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A comparison of vision-related quality of life between Defocus Incorporated Soft Contact (DISC) lenses and single-vision spectacles in Chinese children

  • Ding Han
    Affiliations
    Tianjin Key Laboratory of Retinal Functions and Diseases, Tianjin Branch of National Clinical Research Center for Ocular Disease, Eye Institute and School of Optometry, Tianjin Medical University Eye Hospital, Tianjin 300384, China
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  • Ziyu Zhang
    Affiliations
    Tianjin Key Laboratory of Retinal Functions and Diseases, Tianjin Branch of National Clinical Research Center for Ocular Disease, Eye Institute and School of Optometry, Tianjin Medical University Eye Hospital, Tianjin 300384, China
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  • Bei Du
    Affiliations
    Tianjin Key Laboratory of Retinal Functions and Diseases, Tianjin Branch of National Clinical Research Center for Ocular Disease, Eye Institute and School of Optometry, Tianjin Medical University Eye Hospital, Tianjin 300384, China
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  • Lin Liu
    Affiliations
    Tianjin Key Laboratory of Retinal Functions and Diseases, Tianjin Branch of National Clinical Research Center for Ocular Disease, Eye Institute and School of Optometry, Tianjin Medical University Eye Hospital, Tianjin 300384, China
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  • Meinan He
    Affiliations
    Tianjin Key Laboratory of Retinal Functions and Diseases, Tianjin Branch of National Clinical Research Center for Ocular Disease, Eye Institute and School of Optometry, Tianjin Medical University Eye Hospital, Tianjin 300384, China
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  • Zhuzhu Liu
    Affiliations
    Tianjin Key Laboratory of Retinal Functions and Diseases, Tianjin Branch of National Clinical Research Center for Ocular Disease, Eye Institute and School of Optometry, Tianjin Medical University Eye Hospital, Tianjin 300384, China
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  • Ruihua Wei
    Correspondence
    Corresponding author.
    Affiliations
    Tianjin Key Laboratory of Retinal Functions and Diseases, Tianjin Branch of National Clinical Research Center for Ocular Disease, Eye Institute and School of Optometry, Tianjin Medical University Eye Hospital, Tianjin 300384, China
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Open AccessPublished:August 18, 2022DOI:https://doi.org/10.1016/j.clae.2022.101748

      Abstract

      Objective

      This study aimed to compare the vision-related quality of life (VRQoL) between Defocus Incorporated Soft Contact (DISC) lenses and single-vision spectacles in Chinese children, in order to evaluate their visual performance and subjective acceptance of this bifocal designed contact lenses treatment.

      Methods

      Chinese participants aged 7 to 12 years, with myopia of −4.00 to −0.75 D, astigmatism < 1.50 D, and monocular best-corrected visual acuity 0.0 or better, were recruited in the study. All participants had been wearing DISC lenses, or single-vision spectacles, for the last 6 to 18 months and were requested to complete the routine ocular examination and Chinese version of the Pediatric Refractive Error Profile (PREP 2) questionnaire. The questionnaire consisted of 7 scales: vision, symptoms, appearance, activities, handling, peer perception, and overall score. According to their habitual correction modalities, fifty-four children were allocated to the DISC group and 56 to the single-vision spectacles group. A generalized linear model was fitted to assess variables associated with the PREP 2 score.

      Results

      Participants wearing DISC lenses scored significantly higher than those wearing single-vision spectacles for vision, appearance, activities, peer perception, and overall (all P < 0.05). The improvement of VRQoL in the DISC group was mainly represented in appearance, peer perception, and activities. The quality of life improved more for older participants on scales of vision, symptoms, handling, appearance, and overall score (all P < 0.05). The interaction between treatment and age was statistically significant for the activities scale (P < 0.05).

      Conclusion

      DISC lens wear significantly improves VRQoL in Chinese children compared with single-vision spectacles for most of the survey scales, especially in the areas of appearance, peer perception, and activities. The benefits provided by DISC lenses contribute to greater satisfaction than single-vision spectacles for myopic children.

