Article Text

Original research
Impact of defocus incorporated multiple segments (DIMS) spectacle lenses for myopia control on quality of life of the children: a qualitative study
  1. Mobashir Fatimah1,
  2. Sumita Agarkar2,
  3. Anuradha Narayanan1
  1. 1Elite School of Optometry, Medical Research Foundation, Chennai, Tamilnadu, India
  2. 2Department of Pediatric Ophthalmology and Strabismus, Sankara Nethralaya, Chennai, Tamil Nadu, India
  1. Correspondence to Dr Anuradha Narayanan; anuradhan123{at}gmail.com

Abstract

Objective To assess the impact of DIMS (defocus incorporated multiple segments) spectacle lenses on the quality of life of children using it.

Methods Separate in-depth interviews were conducted with children using DIMS as a myopia control strategy for at least 1 month and their parents based on prepared guides. The recorded audio of the interviews was transcribed, and the significant data points were coded using a hybrid approach, that is, both the inductive and deductive coding methods were used to identify themes. The generated codes were further grouped, categorised and finally fitted as per relevance into the subdomains of the four domains of the WHO Quality of Life—Brief framework, namely the domains of social relationships, physical, psychological and environmental health.

Results A total of 29 interviews were conducted, 15 with children (mean age: 12.47±2.13 years) and 14 with parents. Thematic analysis was done and a total of 63 codes were generated with 2, 16, 17 and 28 codes aligning to the domains of social relationships, environmental, psychological and physical health, respectively. Most parents did not notice any change in their child’s visual behaviour, yet children did experience symptoms such as peripheral blurred vision, eyestrain, headache, haloes and more during the adaptation period. High-cost, scratch-prone nature and difficulty in procurement were a few concerns raised by parents.

Conclusions Participants were satisfied with most of the facets of social relationships, physical and psychological health domains. However, a few facets such as quality, accessibility and finance of the environmental health domain need improvement.

  • Child health (paediatrics)

Data availability statement

No data are available. No data are available

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WHAT IS ALREADY KNOWN ON THIS TOPIC

  • Defocus incorporated multiple segments (DIMS) is a novel myopia control spectacle lenses having a special optical design. Several studies have explored the visual functions and adaptation of DIMS lenses. However, quality of life with DIMS lenses remains unexplored in the current literature.

WHAT THIS STUDY ADDS

  • This study explores the quality of life of children using DIMS and highlights the merits and challenges of using DIMS. Children and their parents were found to be happy with DIMS as a myopia control option. However, it needs to be improved in aspects of quality, accessibility and affordability.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

  • This study can help in further improvement of DIMS as a myopia control option by aiding in a better understanding of DIMS for the stakeholders, that is, eye care practitioners, the children requiring DIMS and their parents to achieve the intended objective of myopia management.

Introduction

Myopia is becoming increasingly common around the world, reaching alarmingly high levels.1 Moreover, the yearly incidence of myopia onset in school-going children is constantly rising, outlining the need to standardise approaches early in life to control the progression of myopia2 as it can cause everlasting sight-threatening complications like glaucoma,3 retinal detachment and myopic macular degeneration.4 This may have a negative impact on the quality of life (QOL).5 The WHO defines QOL as a subjective assessment of one’s view of reality in relation to one’s goals as seen through one’s own lens.6 To prevent myopia progression, various forms of antimyopia interventions are being explored.7–9 One such intervention is defocus incorporated multiple segments (DIMS) spectacles, a novel spectacle lens that has been found to slow down the myopic progression by 52% in terms of the refractive power of the eye and 62% in terms of axial length elongation of the eye.10 These spectacle lenses have a central 9 mm clear zone carrying a distance correction inducing a sharp image on the retina and about 400 small, circular lenslets carrying power of a +3.50 D ADD inducing a myopic defocus,10 which is suspected to be an inhibiting factor for axial length elongation.11

