Lived Experiences of Patients from Eye Enucleation: A phenomenological study from the West of Iran

Lived Experiences of Patients from Eye Enucleation: A phenomenological study from the West of Iran | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Lived Experiences of Patients from Eye Enucleation: A phenomenological study from the West of Iran Raheleh Rasad, Alireza khatony, Amir Jalali, Alireza Abdi, Parvin Abbasi, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7673901/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Introduction Eye enucleation is an extremely stressful experience that depends on the context. However, there is a lack of information regarding the experiences of patients who have undergone eye enucleation in the western region of Iran. Therefore, this study aimed to describe the lived experiences of patients who underwent eye enucleation in Kermanshah. Methods In this qualitative descriptive phenomenological study, data were collected through semi-structured and in-depth interviews. The sample included 13 patients who had undergone eye enucleation at the ophthalmology department of the educational hospital of Kermanshah University of Medical Sciences and were discharged. Participants were selected using purposive sampling. Data were analyzed using Colaizzi's seven-step method, and MAXQDA 10 software was used for data management. To enhance the credibility of the findings, Lincoln and Guba’s criteria were applied. The COREQ checklist was used to report the study. Findings Participants' experiences were categorized into four main themes and 10 subthemes, and 200 codes. In this study, four main themes included:: " Denial," "Catastrophic," "Adaptation," and "Ambivalence ," along with 10 sub-themes . Conclusion The results indicate that the experience of eye enucleation is highly stressful and comes with numerous challenges and stressors. All patients can take solace in the finding that strong initial negative emotions decrease over time, while positive emotions increase. Psychological intervention and support should be provided in the early stages after eye loss to address specific concerns about appearance, mucous discharge, and acquired monocular vision Health sciences/Diseases Health sciences/Health care Health sciences/Medical research Biological sciences/Psychology Social science/Psychology Patients Eye Enucleation Experiences 1. Introduction One type of anophthalmic surgery is enucleation, which, like other anophthalmic treatments (such as evisceration), is an invasive and precise ophthalmologic surgical procedure involving the removal of the entire affected globe ( 1 ). Enucleation refers to the complete removal of the eyeball, whereas evisceration entails the removal of all intraocular contents through a corneal or scleral incision while preserving the conjunctiva, sclera, extraocular muscles, orbital fat, and optic nerve. These procedures have been accepted therapeutic options over the past two centuries for various ocular conditions, including intraocular tumors (enucleation only), severe eye trauma, and blind, painful, or cosmetically disfigured eyes ( 2 , 3 ). Common indications for enucleation include refractory endophthalmitis, cosmetic improvement of a blind eye, painful blind eyes, intraocular malignancy, severe ocular trauma, phthisis with degeneration, and congenital anophthalmia or severe microphthalmia ( 4 ). In a review of 24,444 cases of ocular enucleation over 55 years, Sprawell and Grossniklas ( 5 ) found that trauma accounted for 40.9% of cases and tumors for 24.2%. In contrast, Chaudhry et al. ( 6 ) reported that endophthalmitis was the cause in 45.5% of cases, while phthisis combined with trauma accounted for 39.5%. Indications for removal of the eye are similar in most hospitals and countries. However, the frequency of pathologic conditions leading to this invasive procedure varies by hospital and location ( 1 ). In European countries, the indication for removal of the eye is usually a malignant condition when other therapeutic options have failed or are not feasible ( 7 ). The leading cause for anophthalmic surgery in developing countries is infection or perforating trauma (e.g., gun shot) ( 4 ). The goal of eye enucleation surgery is to protect the eye from the risk of sympathetic ophthalmia, save the patient's life, reduce pain, and sometimes preserve the patient's appearance ( 8 ). Patients often consider enucleation (enucleation or evisceration) to relieve debilitating discomfort and improve the appearance of a disfigured eye ( 9 ). Surgery is undoubtedly a significant life event for patients in all medical fields. Surgical concerns are particularly prominent among ophthalmic patients, as vision is often considered the most valuable sense, and the loss of vision creates immense fear ( 10 ). Surgical intervention to remove an eye is a serious and life-altering event for patients. Eye removal has adverse effects on quality of life, emotional and cognitive functioning ( 11 ). Often, the psychological effects of losing an eye are worse than the physical problems, especially in cases of eye loss due to trauma or unexpected malignancy ( 8 ). While the experience of eye enucleation is highly stressful, there is a lack of information about the experiences of patients who have undergone this procedure. Since "patients' experiences of eye enucleation" is an abstract concept and cannot be objectively studied in the external world, it is necessary to focus on the experiences of those who have undergone it. Therefore, this study used a qualitative research approach with a phenomenological perspective. The goal of this approach is to examine individuals' experiences as they perceive them, without the researcher interpreting the meanings. In this approach, the researcher must suspend all preconceptions and prior knowledge. Studying patients' experiences of eye enucleation provides a valuable opportunity to better understand their challenges, concerns, and needs. This understanding can help develop supportive strategies, enhance psychological care, and improve patients' quality of life. Given the importance of the topic, the aim of this study is to explain the lived experiences of patients from eye enucleation using a phenomenological approach. 2. Materials and methods Study design This qualitative study adopts a phenomenological descriptive design rooted in Husserl’s philosophy. Phenomenology is an approach that aims to discover meaning and essence in people’s experiences to facilitate understanding ( 12 ). The goal of phenomenology is to explore deep and inherently complex phenomena. This approach understands the world as the individual inhabits it, and the researcher seeks to achieve a rich and deep understanding of the phenomenon by setting aside his or her past experiences and exploring meanings ( 13 ). The present study follows the reporting guidelines outlined in the Consolidated Criteria for Reporting Qualitative Research (COREQ) ( 14 ). Study Setting and Participant Recruitment This study was conducted from September 2024 to March 2025 in a city in western Iran. The study population included patients who underwent eye evacuation and were discharged from the ophthalmology department of a teaching hospital affiliated with Kermanshah University of Medical Sciences and were selected through purposive sampling with maximum diversity. Inclusion criteria were having experience with eye evacuation and the patient's willingness to participate in the study. The researcher visited the ophthalmology department of a teaching hospital affiliated with Kermanshah University of Medical Sciences to select eligible participants. The sampling process continued until data saturation was reached ( 15 ). In conducting qualitative studies, saturation is one of the important aspects for consideration. In practice, saturation requires a researcher to collect data from informants to the point that no further information can possibly be collected. Saturation point not only assures the validity and credibility of information for the study but saves researchers’ time and energy in collecting the same ( 16 ). Data saturation was achieved during the ninth interview. However, for greater certainty, four more interviews were conducted. Data Collection This research approved by ethics committee of deputy of research and technology – KUMS number IR.KUMS.REC.1403.293 at 17/09/2024. All methods andsteps were in accordance with ethical guidelines and approved by the committee. In this study, data collection began with obtaining an introductory letter from the Vice Chancellor for Research of Kermanshah University of Medical Sciences, followed by securing the necessary permissions from the hospitals’ research centers. Subsequently, the researcher received the list of patients who had undergone eye evacuation. These patients were then contacted and invited to take part in the study. Data were gathered through semi-structured, in-depth, face-to-face interviews conducted at a time and location selected by the participants. All interviews were carried out by the corresponding author, who was a PhD student in nursing, and they centered on the lived experiences of patients regarding eye evacuation. The interview questions were guided by a framework developed through a detailed review of related studies in collaboration with the research team. Interviews started with a broad question: "Please describe your experience with eye evacuation." Additional questions included: "What does eye evacuation mean to you?" To clarify meanings, exploratory prompts such as “Please explain more,” “What do you mean?” “Why?” and “How?” were applied. It should be noted that preparing the interview guide involved a comprehensive review of prior studies and cooperation with the research team, which ensured the formulation of suitable guiding questions consistent with the study objectives. A total of fifteen interviews were conducted in the ophthalmology clinic, each completed in a single session. Altogether, 15 interviews were