      Keywords

      1. Introduction

      There is an epidemic of myopia in children worldwide in recent years, particularly in some developed countries of east and southeast Asia [
      • Morgan I.G.
      • French A.N.
      • Ashby R.S.
      • Guo X.
      • Ding X.
      • He M.
      • et al.
      The epidemics of myopia: Aetiology and prevention.
      ,
      • Morgan I.G.
      • Wu P.-C.
      • Ostrin L.A.
      • Tideman J.W.L.
      • Yam J.C.
      • Lan W.
      • et al.
      IMI Risk Factors for Myopia.
      ,
      • Flitcroft D.I.
      • He M.
      • Jonas J.B.
      • Jong M.
      • Naidoo K.
      • Ohno-Matsui K.
      • et al.
      IMI – Defining and Classifying Myopia: A Proposed Set of Standards for Clinical and Epidemiologic Studies.
      ,
      • Dolgin E.
      The myopia boom.
      ]. Because high myopia may result in severe pathological changes and consequent visual impairment, it is urgent and necessary to take measures to prevent the progression of myopia in this susceptible population. Various interventions have proved to be effective in myopic control for children [
      • Brennan N.A.
      • Toubouti Y.M.
      • Cheng X.u.
      • Bullimore M.A.
      Efficacy in myopia control.
      ,
      • Bullimore M.A.
      • Ritchey E.R.
      • Shah S.
      • Leveziel N.
      • Bourne R.A.
      • Flitcroft D.I.
      The risks and benefits of myopia control.
      ,
      • Cho P.
      • Tan Q.
      Myopia and orthokeratology for myopia control.
      ]. However, improper corrections could lead to poor vision-related quality of life (VRQoL), manifested as reduced visual performance, limitations in daily life activities, and decreased life satisfaction. Therefore, the VRQoL should also be focused upon to comprehensively evaluate the visual performance and subjective acceptance of these approaches.
      Some standardized questionnaires have been widely used to evaluated the VRQoL in clinical research. The Pediatric Refractive Error Profile (PREP) questionnaire has been specifically designed to evaluate VRQoL in children with refractive error [
      • Walline J.J.
      • Bailey M.D.
      • Zadnik K.
      Vision-specific quality of life and modes of refractive error correction.
      ,
      • Walline J.J.
      • Jones L.A.
      • Chitkara M.
      • Coffey B.
      • Jackson J.M.
      • Manny R.E.
      • et al.
      The Adolescent and Child Health Initiative to Encourage Vision Empowerment (ACHIEVE) study design and baseline data.
      ]. The PREP 2, an updated version of PREP, exhibits good reliability and validity, and could be used as a significant means of quantifying the visual performance and satisfaction levels between various refractive corrections [

      Andersen C, Walline JJ. Validation of the pediatric refractive error profile2, American Academy of Optometry, 2012, https://www.aaopt.org/detail/knowledge-base-article/validation-pediatric- refractive-error-profile-2.

      ,

      Andersen C. Validation and Repeatability of Pediatric Refractive Error Profile 2 (PREP 2), The Ohio State University, 2013.

