There were 12 patients with monocular eye loss who participated in this study. The characteristics of the participants was presented in Table 1. Following the qualitative data analysis, four main themes emerged, which were (1) Impact of ocular loss, (2) Factors influencing psychosocial distress, (3) Psychological adjustment, and (4) Expected treatment outcomes.

Table 1 Sample characteristicsImpact of ocular lossPhysical impairment

All participants seemed to experience some difficulties in their everyday lives with monocular vision. As there were limitations in the field of vision and depth perception, they reported that they struggled to perform normal activities, such as driving, playing sports, ascending or descending stairs, or even walking on a flat ground. However, they were likely to develop strategies to cope with their physical problems, such as seeking ocular rehabilitation, self-help, or peer-related support, and could resume their daily tasks afterwards.

It (eye loss) causes me to do activities much more slowly … when walking down the stairs or even on a flat ground. I have difficulties in perceiving the distance between the steps.

Female 2, 47 years old

I do not yet feel confident in driving a car on main roads. With a restricted field of vision, there are limitations when turning the car or changing lanes.

Male 3, 26 years old

Psychosocial distressStress

Stress appeared to be a common mental problem especially in participants with acquired ocular loss, as their routine lifestyle or career security was greatly affected by functional adequacy from visual difficulties.

It was quite stressful at that time, when I just lost my eye. With the vision loss, I had difficulties with everyday tasks.

Female 1, 22 years old

Anxiety

Participants tended to have anxiety and feared that their disfigurement could have negative affect on their relationship with others. They believed that their ocular loss was a reason why their job applications were rejected. In addition, they thought that they broke up with their partner probably due to their impairment or disfigurement.

It was slightly painful when my job application was rejected. I thought my eye loss could be a reason.

Male 4, 43 years old

I had fear that my eye loss would lead to the breakup with my partners. I also thought that she should not have had to spend difficult time with me.

Male 5, 32 years old

Depression

Participants also felt depressed with their sudden eye loss mostly from accidents or trauma with foreign objects. Some lost interest in their everyday life.

When I found out that my eye needed to be removed, I cried a lot and I did not know what I should do with my life … [crying] … I did not want to do anything even my daily tasks.

Female 5, 20 years old

Social avoidance

Another common psychological distress seemed to be social avoidance. Participants reported that they were worried to be in public. If it was absolutely necessary, they were likely to wear eyeglasses to hide their disfigurement. They felt uncomfortable when being stared at or asked about their disfigurement. One participant reported that she was worried others would feel embarrassed of her.

I found my disfigured appearance is different from others … I need to wear glasses all the time that I am outside. So, I feel more comfortable to stay at home, rather than going outside to do activities, to see friends, …

Male 6, 61 years old

I was afraid that my husband would feel ashamed of my disfigurement in front of his friends.

Female 4, 66 years old

Factors influencing psychosocial distressEtiology of ocular loss

The etiology of ocular loss appeared to affect the level of psychosocial distress. Participants with congenital eye loss were likely to efficiently cope with their psychological problems. As they grew up with monocular vision, they were familiar to live with only the remaining eye. Similarly, participants with gradual ocular loss had a period of time for psychological adjustment.

I have never had this eye since I was born, and I am used to it.

Male 3, 26 years old

I felt disappointed just for a while. It was a bit lucky that it was a gradual loss.

Male 1, 71 years old

Participants who experienced a sudden loss of the eye (e.g., trauma or malignancy) reported they had a difficult time to adapt themselves to resume their daily lives. Since the loss occurred rapidly, these patients struggled to overcome both physical and psychological difficulties.

When I was told that I had to remove the eye even though it was still functioning, I was not able to deal with it … I cried a lot.

Female 5, 20 years old

Social status

The social status of patients can also influence psychological distress. Participants who were studying or working reported that they did not feel confident of being accepted at their workplace. They also worried about their job security, which could be affected by visual impairment or facial disfigurement. Moreover, career position also related to the level of distress.

I was a deputy director, so it would be a bit strange if I had a disfigured face.

Female 6, 62 years old

If the job does not require meeting with customers or something like that, it should be fine.

Female 1, 22 years old

Self-perceived disfigurement

Compared to the severity of disfigured appearance, self-perceived disfigurement appeared to be an important influential factor for psychological distress. In other words, the level of psychological distress depended on how these individuals perceived their appearance. This was also relevant to how important the appearance was in their own perspective.

I now feel very disappointed with how I look (compared to others). I want to be like how I was before … [crying] … to be outside without glasses.

Female 2, 47 years old

Physical appearance plays an important role for me. I always took care of my body … to look good in public ... but now …

Female 4, 66 years old

Psychological adjustment

Following the visual impairment and facial disfigurement, participants reported that they were able to adapt themselves to the changes, leading to improvement in psychological well-being. The key strategies reported by the participants were as follows:

Ocular prosthetic rehabilitation

Participants believed that ocular prosthesis would restore their facial disfigurement, supporting them to resume their daily life. They considered that the ocular prosthesis would make them feel more confident to interact with others and relieve their psychological distress.

If I have the prosthesis, I should not have a problem in making a positive first impression for my job interview.

Female 1, 22 years old

Self-help coping strategies

Several participants reported they had enjoyable and relaxing leisure activities, either indoors or outdoors, to relieve their emotional distress, such as stress, anxiety, and depression.

Just listening to music, doing exercise, and playing sports.

Male 2, 22 years old

Peer-related psychosocial support

Peer-support plays an integral role in reducing psychosocial distress. Words of encouragement from family members and friends appeared to be very supportive to the patients to cope with their mental distress. A social community or group where members could share similar interests or problems with others can also be an effective way to gain psychological support.

Immediately after the eye removal, my partner stayed with me all the time … to give me a hand when I needed help.

Male 4, 43 years old

I would say… trainings for blind people. It did not only help me perform my daily tasks, but also I could talk with others who had similar problems. Several activities were designed for impaired people.

Female 3, 68 years old

Expected treatment outcomesExpectations towards ocular prosthesis

Patients’ expectation towards an ocular prosthesis appeared to be varied, which could impact the level of psychological adjustment. Higher expectations might negatively affect satisfaction towards an ocular prosthesis, if it could not be achieved from the treatment.

I just expected it [an ocular prosthesis] to look more natural than this one [an ocular conformer].

Male 5, 32 years old

I would like the prosthetic eye to have natural movements, similar to the other side.

Female 5, 20 years old

Expectations towards dental professionals

Participants suggested that they would appreciate if the specialist involved in the treatment, i.e. maxillofacial prosthodontist, provided them with psychological support. Not only physical recommendations but also psychological advice could be encouraging to them.

Firstly, I would expect my doctor to understand my situation, and if they could provide words of encouragement, it would be very supportive.

Male 4, 43 years old