Several studies12–15 have assessed the effect of DIMS on the visual functions of the eye and it was found that DIMS do not alter any visual functions of the eye apart from peripheral visual acuity and contrast sensitivity. A couple of studies14 16 reported that DIMS can decrease visual acuity in the periphery by as much as 0.3 Log MAR units. However, all these studies assess the objective parameters and patient-reported outcome measures (PROMs) have received less attention in the current literature. PROMs are tools employed to assess the QOL of an individual. PROMs aid in assessing the impact of a healthcare intervention on an individual’s QOL.17 Vision-related quality of life can be defined as ‘the degree to which vision impacts an individual’s ability to complete activities of daily living (ADLs) and one’s social, emotional and economic well-being’.18 Several vision-specific QOL research has been conducted to evaluate the visual functioning of individuals with vision impairments.19–21 A couple of studies have been done to assess the QOL of individuals receiving myopia management through contact lenses (CLs)22 and atropine eye-drops.23 However, there is a scarcity of evidence on assessing the overall QOL of patients receiving myopia control treatment. Keeping in mind how much FDA emphasises the use of PROMs24 to gauge the effectiveness of a treatment strategy which might have a significant impact on the patient’s functionality and QOL, a qualitative study using in-depth interviews (IDIs) was conducted to assess the overall QOL of children through the perspectives of children and their parents. Instead of using questionnaires, qualitative research was used as it can provide deeper insights into an individual’s thoughts, feelings and experiences.25

Materials and methods

Study design

Snapshot (cross-sectional) qualitative study in which IDIs were conducted at a tertiary eye care centre in Chennai, India between October 2022 and February 2023. Patients or the public were not involved in the design, or conduct, or reporting, or dissemination plans of our research. To maintain the rigour of the qualitative research, guidelines of COnsolidated criteria for REporting Qualitative research were followed (checklist available in online supplemental material). The theory of narrative approach26 was opted. This means weaving together a sequence of events as narrated by the participants in the interviews to generate themes (thematic analysis).

Participants

Purposive sampling was done to recruit children using DIMS and their parents from the myopia clinic of a tertiary eye care centre in Chennai, India. This means participants were selected based on the rationale for being the most informative. Children who had experience using usual single-vision (SV) glasses in the past before using DIMS and had used it for a minimum of 1 month at least were included. Those who were not verbally active or were on any other myopia control strategies in combination with DIMS were excluded. The sample size was determined based on the data saturation technique.27 In other words, interviews were conducted till the time it was realised that no new information was being obtained from the subsequent interviews.

Procedure

Semistructured IDIs were conducted based on a prepared guide. The interview guide (available in online supplemental material) was prepared based on the current literature16 28 29 and considering the day-to-day activities in a child’s life from what is known from the clinical experience of the authors and keeping in mind the ‘WHO Quality of Life Brief’ (WHOQOL-BREF) framework. Questions were finalised after discussion with a qualitative study expert and an expert from the field of myopia research. All the interviews were conducted by MF. Even though children and their parents had separate IDI sessions, parents were allowed to accompany the children but were requested to avoid interruption and keep the interaction as less as possible to eliminate the chances of influencing the child’s response. Interviews were conducted either face to face in a tertiary eye care centre or over telephone calls as per the convenience of the participants. Languages used were English or Hindi (a common Indian Language). All the interviews were audio recorded after obtaining consent from the parents and assent from the children. Interview transcripts were not returned to the participants for feedback as it was deemed to be burdensome for them.

Main outcomes and measures

The perspective of children using DIMS was the primary outcome of the study whereas their parent’s perspective was the secondary outcome.

Data analysis

Microsoft Excel 2016 was used for storing the interview transcripts and manually analysing them. For analysis, the recorded interviews were transcribed verbatim and entered into Microsoft Excel. The transcribed data were then translated into English if the interview was conducted in Hindi. Each transcript was read several times to get familiarised. The translated data were then coded, that is, were assigned labels. To maintain the rigour of thematic analysis, a hybrid approach30 was used to identify themes. This means that both inductive (forming new themes) and deductive coding methods (using a preconstructed theme) were used. Even though the deductive analysis was performed concurrently because the same framework was used for both. The codes were grouped into categories which were further fitted into the relevant subdomains of the WHOQOL-BREF framework. WHOQOL-100 was found to be too lengthy31 for our study. Hence, WHOQOL-BREF, an abbreviated version of WHOQOL-100 was used. Coding was done by two investigators separately and two separate code books were made. Each codebook was then verified by jointly discussing together to make a reference codebook which was then used for the analysis of subsequent transcripts. On revisiting the codebooks, it was realised that themes identified inductively fit well enough into the subdomains of the WHOQOL-BREF. Hence, finally, all of the codes were fitted into the framework of WHOQOL-BREF deductively. Interviews of parents and children were transcribed individually, and inductive thematic analysis was done separately for them. Then, deductive analysis was performed concurrently as the same framework was used for both.

