Because of increasing healthcare costs, the necessity of strabismus surgery is often challenged by health insurance and managed care providers. Such surgery usually aims at providing a normal facial appearance by eliminating diplopia, reducing torticollis, improving binocular vision, and/or expanding the binocular visual field.1 2 Although the realignment of the visual axes to achieve a normal facial appearance is usually an important reason for surgery, few studies have evaluated the impact of clearly visible strabismus on an individual’s life and well-being.

Some studies have analysed the general impact of an abnormal face on individual quality of life (QoL) and well-being. Sarwer et al3 found that a craniofacial anomaly leads to greater dissatisfaction with facial appearance, lower levels of self-esteem and a lower QoL. Similarly, Rankin and Borah4 showed that facial deformities produce significantly adverse consequences for the social functioning of affected persons such as others’ perceptions of employability, honesty, trustworthiness, and effectiveness. Likewise, Rumsey et al5 concluded that visible disfigurement is often associated with high levels of psychological distress, particularly during social interactions that expose the disfigurement to others’ gaze and can result in displays of ignorance and negative comments.

The psychosocial problems experienced by strabismic individuals are similar to those of persons with other craniofacial anomalies. Jackson et al6 measured anxiety and depression, social anxiety and QoL 6 weeks before and 3 months after strabismus surgery. The researchers found not only that strabismic individuals experience greater social anxiety and use more social avoidance strategies but that these subject’s scores reduce to normal levels following surgery. This finding of strabismus negative impact was confirmed by Satterfield et al,7 who found evidence of problems related to strabismus during school, work, play or sports in subjects over age 14. Nonetheless, the authors identified no difference in the amount of psychosocial impairment between esotropic and exotropic subjects. In a similar study, Menon et al8 showed that patients aged 15–25 who had had a constant squint since childhood had difficulties with self-image and interpersonal relationships, faced ridicule at school and work, and generally avoided activities that brought attention to their defect. Burke et al9 showed that strabismus surgery reduced the psychosocial difficulties reported before surgery and improved the quality of psychosocial functioning. Beauchamp et al10 also found that strabismus surgery improved daily functioning, social interaction, self image and job-related problems, and reduced concerns about the future.

Four studies have concentrated on the influence of strabismus on the ability to obtain employment or promotion. Based on digitally altered photographs of a male subject, Olitsky et al11 showed that respondents rated the esotropic photograph negatively on the following personality traits: attentiveness, competency, emotional stability, intelligence, leadership ability, communication and organisational skills. Exotropia was associated with less sincerity. Coats et al12 asked marketing managers to rate male and female job applicants based on similarly qualified job résumés and digitally altered photographs. They found that strabismic women were less likely to be hired, but no such discrimination was directed against the men. Mojon-Azzi and Mojon13 interviewed headhunters and found that visible strabismus has a negative impact on a potential employer’s overall judgment and negatively influences the strabismic individuals’ ability to obtain a job. Based on photographs of male and female officers of the U.S. Army, Goff et al14 showed that strabismus not only affects the ability to gain employment but also affects the ability to earn a promotion or experience job progression. Overall, the research has shown the negative psychosocial impact of esotropia to be mostly stronger than that of extropia.11 14 Thus, not surprisingly, esotropes have demonstrated a greater appreciation of the effects of surgery.9

In this study, we aimed to determine the influence of strabismus on the ability to find a partner by interviewing Swiss dating agents. To the best of our knowledge, this is the first study on this subject.

METHODS

During February 2006, the addresses of 60 Swiss dating agents were retrieved from the Swiss online telephone directory15 and the yellow pages.16 Ten potential respondents were excluded because they were located in the French- or Italian-speaking part of Switzerland and did not speak German. The addresses of six dating agents were invalid, and four agents refused to answer the questions.

The remaining 40 dating agents (29 female and 11 male) were interviewed by telephone using an already-validated questionnaire. A similar questionnaire had first been validated in an earlier study that assessed ability to obtain employment by interviewing headhunters.13 However, because a few questions had been amended, the questionnaire was validated again using focus groups and interviews with eight subjects not involved in healthcare. This validation led to minor editing in order to ensure that the closed-ended questions were unambiguous and helped training the interviewer.17

Each telephone interview consisted of seven closed-ended questions about strabismus and the ability to find a partner and one open-ended question about the general implications of strabismus in finding a partner. The first question asked whether strabismus leads to negative discrimination and, if so, whether this discrimination differs by gender or age group and/or between esotopic and exotropic subjects. A second section asked the dating agents whether strabismus has a negative (−1), positive (+1) or no influence (0) on a potential partner’s perception of 10 personality traits (reliability, honesty, fidelity, likeability, being interesting, success, intelligence, attractiveness, sportiness and eroticism). The final section asked the dating agents to rank the negative influence of both forms of strabismus as well as of five other facial disfigurements on the ability to find a partner, with 1 being the strongest negative impact. Men and women were assessed separately.

