Orbital exenteration, enucleation, and evisceration are surgical procedures that can have extremely significant psychological effects on patients. These interventions are often necessitated by severe ocular trauma, cancer, or other life-threatening conditions, resulting in significant changes in appearance and visual function. Patients can experience a variety of emotional responses such as depression, anxiety, and loss of self-esteem [1]. Loss of the eye or contents of the orbit can also cause body image disturbances, withdrawal from social life, and impaired interpersonal relationships [2]. Furthermore, people can also find it hard to alteration of depth perception and spatial awareness, which can be hampered in daily activities and independence [3]. Although these surgical procedures have been known to impact the quality of life of the affected patients, the extent of their psychiatric effects remains unclear.

To address this gap, we utilized Korean healthcare big data to analyze the patterns of psychiatric disorders in patients who underwent these procedures. This analysis can contribute to improved postoperative patient management and serve as a significant reference for determining the surgical approach between eye-sacrificing and eye-sparing surgery. Our study aimed to assess the incidence of new-onset psychiatric disorders in individuals, who underwent surgery and those who did not undergo surgery using data from a nationwide healthcare database.

This large-scale nationwide insurance claims database study aimed to assess the relationship between orbital ablative surgery and the development of psychiatric disorders such as depression, anxiety, and trauma-related disorders. The surgery group had significantly higher IRRs for all three conditions, with stronger effects in younger men (20-40 years). Patients with pre-existing comorbidities and high SES had lower HRs than those without. Wider resections were associated with higher psychiatric risk. This study examined the psychological impact of eye removal alongside social factors like SES and comorbidities, highlighting the need for integrated care strategies.

The increased incidence of psychiatric disorders, particularly trauma-related conditions, aligns with previous findings on post-surgical mental health risks [9,10]. Prior research has shown elevated depression and anxiety after major operations, reflecting the psychological burden of invasive procedures. Given that ocular removal often follows trauma [11], the high prevalence of trauma-related disorders may result from both initial injury and surgery. Surgery itself can function as a traumatic stressor [12], potentially triggering psychiatric symptoms in vulnerable individuals. Our findings underscore the complex interaction between physical trauma, surgical stress, and mental health outcomes. Psychiatric disorders were more common in surgery group 1, which underwent more extensive resections, suggesting that surgical extent influences psychiatric risk. Similar patterns have been noted in other surgical populations, where more invasive procedures are linked to worse mental health outcomes due to extended recovery periods, functional limitations, and aesthetic concerns [13]. Patients undergoing enucleation frequently report difficulties in maintaining social connections, hobbies, and occupational roles [14,15]. Nearly half experience challenges in sports and recreational activities they once enjoyed [14], contributing to poorer mental health outcomes, particularly in those receiving more extensive surgeries. Psychiatric risks declined over time. In men, HRs for psychiatric disorders, depression, and trauma-related disorders fell by 6 months, while anxiety declined after 1 year. In women, total disorders and depression decreased at 6 months; anxiety and trauma-related disorders declined more gradually. This suggests initial distress may reflect acute trauma reactions, while prolonged anxiety relates to identity challenges and long-term social adaptation—highlighting the need for extended psychological support.