      ,
      • Han D.
      • Gao M.
      • Du B.
      • Liu L.
      • Liu Z.
      • He M.
      • et al.
      The Chinese version of the Pediatric Refractive Error Profile2 (PREP2): Translation, validation and reliability.
      ]. Some studies compare the VRQoL scores in children wearing soft contact lenses (CLs) and single-vision spectacles, and the results reveal that participants with soft CLs report a better VRQoL, especially in the scales of appearance, activities and satisfaction with correction [
      • Walline J.J.
      • Gaume A.
      • Jones L.A.
      • Rah M.J.
      • Manny R.E.
      • Berntsen D.A.
      • et al.
      Benefits of contact lens wear for children and teens.
      ,
      • Walline J.J.
      • Jones L.A.
      • Sinnott L.
      • Chitkara M.
      • Coffey B.
      • Jackson J.M.
      • et al.
      Randomized trial of the effect of contact lens wear on self-perception in children.
      ,
      • Rah M.J.
      • Walline J.J.
      • Jones-Jordan L.A.
      • Sinnott L.T.
      • Jackson J.M.
      • Manny R.E.
      • et al.
      Vision specific quality of life of pediatric contact lens wearers.
      ]. Myopic children wearing orthokeratology (OK) contact lenses also report significant improvement in the VRQoL when compared to those wearing single-vision spectacles for all survey scales, except for handling and near vision [
      • Santodomingo-Rubido J.
      • Villa-Collar C.
      • Gilmartin B.
      • Gutiérrez-Ortega R.
      Myopia control with orthokeratology contact lenses in Spain: a comparison of vision-related quality-of-life measures between orthokeratology contact lenses and single-vision spectacles.
      ].
      Recent studies have indicated that the bifocal CLs could effectively retard myopia progression in children compared with single-vision spectacles [
      • Flitcroft D.I.
      • He M.
      • Jonas J.B.
      • Jong M.
      • Naidoo K.
      • Ohno-Matsui K.
      • et al.
      IMI – Defining and Classifying Myopia: A Proposed Set of Standards for Clinical and Epidemiologic Studies.
      ,
      • Aller T.A.
      • Liu M.
      • Wildsoet C.F.
      Myopia Control with Bifocal Contact Lenses: A Randomized Clinical Trial.
      ,
      • Anstice N.S.
      • Phillips J.R.
      Effect of dual-focus soft contact lens wear on axial myopia progression in children.
      ,
      • Lam C.S.Y.
      • Tang W.C.
      • Tse D.-Y.-Y.
      • Tang Y.Y.
      • To C.H.
      Defocus Incorporated Soft Contact (DISC) lens slows myopia progression in Hong Kong Chinese schoolchildren: a 2-year randomised clinical trial.
      ,
      • Li S.-M.
      • Kang M.-T.
      • Wu S.-S.
      • Meng B.o.
      • Sun Y.-Y.
      • Wei S.-F.
      • et al.
      Studies using concentric ring bifocal and peripheral add multifocal contact lenses to slow myopia progression in school‐aged children: a meta‐analysis.
      ]. However, few studies have focused on the visual performance and VRQoL in children wearing these lenses. One previous study indicated that Spanish children wearing MiSight CLs, a bifocal designed soft CLs, significantly improve VRQoL scores at 12- and 24-month follow-up visits, as regard appearance, satisfaction, activities, handling, peer perceptions, and the overall score in comparison with single-vision spectacles wear [
      • Pomeda A.R.
      • Pérez-Sánchez B.
      • Cañadas Suárez M.D.P.
      • Prieto Garrido F.L.
      • Gutiérrez-Ortega R.
      • Villa-Collar C.
      MiSight Assessment Study Spain: A Comparison of Vision-Related Quality-of-Life Measures Between MiSight Contact Lenses and Single-Vision Spectacles.
      ].
      With the dramatically growing incidence of myopia in at-risk child populations in China, parents are apparently worried and tend to use various approaches to control myopia progression. Low-concentration atropine eye drops have not been officially approved for myopia control by the Chinese Food and Drug Administration [
      • Jiang J.
      Expert consensus on myopia management white paper (2019).
      ]. Some specially designed lenses are popular among children in China, for example, bifocal soft CLs, OK contact lenses and bifocal spectacles. However, OK contact lenses are only officially approved for those no younger than eight years old in China, and are often provided to mild to moderate myopic children [

      The Group of Optometry, Society of Ophthalmology, Chinese Medical Association, Expert consensus on orthokeratology fitting process (2021), Chinese Journal of Optometry Ophthalmology and Visual Science 23 (2021) 1-5, https://10.3760/cma.j.cn115909-20201201-00464.

      ]. Meanwhile, many children or their parents tend to choose contact lenses because of their advantages for activities such as sports or dancing and prefer their appearance compared to spectacles [
      • Walline J.J.
      • Jones L.A.
      • Sinnott L.
      • Chitkara M.
      • Coffey B.
      • Jackson J.M.
      • et al.
      Randomized trial of the effect of contact lens wear on self-perception in children.
      ,
      • Rah M.J.
      • Walline J.J.
      • Jones-Jordan L.A.
      • Sinnott L.T.
      • Jackson J.M.
      • Manny R.E.
      • et al.
      Vision specific quality of life of pediatric contact lens wearers.
      ]. Therefore, bifocal soft CLs are an effective and distinctive choice for myopia control in China. The Defocus Incorporated Soft Contact (DISC) lens is a bifocal soft CL with a concentric ring design, comprised of a correction zone in the center and alternating treatment and correction zones extending towards the periphery. It is intended to simultaneously generate myopic retinal defocus and maintain clear vision [
      • Lam C.S.Y.
      • Tang W.C.
      • Tse D.-Y.-Y.
      • Tang Y.Y.
      • To C.H.
      Defocus Incorporated Soft Contact (DISC) lens slows myopia progression in Hong Kong Chinese schoolchildren: a 2-year randomised clinical trial.
      ]. DISC lenses have become increasingly popular for myopia control in China in recent years. However, previous studies have not investigated the vision-related quality of life among Chinese children wearing this bifocal CL.
      Therefore, the aim of this study was to compare the VRQoL between children wearing DISC lenses and single-vision spectacles in a sample of Chinese children using the Chinese version of the PREP 2 questionnaire, in order to evaluate the visual performance and subjective acceptance of this bifocal designed CL treatment.

