***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Abstract Introduction : The psychological impact of strabismus is well recognized . Patients with strabismus have lower levels of psychological well being compared to normal controls . Few studies have evaluated the relationship between levels of psychological distress and the angle of deviation , age , sex , presence of diplopia , visual acuity and direction of deviation . Methods : 50 patients with strabismus who attended the adult strabismus clinic were included in this question naire based prospect i ve study . The Psychological Impact question naire was used to assess the psychological impact of noticeable strabismus . We measured the angle of deviation , age , sex , presence of diplopia , visual acuity and direction of deviation and correlated these with psychological impact scores . Student ’s t-test and Pearson ’s correlation coefficient ( r ) were used in statistical analysis . Results : The average age was 48 years ( range 15 - 84 ) and there were 26 females and 24 males . There was no correlation between psychological impact score and the maximum degree of horizontal deviation r = 0.02 ( 95 % CI −0.26 to 0.29 ) , p = 0.9 , the maximum angle of vertical deviation r = 0.26 ( 95 % CI −0.01 to 0.51 ) , p = 0.06 , age r = −0.09 ( 95 % CI −0.36 to 0.19 ) , p = 0.5 , sex ( p = 0.96 ) , presence of diplopia ( p = 0.6 ) , visual acuity of the worse eye r = −0.01 ( 95 % CI −0.29 to 0.27 ) , p = 0.9 and direction of deviation ( p = 0.8 for eso-deviations compared to exo-deviations , p = 0.4 for horizontal compared to vertical deviations ) . There was a slight negative correlation between psychological impact score and visual acuity of the better eye r = −0.28 ( 95 % CI −0.52 to −0.01 ) , p = 0.04 . Conclusion : The psychological impact of strabismus does not appear to be related to the patient ’s angle of deviation , age , sex , presence of diplopia , visual acuity or direction of deviation . Larger studies are required using strabismus specific tools for evaluating psychological impact to further investigate these findings Aim : To analyse psychological causes for low compliance with occlusion therapy for amblyopia . Method : In a r and omised trial , the effect of an educational programme on electronically measured compliance had been assessed . 149 families who participated in this trial completed a question naire based on the Protection Motivation Theory after 8 months of treatment . Families with compliance less than 20 % of prescribed occlusion hours were interviewed to better underst and their cause for non-compliance . Results : Poor compliance was most strongly associated with a high degree of distress ( p<0.001 ) , followed by low perception of vulnerability ( p = 0.014 ) , increased stigma ( p = 0.017 ) and logistical problems with treatment ( p = 0.044 ) . Of 44 families with electronically measured compliance less than 20 % , 28 could be interviewed . The interviews confirmed that lack of knowledge , distress and logistical problems result ed in non-compliance . Conclusion : Poor parental knowledge , distress and difficulties implementing treatment seemed to be associated with non-compliance . For the same domains , the scores were more favourable for families who had received the  educational programme  than for those who had not OBJECTIVE To develop a question naire to assess the acceptability of  amblyopia treatment  and its effect on the child and family . METHODS A 20-item parental survey was developed and pilot tested on 64 subjects , aged 3 to 6 years , participating in the Amblyopia Treatment Study , a r and omized trial comparing patching and atropine as treatments for moderate amblyopia . The survey was administered after 4 weeks of treatment . A descriptive item analysis and an internal consistency reliability analysis were performed . RESULTS Nineteen of the 20 items demonstrated adequate variability as evidence d by the frequency distributions for item responses . Only 4 ( < 1 % ) of 1280 possible item responses were missing , one each by 4 different respondents . Factor analysis identified 3 treatment-related factors--"adverse effects , " " compliance , " and " social stigma "-- among 11 of the 20 items . The internal-consistency reliability alpha for the 5-item adverse effects subscale was 0.82 , the 4-item compliance subscale alpha was 0.81 , and the 2-item social stigma subscale alpha was 0.84 . CONCLUSIONS The Amblyopia