held, and although participants were free to withdraw at any stage, none chose to do so. Each interview lasted between 40 and 60 minutes. It is also notable that all interviews were conducted in one session without the need for repetition. With the consent of the participants, every interview was transcribed and analyzed immediately afterward. Data Analysis Immediately after each interview, participants’ statements were transcribed verbatim and subjected to analysis. Data analysis followed Colaizzi’s seven-step method, which is a well-established and rigorous approach for meaning-making in phenomenological research ( 17 ). In the first step, to gain a deep understanding of participants’ experiences and immerse in the data, audio recordings were repeatedly listened to, transcribed in full, and carefully reviewed by the researchers. In the second step, approximately 200 key statements relevant to the conceptual meanings were extracted. The third step involved interpreting the open codes into meanings and concepts, during which the researchers reflexively bracketed their preconceptions and assumptions. In the fourth step, similar codes were clustered into thematic categories, resulting in the classification of the initial codes codes into 10 subthemes and four main themes. In the fifth step, these themes were partially described and integrated into the research content. The sixth step provided an exhaustive description of the phenomenon under study, articulated in a clear and concise statement that reflected the essential aspects of its structure. In the seventh step, the findings were returned to participants for validation and confirmation ( 18 ). Moreover, throughout the data analysis process, the research team held regular and critical meetings to continuously review and refine the analysis. **MAXQDA** software was employed to facilitate data management ( 19 ). Rigour and reflexivity To ensure accuracy and validity, Lincoln and Guba's criteria, including validity, reliability, confirmability, and transferability ( 20 , 21 ), were applied. Validity was established through long-term engagement with participants, as well as peer questioning and member review to confirm the codes and categories identified. An audit trail that documented each step of the study supported reliability and allowed readers to assess the reliability of the findings. For verification, two transcripts, including codes and categories, were reviewed by three expert faculty members to confirm the accuracy of the coding. Transferability was assessed by comparing the experiences of four non-participating patients with those of study participants, further validating the identified codes and categories. 3. Results In this study, 13 patients who had undergone eye enucleation at the ophthalmology department of the educational hospital of Kermanshah University of Medical Sciences participated. Of these, nine (69.23%) were male, nine (69.23%) were married, one (7.69%) had a bachelor's degree, one had a diploma, and the rest had elementary education. The age range of participants was 29 to 66 years, with an average age of 40.61 years and an average duration of eye enucleation of 2.76 years (Table 1 ). Table 1 Demographic characteristics of the participants Participant Sex Marital status Age (years) Education Eye Enucleation time (years) P1 Male Married 36 BSc 3 P2 Male Married 38 elementary 4 P3 Female Married 66 elementary 3 P4 male Married 33 elementary 3 P5 male Married 39 elementary 4 P6 Male Single 29 Associate degree 3 P7 male Single 32 elementary 0/5 P8 male Married 66 elementary 3 P9 male Married 41 elementary 3 P10 Female Single 38 elementary 3 P11 male Married 31 elementary 3 P12 Female Married 46 elementary 0/5 P13 Female Single 33 elementary 3 From the qualitative data analysis, four main themes emerged: "Denial," "Catastrophic," "Adaptation," and "Ambivalence," along with 10 sub-themes(Table 2 ). Table 2 Themes and Sub-themes Themes Sub-themes Examples of codes 1. Denial Inability to Cope 2. Catastrophic Equivalent to Death Forced Acceptance and Dead End Family Burden Stigmatization 3. Adaptation Displacement Job Change Support 4. Ambivalence Hope for the Future Unpleasant Feelings 1. Denial All participants stated that hearing the news of eye enucleation was very difficult for them, and most did not accept the need for enucleation. They visited several ophthalmologists, asking if there was any alternative to enucleation, and experienced "inability to cope." In this regard, Participant 6 stated: "It was very hard for me, and I didn't accept that my eye should be removed. I attempted suicide three times in a year, and my appearance has changed). Participant 5 also stated, "I tried my best and visited countless doctors to avoid enucleation" . 2. Catastrophic Based on the findings from the experiences of patients who underwent eye enucleation, the acceptance of enucleation was experienced as a process equivalent to death, forced acceptance, reaching a dead end, family burden, and stigmatization. 2.1. Being equivalent to death Some participants stated that if they were in a situation where they had to choose between death and eye enucleation, they would definitely choose death, as death was easier for them than agreeing to enucleation. As Participant 4 (a 33-year-old man) stated, "I swear to God, I said dying is better than living with one eye, and I said I wouldn't survive" (Interview 4). Participant 6 (a 29-year-old man) also explained, "I swear to God, if I were told to choose between death and enucleation, I would choose death" . 2.2 Forced Acceptance Some participants stated that they had no choice but to undergo enucleation and had reached a dead end And finally they were forced to enucleation the eye.. In this regard , Participant 5 (a 39-year-old man) stated: "I had no choice but to undergo enucleation" . Participant 9 (a 41-year-old man) also explained, " What happened has happened, but if someone has money and can go to an eye transplant center, they can get a transplant. If they don't have money, there's no choice but enucleation. " 2.3 Family Burden Some participants emphasized the importance of preventing emotional harm to their families after enucleation. Participant 7 (a 32-year-old man) explained: " I remove and wash the prosthesis about once every 10 days and put it back in place. When I remove the prosthesis, I don't let anyone in my family see my empty eye socket, and I do it alone. I don't want them to be upset ." Participant 9 (a 41-year-old man) also stated: " But when I remove it, I try to be alone because it's easier, and I'm more upset about my child being emotionally hurt ." 2.4 Stigmatization Some participants stated that some people in society ridiculed and humiliated them for having only one eye, which deeply upset them. As Participant 4 (a 33-year-old man) stated: " I swear to God, it's so hard to have one eye because when you get into a fight, others mock you and make fun of you ." Participant 6 (a 29-year-old man) also explained, " When I went out, people mocked me. For example, when I walked down the street, children would stare at my eye, and I had pride, so my pride was hurt, and I felt upset. " 3. Adaptation The experience of losing an eye is one of the most difficult and complex experiences that individuals face in their lives. Based on the findings from the experiences of patients who underwent eye enucleation, the process of adapting to this loss included a wide range of coping strategies, such as turning to drugs, seeking social relationships, changing jobs after enucleation, and the supportive role of family and friends in accepting the problem. In this regard, three sub-themes emerged: " Displacement," "Job Change," and "Support ." 3.1Displacement Based on the findings from the experiences of some patients who underwent enucleation, some used the defense mechanism of displacement to reduce existing anxieties and tensions. In this regard, Participant 1 (a 36-year-old man) explained, "I used to consume opium because I worked in construction, and since I became housebound, I've been distracting myself with drugs. Even now, if it weren't for the drugs, I would think about revenge for the harm done to me, and the drugs silence the pain from my injury . " Participant 2 (a 38-year-old man) also stated: " I distracted myself by spending time with friends, and when I was at home, I thought about my eyes 24/7 and had lost my spirit. " 3.2 Job Change After enucleation surgery, work activities that require precision, as well as jobs that could harm the healthy eye, such as welding, masonry, etc., are limited. In this regard, Participant 2 (a 38-year-old man) explained, " After enucleation, I couldn't do my previous work. I used to be a construction worker, but now I've changed my job and work as a security guard because dust is harmful to my eye, and I can't lift heavy objects that could harm my other eye or cause injury. There are many things I have to be careful about after the surgery ." Participant 5 (a 39-year-old man) also stated: " I swear to God, I was a mechanic for 16 years. Now, in mechanics, you have to tighten screws and things, and you need a lot of precision, but I don't have the precision I used to have. You can't do detailed work with one eye ." 3.3 Support The first and most important way to cope with the loss is empathy from family and friends. Participant 8 (a 66-year-old man) stated: " My wife and children always encouraged me and were around to take care of me. They would put in my eye drops, and when I said my eye was empty, my children promised to buy me the best prosthetic eye. First, God, and second, my son-in-law was always following up on my treatment and comforting me ." Participant 5 (a 39-year-old man) also stated: " My wife has told me many times that she accepts me no matter what, and that her love for me won't decrease just because I have one eye and can't work ." 