Results

A total of 29 IDIs were conducted, out of which 15 were of children (mean age: 12.47±2.13 years) and 14 were of their parents (demographics present in table 1). A total of 33 people were approached for the study out of which 4 refused due to lack of interest. The number of male and female participants was almost the same. The children were using DIMS on an average for 8 months and wore it for 12–16 hours per day. Spherical equivalent refraction of the children ranged from −2.25 D to −9.00 D and the best-corrected visual acuity was 6/9 or better in each eye.

Table 1

Demographic and clinical profile of the participants and information on the in-depth interviews (IDIs)

As this is a qualitative study, results will be displayed in the form of quotes (present in table 2) from the participants and codes rather than numbers. Significant data points obtained from the transcripts were coded and a total of 63 codes were generated which were categorised, further grouped into several subdomains and fitted into the four domains of WHOQOL-BREF namely, Physical Health (28 codes), Psychological Health (17 codes), Social Relationships (2 codes) and Environmental Health (16 codes) as per relevance. All the responses from the participants including the positives and the challenges faced while using DIMS have been reported domain-wise in the form of codes in figure 1 (physical health domain), figure 2 (psychological health domain), figure 3 (environmental health domain) and online supplemental figure (social relationship domain). Quotes from the participants were identified by assigning ‘IDIC’ for children and ‘IDIPAR’ for their parents followed by a unique number for each. We have replaced the brand name of the spectacles with ‘DIMS’ in the quotes from the participants.

Table 2

Quotes from the participants (derived from the interview transcripts)

Figure 1

Code tree depicting the codes grouped, categorised and fitted in the subdomains of the Physical Health domain. ADL, activity of daily living; CL, contact lense; DIMS, defocus incorporated multiple segments.

Figure 2

Code tree depicting the codes grouped, categorised and fitted in the subdomains of the psychological health domain. DIMS, defocus incorporated multiple segments.

Figure 3

Code tree depicting the codes grouped, categorised and fitted in the subdomains of the environmental health domain.

Domain 1: physical health

Most of the DIMS wearers complained about having symptoms like peripheral blurred vision, eyestrain, dizziness, headache, image jump, haloes, shaking of objects, uneasiness and magnified view during the adaptation period. All the symptoms except peripheral blurred vision faded away with time. The adaptation period ranged from 2 days to 1 month. A child narrated an incident of how he was facing difficulty while riding his bicycles in the initial days of DIMS lens wear but within a few days, he adapted to them and could ride his bicycle smoothly even with his glasses on. Most of the children and their parents preferred DIMS over other myopia control options like atropine eye-drops and CLs. Most parents did not opt for CL as they thought their child was too young to handle CLs. They found it to be cumbersome and less safe. When it comes to atropine eye-drops, parents did not opt for them because of their invasive nature.

Few children in our study had a history of using atropine in the past and later switched to DIMS. Even they preferred DIMS lenses over atropine, complaining that the latter gave them headaches and irritated their eyes.

All children reported that their vision was blurred while seeing through the peripheral zones of DIMS. Most of them were not significantly bothered by it. One child reported that he used coping strategies like lowering his head or moving himself to see through the central clear zone.

Subdomain: mobility

Most of the children had difficulty climbing the stairs during the adaptation period because of symptoms such as image jump and slanted view.

Subdomain: impact on ADL

Predominantly, most subjects did not have difficulties in performing ADLs. However, a participant reported that she has difficulty reading minute text when viewing through the peripheral defocus zone. Likewise, few children reported difficulties copying from the blackboard. They said that it takes a while to refocus again on the notebook after seeing the blackboard.