      2. Materials and methods

      2.1 Participants

      This was a retrospective cross-sectional study. Chinese participants aged 7 to 12 years, with myopia from −4.00 to −0.75 D, astigmatism < 1.50 D, and monocular best-corrected visual acuity (BCVA) of 0.0 or better, participated in the study. All participants had already been wearing DISC lenses or single-vision spectacles for the last 6 to 18 months and had no systemic or ocular disease. Participants were recruited when they came back for the follow-up visit in the out-patient clinic of the Tianjin Medical University Eye Hospital, China.
      In the current study, the DISC lenses were bifocal and concentric designed soft CLs, consisting of a central correction zone to correct the refractive error, and a series of surrounding treatment and correction zones extending to the periphery, which could result in 3.00 diopters of myopic retinal defocus. The contact lenses were made from hydroxyethyl methacrylate, with 55 % water content, diameter of 14.2 mm, and base curve of 8.6 mm.
      The protocol of the study was reviewed and approved by the ethics committee of the Tianjin Medical University Eye Hospital, China, following the tenets of the Declaration of Helsinki. After a verbal explanation of the purpose and possible risks of the study, both the children and their parents provided informed consent to take part in the study.

      2.2 Measurements

      All participants were required to complete the Chinese version of the PREP 2 questionnaire before ocular examination. BCVA were obtained with the trial frame and recorded as the logarithm of the minimal angle of resolution (LogMAR). Refractive error was measured by cycloplegic subjective refraction using 1.0 % tropicamide drops. The demographic characteristics and duration of lens wearing was also recorded.
      The Chinese version of the PREP 2 questionnaire was translated according to standardized procedure and showed good acceptability, reliability, and validity [
      • Han D.
      • Gao M.
      • Du B.
      • Liu L.
      • Liu Z.
      • He M.
      • et al.
      The Chinese version of the Pediatric Refractive Error Profile2 (PREP2): Translation, validation and reliability.
      ]. It consisted of 7 scales: vision, symptoms, appearance, activities, handling, peer perception, and the overall score, and each scale contains 8 statements [
      • Han D.
      • Gao M.
      • Du B.
      • Liu L.
      • Liu Z.
      • He M.
      • et al.
      The Chinese version of the Pediatric Refractive Error Profile2 (PREP2): Translation, validation and reliability.
      ]. The answers of each statement consist of “strongly disagree,” “disagree,” “neutral,” “agree,” or “strongly agree,” with raw scores from 1 (negative) to 5 (positive) accordingly. The final scores were recorded by subtracting one from the raw score and multiplying by 25, and scaled from 0 (poor visual quality of life) to 100 (good visual quality of life). All participants were requested to read and complete all the 56 questions carefully, and choose only one answer for each question.
      The PREP 2 questionnaire was administered by a researcher who did not participate in the data processing. The children were asked to answer the questionnaire independently, and their parents could not give any suggestions and comments. If the children had difficulties completing the survey, the researcher could read and explain the questions to the participants.

      2.3 Statistical analysis

      Statistical analysis was performed using the Statistical Package for Social Sciences (SPSS) (version 26; IBM, Armonk, NY, USA). Kolmogorov-Smirnov tests were used to determine the normality of data. Mean and SD were reported for normally distributed data, while median, range, skewness, and kurtosis were reported for non-normally distributed data. Independent t-test and Mann-Whitney test were performed for normally and non-normally distributed data, respectively. A Chi-Square test was used for gender comparison. A generalized linear model (GLM) was fitted to assess variables associated with the PREP 2 score. The outcome was the score of each of the 7 scales. The predictors included treatment (DISC lenses vs Single-vision spectacles) and gender as categorical variables, and three continuous variables, i.e., the participant’s age, duration of lens wear, and spherical equivalent refractive error. A p-value of<0.05 was defined as statistically significant.