4. Ambivalence Some participants felt hopeful about having a prosthesis and retaining vision in one eye, while simultaneously experiencing feelings of "regret," "self-blame," "shame in front of others," "self-disgust," and "loss of body image" after losing an important part of their body. In this context, two sub-themes emerged: " Hope for the Future" and "Unpleasant Feelings ." 4.1Hope for the Future The experience of hope for the future was reflected in some participants as a feeling of optimism due to retaining partial vision in one eye and the joy of having a prosthesis that closely resembles their healthy eye. In this regard, Participant 5 (a 39-year-old man) stated: " When I went to Noor Hospital in Tehran, I saw things that made me feel hopeful. They brought in a baby who had been blind since birth, and I thought, 'This poor child has been like this since birth, but I'm 39 years old, and it's God's will. '" Also, Participant 6 (a 29-year-old man) said, " After getting the prosthesis, it felt like I was reborn, and the person I used to be had died and was born again. It felt like I was young again ." 4.2 Unpleasant Feelings Some participants experienced unpleasant feelings after losing an eye, including " regret for not having the eye," "self-blame for neglecting their physical condition," "shame in front of others," "self-disgust due to changes in the eye's appearance," and "loss of body image after losing the eye." In this regard, Participant 7 (a 32-year-old man) explained, " I wish I still had my own eye, and I sometimes talk to myself, saying, 'I wish I weren't like this .'" Participant 8 (a 66-year-old man) explained, " For a while in my childhood, my eyes had discharge. First, I had conjunctivitis, and I didn't take it seriously. Then I gradually developed glaucoma, and since we lived in a village, I didn't take my eye problem seriously until I lost my eye and had to have it removed. I blame myself for not following up on it earlier. " In this regard, Participant 3 (a 66-year-old woman) stated, " I've had this eye protector for three years, and I feel ashamed when I take it off and others look at me ." Participant 9 (a 41-year-old man) stated " Until I got the prosthesis, I couldn't look in the mirror, and for a while, I didn't look at all (Why didn't you look?) Because I really felt disgusted and didn't want to look at my empty eye socket ." Participant 7 (a 32-year-old man) explained, " It's really hard for someone who has just experienced this (Can you elaborate?), Well, I've only been through this for a few months, and it's hard to suddenly lose your eye and wake up in the morning, brush your teeth, and see yourself in the mirror. These things really affect you and make me feel upset ." 4. Discussion This study aimed to explain the lived experiences of patients from eye enucleation using a descriptive phenomenological approach. With this approach, the main themes that emerged from the analysis of participants' statements were: " Denial," "Catastrophic," "Adaptation," and "Ambivalence ." The first main theme of the study's findings is "Denial," which includes the sub-theme "Inability to Cope." According to our findings, Enock et al. (2008) also reported that the decision to remove the eyeball is usually difficult for both the surgeon and the patient ( 11 ). Another main theme of the study's findings is "Catastrophic," which includes four sub-themes: "Equivalent to Death," "Forced Acceptance and Reaching a Dead End," "Family Burden," and "Stigmatization," which were experienced by patients when accepting enucleation. "Equivalent to Death" was a new sub-theme in which some participants stated that if they had to choose between death and enucleation, they would choose death. This was not found in any of the articles related to patients' experiences of enucleation. According to our findings, Enock et al. (2008) also reported that the decision to remove the eyeball is usually difficult for both the surgeon and the patient. Thus, when all other efforts to save the eye have failed, it is the last option for the surgeon and patient ( 11 ). Some participants emphasized the importance of preventing emotional harm to their families after enucleation. Some participants stated that some people in society ridiculed and humiliated them for having only one eye. "Family Burden" and "Stigmatization" were new sub-themes not found in any of the articles related to patients' experiences of enucleation. Another main theme of the study's findings is "Adaptation," which included three sub-themes: "Displacement," "Job Change," and "Support." McLean suggested that adaptation after sudden eye loss usually takes a year or less ( 22 ). Based on the findings from the experiences of some patients who underwent enucleation, some used the defense mechanism of displacement by turning to drugs and social relationships to reduce existing anxieties and tensions. "Displacement" was a new sub-theme not found in any of the articles related to patients' experiences of enucleation. According to the study's findings, after enucleation surgery, work activities that require precision, as well as jobs that could harm the healthy eye, such as welding, masonry, etc., are limited. However, in McBain et al.'s study, contrary to the findings of this study, they confirmed that over time, participants developed strategies to compensate for their deficiencies and were able to resume their previous work and daily activities ( 23 ). According to our findings, Jones et al. (2020) also found that family and friend support facilitated coping. Support was provided in the form of practical help, such as administering eye drops after surgery, and emotional support to help cope with anxiety. It is common for visually impaired patients to rely on informal caregivers such as spouses, partners, friends, or family for support ( 10 ). Another main theme of the study's findings is "Ambivalence," which includes two sub-themes: "Hope for the Future" and "Unpleasant Feelings." According to our findings, Wang, Zhang, Chen, and Li's longitudinal study in 2012 ( 24 ) also showed a significant reduction in anxiety and depression symptoms, social anxiety related to appearance, and social avoidance following the insertion of a prosthetic eye after enucleation. Over time, participants' negative emotions decreased (also found by Goiato et al.)( 25 ), while positive emotions increased. The results of another study showed that feelings of happiness and acceptance significantly increased after at least six months of using a prosthetic eye, which is an encouraging result that patients who have recently lost an eye should be aware of ( 26 ). Satisfaction with the prosthetic eye was higher for those who felt their prosthesis was inconspicuous to others ( 26 ). Some participants experienced unpleasant feelings after losing an eye, including "regret for not having the eye," "self-blame for neglecting their physical condition," "shame in front of others," "self-disgust due to changes in the eye's appearance," and "loss of body image after losing the eye." This finding, that participants experienced moderate to strong negative emotions in the first few months after receiving their first prosthesis, is similar to the results of Goiato et al. (2013)( 25 ). These negative emotions occur when patients who have undergone enucleation are still processing the event, going through the early stages of grief ( 26 ), and coping with their changed appearance and the functional effects of losing an eye. This is a very difficult and confusing time for patients. Long-term negative emotions (mainly shyness and preoccupation with hiding the eye) may be due to the poor behavior of others, which can be internalized and become part of the individual's self-image ( 27 ), leading to more persistent feelings of insecurity. Negative social, occupational, or recreational experiences can also create negative self-perceptions, leading to negative emotions that may be exacerbated by unhelpful coping strategies such as avoidance, which maintains negative beliefs because incorrect information is not obtained ( 28 ). Participants in this study paid significantly more attention to how they appeared to others compared to how they appeared to themselves. Observing one's condition can have a significant psychological impact and create problems in body image, self-esteem, quality of life, and social interactions ( 29 ). One of the main sources of stress for those with facial abnormalities is the inevitability of sharing their condition with others, which is the most common problem related to social interaction ( 30 ). 5. Conclusion In a broader sense, the experiences of patients who underwent eye enucleation were categorized into four main themes: "Denial," "Catastrophic," "Adaptation," and "Ambivalence." To provide care for enucleation patients, our findings can help nursing managers prepare young nurses to care for patients undergoing eye enucleation surgery. All patients can take solace in the finding that strong initial negative emotions decrease over time, while positive emotions increase. Psychological intervention and support should be provided in the early stages after eye loss to address specific concerns about appearance, mucous discharge, and acquired monocular vision. Strengths and limitations of the study This study investigates the lived experiences of patients who underwent eye enucleation, an area with limited empirical evidence. The study utilized a purposive sampling technique and conducted in-depth interviews to ensure a comprehensive understanding of the experiences of patients who underwent eye enucleation. Another strength of this study is the rigorous implementation of Colaizzi’s seven-step method as a research methodology. The application of Lincoln and Guba’s four criteria further enhanced the credibility of the data. However, the study also faced certain limitations that warrant consideration. Firstly, In western regions of Iran, socio-economic variables such as access to health services, education level, and economic status can have a significant impact on patients' experiences. These variables may not be fully considered