic photograph and compare it to the orthotropic photograph of the same children. This allowed for the neutralization of an assessor's bias for particular facial features of the photographed child. Parents were also asked to rate the characteristics of two pictures on a scale of 1–5. The Hospital's Research Ethics Committee granted ethical clearance for the study.

All statistical analyses were conducted using IBM SPSS, version 23 (IBM Corp., Armonk, NY, USA). Results are presented as frequencies and percentages for categorical and nominal variables and means and standard deviations for continuous variables. The popularity of an image was computed as a percentage based on how frequent the child in the photograph was selected as a playmate. Thus, a photograph with an index close to 100% was considered popular.

A paired sample t-test was used to determine whether strabismus influenced children's preferences in the selection of playmates across gender and age groups and to check the likelihood that a child with either large or small eyes would be selected as a playmate. A Chi-square test was used to check whether a difference existed among categorical variables, while an independent t-test and one-way ANOVA were used to compare two group means and more than two groups, respectively. These tests were conducted with the assumption of normal distribution. Finally, a significance level <0.05 was chosen to check the hypothesis.

Results

Of the 247 children who participated in the study, 14 were excluded. Participants underwent a vision examination and were found to have 20/40 or better vision (91.8% had 20/20 vision). One child was excluded for having 20/100 VA. Three were excluded for side bias and one for being older than 16 years. All children were also tested for any misalignment and nine were excluded for strabismus. The mean age of the sample (n = 233) was 9.94 years, and boys represented 51.5% of the sample.

The presence or absence of strabismus had a significant effect on playmate face preference in 3–12-year-old children. Out of 233 participants, 69.6% were significantly in favor of orthotropic faces as opposed to 30.4% who were in favor of strabismic faces (P < 0.0001). This difference was consistent across gender (P < 0.001) and across the three age groups (P < 0.001). Furthermore, 143 children (61.4%) clarified the reason for their choice to be attributed to the eyes, followed by “no reason” (n = 69; 29.6%) and “empathy” (n = 21; 9.0%).

Two hundred and thirty-three children made 12 playmate selections each, providing 2796 total playmate choices. Overall, 1946 playfellows selected were orthotropic and 850 were strabismic (P < 0.001) [Table 1]. This difference was significant across gender (P < 0.001) and across the three age groups (P < 0.001). As a group, participants aged 3–12 years were less likely to choose strabismic children as fellows. Figure 2 illustrates that younger children (aged ≤6) were more likely to choose playmates with strabismus as opposed to older children in the preschool or adolescent age groups (P < 0.001).

Table 1

Frequency of faces selected based on the presence or absence of strabismus

Direction	Photographs selected (%)	Photographs not selected (%)	P
Straight	1946 (46.4)	850 (20.3)	<0.001*
ET	903 (21.5)	961 (22.9)
XT	773 (18.4)	1092 (26.0)
HT	572 (13.6)	1291 (30.8)

*Significant using the Chi‑square test with an α level<0.05. ET: Esotropia, XT: Exotropia, HT: Hypertropia

Figure 2

Children's selection of a playmate as a function of age

The direction of the misaligned eye was also found to affect a child's likelihood of being selected as a playfellow [Table 1]. Esotropia was preferred over hypertropia and exotropia (P < 0.0001) and exotropia was preferred over hypertropia (P < 0.001) [Table 2]. In addition, the magnitude of ocular misalignment (20 or 40 D) was found to affect a child's likelihood of being selected as a playfellow. Approximately 39.0% of the participants chose small-angle strabismus versus orthotropic faces as opposed to 21.6% who chose large-angle strabismus versus orthotropic faces (P < 0.001). Gender did not affect the way children perceived strabismus. Conversely, age was found to have impacted their choices. This was true for the youngest age group compared to preschoolers (P = 0.01) and adolescents (P = 0.04).

Table 2

Comparison of the children’s selection of playmates across different types of strabismus

Variables	n (%)	P
XT versus ET
XT	91 (19.5)	<0.001*
ET	375 (80.5)
HT versus ET
HT	180 (38.6)	<0.001*
ET	286 (61.4)
HT versus XT
HT	138 (29.6)	<0.001*
XT	328 (70.4)

*Significant using the Chi‑square test with an α level<0.05. ET: Esotropia, XT: Exotropia, HT: Hypertropia

The average popularity percentage for all photographs with strabismus was calculated (40.2%) and compared with the average of the popularity indices for all orthotropic photographs (69.6%) to investigate whether the rating of an image was impacted by the presence of strabismus. The top six popular choices were for orthotropic pictures ranging from 75.5% to 83.7%. This was followed by esotropia (large angle) at 75.5%, exotropia (large angle) at 73.4%, and hypertropia (small angle) at 49.8%. The least popular was hypertropia (large angle) at 16.3%.