      3. Results

      A total of 110 participants were recruited for the study. Fifty-four children (49.1 %) were allocated to the DISC group and 56 (50.9 %) to the single-vision spectacles group according to the correction modalities. All the participants completed the Chinese version of the PREP 2 questionnaire and ocular examination. There were no statistically significant differences in any of the baseline demographics, refractive data, BCVA, and duration of lens wearing between the two groups (P > 0.05) (Table 1).
      Table 1Characteristics of demographic and ocular data for participants.
      DISC groupsingle-vision spectacles groupP
      Age, yrs*9 (7–12)9 (7–12)0.822
      Gender, male/female***25/2928/280.698
      SE for right eye, D**−2.42 ± 1.07−2.56 ± 1.050.486
      SE for left eye, D**−2.45 ± 1.05−2.47 ± 1.040.886
      BCVA, LogMAR*0.00 (−0.20–0.00)0.00 (−0.20–0.00)0.742
      Duration of waring lens, months*10 (6–18)12 (6–18)0.203
      SE, spherical equivalent; D, diopters; BCVA, best-corrected visual acuity; LogMAR, the logarithm of the minimal angle of resolution. Data are presented as median (range) for Age, BCVA and Duration of wearing lens, and as Mean ± SD for SE. *Mann-Whitney, **Independent t-test, ***Chi-Square test.
      single-vision spectacles.
      The observed PREP 2 scores for the DISC and single-vision spectacles groups are provided in Table 2. Five out of 7 scales of the differences in scores between the two groups were statistically significant (all P < 0.05), except for symptoms and handling (P = 0.199, 0.815, respectively). Participants wearing DISC lenses showed scores for vision, appearance, activities, peer perception, and overall that were significantly higher than those wearing single-vision spectacles (all P < 0.05). The improvement of vision-related quality of life in the DISC group was mainly represented in appearance and activities.
      Table 2Comparison of PREP scale scores between the DISC and single-vision spectacles group.
      DISC groupsingle-vision spectacles groupP
      Vision78.13 (50–100), −0.31/−0.1365.63 (50–93.75), 0.31/−0.03< 0.001
      Symptoms71.88 (28.13–96.88), −0.97/3.1271.88 (28.13–93.75), −0.77/0.340.199
      Appearance87.5 (56.25–100), −0.59/−0.1567.19 (37.5–93.75), −0.21/−0.30< 0.001
      Activities75 (37.5–96.88), −1.00/2.7659.38 (9.38–81.25), −0.94/0.96< 0.001
      Handling68.75 (37.5–100), −0.001/−0.0673.44 (40.63–90.63), −0.49/−0.460.815
      Peer perceptions79.69 (43.75–100), −0.87/0.5968.75 (28.13–96.88), −0.54/0.21< 0.001
      Overall78.13 (46.88–100), −0.68/0.0465.63 (37.5–100), 0.30/1.06<0.001
      Data are presented as median (range), skewness/kurtosis and p-values represent comparison between the DISC and single-vision spectacles group (Mann-Whitney test).
      Results of the Generalized linear model indicated that sex, BCVA, spherical equivalent, and duration of lens wear did not affect the score in any PREP 2 scales, while treatment and age had statistically significant effects on the scores of at least one of the scales. There were no significant interactions between treatment and age for six scales, except for activities. Therefore, the models for these scales fitted with main effects are shown in Table 3.
      Table 3Modeling of PREP 2 scales without significant interactions.
      Effect of treatment(95 %CI)PAge (increased per year) (95 %CI)P
      Vision9.15 (5.92–12.38)<0.0013.59 (2.57–4.61)<0.001
      Symptoms3.83 (−0.59–8.24)0.0892.31 (0.91–3.70)0.001
      Appearance17.01 (12.83–21.18)<0.0012.77 (1.45–4.09)<0.001
      Handling0.21 (−1.82–2.24)0.8376.70 (6.06–7.34)<0.001
      Peer perceptions12.63 (7.44–17.82)<0.0011.48 (−0.16–3.12)0.077
      Overall10.49 (6.83–14.15)<0.0013.65 (2.50–4.81)<0.001
      The results indicated that the PREP 2 score adjusted for sex, spherical equivalent, BCVA, durations of lens wear, and interactions were significantly higher in the DISC group than the single-vision spectacles group by about 9.1 points for the vision scale (P < 0.001). The scores also increased by about 3.6 points with every additional year of age (P < 0.001).
      The score was about 12.6 points higher for participants wearing contact lenses than spectacles in the peer perception scale (P < 0.001). For appearance and overall PREP 2 scales, the scores were significantly higher for DISC lenses wearers than single-vision spectacles wearers by about 17.0 and 10.5 points, respectively (both P < 0.001). Meanwhile, there was an age effect for these two scales regardless of treatment group, with about 2.7 points and 3.6 points higher scores for each additional year of age, respectively (both P < 0.001).
      As regard scales of symptoms and handling, the scores were not significantly different for DISC lenses wearers compared to spectacles wearers (P = 0.089, P = 0.837, respectively) after adjusting for sex, spherical equivalent, BCVA, durations of lens wear, and interactions. But the scores increased by about 2.3 points for symptoms scale (P = 0.001) and 6.7 points (P < 0.001) for handling scale with every increased year of age.
      The interaction between treatment and age was statistically significant for the activities scale (P < 0.05). The scores for the activities scale were significantly higher in the DISC group than single-vision spectacles group, and the differences were greater for the older participants.