Treatment Index appears to be a useful instrument for assessing the impact of amblyopia treatment in 3- to 6-year-old children PURPOSE To evaluate the ability of strabismus surgery to improve the health-related quality of life ( HRQOL ) assessment scores of children with intermittent exotropia and their parents . METHODS For this prospect i ve , r and omized , parallel group study , 130 children ( 8 - 17 year of age ) with intermittent exotropia were recruited and r and omized to undergo either corrective strabismus surgery or active monitoring without surgery . Each child was accompanied by a parent . HRQOL was assessed with 3 intermittent exotropia question naires (IXTQ)--the child self-report , parental proxy report , and parental self-report -- administered at enrollment and 3 months after intervention . The primary outcome was change in IXTQ score after 3 months for both groups . RESULTS At enrollment the scores of the surgery group ( n = 63 ) and monitoring group ( n = 57 ) did not differ significantly ( P > 0.05 ) . The sex of the reporting parent had no significant influence on the proxy or parental scores at enrollment or at 3 months ( P > 0.05 , multivariate analysis ) . Strabismus surgery significantly improved all parts of the IXTQ scores ( P < 0.0001 , repeated measures analysis of variance ) . No significant changes were found for the child scores at 3 months in the monitoring group ( P = 0.33 ) . However , the parental and proxy scores were significantly decreased ( P < 0.0001 ) . CONCLUSIONS Corrective strabismus surgery significantly improved the HRQOL scores of the children with intermittent exotropia and their parents OBJECTIVE To provide objective information on patient discomfort after strabismus surgery .  DESIGN Prospect i ve cohort study . PARTICIPANTS Forty-nine consecutive adult patients undergoing strabismus surgery .  METHODS A question naire was used to evaluate the following on a scale of 0 ( absent ) to 10 ( very severe ) : patients ' expectations of pain , blurred vision , daily life disruption , diplopia , conjunctival redness , foreign body sensation , eyelid swelling , postoperative nausea and vomiting ( PONV ) , and preoperative cosmetic satisfaction . Patients answered the question naire at 6 hours , 1 day , 2 days , 3 days , 1 week , 2 weeks , 1 month , and 3 months after surgery , focusing on the actual experience . Patient was also investigated according to previous surgical history and the surgery type . RESULTS In the 42 patients included in the analyses , postoperative pain ( p = 0.049 ) and PONV ( p = 0.039 ) occurred at significantly lower-than-anticipated levels . Blurred vision ( p = 0.019 ) , daily life disruption ( p = 0.009 ) , and conjunctival redness ( p < 0.001 ) occurred at significantly higher-than-expected levels , and patients felt that conjunctival redness was the most severe symptom occurring immediately after surgery . Patients who required vertical or oblique muscle procedures ( p = 0.046 ) or had undergone previous ophthalmic surgery ( p = 0.025 ) experienced higher levels of postoperative pain than they had preoperatively anticipated . CONCLUSIONS Preoperative anticipations were quite different from actual postoperative experiences in adults undergoing strabismus surgery . Our results will allow surgeons to objective ly educate patients before the operation about the postoperative course and to explain the inconveniences and minor side effects expected during the recovery process PURPOSE To characterize the relationship between binocular summation ( BiS ) and binocular inhibition ( BI ) on the quality of life of adults and children with strabismus . METHODS Strabismus patients at a single center from 2010 to 2012 were prospect ively enrolled . A BiS score was measured using ETDRS and Sloan low-contrast visual acuity ( LCA ) protocol s at 2.5 % and 1.25 % contrast . Patients were categorized as having BiS ( binocular better than better-eye visual acuity by ≥5 letters ) , BI ( binocular worse than better-eye visual acuity by ≥5 letters ) , or otherwise indeterminate visual acuity ( a difference between binocular visual acuity and monocular visual acuity of the better eye of < 5 letters )  . Quality of life was evaluated by the National Eye Institute Visual Functioning Question naire 25 ( VFQ-25 ) , 20-item Adult Strabismus Question naire ( AS-20 ) , and the Amblyopia and Strabismus Question naire . RESULTS A total of 108 patients were included . There