Table 3 shows the responses of parents to questions on strabismus surgery and whether these responses were affected by having a family member/friend with strabismus. One hundred and fifty-three (65.7%) parents who responded to the questionnaire were female. Approximately 12.5% of the mothers and 12.9% of the fathers had completed secondary school or lower. The employment rate was higher in fathers (97.0%) than mothers (44.6%). Approximately 16.7% of the parents were underprivileged. Gender had no impact on the parents' responses; however, middle-aged parents were more likely to believe that strabismus corrective surgery was purely cosmetic (P = 0.029).

Table 3

Summary of parents’ responses to questions on strabismus surgery

Variables	Total	Do you have any family member/friend with squint?		P*
		No (%)	Yes (%)
Total	233	171 (73.4)	62 (26.6)	-
Do you think people with strabismus should undergo surgery for correction?
No	27 (11.6)	17 (63.0)	10 (37.0)	0.192
Yes	206 (88.4)	154 (74.8)	52 (25.2)
Do you think surgery for strabismus correction is purely cosmetic?
No	160 (68.7)	114 (71.3)	46 (28.8)	0.274
Yes	73 (31.3)	57 (78.1)	16 (21.9)
Do you think strabismus surgeries should be covered by insurance companies?
No	11 (4.7)	9 (81.8)	2 (18.2)	0.517
Yes	222 (95.3)	162 (73.0)	60 (27.0)

*Using the Chi-square test

To explore the parents' perception of children with strabismus, the parents were asked to rate the characteristics of two images (one orthotropic and one strabismic). Table 4 shows that the strabismic face was scored worse on all characters compared to the orthotropic face.

Table 4

Parents’ mean scores of the photographs based on the character scale

Variables	n	Mean (SD)	Mean difference	95% CI of the difference		P
				Lower	Upper
Intelligence
Orthotropic	233	3.96 (1.1)	0.880	0.680	1.079	<0.001*
Strabismic		3.08 (1.2)
Cuteness
Orthotropic	233	3.88 (1.1)	0.571	0.394	0.748	<0.001*
Strabismic		3.31 (1.1)
Activeness
Orthotropic	233	3.91 (1.1)	0.528	0.358	0.698	<0.001*
Strabismic		3.39 (1.2)
Aggressiveness
Orthotropic	233	2.35 (1.2)	-0.352	-0.580	-0.124	0.003*
Strabismic		2.70 (1.5)
Sentimentality
Orthotropic	233	3.62 (1.1)	0.292	0.122	0.461	0.001*
Strabismic		3.33 (1.2)
Happiness
Orthotropic	233	3.71 (1.3)	0.661	0.456	0.865	<0.00*
Strabismic		3.05 (1.2)
Health
Orthotropic	233	4.11 (1.2)	0.996	0.792	1.199	<0.001*
Strabismic		3.11 (1.3)

*Significant using the paired samples t‑test with an α level<0.05. CI: Confidence interval, SD: Standard deviation

Discussion

This study analyzed orthotropic children's perception of strabismus through photographs. The results showed that young children (≤6 years) were significantly more likely not to distinguish between orthotropic and strabismic children. Approximately 70% of the children were significantly in favor of orthotropic faces rather than strabismic ones, and they perceived esotropia as less disturbing than exotropia and hypertropia. Smaller magnitudes of strabismus were significantly preferred over larger angles.

