A Novel Arabic-Language Questionnaire to Assess Patient Satisfaction After Refractive Surgery

This cross-sectional study developed and validated a novel 25-item Arabic-language questionnaire, demonstrating its reliability and validity for assessing patient satisfaction following refractive surgery through factor analysis, Cronbach's alpha, and Rasch analysis.

The Gist

Imagine you just got a brand-new pair of glasses or had laser eye surgery. The doctor checks your eyes with a chart, and everything looks perfect: "20/20 vision!" But when you go home, you might still feel like something is "off." Maybe the lights look a bit fuzzy at night, or your eyes feel dry. Standard medical tests can't always catch these feelings.

This paper is about building a special "feeling thermometer" for people who have had laser eye surgery, specifically designed for Arabic speakers.

Here is the story of how the researchers built this tool, explained simply:

1. The Problem: The "Silent" Complaints

Think of eye surgery like buying a high-performance car. The mechanic (the doctor) can tell you the engine runs perfectly and the tires are new. But you are the driver. You might feel the car vibrates a little on the highway or the radio sounds weird. If the mechanic only checks the engine, they miss your experience.

In the Middle East, most people speak Arabic. The researchers realized that existing "feeling thermometers" were written in English or translated from other languages. But just like you can't translate a joke perfectly without losing the humor, you can't translate a medical survey perfectly without losing the cultural context. They needed a tool built from the ground up in Arabic.

2. The Construction: Building the Questionnaire

The team started with a huge pile of 50 potential questions (like a chef gathering 50 ingredients). They asked a group of experts to taste-test these ingredients and cut the list down to the 25 best questions.

They organized these 25 questions into three "flavors" or sections:

• The Vision Taste: Can you read subtitles? Can you drive at night? Can you see your phone clearly? (15 questions)
• The Eye Symptom Taste: Does your eye burn? Does it water? Do you get headaches? (5 questions)
• The Satisfaction Taste: Do you regret the surgery? Do you feel independent now? (5 questions)

3. The Stress Test: Did It Work?

To make sure this new tool wasn't just a fluke, they gave it to 327 patients three months after their surgery. They treated the data like a rigorous science experiment:

• The "Group Hug" Test (Reliability): They checked if the questions agreed with each other. If a patient said they were happy with their night vision, did they also say they were happy with their driving? The results showed a strong "group hug" (high reliability scores), meaning the questions were consistent.
• The "Map" Test (Validity): They used a statistical method called "Rasch analysis" (think of it as a GPS for the survey). They wanted to make sure the questions were placed in the right order of difficulty.
  • The Result: The survey worked like a good map. It correctly identified that things like "Night Driving" were harder for patients to get perfect than "Day Vision."
  • One Glitch: One question about "Halos around lights" was a bit tricky (it didn't fit the map perfectly), but the rest were spot on.

4. The Findings: Who Was Happy?

The survey revealed some interesting patterns, like a detective solving a mystery:

• The Happy Campers: People who had surgery on both eyes at once, people who had LASIK, and people who were nearsighted (myopic) tended to be the happiest.
• The Less Happy Campers: People who had surgery on only one eye, those with PRK (a different type of laser surgery that takes longer to heal), and those with mixed vision problems felt less satisfied.
• The "Why": The researchers noted that PRK patients might just need more time. It's like baking a cake; if you check it after 10 minutes, it's still raw. You need to wait for it to cool completely. Since they checked PRK patients at 3 months, the "cake" might not have been fully baked yet.

5. The Big Picture: Why This Matters

This paper is a blueprint. It proves that you can create a scientifically valid tool in Arabic that captures the human side of eye surgery, not just the medical side.

The Future Plan:
The authors want to turn this paper questionnaire into a mobile app. Imagine a patient getting a notification on their phone: "Hey, how are your eyes feeling today?" This would help doctors understand side effects better and make future surgeries even safer and more satisfying for everyone.

In a nutshell: The researchers built a culturally sensitive, scientifically sound "happiness meter" for Arabic-speaking eye surgery patients, ensuring that doctors listen not just to the eyes, but to the people behind them.

Technical Summary

1. Problem Statement

Refractive surgery (e.g., LASIK, PRK) has high success rates regarding objective measures like visual acuity and refraction. However, patient satisfaction is subjective and often diverges from clinical outcomes; patients may remain dissatisfied despite excellent objective results due to unmeasured symptoms (e.g., glare, dryness) or cultural expectations.

• The Gap: Existing satisfaction questionnaires are predominantly in English or other Western languages. Translating these instruments is often inappropriate due to cultural and environmental differences, particularly in the Middle East where Arabic is the native language.
• The Need: There is a lack of a validated, culturally adapted, Arabic-language instrument specifically designed to assess patient satisfaction following corneal refractive surgery in this region.