in phenomenological analyses. Secondly, The specific cultural characteristics of western regions of Iran may influence the way patients express their experiences. Patients may be reluctant to express their feelings and experiences, which could affect the richness of the data collected. Declarations Ethics approval and consent to participate Informed consent obtained from all participants in the study and this study conducted by the Kermanshah University of Medical Sciences, grant no 50004695. Identity letter obtained from deputy of research and technology to collecting data. This research approved by ethics committee of deputy of research and technology – KUMS number IR.KUMS.REC.1403.293 at 17/09/2024. All methods andsteps were in accordance with ethical guidelines and approved by the committee. Consent for publication All authors read and confirmed the manuscript. Availability of data and materials Datasets are available through the corresponding author upon reasonable request. Competing interests The authors declare that they have no conflict of interest. Funding Kermanshah University of Medical Sciences, grant no 50004695. Authors ’ contributions RJ contributed to the design, analysis, participated in most of the study steps. RJ and RR prepared the manuscript. AK, AB, AJ, PA and AVR assisted in designing the study, and helped in the, interpretation of the study. All authors have read and approved the content of the manuscript. References Leister N, Löser J, Gostian A-O, Gostian M, Rokohl AC, Fieber MA, et al. Postoperative Pain Following Eye Enucleation: A Prospective Observational Study. Medicina. 2024;60(4):614. Soares ÍP, França VP, editors. Evisceration and enucleation. Seminars in Ophthalmology; 2010: Taylor & Francis. Yousuf SJ, Jones LS, Kidwell Jr ED. Enucleation and evisceration: 20 years of experience. Orbit. 2012;31(4):211-5. Ababneh OH, AboTaleb EA, Abu Ameerh MA, Yousef YA. 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Time heals: an investigation into how anophthalmic patients feel about eye loss and wearing a prosthetic eye. J Ophthalmol Vis Sci. 2017;2(2):1018. Pine NS, Pine KR. Depression, anxiety and stress indicators for prosthetic eye wearers. Clinical Ophthalmology. 2020:1715-23. Beck JS. Cognitive behavior therapy: Basics and beyond: Guilford Publications; 2020. Rumsey N, Harcourt D. Body image and disfigurement: issues and interventions. Body image. 2004;1(1):83-97. Pine NS, de Terte I, Pine KR. An investigation into discharge, visual perception, and appearance concerns of prosthetic eye wearers. Orbit. 2017;36(6):401-6. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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09:58:25","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":289942,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7673901/v1/7b9a2034-0a21-4f6d-8099-84980652695f.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Lived Experiences of Patients from Eye Enucleation: A phenomenological study from the West of Iran","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eOne type of anophthalmic surgery is enucleation, which, like other anophthalmic treatments (such as evisceration), is an invasive and precise ophthalmologic surgical procedure involving the removal of the entire affected globe (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eEnucleation refers to the complete removal of the eyeball, whereas evisceration entails the removal of all intraocular contents through a corneal or scleral incision while preserving the conjunctiva, sclera, extraocular muscles, orbital fat, and optic nerve. These procedures have been accepted therapeutic options over the past two centuries for various ocular conditions, including intraocular tumors (enucleation only), severe eye trauma, and blind, painful, or cosmetically disfigured eyes (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eCommon indications for enucleation include refractory endophthalmitis, cosmetic improvement of a blind eye, painful blind eyes, intraocular malignancy, severe ocular trauma, phthisis with degeneration, and congenital anophthalmia or severe microphthalmia (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). In a review of 24,444 cases of ocular enucleation over 55 years, Sprawell and Grossniklas (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) found that trauma accounted for 40.9% of cases and tumors for 24.2%. In contrast, Chaudhry et al. (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e) reported that endophthalmitis was the cause in 45.5% of cases, while phthisis combined with trauma accounted for 39.5%.\u003c/p\u003e\u003cp\u003eIndications for removal of the eye are similar in most hospitals and countries. However, the frequency of pathologic conditions leading to this invasive procedure varies by hospital and location (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). In European countries, the indication for removal of the eye is usually a malignant condition when other therapeutic options have failed or are not feasible (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). The leading cause for anophthalmic surgery in developing countries is infection or perforating trauma (e.g., gun shot) (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe goal of eye enucleation surgery is to protect the eye from the risk of sympathetic ophthalmia, save the patient's life, reduce pain, and sometimes preserve the patient's appearance (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Patients often consider enucleation (enucleation or evisceration) to relieve debilitating discomfort and improve the appearance of a disfigured eye (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eSurgery is undoubtedly a significant life event for patients in all medical fields. Surgical concerns are particularly prominent among ophthalmic patients, as vision is often considered the most valuable sense, and the loss of vision creates immense fear (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Surgical intervention to remove an eye is a serious and life-altering event for patients. Eye removal has adverse effects on quality of life, emotional and cognitive functioning (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Often, the psychological effects of losing an eye are worse than the physical problems, especially in cases of eye loss due to trauma or unexpected malignancy (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eWhile the experience of eye enucleation is highly stressful, there is a lack of information about the experiences of patients who have undergone this procedure.\u003c/p\u003e\u003cp\u003eSince \"patients' experiences of eye enucleation\" is an abstract concept and cannot be objectively studied in the external world, it is necessary to focus on the experiences of those who have undergone it. Therefore, this study used a qualitative research approach with a phenomenological perspective. The goal of this approach is to examine individuals' experiences as they perceive them, without the researcher interpreting the meanings. In this approach, the researcher must suspend all preconceptions and prior knowledge.\u003c/p\u003e\u003cp\u003eStudying patients' experiences of eye enucleation provides a valuable opportunity to better understand their challenges, concerns, and needs. This understanding can help develop supportive strategies, enhance psychological care, and improve patients' quality of life. Given the importance of the topic, the aim of this study is to explain the lived experiences of patients from eye enucleation using a phenomenological approach.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e"},{"header":"2. Materials and methods","content":"\u003cp\u003e\u003cb\u003eStudy design\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThis qualitative study adopts a phenomenological descriptive design rooted in Husserl\u0026rsquo;s philosophy. Phenomenology is an approach that aims to discover meaning and essence in people\u0026rsquo;s experiences to facilitate understanding (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). The goal of phenomenology is to explore deep and inherently complex phenomena. This approach understands the world as the individual inhabits it, and the researcher seeks to achieve a rich and deep understanding of the phenomenon by setting aside his or her past experiences and exploring meanings (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). The present study follows the reporting guidelines outlined in the Consolidated Criteria for Reporting Qualitative Research (COREQ) (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cb\u003eStudy Setting and Participant Recruitment\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThis study was conducted from September 2024 to March 2025 in a city in western Iran. The study population included patients who underwent eye evacuation and were discharged from the ophthalmology department of a teaching hospital affiliated with Kermanshah University of Medical Sciences and were selected through purposive sampling with maximum diversity. Inclusion criteria were having experience with eye evacuation and the patient's willingness to participate in the study. The researcher visited the ophthalmology department of a teaching hospital affiliated with Kermanshah University of Medical Sciences to select eligible participants. The sampling process continued until data saturation was reached (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). In conducting qualitative studies, saturation is one of the important aspects for consideration. In practice, saturation requires a researcher to collect data from informants to the point that no further information can possibly be collected. Saturation point not only assures the validity and credibility of information for the study but saves researchers\u0026rsquo; time and energy in collecting the same (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Data saturation was achieved during the ninth interview. However, for greater certainty, four more interviews were conducted.