Subdomain: dependence on medical aid

Parents of children using DIMS complained that because of the high cost, maintenance and availability in select locations, they can afford only one pair of DIMS spectacles at a time. This makes the child dependent on the only pair of DIMS spectacle lenses.

Domain 2: psychological health

Parents expressed their satisfaction with the ‘normal look’ of the lenses. A parent said that if DIMS glasses did not look as normal as it does, he would have not chosen them as that could subject his child to bullying at school.

Subdomain: positive feelings

If children’s myopic power got stable at the follow-up visit after using DIMS lenses, parents were satisfied. Most of the parents could not detect the lenslets but those who could detect them had a feeling of assurance about the glasses being special treatment glasses.

Subdomain: negative feelings

When children’s myopic power did not get stable after using DIMS lenses, parents expressed their heartfelt disappointment.

Domain 3: social relationships

Children were particular about safeguarding their spectacles from their peers but none of them reported any such event which could affect their relationship with their friends. They did not even have any difficulty participating in team activities like sports.

Domain 4: environmental health

Subdomain: healthcare: quality

A mother reported that DIMS lenses are robust. She narrated an incident on how once the spectacles fell and the frame broke but nothing happened to the lenses. Several parents expressed their concern about DIMS lenses being prone to scratches. Additionally, a mother complained about the unavailability of the photochromic feature which usually comes with SV glasses.

Subdomain: healthcare: accessibility

Parents found the general maintenance of DIMS lenses like repair and replacement difficult. They were apprehensive that if the spectacles gets damaged, they would not find a dispensing unit to amend it. It was a matter of concern for most parents that DIMS lenses are not available in all optical outlets in all the cities.

Subdomain: transport

The only mode of transport driven by the children was a bicycle. None of them reported any issues riding a bicycle wearing DIMS lenses.

Subdomain: participation in leisure activities

DIMS did not prevent the children from participating in any kind of sports as they usually did. Children in our study all kinds of sports like cricket, dodgeball, football, badminton and basketball.

Subdomain: finance

Most of the parents complained about DIMS lenses being expensive. They suggested lowering the cost so that all parents whose children require these spectacles can attain them. However, a few parents reported having no issues with the cost of the DIMS lenses. They said that as long as DIMS lenses are aiding in myopia control for their child, they do not mind spending on them.

Discussion

To the best of our knowledge, this is the first qualitative study done to assess the QOL of children using a novel myopia control spectacle lens, DIMS. This study highlights the merits and challenges faced by using DIMS from the perspectives of the children using it and their parents.

Perspectives of parents were also taken into account in this study as they are one of the most important stakeholders when treatment is implemented in a paediatric population. Although there is a considerable amount of evidence in the literature that children can self-report their health,32 33 parents’ perspectives can help in overcoming any potential cognitive limitations in children.34 Additionally, a few subdomains of the WHOQOL-BREF were found to be parent-specific like the subdomains of financial resources and healthcare-accessibility.

Peripheral blurred vision was the most frequently reported symptom in our study, consistent with findings from a study by Lu et al.16 Although all children reported to have peripheral blurred vision, it had no impact on their ADLs. This aligns with the current literature which states that even though DIMS lenses can decrease visual acuity in the periphery by 0.3 log MAR units,14 16 neither it affects the gross recognition of objects14 nor causes any significant alterations in the monocular or binocular visual functions of the eyes.12 13 15 Apart from peripheral blurred vision, DIMS wearers reported many other symptoms, eye strain being one of them. This is in contrast to the findings by Ryu et al who reported that DIMS lenses could decrease eyestrain from a visual search task.35 The study10 that reports the effectiveness of DIMS over a 2-year RCT also discusses the visual symptoms experienced by the DIMS users and found that symptoms like dizziness and headache occurred occasionally whereas these symptoms were frequently experienced by the participants of our study. Using a narrative approach helped to understand these sequence of events including challenges faced with DIMS lenses and how the children adapted to them. Although there is a study16 which recruited volunteers who reported on the visual symptoms experienced with DIMS, to the best of our knowledge our study is the only one to extensively report on these symptoms using patient-reported outcomes (PROs).