Each telephone interview lasted between 10 and 25 min and was performed by the same interviewer. Twenty-three of the 40 dating agents interviewed had access to the internet and could view digitally altered versions of a frontal face and shoulder photograph of a woman and a man. Dating agents without internet access were not able to see the photographs and based their responses on their perception of strabismus from previous experiences. Because responses could vary between the two groups, for all questions based on photographs a separate analysis of the two groups was performed. As the interviewees were being asked whether strabismic subjects have more difficulty finding a partner and whether gender or type of strabismus has an influence, they were simultaneously shown four photographs of a left esotropic and a left exotropic man and woman (see fig 1, males 2 and 3; females 10 and 11). The squint angles corresponded to 50 prism dioptres. This squint angle was chosen to allow a better comparison between studies, since the majority of previous studies used that angle.11^–13 Similarly, as the respondents were being asked to rank seven different facial disfigurements for a man, they were simultaneously shown the following images: normal appearance, left esotropia, left exotropia, facial scar, protruding ears, big nose, acne and a visible missing tooth (see fig 1, males 1–8). The same procedure was used while an interviewee was being asked about the same facial disfigurements for a woman (see fig 1, females 9–16). All digital alterations were made in Adobe Photoshop 6.0 using merging, erasing or distortion.

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Figure 1 Photographs of a man and woman with and without seven computer-generated facial anomalies. Subject consent has been obtained for publication of this figure.

Statistical analyses were carried out using R (version 2.1.0). Confidence intervals were calculated using either the chi-squared test—for data with only two categories (eg, yes/no) —or a two-tailed t test if a third neutral possibility had been included (eg, more (1), same (0), less (−1)). Results were considered significant at p<0.05, and the Holm correction was applied for multiple testing.

RESULTS

Of the 40 Swiss dating agents that participated in the telephone interviews (mean age 48.56 years, 95% CI 44.65 to 52.46), 37 (92.5%) estimated that strabismic subjects had more difficulty finding a partner, while only three (7.5%) indicated that strabismic individuals had no more difficulty finding a partner (strabismic versus orthotropic subjects, chi-squared test: p<0.001). Of the former, 10 believed that women had more difficulty, eight that men had more difficulty and 19 that both sexes had the same level of difficulty. Twenty-four believed that the discrimination depended on the strabismic person’s age—with younger persons having more problems finding a partner—but 13 responded that age had no influence. However, 20 respondents believed that exotropia had a stronger impact than esotropia: only four responded that esotropia had the greater impact, 10 that both conditions have the same impact and three did not know. Therefore, the influence of strabismus on a potential partner does not apparently depend on gender (women versus men, t test; p>0.1) or age (younger versus older persons, chi-squared test; p>0.05) but rather is perceived as stronger in exotropic than in esotropic persons (t test; p value<0.001).

Table 1 lists the average dating agents’ opinions about the influence of strabismus on a potential partner’s perception of the 10 personality traits where each dating agent could chose between a negative (−1), a positive (+1) or a nonexistent (0) influence of strabismus. With the help of the t test, it shows which of the analysed personality traits are perceived significantly differently in strabismic than in orthotropic subjects.

The average scores for each personality trait showed strabismic subjects to be perceived as significantly less attractive (p<0.001), erotic (p<0.001), likeable (p<0.001), interesting (p<0.001), successful (p<0.001), intelligent (p = 0.001) and sporty (p = 0.01). The results for the agents having internet access were similar to those for all interviewed dating agents.

The ranking for the seven facial disfigurements (see fig 2 and table 2) confirms that exotropia is perceived as worse than esotropia.

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Figure 2 Dating agents’ opinions on the impact of seven facial disfigurements on the ability to find a partner (ranked from 1, strongest impact, to 7, weakest impact).