\u003c/p\u003e\u003cp\u003e\u003cb\u003eData Collection\u003c/b\u003e\u003c/p\u003e\u003cp\u003e This research approved by ethics committee of deputy of research and technology \u0026ndash; KUMS number IR.KUMS.REC.1403.293 at 17/09/2024. All methods andsteps were in accordance with ethical guidelines and approved by the committee. In this study, data collection began with obtaining an introductory letter from the Vice Chancellor for Research of Kermanshah University of Medical Sciences, followed by securing the necessary permissions from the hospitals\u0026rsquo; research centers. Subsequently, the researcher received the list of patients who had undergone eye evacuation. These patients were then contacted and invited to take part in the study. Data were gathered through semi-structured, in-depth, face-to-face interviews conducted at a time and location selected by the participants. All interviews were carried out by the corresponding author, who was a PhD student in nursing, and they centered on the lived experiences of patients regarding eye evacuation. The interview questions were guided by a framework developed through a detailed review of related studies in collaboration with the research team. Interviews started with a broad question: \"Please describe your experience with eye evacuation.\" Additional questions included: \"What does eye evacuation mean to you?\" To clarify meanings, exploratory prompts such as \u0026ldquo;Please explain more,\u0026rdquo; \u0026ldquo;What do you mean?\u0026rdquo; \u0026ldquo;Why?\u0026rdquo; and \u0026ldquo;How?\u0026rdquo; were applied. It should be noted that preparing the interview guide involved a comprehensive review of prior studies and cooperation with the research team, which ensured the formulation of suitable guiding questions consistent with the study objectives. A total of fifteen interviews were conducted in the ophthalmology clinic, each completed in a single session. Altogether, 15 interviews were held, and although participants were free to withdraw at any stage, none chose to do so. Each interview lasted between 40 and 60 minutes. It is also notable that all interviews were conducted in one session without the need for repetition. With the consent of the participants, every interview was transcribed and analyzed immediately afterward.\u003c/p\u003e\u003cp\u003e\u003cb\u003eData Analysis\u003c/b\u003e\u003c/p\u003e\u003cp\u003e Immediately after each interview, participants\u0026rsquo; statements were transcribed verbatim and subjected to analysis. Data analysis followed Colaizzi\u0026rsquo;s seven-step method, which is a well-established and rigorous approach for meaning-making in phenomenological research (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). In the first step, to gain a deep understanding of participants\u0026rsquo; experiences and immerse in the data, audio recordings were repeatedly listened to, transcribed in full, and carefully reviewed by the researchers. In the second step, approximately 200 key statements relevant to the conceptual meanings were extracted. The third step involved interpreting the open codes into meanings and concepts, during which the researchers reflexively bracketed their preconceptions and assumptions. In the fourth step, similar codes were clustered into thematic categories, resulting in the classification of the initial codes codes into 10 subthemes and four main themes. In the fifth step, these themes were partially described and integrated into the research content. The sixth step provided an exhaustive description of the phenomenon under study, articulated in a clear and concise statement that reflected the essential aspects of its structure. In the seventh step, the findings were returned to participants for validation and confirmation (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Moreover, throughout the data analysis process, the research team held regular and critical meetings to continuously review and refine the analysis. **MAXQDA** software was employed to facilitate data management (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cb\u003eRigour and reflexivity\u003c/b\u003e\u003c/p\u003e\u003cp\u003eTo ensure accuracy and validity, Lincoln and Guba's criteria, including validity, reliability, confirmability, and transferability (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e), were applied. Validity was established through long-term engagement with participants, as well as peer questioning and member review to confirm the codes and categories identified. An audit trail that documented each step of the study supported reliability and allowed readers to assess the reliability of the findings. For verification, two transcripts, including codes and categories, were reviewed by three expert faculty members to confirm the accuracy of the coding. Transferability was assessed by comparing the experiences of four non-participating patients with those of study participants, further validating the identified codes and categories.\u003c/p\u003e"},{"header":"3. Results","content":"\u003cp\u003eIn this study, 13 patients who had undergone eye enucleation at the ophthalmology department of the educational hospital of Kermanshah University of Medical Sciences participated. Of these, nine (69.23%) were male, nine (69.23%) were married, one (7.69%) had a bachelor's degree, one had a diploma, and the rest had elementary education. The age range of participants was 29 to 66 years, with an average age of 40.61 years and an average duration of eye enucleation of 2.76 years (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDemographic characteristics of the participants\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eParticipant\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSex\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMarital status\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eAge (years)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eEducation\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eEye Enucleation time\u003c/p\u003e\u003cp\u003e(years)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eP1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMarried\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e36\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eBSc\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eP2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMarried\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eelementary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eP3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMarried\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e66\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eelementary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eP4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003emale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMarried\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eelementary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eP5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003emale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMarried\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e39\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eelementary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eP6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSingle\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eAssociate degree\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eP7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003emale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSingle\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eelementary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0/5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eP8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003emale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMarried\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e66\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eelementary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eP9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003emale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMarried\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e41\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eelementary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eP10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSingle\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eelementary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eP11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003emale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMarried\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e31\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eelementary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eP12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMarried\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e46\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eelementary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0/5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eP13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSingle\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eelementary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eFrom the qualitative data analysis, four main themes emerged: \"Denial,\" \"Catastrophic,\" \"Adaptation,\" and \"Ambivalence,\" along with 10 sub-themes(Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eThemes and Sub-themes\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eThemes\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSub-themes\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eExamples of codes\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1. Denial\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eInability to Cope\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2. Catastrophic\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEquivalent to Death\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eForced Acceptance and Dead End\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFamily Burden\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eStigmatization\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3. Adaptation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDisplacement\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eJob Change\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSupport\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e4. Ambivalence\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHope for the Future\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUnpleasant Feelings\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\n\u003ch3\u003e1. Denial\u003c/h3\u003e\n\u003cp\u003eAll participants stated that hearing the news of eye enucleation was very difficult for them, and most did not accept the need for enucleation. They visited several ophthalmologists, asking if there was any alternative to enucleation, and experienced \u003cb\u003e\"inability to cope.