In our study, the majority of the children and their parents preferred DIMS over atropine and CL as a myopia control option. They found using spectacle lenses is easier as compared with the otheranti-myopia interventions. This is similar to the findings of the Contact Lens And Myopia Progression study.36 Our study participants reported DIMS to be less cumbersome, safe, easy to handle, convenient to use and associated with fewer side effects. This was reported in comparison to other antimyopia control options like atropine which is associated with adverse effects such as photophobia and allergy in the current literature.37

Children and especially parents were satisfied that DIMS looked like any other usual SV glasses. Despite being a treatment entity, which is worn by the child throughout the time he/she attends school, it has no negative effects on the bond which the child shares with his/her friends. This satisfies the domain of social relationships and the subdomain of bodily image and appearance belonging to the domain of psychological health.

While DIMS did well in the domains of physical and psychological health, it lacked in aspects like quality, accessibility and affordability which are important pillars of healthcare services. When it comes to parents’ perspectives on the quality, DIMS was found to be dual-faceted having both advantages of being robust and possessing a drawback of being scratch-prone. Both these attributes of DIMS are due to the material used in its making viz. polycarbonate which has got high impact resistance38 but being a soft material, it is also prone to scratches.39 Additionally, parents reported that DIMS lenses or their accessories like photochromic features are not widely available and are difficult to procure, repair and maintain. Although the brand has launched photochromic DIMS lenses in the recent past,40 it was not available in this country throughout the course of this research. Most parents were unhappy with the high cost of the lenses. The cost of DIMS may have had a significant impact on the subdomains namely positive and negative feelings of the psychological health domain as more investment leads to more expectations. Working on these aspects should be considered by the manufacturers and distributors to further improve the acceptance of DIMS by the stakeholders.

To reduce the potential bias of preconceptions41 which is ingrained in the qualitative nature of the study a neutral approach was maintained using open-ended questions avoiding direct questions and a hybrid approach incorporating both inductive and deductive means was used for thematic analysis. To reduce the chances of participants’ perspectives getting influenced by the performance of DIMS in controlling myopia, few IDIs were conducted before the participants became aware of the results and it was found that apart from the subdomains namely positive feelings and negative feelings of the psychological health domain none of the other perceptions were influenced by the efficacy of DIMS in controlling myopia.

A limitation of this study is that even though analysis was done using a hybrid approach, deductive means was used to gather the data as the interview guide was constructed keeping in mind a prestructured framework, the WHOQOL-BREF. This may potentially miss out on a few aspects when assessing the overall QOL. Another limitation was that children were interviewed before their parents to reduce the influence of parents’ responses on their answers. However, this did not prevent parents’ responses from getting influenced by their child’s answers. It would have been interesting to find if any difference in findings existed if any QOL questionnaire for refractive errors like The Quality of Life Impact Refractive Correction42 was used in addition to WHOQOL-BREF.

To conclude, DIMS lenses are a preferred choice of intervention for myopia control for both parents and children. They found DIMS lenses to be less cumbersome, effortless to use, usual looking, easy to handle and free of adverse effects. Thus, satisfying most of the facets of the social relationships, physical and psychological health domains. However, a few facets like quality, accessibility and finance need to be improved.

This study can help in further improvement of DIMS as a myopia control option by aiding in better acceptance by the stakeholders to achieve the intended objective. This may also set the groundwork through item banking for the establishment of a PRO to assess the QOL of patients receiving myopia control therapies.

Data availability statement

No data are available. No data are available

Ethics statements

Patient consent for publication

Ethics approval

This study involves human participants and was approved by the Institutional Review Board and Ethics Committee of the Vi-sion Research Foundation, Chennai. (Study ID: 1096-2022-P). Participants gave informed consent to participate in the study before taking part.

References

Supplementary material

  • Supplementary Data

    This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

Footnotes

  • Contributors AN is the guarantor. The principal investigator MF and the corresponding author AN had full access to all the data in the study and took responsibility for the integrity of the data and the accuracy of the data analysis. Concept and design: MF and AN. Acquisition of the data: MF. Drafting of the manuscript: MF and AN. Critical revision of the manuscript for important intellectual content: MF, AN and SA. Data Analysis: MF and AN. Administrative, technical, or material support: SA and AN. Supervision: AN.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.