How Does Contact Lens Wear Impact Quality of Life?
BY ERIC PAPAS, PHD, MCOPTOM, DIPCL, FAAO
It is probably fair to say that the majority of practitioners have experienced positive responses from their contact lens patients and so are of the opinion that, in general, patients like their contact lenses and would be highly resistant to any suggestion that they give them up. Such reactions appear to indicate that contact lenses have a beneficial impact on the quality of life of their wearers.
Assessing Quality of Life
Several quality of life assessment instruments have relevance to vision and are applicable to refractive corrections. These tools all have similar basic designs in that they ask a series of questions related to several areas of experience that are familiar to participants by virtue of their use of the correcting modality.
Known as “dimensions,” these experiential groupings are adjusted during the development of the questionnaire, using statistical procedures such as Rasch analysis, to ensure that each is psychometrically distinct from all the rest. Thus, questions about cosmesis, for example, do not overlap with those about visual efficacy at distance or near. In this way, it is possible to derive a meaningful score for the instrument as a whole as well as probe the relative contributions of the various dimensions that make up the total wearer experience.
A few studies in the literature have used this type of instrument to compare the quality of life impact of contact lenses with that of other correction methods. To me, at least, the results are quite thought provoking.
As an example, let us look at the comparison between contact lenses and spectacles—surely a contest you might think would be a win for the contact lens team? Two studies (Hays et al, 2003; Queirós et al, 2012), conducted nine years apart but using the same questionnaire, made this evaluation, and the results are in reasonably good agreement. Predictably, contact lenses came out as being highly rated for appearance and cosmetic factors, and were seen as moderately less restrictive during active pursuits.
On the downside, however, subjects reported that during contact lens wear, they experienced more problems with fluctuating vision. When asked about their overall satisfaction with the two modalities, there was, in fact, no significant difference between the sampled populations.
A very similar trend emerged from a third study that used a different questionnaire (Pesudovs et al, 2006). Here participants were positive toward the benefits of contact lenses in various lifestyle-related areas. For example, they liked the fact that they could wear non-prescription sunglasses. They also had less trouble during activities such as going to the gym and driving in conditions in which glare was present. In addition, contact lens wearers reported that they felt more attractive and that they received more compliments on their appearance compared to spectacle wearers. Despite these positive responses, however, the overall impact on their quality of life score was only mildly in favor of contact lens correction.
A Bigger Difference for Younger Patients
While all of the previously mentioned studies were conducted among adults, contact lenses did receive more favorable responses when children and teenagers were surveyed (Rah, 2010). Once again, spectacles fared particularly poorly in those dimensions concerned with appearance and physical activity, and, in this younger group, the “satisfaction with correction” scores were markedly superior for the contact lens wearers. The questionnaire instrument used in this work was apparently not validated, but the results do suggest that younger subjects are more positively disposed toward contact lenses than they are toward spectacles.
Even so, it seems that the rosy glow wanes as adolescence passes and has largely abated by the time the cares of adulthood arrive.
Where Do We Go from Here?
This is quite depressing, and it is even more sobering to consider how the quality of life experienced with contact lenses compares with that of uncorrected emmetropes or those having undergone refractive surgery. For both of these modalities, “satisfaction with correction” scores are considerably higher compared to those of contact lens wearers. Although it is encouraging that the gap may have narrowed slightly in work conducted more recently, it remains a substantial enough differential to demonstrate a need for improvement.
We can derive some idea of where to concentrate our efforts in that regard by scrutinizing the quality of life data. The three key areas that emerge are 1) symptoms, 2) vision, and 3) dependence on correction.
Symptoms Taking these in order, the issue of contact lens discomfort has been a recognized problem for many years as well as the subject of much recent discussion (Nichols et al, 2013). The perspective offered by a quality of life analysis does nothing but accentuate the importance of continuing to pursue research and apply clinical management strategies (Papas et al, 2013) that will eliminate this particular problem.
Vision That vision should feature on the list is something of a slap in the face for us all. Providing excellent visual outcomes is surely the primary purpose of our professional activities, and yet the evidence indicates that contact lenses often fail in this regard.
Perhaps it is time to refocus (pun intended) some of our research resources into creating perceptibly better and more consistent visual outcomes for wearers. In the meantime, the onus remains on practitioners to do the best possible job of correcting the presenting refractive error, whatever its nature. This means utilizing all the available technology and options to deal with astigmatism, presbyopia, and perhaps even higher-order aberrations.
Dependence on Correction The final problem area is dependence on correction, which reflects the fact that relying on a device for which daily application, removal, and care are required is likely to be less favorable compared to when, as in the case of post-refractive surgery, there is no need for such paraphernalia. Simplifying the contact lens system thus emerges as a critical factor in the battle for qualitative equality. Anything that can be done to reduce the need for handling and compliance with multi-stepped cleaning/disinfection routines would be helpful.
In terms of current practices, utilizing daily disposables seems likely to be the closest approach to the ideal. Another potential alternative is extended wear, although the associated heightened risk of infection is a deterrent that remains to be controlled.
Further insight into these phenomena is evident when considering orthokeratology, which is one application of overnight wear that appears to be gaining in popularity (Efron et al, 2013). Quality of life studies with orthok show that it performs markedly better compared to regular soft contact lenses in both the areas of dependence on correction and symptoms (Lipson et al, 2005). In fact, for these two dimensions in which conventional contact lenses struggle, scores for ortho-k were similar to those for refractive surgery (Queirós et al, 2012).
The Search Continues
Unfortunately, ortho-k still is not the perfect alternative because it lacks in other areas such as glare performance. Nevertheless, these data do indicate that the potential exists for a contact lens correction to compete with other modalities in terms of subject “likes.” The ability to add these positive attributes in a clinically acceptable way is a critical challenge for our industry, but one that must be quickly accepted and vigorously pursued. CLS
For references, please visit www.clspectrum.com/references.asp and click on document #218.
Professor Eric Papas is executive director of Research & Development, Brien Holden Vision Institute and Vision Cooperative Research Centre, and professorial visiting fellow, School of Optometry & Vision Science, University of New South Wales, Sydney, Australia. The Brien Holden Vision Institute and Vision Cooperative Research Centre have received research funds from B+L, AMO, and Allergan and have proprietary interest in products from Alcon, Cooper-Vision, and Carl Zeiss. You can reach him at firstname.lastname@example.org.