\"\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eIn this regard, Participant 6 stated: \"It was very hard for me, and I didn't accept that my eye should be removed. I attempted suicide three times in a year, and my appearance has changed). Participant 5 also stated, \"I tried my best and visited countless doctors to avoid enucleation\" .\u003c/b\u003e\u003c/p\u003e\n\u003ch3\u003e2. Catastrophic\u003c/h3\u003e\n\u003cp\u003eBased on the findings from the experiences of patients who underwent eye enucleation, the acceptance of enucleation was experienced as a process equivalent to death, forced acceptance, reaching a dead end, family burden, and stigmatization.\u003c/p\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003e2.1. Being equivalent to death\u003c/h2\u003e\u003cp\u003eSome participants stated that if they were in a situation where they had to choose between death and eye enucleation, they would definitely choose death, as death was easier for them than agreeing to enucleation. \u003cem\u003eAs Participant 4 (a 33-year-old man) stated, \"I swear to God, I said dying is better than living with one eye, and I said I wouldn't survive\" (Interview 4). Participant 6 (a 29-year-old man) also explained, \"I swear to God, if I were told to choose between death and enucleation, I would choose death\" .\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003e2.2 Forced Acceptance\u003c/h2\u003e\u003cp\u003eSome participants stated that they had no choice but to undergo enucleation and had reached a dead end And finally they were forced to enucleation the eye.. \u003cem\u003eIn this regard\u003c/em\u003e, Participant 5 (a 39-year-old man) stated: \u003cem\u003e\"I had no choice but to undergo enucleation\"\u003c/em\u003e. Participant 9 (a 41-year-old man) also explained, \"\u003cem\u003eWhat happened has happened, but if someone has money and can go to an eye transplant center, they can get a transplant. If they don't have money, there's no choice but enucleation.\u003c/em\u003e\"\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003e2.3 Family Burden\u003c/h2\u003e\u003cp\u003e Some participants emphasized the importance of preventing emotional harm to their families after enucleation. Participant 7 (a 32-year-old man) explained: \"\u003cem\u003eI remove and wash the prosthesis about once every 10 days and put it back in place. When I remove the prosthesis, I don't let anyone in my family see my empty eye socket, and I do it alone. I don't want them to be upset\u003c/em\u003e.\" Participant 9 (a 41-year-old man) also stated: \"\u003cem\u003eBut when I remove it, I try to be alone because it's easier, and I'm more upset about my child being emotionally hurt\u003c/em\u003e.\"\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\u003ch2\u003e2.4 Stigmatization\u003c/h2\u003e\u003cp\u003eSome participants stated that some people in society ridiculed and humiliated them for having only one eye, which deeply upset them. As Participant 4 (a 33-year-old man) stated: \"\u003cem\u003eI swear to God, it's so hard to have one eye because when you get into a fight, others mock you and make fun of you\u003c/em\u003e.\" Participant 6 (a 29-year-old man) also explained, \"\u003cem\u003eWhen I went out, people mocked me. For example, when I walked down the street, children would stare at my eye, and I had pride, so my pride was hurt, and I felt upset.\u003c/em\u003e\"\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003e3. Adaptation\u003c/h3\u003e\n\u003cp\u003eThe experience of losing an eye is one of the most difficult and complex experiences that individuals face in their lives. Based on the findings from the experiences of patients who underwent eye enucleation, the process of adapting to this loss included a wide range of coping strategies, such as turning to drugs, seeking social relationships, changing jobs after enucleation, and the supportive role of family and friends in accepting the problem. In this regard, three sub-themes emerged: \"\u003cb\u003eDisplacement,\" \"Job Change,\" and \"Support\u003c/b\u003e.\"\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003e3.1Displacement\u003c/h2\u003e\u003cp\u003eBased on the findings from the experiences of some patients who underwent enucleation, some used the defense mechanism of displacement to reduce existing anxieties and tensions.\u003c/p\u003e\u003cp\u003e\u003cb\u003eIn this regard, Participant 1 (a 36-year-old man) explained, \"I used to consume opium because I worked in construction, and since I became housebound, I've been distracting myself with drugs. Even now, if it weren't for the drugs, I would think about revenge for the harm done to me, and the drugs silence the pain from my injury\u003c/b\u003e.\u003cb\u003e\" Participant 2 (a 38-year-old man) also stated: \"\u003c/b\u003e\u003cb\u003eI distracted myself by spending time with friends, and when I was at home, I thought about my eyes 24/7 and had lost my spirit.\u003c/b\u003e\u003cb\u003e\"\u003c/b\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003e3.2 Job Change\u003c/h2\u003e\u003cp\u003eAfter enucleation surgery, work activities that require precision, as well as jobs that could harm the healthy eye, such as welding, masonry, etc., are limited. In this regard, Participant 2 (a 38-year-old man) explained, \"\u003cem\u003eAfter enucleation, I couldn't do my previous work. I used to be a construction worker, but now I've changed my job and work as a security guard because dust is harmful to my eye, and I can't lift heavy objects that could harm my other eye or cause injury. There are many things I have to be careful about after the surgery\u003c/em\u003e.\" Participant 5 (a 39-year-old man) also stated: \"\u003cem\u003eI swear to God, I was a mechanic for 16 years. Now, in mechanics, you have to tighten screws and things, and you need a lot of precision, but I don't have the precision I used to have. You can't do detailed work with one eye\u003c/em\u003e.\"\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003e3.3 Support\u003c/h2\u003e\u003cp\u003eThe first and most important way to cope with the loss is empathy from family and friends. Participant 8 (a 66-year-old man) stated: \"\u003cem\u003eMy wife and children always encouraged me and were around to take care of me. They would put in my eye drops, and when I said my eye was empty, my children promised to buy me the best prosthetic eye. First, God, and second, my son-in-law was always following up on my treatment and comforting me\u003c/em\u003e.\" Participant 5 (a 39-year-old man) also stated: \"\u003cem\u003eMy wife has told me many times that she accepts me no matter what, and that her love for me won't decrease just because I have one eye and can't work\u003c/em\u003e.\"\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003e4. Ambivalence\u003c/h3\u003e\n\u003cp\u003eSome participants felt hopeful about having a prosthesis and retaining vision in one eye, while simultaneously experiencing feelings of \"regret,\" \"self-blame,\" \"shame in front of others,\" \"self-disgust,\" and \"loss of body image\" after losing an important part of their body. In this context, two sub-themes emerged: \"\u003cb\u003eHope for the Future\" and \"Unpleasant Feelings\u003c/b\u003e.\"\u003c/p\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003e4.1Hope for the Future\u003c/h2\u003e\u003cp\u003eThe experience of hope for the future was reflected in some participants as a feeling of optimism due to retaining partial vision in one eye and the joy of having a prosthesis that closely resembles their healthy eye. In this regard, Participant 5 (a 39-year-old man) stated: \"\u003cem\u003eWhen I went to Noor Hospital in Tehran, I saw things that made me feel hopeful. They brought in a baby who had been blind since birth, and I thought, 'This poor child has been like this since birth, but I'm 39 years old, and it's God's will.\u003c/em\u003e'\" Also, Participant 6 (a 29-year-old man) said, \"\u003cem\u003eAfter getting the prosthesis, it felt like I was reborn, and the person I used to be had died and was born again. It felt like I was young again\u003c/em\u003e.\"\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003e4.2 Unpleasant Feelings\u003c/h2\u003e\u003cp\u003eSome participants experienced unpleasant feelings after losing an eye, including \"\u003cb\u003eregret for not having the eye,\" \"self-blame for neglecting their physical condition,\" \"shame in front of others,\" \"self-disgust due to changes in the eye's appearance,\" and \"loss of body image after losing the eye.\"\u003c/b\u003e\u003c/p\u003e\u003cp\u003eIn this regard, Participant 7 (a 32-year-old man) explained, \"\u003cem\u003eI wish I still had my own eye, and I sometimes talk to myself, saying, 'I wish I weren't like this\u003c/em\u003e.'