Specifically, respondents rated a visible missing tooth and strong acne as having a significantly stronger negative influence on the ability to find a partner than large exotropia and esotropia. They also judged strongly protruding ears to have a larger negative impact on a potential partner’s perception of a man than of a woman, probably because women can hide their ears under their hair. For both men and women, the dating agents believed a very large nose and a visible facial scar would have a significantly weaker influence on the ability to find a partner than would strabismus. The results for all interviewed dating agents were similar to those calculated only for the agents having internet access to the pictures with facial disfigurements.

Three dating agents stressed that any handicap or anomaly makes it very difficult (two agents) or even impossible (one agent) for an individual to find a partner through a dating agency. Another three agents added that weight also plays a major role. In addition, respondents referred to men’s seemingly greater interest in appearance (three agents) and women’s in a potential partner’s financial situation (two agents). One dating agent found it particularly disturbing that strabismic persons had not taken advantage of available corrective surgery, while others commented that older men (according to one agent) or particularly religious persons (according to another agent) are more tolerant toward aesthetic criteria. Nonetheless, two agents agreed that, in general, appearance is much more important nowadays than in previous years.

DISCUSSION

According to the interview responses of 40 Swiss dating agents to a validated questionnaire, both esotropia and exotropia have a negative impact on an individual’s ability to find a partner. Specifically, the dating agents judged that potential partners would perceive strabismic individuals as less attractive, erotic, likeable, interesting, successful, intelligent and/or sporty. Moreover, our results differ from those of other studies in that exotropia was perceived as having a stronger impact than esotropia. We assume that this is due to the different valuation of personality traits in working environment and in partnership—for example, attractiveness was found to have a low influence on the perception of persons with strabismus by employers.13 In addition, the rankings of the seven facial disfigurements showed that both forms of strabismus have a larger negative influence on a potential partner’s perception than strongly protruding ears, a very large nose and/or a visible facial scar. Indeed, both a visible missing tooth and strong acne were judged as having a stronger impact than exotropia or esotropia.

Based on the assumption that the only valid indications for strabismus surgery in adults are to achieve fusion or to correct diplopia, insurance companies and managed care providers often challenge the necessity of strabismus surgery.18 Yet, some studies have already demonstrated that persons with visible strabismus not only have problems with social functioning, finding gainful employment, or performing well in school, sports or leisure activities, but also suffer higher levels of psychological distress.7 8 11^–13 In addition, our results indicate that strabismic individuals are perceived less favourably by potential partners and therefore have more difficulty finding a partner. These negative effects could be eliminated by successful strabismus surgery6 9 10 aimed at restoring the eyes to the normal functioning position in which both are aligned for simultaneous viewing of the same object.1 Thus, given its purpose of restoring the human norm rather than adorning or beautifying,1 strabismus surgery should not be considered cosmetic.2

Most particularly, besides eliminating diplopia or visual confusion, allowing sensory binocular fusion and expanding the peripheral field, successful strabismus surgery may also improve psychosocial functioning.19 Indeed, based on a time trade-off utility, Beauchamp et al20 calculated the gain of strabismus surgery to be 2.61 QALYs with a cost–utility of $1632/QALY, well below the 50 000/QALY considered highly cost effective in the U.S. The authors also demonstrated that in adults, strabismus surgery is more cost-effective than cataract surgery, diabetic pars plana vitrectomy for vitreous haemorrhage or amblyopia therapy. Only laser treatment for retinopathy was found to be even more cost-effective than strabismus surgery.

Admittedly, this current study has limitations. Since the interviews were done in Switzerland, the results may not be valid for other countries. Moreover, the results reflect dating agents’ perceptions of the difficulties encountered by strabismic persons in finding a partner through a dating agency, which may not correspond to experiences in real-life situations.

Nonetheless, based on the opinions of these Swiss dating agents, we conclude that in Switzerland, potential partners perceive strabismic persons, independent of age and gender, to be less attractive, erotic, likeable, interesting, successful, intelligent and sporty, which causes strabismic individuals more difficulty in finding a partner. Not only is this negative impact stronger in exotropic than in esotropic subjects, but it is greater than that of a visible scar, protruding ears or a very large nose, although weaker than that of a missing tooth or strong acne. As a result, strabismus can negatively influence the ability to find employment or a partner—two major social and life goals—and thus negatively impact a person’s well-being and self-esteem. Hence, because strabismus surgery restores a normal functional condition and reduces not only physical but also psychosocial difficulties, it should not be considered a cosmetic procedure, especially as strabismus surgery has been shown to be highly cost-effective. Moreover, to avoid discrimination against strabismic individuals who cannot afford this surgical procedure, strabismus surgery should be reimbursed by health insurance.