      4. Discussion

      The results of this study showed that Chinese children wearing DISC lenses reported better vision-related quality of life compared with those wearing single vision spectacles for most of the survey scales, especially in the areas of appearance, peer perception and activities. These findings could be attributed to the improvement of cosmetic appearance and the convenience of participating in activities provided by DISC lenses in comparison to spectacles.
      With regards to the visual performance scale, better vision was reported with DISC lenses in this study, despite of the fact that there was no significant difference in BCVA between the two groups. This may reflect the observation, reported by several studies, that visual acuity is an unsatisfactory indicator of visual performance, and that subjective measures offer better sensitivity [
      • Papas E.B.
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      Utility of short-term evaluation of presbyopic contact lens performance.
      ,
      • Diec J.
      • Tilia D.
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      • Bakaraju R.C.
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      ,
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      • Sha J.
      • Diec J.
      • Thomas V.
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      ]. Nevertheless, reduced visual acuity and stability [
      • Chen S.-T.
      • Tung H.-C.
      • Chen Y.-T.
      • Tien C.-L.
      • Yeh C.-W.
      • Lian J.-S.
      • et al.
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      ], or worse near vision [
      • Pomeda A.R.
      • Pérez-Sánchez B.
      • Cañadas Suárez M.D.P.
      • Prieto Garrido F.L.
      • Gutiérrez-Ortega R.
      • Villa-Collar C.
      MiSight Assessment Study Spain: A Comparison of Vision-Related Quality-of-Life Measures Between MiSight Contact Lenses and Single-Vision Spectacles.
      ], have been reported when wearing progressive or bifocal contact lenses, compared to single-vision spectacles, while other studies failed to find any significant difference for near vision [
      • Walline J.J.
      • Gaume A.
      • Jones L.A.
      • Rah M.J.
      • Manny R.E.
      • Berntsen D.A.
      • et al.
      Benefits of contact lens wear for children and teens.
      ,
      • Yang B.i.
      • Ma X.
      • Liu L.
      • Cho P.
      Vision-related quality of life of Chinese children undergoing orthokeratology treatment compared to single vision spectacles.
      ]. These variable outcomes may be due to differences in the optical design of the contact lens, or other factors, such as misalignment with the pupil center.
      There was no significant difference in daytime symptoms between the two groups in the current study. The results were similar to a previous report showing that symptoms did not differ between children wearing bifocal CLs and single-vision spectacles at 24 months follow-up, despite being significantly higher with the CLs at 12 months [
      • Pomeda A.R.
      • Pérez-Sánchez B.
      • Cañadas Suárez M.D.P.
      • Prieto Garrido F.L.
      • Gutiérrez-Ortega R.
      • Villa-Collar C.
      MiSight Assessment Study Spain: A Comparison of Vision-Related Quality-of-Life Measures Between MiSight Contact Lenses and Single-Vision Spectacles.
      ]. Other studies have reported a range of visual complications with bifocal and multifocal contact lens including positive dysphotopsia, altered contrast sensitivity, light disturbance, and poorer visual comfort scores compared to single-vision CLs [
      • Chamberlain P.
      • Peixoto-de-Matos S.C.
      • Logan N.S.
      • Ngo C.
      • Jones D.
      • Young G.
      A 3-year Randomized Clinical Trial of MiSight Lenses for Myopia Control.
      ,
      • García-Marqués J.V.
      • Macedo-De-Araújo R.J.
      • Cerviño A.
      • García-Lázaro S.
      • McAlinden C.
      • González-Méijome J.M.
      Comparison of short-term light disturbance, optical and visual performance outcomes between a myopia control contact lens and a single-vision contact lens.
      ]. Orthokeratology, however, is associated with fewer symptoms of dryness, itching, and burning compared to either soft CLs [
      • Lipson M.J.
      • Sugar A.
      • Musch D.C.
      Overnight corneal reshaping versus soft daily wear, A visual quality of life study (interim results).
      ,
      • Lipson M.J.
      • Sugar A.
      • Musch D.C.