\" Participant 8 (a 66-year-old man) explained, \"\u003cem\u003eFor a while in my childhood, my eyes had discharge. First, I had conjunctivitis, and I didn't take it seriously. Then I gradually developed glaucoma, and since we lived in a village, I didn't take my eye problem seriously until I lost my eye and had to have it removed. I blame myself for not following up on it earlier.\u003c/em\u003e\" In this regard, Participant 3 (a 66-year-old woman) stated, \"\u003cem\u003eI've had this eye protector for three years, and I feel ashamed when I take it off and others look at me\u003c/em\u003e.\" Participant 9 (a 41-year-old man) stated \"\u003cem\u003eUntil I got the prosthesis, I couldn't look in the mirror, and for a while, I didn't look at all (Why didn't you look?) Because I really felt disgusted and didn't want to look at my empty eye socket\u003c/em\u003e.\" Participant 7 (a 32-year-old man) explained, \"\u003cem\u003eIt's really hard for someone who has just experienced this (Can you elaborate?), Well, I've only been through this for a few months, and it's hard to suddenly lose your eye and wake up in the morning, brush your teeth, and see yourself in the mirror. These things really affect you and make me feel upset\u003c/em\u003e.\"\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThis study aimed to explain the lived experiences of patients from eye enucleation using a descriptive phenomenological approach. With this approach, the main themes that emerged from the analysis of participants' statements were: \"\u003cb\u003eDenial,\" \"Catastrophic,\" \"Adaptation,\" and \"Ambivalence\u003c/b\u003e.\"\u003c/p\u003e\u003cp\u003eThe first main theme of the study's findings is \"Denial,\" which includes the sub-theme \"Inability to Cope.\" According to our findings, Enock et al. (2008) also reported that the decision to remove the eyeball is usually difficult for both the surgeon and the patient (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eAnother main theme of the study's findings is \"Catastrophic,\" which includes four sub-themes: \"Equivalent to Death,\" \"Forced Acceptance and Reaching a Dead End,\" \"Family Burden,\" and \"Stigmatization,\" which were experienced by patients when accepting enucleation.\u003c/p\u003e\u003cp\u003e\"Equivalent to Death\" was a new sub-theme in which some participants stated that if they had to choose between death and enucleation, they would choose death. This was not found in any of the articles related to patients' experiences of enucleation. According to our findings, Enock et al. (2008) also reported that the decision to remove the eyeball is usually difficult for both the surgeon and the patient. Thus, when all other efforts to save the eye have failed, it is the last option for the surgeon and patient (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Some participants emphasized the importance of preventing emotional harm to their families after enucleation. Some participants stated that some people in society ridiculed and humiliated them for having only one eye. \"Family Burden\" and \"Stigmatization\" were new sub-themes not found in any of the articles related to patients' experiences of enucleation.\u003c/p\u003e\u003cp\u003eAnother main theme of the study's findings is \"Adaptation,\" which included three sub-themes: \"Displacement,\" \"Job Change,\" and \"Support.\" McLean suggested that adaptation after sudden eye loss usually takes a year or less (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eBased on the findings from the experiences of some patients who underwent enucleation, some used the defense mechanism of displacement by turning to drugs and social relationships to reduce existing anxieties and tensions. \"Displacement\" was a new sub-theme not found in any of the articles related to patients' experiences of enucleation. According to the study's findings, after enucleation surgery, work activities that require precision, as well as jobs that could harm the healthy eye, such as welding, masonry, etc., are limited. However, in McBain et al.'s study, contrary to the findings of this study, they confirmed that over time, participants developed strategies to compensate for their deficiencies and were able to resume their previous work and daily activities (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). According to our findings, Jones et al. (2020) also found that family and friend support facilitated coping. Support was provided in the form of practical help, such as administering eye drops after surgery, and emotional support to help cope with anxiety. It is common for visually impaired patients to rely on informal caregivers such as spouses, partners, friends, or family for support (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eAnother main theme of the study's findings is \"Ambivalence,\" which includes two sub-themes: \"Hope for the Future\" and \"Unpleasant Feelings.\" According to our findings, Wang, Zhang, Chen, and Li's longitudinal study in 2012 (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e) also showed a significant reduction in anxiety and depression symptoms, social anxiety related to appearance, and social avoidance following the insertion of a prosthetic eye after enucleation. Over time, participants' negative emotions decreased (also found by Goiato et al.)(\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e), while positive emotions increased. The results of another study showed that feelings of happiness and acceptance significantly increased after at least six months of using a prosthetic eye, which is an encouraging result that patients who have recently lost an eye should be aware of (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Satisfaction with the prosthetic eye was higher for those who felt their prosthesis was inconspicuous to others (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eSome participants experienced unpleasant feelings after losing an eye, including \"regret for not having the eye,\" \"self-blame for neglecting their physical condition,\" \"shame in front of others,\" \"self-disgust due to changes in the eye's appearance,\" and \"loss of body image after losing the eye.\" This finding, that participants experienced moderate to strong negative emotions in the first few months after receiving their first prosthesis, is similar to the results of Goiato et al. (2013)(\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). These negative emotions occur when patients who have undergone enucleation are still processing the event, going through the early stages of grief (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e), and coping with their changed appearance and the functional effects of losing an eye. This is a very difficult and confusing time for patients. Long-term negative emotions (mainly shyness and preoccupation with hiding the eye) may be due to the poor behavior of others, which can be internalized and become part of the individual's self-image (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e), leading to more persistent feelings of insecurity. Negative social, occupational, or recreational experiences can also create negative self-perceptions, leading to negative emotions that may be exacerbated by unhelpful coping strategies such as avoidance, which maintains negative beliefs because incorrect information is not obtained (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). Participants in this study paid significantly more attention to how they appeared to others compared to how they appeared to themselves. Observing one's condition can have a significant psychological impact and create problems in body image, self-esteem, quality of life, and social interactions (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). One of the main sources of stress for those with facial abnormalities is the inevitability of sharing their condition with others, which is the most common problem related to social interaction (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eIn a broader sense, the experiences of patients who underwent eye enucleation were categorized into four main themes: \"Denial,\" \"Catastrophic,\" \"Adaptation,\" and \"Ambivalence.\" To provide care for enucleation patients, our findings can help nursing managers prepare young nurses to care for patients undergoing eye enucleation surgery. All patients can take solace in the finding that strong initial negative emotions decrease over time, while positive emotions increase. Psychological intervention and support should be provided in the early stages after eye loss to address specific concerns about appearance, mucous discharge, and acquired monocular vision.\u003c/p\u003e\u003cp\u003e\u003cb\u003eStrengths and limitations of the study\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThis study investigates the lived experiences of patients who underwent eye enucleation, an area with limited empirical evidence. The study utilized a purposive sampling technique and conducted in-depth interviews to ensure a comprehensive understanding of the experiences of patients who underwent eye enucleation. Another strength of this study is the rigorous implementation of Colaizzi\u0026rsquo;s seven-step method as a research methodology. The application of Lincoln and Guba\u0026rsquo;s four criteria further enhanced the credibility of the data.\u003c/p\u003e\u003cp\u003eHowever, the study also faced certain limitations that warrant consideration. Firstly, In western regions of Iran, socio-economic variables such as access to health services, education level, and economic status can have a significant impact on patients' experiences. These variables may not be fully considered in phenomenological analyses. Secondly, The specific cultural characteristics of western regions of Iran may influence the way patients express their experiences. Patients may be reluctant to express their feelings and experiences, which could affect the richness of the data collected.