2. Methodology

Study Design:

• Cross-sectional observational study using a survey.
• Setting: Sohag University, Egypt.
• Participants: 327 patients (612 eyes) who underwent uncomplicated corneal refractive surgery 3 months prior.
  • Inclusion: Age 21–40; correction of myopia, hyperopia, or mixed astigmatism.
  • Exclusion: Previous non-refractive eye surgery, ocular/systemic diseases affecting vision, or medications affecting vision.
• Sample Composition:
  • Myopia/Myopic Astigmatism: 297 patients.
  • Hyperopia/Hyperopic Astigmatism: 3 patients.
  • Mixed Astigmatism: 27 patients.
  • Surgery Types: Conventional LASIK, PRK, Femto-LASIK, and Wavefront-Guided (WFG) variants.

Instrument Development:

• Initial Draft: A 50-item questionnaire was created based on literature review and patient complaints.
• Reduction: An expert focus group reduced the items to 25 questions.
• Structure: The questionnaire comprises three subscales:
  1. Vision Assessment: 15 items (e.g., day/night vision, reading, sports).
  2. Eye Symptoms: 5 items (e.g., burning, foreign body sensation, halos).
  3. Direct Satisfaction: 5 items (e.g., regret, need for glasses, self-sufficiency).
• Scoring: A 3-point Likert scale (2 = High satisfaction, 1 = Moderate, 0 = Low) plus an "I do not know" option.
  • Scores were converted to a percentage.
  • Grading: High (>80%), Moderate (60–80%), Low (<60%).
  • Exclusion: Patients answering "I do not know" to >5 items were excluded.

Statistical Analysis:

• Software: SPSS v26 and Winsteps (v16.9).
• Validity: Exploratory Factor Analysis (EFA) using Principal Component Analysis (PCA) with Varimax rotation.
• Reliability: Cronbach's Alpha for internal consistency.
• Advanced Psychometrics: Rasch analysis to evaluate item fit, person reliability, and item difficulty.

3. Key Contributions

• Cultural Adaptation: Development of the first questionnaire specifically designed in Arabic for refractive surgery patients, avoiding the pitfalls of direct translation.
• Comprehensive Validation: The study utilized a dual-method approach for validation:
  1. Traditional Psychometrics: Factor analysis and Cronbach's Alpha.
  2. Rasch Modeling: A more rigorous statistical method to ensure the questionnaire functions as a linear measure of satisfaction.
• Cultural Insight: Identified specific cultural factors affecting responses (e.g., lower engagement with "driving" or "sports" questions among female participants in the study cohort), highlighting the necessity of local context in questionnaire design.

4. Key Results

Demographics & Clinical Data:

• Mean age: 26.7 ± 5.6 years (270 females, 57 males).
• 87% underwent bilateral surgery.
• Preoperative myopic group showed significant improvement in uncorrected visual acuity (64% achieved 6/6).

Validity (Factor Analysis):

• KMO & Bartlett: Confirmed data suitability for factor analysis.
• Factor Loadings: Ranged from 0.44 to 0.88.
• Structure: The 25 items clearly loaded onto the three intended factors (Vision, Symptoms, Satisfaction) with minimal cross-loading.
  • Example: "Night Driving" loaded highest on Vision (0.61); "Burning Sensation" on Symptoms (0.88); "Regret" on Satisfaction (0.78).

Reliability:

• Cronbach's Alpha:
  • Overall Scale: 0.894 (Excellent).
  • Vision Subscale: 0.858.
  • Eye Symptoms Subscale: 0.699 (Acceptable).
  • Satisfaction Subscale: 0.720.
• Rasch Analysis:
  • Item Reliability: 0.94.
  • Person Reliability: 0.88.
  • Item Fit: Most items fell within the acceptable Infit/Outfit MNSQ range (0.6–1.4).
  • Exception: Q10 (Halos) showed slight underfit (Outfit MNSQ = 1.45).
  • Ceiling Effect: The sample mean ability was slightly higher than item difficulty, suggesting the questionnaire may be slightly easy for patients with excellent visual recovery.

Factors Influencing Satisfaction:

• High Satisfaction (>80%) was significantly associated with:
  • Bilateral surgery (p=0.005).
  • Preoperative myopia (p=0.02).
  • LASIK procedures (p<0.001).
• Lower Satisfaction was associated with:
  • Unilateral surgery.
  • Mixed astigmatism.
  • PRK (likely due to the 3-month follow-up window, as PRK healing is slower).
• Non-Significant Factors: Sex and customized (wavefront-guided) vs. conventional surgery showed no statistical difference in satisfaction levels.

5. Significance and Conclusion

• Clinical Utility: This study provides a validated, reliable tool for ophthalmologists in Arabic-speaking regions to objectively measure subjective patient outcomes, bridging the gap between clinical metrics and patient experience.
• Research Impact: It establishes a benchmark for future studies in the Middle East, allowing for standardized comparisons of surgical techniques and outcomes.
• Future Directions: The authors propose converting the questionnaire into a mobile application for broader accessibility and plan to refine scoring using Rasch analysis to weight items based on their specific impact on vision.
• Limitations: The study was limited to corneal refractive surgery (excluding phakic IOLs) and had a skewed demographic toward myopia and female participants.

Conclusion: The novel 25-item Arabic questionnaire is a valid and reliable instrument for assessing patient satisfaction after refractive surgery, capable of capturing cultural nuances and providing actionable data for improving surgical outcomes in the region.