was no significant BiS or BI for high-contrast ETDRS or 2.5 % LCA tests ; however , a mean BiS score of -2.14 ± 7.0 letters for 1.25 % LCA demonstrated significant binocular inhibition ( P = 0.004 ) for this contrast level . The mean composite VFQ-25 score was significantly lower in subjects with BI on ETDRS ( 80 ± 19 vs 57 ± 7 for subjects with BiS and BI , resp . [ P = 0.03 ] ) , 2.5 % LCA ( 81 ± 14 vs 66 ± 16 for subjects with BiS and BI , resp . [ P = 0.01 ] ) , and 1.25 % LCA tests ( 91 ± 9 vs 72 ± 14 for subjects with BiS and BI , resp . [ P = 0.005 ] ) . After accounting for potential covariates , significant association persisted for BI , demonstrated by 1.25 % LCA ( P = 0.01 ) . With BI demonstrable at 2.5 % , AS-20 scores were also significantly lower ( P = 0.04 ) . CONCLUSIONS Strabismic patients  with BI had significantly lower quality -of -life scores than those who did not , even after accounting for potential covariates and the absence of diplopia Introduction Quantification of the psychosocial effects of manifest strabismus has been made possible by the introduction of the Adult Strabismus 20 ( AS-20 ) question naire . We investigated the effects of strabismus surgery and patient demographics on the pre- and postoperative AS-20 scores . Methods A prospect i ve , cohort study of adult patients undergoing strabismus surgery .  Full pre- and postoperative orthoptic measurements were analysed and compared with the AS-20 total scores and its subscales ( psychosocial and functional ) . Any relationship between : gender ; direction ; and size of preoperative deviation and the changes in AS-20 score was investigated . Results Eighty-six patients were included with a follow-up of 91 days following surgery . Median deviation preoperatively was 30.5 prism diopters ( PD ) and the median preoperative AS-20 score was 45 . Postoperatively , the median deviation was 8 PD and the AS-20 score was significantly ( Z=−7.83 , P<0.0001 ) higher at 73.1 . Females have a lower preoperative AS-20 score ( P=0.01 ) but show a greater improvement in scores following surgery compared with males ( P=0.058 ) . There is a close correlation between change in AS-20 score and change in deviation size ( r=0.291 , P=0.006 ) . ConclusionS trabismus surgery gives a highly significant improvement in quality -of-life scores . Females gain more benefit from surgery and there is a greater improvement in the score with larger changes in deviation size . The smaller the postoperative angle , the larger the final AS-20 score PURPOSE As a first step in the development of a health-related quality of life ( HRQOL ) instrument , we conducted in-depth interviews to identify the specific concerns of adults with strabismus . DESIGN Prospect i ve cross-sectional study . METHODS Thirty adults with strabismus , 17 with diplopia , and 13 without were recruited .  Individual interviews , using 11 open-ended questions , were audiotaped , transcribed , and transcripts review ed independently by three investigators . Phrases regarding how strabismus affected everyday life were grouped into topic areas and the frequency of each topic analyzed for subjects with and without diplopia . RESULTS A total of 1,508 phrases were extracted : 207 ( 14 % ) of 1,508 were excluded because they did not pertain to HRQOL . From the remaining 1,301 phrases , 48 topic areas were apparent . For patients with diplopia , the most frequently occurring topics were : nonspecific negative feeling ( 15/17 ; 88 % ) ( " really hard " ) ; general disability ( 15/17 ; 88 % ) ( " affects everything " ) ; and driving ( 14/17 ; 82 % ) . In those without diplopia , the most frequently mentioned topics were appearance to others ( 12/13 ; 92 % ) ( " people notice my eyes " ) followed by problems with eye contact ( 10/13 ; 77 
    Output:
    
Out of all the disease-specific instruments , just four have been subjected to modern psychometric tests and only the adult strabismus question naire ( AS-20 ) demonstrated good measurement properties .
Most of the amblyopia-specific instruments measured the impact of the treatment of amblyopia on children , while most of the strabismus-specific instruments measured concerns related to appearance and treatment outcome in adults .
All instruments have gaps in their content and failed to address QoL comprehensively .
All the existing amblyopia- and /or strabismus-specific instruments fall short of desired quality and /or comprehensiveness of content .