Further analysis, stratified by gender and age, revealed distinct psychiatric risk patterns. Although depression, anxiety, and trauma-related disorders are more prevalent in women [16], men exhibited higher post-surgery incidence rates, particularly in the surgery group 1. Individuals aged 20-40 years had the highest incidence rates, which could be attributed to their career instability and financial insecurity. Job disruptions at this stage may have a greater impact as financial hardship is a known risk factor for mental health issues, including psychological distress and suicidal ideation [17,18]. Prior studies have suggested that job instability has a stronger psychological effect on men [19,20], which aligns with our findings that global and orbital ablative surgeries disproportionately affect younger men. Sudden income losses and employment disruptions have been linked to immediate psychological distress among younger individuals [21,22]. Lower SES was associated with higher psychiatric risk, reinforcing financial stability as a protective factor [23,24]. Limited economic resources may restrict access to rehabilitation, assistive devices, mental health care, and post-surgical distress [13]. In addition to functional impairments, the cosmetic impact of eye loss may contribute significantly to psychiatric distress. Facial appearance plays a crucial role in social interactions and self-identity, and disfigurement has been strongly associated with increased depression and anxiety, regardless of prosthetic rehabilitation [2,25]. Studies have indicated that visible facial deformities can lead to social avoidance, low self-esteem, and heightened emotional distress [26,27]. Younger individuals who are more sensitive to self-image and societal perceptions may be particularly affected [28,29]. The psychosocial burden of facial disfigurement has been shown to affect social functioning and emotional well-being, with a strong link to psychiatric disorders [27,30]. Additionally, lower education levels were correlated with higher depression levels, possibly because of reduced mental health awareness and care access [31,32]. These findings highlight the need for a multidimensional approach that integrates financial, social, and psychological support into postsurgical care. Addressing economic instability, social stigma, and functional rehabilitation may help to mitigate psychiatric distress, particularly in younger individuals and those undergoing extensive resections.

In our HR interaction analysis, only men aged 20-40 years had a significantly increased depression risk post-surgery. This effect was absent in women and other disorders, suggesting age- and gender-specific vulnerability. Several factors may contribute to this pattern. Young and middle-aged men often face strong gendered expectations and psychological pressures related to work and social roles. In Korean society, cultural norms emphasizing resilience and emotional restraint may, in part, discourage help-seeking, thereby increasing psychological strain [33,34]. However, gender differences in healthcare utilization, diagnostic patterns, and possible biological vulnerability may also underlie these findings [35-37]. Additionally, global and orbital ablative surgeries affect physical appearance, challenging masculinity and self-worth [2]. In contrast, women tended to use social support more effectively, aiding psychological recovery [38]. The greater impact in the 20-40 year age group may reflect heightened career and social pressures, where physical changes can affect professional and personal identity [39]. Career instability and self-perceived concerns may contribute to increased distress in younger man patients. Depression rather than anxiety- or trauma-related symptoms was the predominant psychological response, aligning with the long-term adaptation process to global and orbital ablative surgeries. Although anxiety and post-traumatic stress disorder like symptoms are common after acute trauma, prolonged social and occupational limitations are more likely to lead to depression [1,40]. In addition, men are more prone to internalizing distress, which may cause anxiety to progress into depression over time [41].

This study has several limitations. First, its retrospective design and reliance on claims data limited assessment of individual factors such as psychiatric history and social support. Because psychiatric diagnoses were identified through ICD-10 codes in insurance claims, potential underdiagnosis or misclassification cannot be excluded. Some patients with subclinical depression or anxiety may not have sought psychiatric care, leading to an underestimation of the true incidence of postoperative psychiatric disorders. Second, unmeasured confounders like resilience and informal support may have influenced outcomes. Third, using insurance premium quantiles for SES may have reduced precision. Fourth, the small size of surgery group 1 precluded direct matching, limiting subgroup comparisons. Fifth, although several interaction terms (time, comorbidity index, SES, and age group) were included in the Cox models, formal interaction testing between surgery and gender was not performed. Therefore, subgroup differences by gender should be interpreted with caution. Lastly, psychiatric outcomes were only tracked for three years, leaving long-term effects unknown. Future studies should include longer follow-up and broader psychosocial assessments.

In conclusion, this research identified a higher risk of psychiatric disorders among young men and those who received major resection. Financial instability, career disturbance, and appearance concern probably contributed to these findings. Using a large-scale population-based dataset with propensity score matching, this study minimized selection bias while providing insights into the roles of gender, age, SES, and surgical extent in psychiatric outcomes. These findings underscore the importance of comprehensive mental health care in ophthalmologic care, with a focus on early intervention and interdisciplinary treatment to enhance postoperative well-being.