      Overnight corneal reshaping versus disposable contact lenses: vision related quality-of-life differences from a randomized clinical trial.
      ] or single-vision spectacles [
      • Santodomingo-Rubido J.
      • Villa-Collar C.
      • Gilmartin B.
      • Gutiérrez-Ortega R.
      Myopia control with orthokeratology contact lenses in Spain: a comparison of vision-related quality-of-life measures between orthokeratology contact lenses and single-vision spectacles.
      ], perhaps because wear is limited to the hours of sleep.
      It was noted from the symptom scales in the current study that scores increased by about 2.3 points with every additional year of age, regardless of different treatment. Walline et al. reported a similar improvement in older participants, speculating that better visual-related quality of life may be more obvious after ten years of age [
      • Rah M.J.
      • Walline J.J.
      • Jones-Jordan L.A.
      • Sinnott L.T.
      • Jackson J.M.
      • Manny R.E.
      • et al.
      Vision specific quality of life of pediatric contact lens wearers.
      ]. Clinical experience suggests that as children get older, they are able to avoid habits such as eye rubbing, and become less reactive to uncomfortable symptoms. These factors may be contributing to the age-related differences seen in the data.
      The better performance on appearance, peer perception, activities and overall scores with DISC lenses in comparison with single-vision spectacles agreed with one previous study [
      • Pomeda A.R.
      • Pérez-Sánchez B.
      • Cañadas Suárez M.D.P.
      • Prieto Garrido F.L.
      • Gutiérrez-Ortega R.
      • Villa-Collar C.
      MiSight Assessment Study Spain: A Comparison of Vision-Related Quality-of-Life Measures Between MiSight Contact Lenses and Single-Vision Spectacles.
      ], and the improvements were greater in older children for the appearance and overall scores. Another study [
      • Walline J.J.
      • Jones L.A.
      • Sinnott L.
      • Chitkara M.
      • Coffey B.
      • Jackson J.M.
      • et al.
      Randomized trial of the effect of contact lens wear on self-perception in children.
      ] using the Self-Perception Profile for Children, included physical appearance, athletic competence, and peer interactions components, and while this is a different kind of questionnaire to that used in the current study, the results were similar in finding advantages for contact lenses over spectacle. Likewise, improvements on these scales with OK CLs were shown by Yang et al. [
      • Yang B.i.
      • Ma X.
      • Liu L.
      • Cho P.
      Vision-related quality of life of Chinese children undergoing orthokeratology treatment compared to single vision spectacles.
      ], and Santodomingo et al. [
      • Santodomingo-Rubido J.
      • Villa-Collar C.
      • Gilmartin B.
      • Gutiérrez-Ortega R.
      Myopia control with orthokeratology contact lenses in Spain: a comparison of vision-related quality-of-life measures between orthokeratology contact lenses and single-vision spectacles.
      ] Presumably, it is the perceived enhancement of appearance and the convenience of engaging in activities without spectacles during the daytime that drives these outcomes. In contrast, Garcia et al. reported that the bifocal designed soft CLs worsened the satisfaction and psychometric visual-related quality compared to a single-vision CLs in the same material [
      • García-Marqués J.V.
      • Macedo-De-Araújo R.J.
      • Cerviño A.
      • García-Lázaro S.
      • McAlinden C.
      • González-Méijome J.M.
      Comparison of short-term light disturbance, optical and visual performance outcomes between a myopia control contact lens and a single-vision contact lens.
      ]. However, this assessment was made in adults, after only 25 min of wear, in dim-light conditions, which may explain the different results compared to the current study. Overall, it appears that contact lenses provide good visual performance and increase satisfaction with recreational activities and cosmetic appearance, especially among older children who are likely to pay more attention to these factors.
      With regards to scales of handling, no significant differences were found between children wearing DISC lenses and single-vision spectacles, which disagreed with previous studies. Pomeda et al. surprisingly found that the rated score of handling with CLs was higher than spectacles in children, and they assumed the reason was the strong desire to use contact lenses for vision correction and enjoy the perceived convenience they provided [