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent obtained from all participants in the study and this study conducted by the Kermanshah University of Medical Sciences, grant no 50004695. Identity letter obtained from deputy of research and technology to collecting data. This research approved by ethics committee of deputy of research and technology \u0026ndash; KUMS number IR.KUMS.REC.1403.293\u003cspan dir=\"RTL\"\u003e\u0026nbsp;\u003c/span\u003eat 17/09/2024. All methods andsteps\u003cspan dir=\"RTL\"\u003e\u0026nbsp;\u003c/span\u003e\u0026nbsp; were in accordance with ethical guidelines and approved by the committee.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors read and confirmed the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDatasets are available through the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eKermanshah University of Medical Sciences, grant no 50004695.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u003cspan dir=\"RTL\"\u003e\u0026rsquo;\u003c/span\u003econtributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRJ contributed to the design, analysis, participated in most of the study steps. RJ and RR prepared the manuscript. AK, AB, AJ, PA and AVR assisted in designing the study, and helped in the, interpretation of the study. All authors have read and approved the content of the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eLeister N, Löser J, Gostian A-O, Gostian M, Rokohl AC, Fieber MA, et al. Postoperative Pain Following Eye Enucleation: A Prospective Observational Study. Medicina. 2024;60(4):614.\u003c/li\u003e\n\u003cli\u003eSoares ÍP, França VP, editors. Evisceration and enucleation. Seminars in Ophthalmology; 2010: Taylor \u0026amp; Francis.\u003c/li\u003e\n\u003cli\u003eYousuf SJ, Jones LS, Kidwell Jr ED. Enucleation and evisceration: 20 years of experience. Orbit. 2012;31(4):211-5.\u003c/li\u003e\n\u003cli\u003eAbabneh OH, AboTaleb EA, Abu Ameerh MA, Yousef YA. Enucleation and evisceration at a tertiary care hospital in a developing country. BMC ophthalmology. 2015;15(1):120.\u003c/li\u003e\n\u003cli\u003eSpraul CW, Grossniklaus HE. Analysis of 24,444 surgical specimens accessioned over 55 years in an ophthalmic pathology laboratory. International Ophthalmology. 1997;21(5):283-304.\u003c/li\u003e\n\u003cli\u003eChaudhry IA, AlKuraya HS, Shamsi FA, Elzaridi E, Riley FC. Current indications and resultant complications of evisceration. Ophthalmic Epidemiology. 2007;14(2):93-7.\u003c/li\u003e\n\u003cli\u003eMartel A, Baillif S, Thomas P, Almairac F, Galatoire O, Hamedani M, et al. Phantom vision after eye removal: prevalence, features and related risk factors. British Journal of Ophthalmology. 2022;106(11):1603-9.\u003c/li\u003e\n\u003cli\u003eFarokhfar A, Ahmadzadeh-Amiri A, Sheikhrezaee M, Gorji MAH, Agaei N. Common causes of eye enucleation among patients. Journal of natural science, biology, and medicine. 2017;8(2):150.\u003c/li\u003e\n\u003cli\u003eMorgan-Warren PJ, Mehta P, Ahluwalia HS. Visual function and quality of life in patients who had undergone eye removal surgery: a patient survey. Orbit. 2013;32(5):285-93.\u003c/li\u003e\n\u003cli\u003eJones L, Taylor DJ, Sii F, Masood I, Crabb DP, Shah P. Only eye study 2 (OnES 2):‘Am I going to be able to see when the patch comes off?’A qualitative study of patient experiences of undergoing high-stakes only eye surgery. BMJ open. 2020;10(11):e038916.\u003c/li\u003e\n\u003cli\u003eEnock M, Omoti A, Fuh U, Alikah A. Indications for surgical removal of the eye in Irrua, Nigeria. Nigerian Journal of Ophthalmology. 2008;16(1):16-9.\u003c/li\u003e\n\u003cli\u003eShorey S, Ng ED. Examining characteristics of descriptive phenomenological nursing studies: A scoping review. Journal of Advanced Nursing. 2022;78(7):1968-79.\u003c/li\u003e\n\u003cli\u003eNeubauer BE, Witkop CT, Varpio L. How phenomenology can help us learn from the experiences of others. Perspectives on medical education. 2019;8(2):90-7.\u003c/li\u003e\n\u003cli\u003eTong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. International journal for quality in health care. 2007;19(6):349-57.\u003c/li\u003e\n\u003cli\u003eHosseinabadi-Farahani M, Pourebrahimi M, Ghods MJ, Fallahi-Khoshknab M. Exploring the experiences of nurses in providing care to patients with COVID-19: a qualitative study in Iran. Florence Nightingale Journal of Nursing. 2023;31(1):26.\u003c/li\u003e\n\u003cli\u003eMwita K. Factors influencing data saturation in qualitative studies. Available at SSRN 4889752. 2022.\u003c/li\u003e\n\u003cli\u003eMorrow R, Rodriguez A, King N. Colaizzi’s descriptive phenomenological method. The psychologist. 2015;28(8):643-4.\u003c/li\u003e\n\u003cli\u003eSchwandt TA, Lincoln YS, Guba EG. Judging interpretations: But is it rigorous? Trustworthiness and authenticity in naturalistic evaluation. New directions for evaluation. 2007;2007(114).\u003c/li\u003e\n\u003cli\u003eEdward K-L, Welch T. The extension of Colaizzi’s method of phenomenological enquiry. Contemporary nurse. 2011;39(2):163-71.\u003c/li\u003e\n\u003cli\u003eMirghafourvand M, Farshbaf-Khalili A, Ghanbari-Homayi S. Marital adjustment and its relationship with religious orientations among iranian infertile and fertile women: A cross-sectional study. Journal of religion and health. 2019;58(3):965-76.\u003c/li\u003e\n\u003cli\u003eDenzin NK, Lincoln YS. The Sage handbook of qualitative research: sage; 2011.\u003c/li\u003e\n\u003cli\u003eMcLean M. Adapting to loss of an eye. British Columbia Medical Journal. 2011;53(10).\u003c/li\u003e\n\u003cli\u003eMcBain HB, Ezra DG, Rose GE, Newman SP, Collaboration AR. The psychosocial impact of living with an ocular prosthesis. Orbit. 2014;33(1):39-44.\u003c/li\u003e\n\u003cli\u003eWang J, Zhang H, Chen W, Li G. The psychosocial benefits of secondary hydroxyapatite orbital implant insertion and prosthesis wearing for patients with anophthalmia. Ophthalmic Plastic \u0026amp; Reconstructive Surgery. 2012;28(5):324-7.\u003c/li\u003e\n\u003cli\u003eGoiato MC, dos Santos DM, Bannwart L, Moreno A, Pesqueira AA, Haddad M, et al. Psychosocial impact on anophthalmic patients wearing ocular prosthesis. International journal of oral and maxillofacial surgery. 2013;42(1):113-9.\u003c/li\u003e\n\u003cli\u003ePine N, De Terte I, Pine K. Time heals: an investigation into how anophthalmic patients feel about eye loss and wearing a prosthetic eye. J Ophthalmol Vis Sci. 2017;2(2):1018.\u003c/li\u003e\n\u003cli\u003ePine NS, Pine KR. Depression, anxiety and stress indicators for prosthetic eye wearers. Clinical Ophthalmology. 2020:1715-23.\u003c/li\u003e\n\u003cli\u003eBeck JS. Cognitive behavior therapy: Basics and beyond: Guilford Publications; 2020.\u003c/li\u003e\n\u003cli\u003eRumsey N, Harcourt D. Body image and disfigurement: issues and interventions. Body image. 2004;1(1):83-97.\u003c/li\u003e\n\u003cli\u003ePine NS, de Terte I, Pine KR. An investigation into discharge, visual perception, and appearance concerns of prosthetic eye wearers. Orbit. 2017;36(6):401-6.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Patients, Eye Enucleation, Experiences","lastPublishedDoi":"10.21203/rs.3.rs-7673901/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7673901/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eIntroduction\u003c/h2\u003e\u003cp\u003eEye enucleation is an extremely stressful experience that depends on the context. However, there is a lack of information regarding the experiences of patients who have undergone eye enucleation in the western region of Iran. Therefore, this study aimed to describe the lived experiences of patients who underwent eye enucleation in Kermanshah.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eIn this qualitative descriptive phenomenological study, data were collected through semi-structured and in-depth interviews. The sample included 13 patients who had undergone eye enucleation at the ophthalmology department of the educational hospital of Kermanshah University of Medical Sciences and were discharged. Participants were selected using purposive sampling. Data were analyzed using Colaizzi's seven-step method, and MAXQDA 10 software was used for data management. To enhance the credibility of the findings, Lincoln and Guba\u0026rsquo;s criteria were applied. The COREQ checklist was used to report the study.\u003c/p\u003e\u003ch2\u003eFindings\u003c/h2\u003e\u003cp\u003eParticipants' experiences were categorized into four main themes and 10 subthemes, and 200 codes. In this study, four main themes included:: \"\u003cb\u003eDenial,\" \"Catastrophic,\" \"Adaptation,\" and \"Ambivalence\u003c/b\u003e,\" along with \u003cb\u003e10 sub-themes\u003c/b\u003e.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eThe results indicate that the experience of eye enucleation is highly stressful and comes with numerous challenges and stressors. All patients can take solace in the finding that strong initial negative emotions decrease over time, while positive emotions increase. Psychological intervention and support should be provided in the early stages after eye loss to address specific concerns about appearance, mucous discharge, and acquired monocular vision\u003c/p\u003e","manuscriptTitle":"Lived Experiences of Patients from Eye Enucleation: A phenomenological study from the West of Iran","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-28 16:44:13","doi":"10.21203/rs.3.rs-7673901/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ee610e69-9486-42a8-a102-e8531c8f227f","owner":[],"postedDate":"October 28th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":56835576,"name":"Health sciences/Diseases"},{"id":56835577,"name":"Health sciences/Health care"},{"id":56835578,"name":"Health sciences/Medical research"},{"id":56835579,"name":"Biological sciences/Psychology"},{"id":56835580,"name":"Social science/Psychology"}],"tags":[],"updatedAt":"2026-05-04T08:55:56+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-28 16:44:13","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7673901","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7673901","identity":"rs-7673901","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}