To date, a paucity of studies has investigated children's perception of their peers with strabismus.[2389] Physical appearance has been reported to play a considerable role in social interaction.[10] This has been widely studied in adults and has been linked to psychosocial problems.[111213141516] One study by Raffa et al.[17] showed that the presence of strabismus rouses the average viewer to pay attention to the eye region, and to the strabismic eye in particular. Indeed, we found that 70% of the observers in our study were significantly in favor of orthotropic faces rather than strabismic ones. Nevertheless, Johns et al.[18] did not find that strabismus had an impact on young children's (3–8 years old) selection of a playmate. Our result confirms Paysse et al.'s[3] findings; who reported that older children had more negative attitudes toward strabismus than younger ones. Younger children were reported to have a poorer conceptual understanding than older children,[19] and no interpersonal issues with other children emerged until age six.[1] Harper[20] demonstrated that the general population holds a negative bias toward people with visible facial differences and that girls and children younger than 12 years old are generally more positive toward peers with physical differences than boys and older children. We showed no difference in gender; however, young children (≤6 years) were significantly more likely not to distinguish between orthotropic and strabismic children. In this study, children were asked about their reasons for playmate selection. Approximately 61.4% attributed their reasons to specific comments about their eyes; 9.0% of the cases revealed concerns about the children and felt bad for them.

Our study found that the children perceived esotropia as less disturbing than exotropia and hypertropia, which is in agreement with one study that explored the opinions of headhunters, who rated exotropia to be worse than esotropia.[15] On the other hand, in studies conducted on adults[4] and children,[239] esotropia was rated worse than exotropia. Moreover, another study on children reported that the direction of strabismus has no influence on participant's preferences.[18] Regarding magnitudes of strabismus, we found that smaller magnitudes of strabismus were significantly preferred over larger angles. Conversely, Johns et al.[18] did not find significant differences between children's selection of a playmate and the magnitude of strabismus, and the impact of different magnitudes of strabismus was not explored in the other studies investigating children's perception of strabismus.[238]

Parents scored strabismic faces significantly lower for all characteristics, including intelligence, cuteness, activeness, aggressiveness, sentimentality, happiness, and health than they did for orthotropic faces. This result is in agreement with the study by Uretmen et al.,[2] who reported that teachers rated strabismic children lower than nonstrabismic children based on various personal characteristics. These findings have important implications regarding the appropriate time to perform surgery in children with visible strabismus without prospects for stereoscopic vision. It is imperative to perform surgery before negative attitudes toward strabismus develop.[89] Eighty-eight percent of the parents in this study thought that strabismic patients should undergo surgery for correction and 95% thought that the procedures should be covered by compulsory health insurance. This is in agreement with the psychosocial prejudice that has long been documented toward adults with strabismus[421] and the reported improvements in the quality of psychosocial functioning following corrective surgery for strabismus in both adults[622] and children.[23]

The limitations of our study include the fact that observers chose between two-dimensional images that might not reflect real-life scenarios. The possibilities of personal and social aspects when encountering people in reality could, thus, not be taken into consideration. An observational study of children interacting with their strabismic peers in a classroom would allow for better control of some confounding factors. In addition, the authors did not assess the role of eyeglass wear on the participants' perception of strabismus because of its controversial effect on children's popularity.[2425] It has been found that spectacles alone may negatively impact the child's peer acceptance.[24] On the other hand, Walline et al. reported that spectacles made children appear smarter and more honest.[25] We attempted to study the differences in orthotropic versus strabismic observers and its impact on playmate selection; however, a large sample size of strabismic observers could not be collected for analysis.

The strengths of this study include that it is the first study to investigate the impact of strabismus in young children in a Saudi sample. Ethnicity is known to impact such perceptions, and findings from other studies cannot be extrapolated to our context. We used 18 sets of images to explore different types and magnitudes of strabismus, while Lukman et al.[8] used only four sets of images. We paired the same child, excluding bias due to differences in other facial features, hairstyles, clothing, etc., We also included older age groups in the analysis, contrary to other investigators who limited their samples to younger age groups.[3918]

Conclusion

Overall, this study showed that children with apparent strabismus are perceived negatively in this hospital-based study in Jeddah. Therefore, campaigns directed at teachers, students, and parents to educate them on diversity and peer social acceptance should be promoted to avoid the potential negative impact of strabismus on the child's education and social life. In addition, the caregivers of children suffering from strabismus should be made aware of the negative psychosocial impact of strabismus and the fact the strabismus surgery is considered reconstructive and not merely cosmetic. Moreover, early intervention to correct for ocular misalignment could be considered to protect children with strabismus from possible social alienation by positively altering the perceived negative characteristics of these children. Parents should, however, be aware that recurrence of strabismus postsurgical correction might occur in some cases with no binocularity fusion potential. Finally, larger studies to measure the extent of the psychosocial impact on the children in our society may be beneficial.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the guardians have given their consent for images and other clinical information to be reported in the journal. The guardians understand that names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.