      • Pomeda A.R.
      • Pérez-Sánchez B.
      • Cañadas Suárez M.D.P.
      • Prieto Garrido F.L.
      • Gutiérrez-Ortega R.
      • Villa-Collar C.
      MiSight Assessment Study Spain: A Comparison of Vision-Related Quality-of-Life Measures Between MiSight Contact Lenses and Single-Vision Spectacles.
      ]. A different study found lower handling scores with OK CLs than for spectacles; [
      • Yang B.i.
      • Ma X.
      • Liu L.
      • Cho P.
      Vision-related quality of life of Chinese children undergoing orthokeratology treatment compared to single vision spectacles.
      ] a result which, while children and adolescents are reported to be competent and capable of independently managing contact lenses of all types (soft, daily disposable, rigid gas permeable and OK) [
      • Rah M.J.
      • Walline J.J.
      • Jones-Jordan L.A.
      • Sinnott L.T.
      • Jackson J.M.
      • Manny R.E.
      • et al.
      Vision specific quality of life of pediatric contact lens wearers.
      ,
      • Pomeda A.R.
      • Pérez-Sánchez B.
      • Cañadas Suárez M.D.P.
      • Prieto Garrido F.L.
      • Gutiérrez-Ortega R.
      • Villa-Collar C.
      MiSight Assessment Study Spain: A Comparison of Vision-Related Quality-of-Life Measures Between MiSight Contact Lenses and Single-Vision Spectacles.
      ,
      • Katz J.
      • Schein O.D.
      • Levy B.
      • Cruiscullo T.
      • Saw S.-M.
      • Rajan U.
      • et al.
      A randomized trial of rigid gas permeable contact lenses to reduce progression of children’s myopia.
      ,
      • Li L.
      • Moody K.
      • Tan D.T.
      • Yew K.C.
      • Ming P.Y.
      • Long Q.B.
      Contact lenses in pediatrics study in Singapore.
      ,
      • Cho P.
      • Cheung S.W.
      • Edwards M.
      The longitudinal orthokeratology research in children (LORIC) in Hong Kong: A pilot study on refractive changes and myopic control.
      ,
      • Horner D.G.
      • Soni P.S.
      • Salmon T.O.
      • Swartz T.S.
      Myopia progression in adolescent wearers of soft contact lenses and spectacles.
      ], might be attributed to the strict care procedures required to maintain safety and avoid complications during wear [
      • Cho P.
      • Cheung S.W.
      • Mountford J.
      • White P.
      Good clinical practice in orthokeratology.
      ]. Certainly, in the present study, enrolled participants wore DISC for 6 months without significant issues and handling scores improved by about 6.7 points per year of age, so it may not be so surprising that performance was not different between the two groups.
      The current study had a retrospective design, and a prospective investigation would be preferable in future, to reduce the effects of recall bias. Since all the children wore their CLs or spectacles for 6–18 months and the visual-related quality of life stabilizes after 3 months [

      Andersen C, Walline JJ. Validation of the pediatric refractive error profile2, American Academy of Optometry, 2012, https://www.aaopt.org/detail/knowledge-base-article/validation-pediatric- refractive-error-profile-2.

      ], the current results are likely to reflect real-world VRQoL responses. On the other hand, visual performance among children with high myopia may differ from those with low to moderate myopia [
      • Liou S.W.
      • Chiu C.J.
      Myopia and contrast sensitivity function.
      ], so it would be useful to compare between these levels. Unfortunately, access to sufficient numbers of children with high myopia, who are wearing DISC lenses, was limited in this case, but this remains an interesting avenue for further study.
      In conclusion, DISC lenses wear significantly improved the vision-related quality of life in Chinese children, compared with single-vision spectacles wear, for most of the survey scales, especially in the areas of appearance, peer perception and activities. The benefits provided by DISC lenses beyond efficacy in the retardation of myopia contribute to greater satisfaction than with single-vision spectacles for myopic children.

      Funding

      This work was supported by the National Natural Science Foundation of China [grant number 82070929].

      Declaration of Competing Interest

      The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

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