Studying the prevalnce, habits and outcomes of using contact lenses among students in the Syrian Private University

doi:10.21203/rs.3.rs-3616321/v1

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Systematic Review

Studying the prevalnce, habits and outcomes of using contact lenses among students in the Syrian Private University

https://doi.org/10.21203/rs.3.rs-3616321/v1

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Background: The lack of sufficient research on wearing contact lenses, and the most common symptoms and complications that lens wearers complain about in the Arab world, and Syria in particular, despite their widespread use, is what prompted us to conduct this study.

Methods: A cross-sectional study, conducted on students at the Syrian Private University. Data was collected between 10/27/2022 and 4/7/2023, and we obtained 1,750 responses. After including only students who are still studying at the university and who wear contact lenses, we arrived at a sample of 500 students.

Results: The study included 500 students. Females constituted most of the study sample (89%), compared to males (11%). The average age of the students was 22.41 years. Nonsmoking students constituted the largest percentage (43%), and most students reported that they did not work (81%). Human medicine students constituted the largest percentage of participating colleges (26%). More than half of students (65%) use lenses without a doctor's prescription. Most students wear lenses with both eyes (98%), compared to 2% who wear them with only one eye. The largest percentage of people wearing contact lenses was cosmetic (44%). Type of contact lenses used; the largest percentage was for flexible lenses (57%). The most common symptoms are dry eyes (58%), redness of the conjunctiva (36%), puffiness of the eyelids (20%), white purulent discharge (17%), and finally sticking of the eyelids when waking up from sleep (13%).

contact lenses

symptoms

complications

Contact lenses are thin and transparent structures that are placed on the corneal surface (1) Leonardo da Vinci was the first who engaged the idea of neutralizing the cornea by a new refracting surface using CLs in 1508 (2). During the last few decades the use of Contact lenses spread to all nations overall among grown-ups and the youths, yet additionally among kids and elderly patients. There are about 140 million people who wear Contact lenses (CLs) worldwide, most of them are teenagers (3)

Soft contact lenses are the most common types of CLs prescribed globally, while gas-permeable CLs only form a small percentage. (2) A cross-sectional design was done in King’s Abdulaziz University, Jeddah, Saudi Arabia showed included 536 medical students 80.2% of the CLs wearers used soft lenses.(4)

Contact lenses are also used for the management of refractive errors that cannot be managed by spectacles such as keratoconus, irregular cornea, aniridia and aphakia. (5–6–7–8–9–10–8–11–12–8) Nevertheless contact lenses have improved the wearers’ self-confidence and acceptance by peers as contact lenses are used for cosmetic purposes. (13–14) Contact lenses showed well safety records when hygiene recommendations given by the ophthalmologist are followed by the wearers. (15–16)

Regardless of the many advantages that the contact lenses provide, many complications can develop following the frequent and improper wear of contact lenses. (17) Around 98% of CLs complications is associated with improper activities such as a poor hand hygiene, storing the CLs in tap water and overnight wear of CLs that are not made up for night usage.(18) The most common complications are ocular infections, corneal neovascularization that presents as corneal redness, dry eyes, corneal ulcers, and giant papillary conjunctivitis. (19–20). A study that was carried out in King Faisal University, AlAsha, among medical students showed that among total of 208 participants 76% of them reported eye redness and 57.7% of them reported eye dryness.(4)

CLs are a significant predisposing factor of keratitis which is an active inflammation of the cornea caused by microorganisms such as bacteria mainly ,virus fungi and parasites.(21) Normally there are several defence mechanisms which limit the invasion of pathogens such as blinking, tight junctions between corneal epithelial cells and presence of chemicals that control bacterial growth.(22) As referred to a study, CLs reduce the epithelial barrier function by interfering with normal corneal epithelial cell proliferation and differentiation. Moreover hypoxia resulting from extended lens wear has been engaged in reducing corneal barrier function.(23–24)

On the other hand CLs act as a harbour for variety of microorganisms and pathogens thus invading the ocular surface in the presence of reduced tissue resistance, producing infections or inflammations. Coagulase-negative Staphylococci are most commonly cultured from worn lenses. Pseudomonas aeruginosa can adhere to the surface of the contact lenses as well, and cohabit in CLs storage cases which may lead to corneal. (25–26) Approximately 1.5 to 2 million cases of corneal ulcers occur annually in developing countries.

Poor tear film stability and hypoxia contribute to dry eye disease in CLs wearers. In situ CLs divide the tear film into pre- and post-lens films. This division affects the physical and chemical properties of the tear film. Additionally the limbus can respond to CLs wear by swelling the limbal vasculature which manifests as limbal redness.(28)

Non-modifiable factors that may be associated with CLs discomfort and complications are the sex, age, systemic diseases and poor tear quality/ quantity of the CLs wearers. Modifiable factors include medications, smoking and compliance.(28)

So far there are limited studies about the status of CLs wearers in Syria especially among university students. Thus the aim of this study is to determine the prevalence of CL wearers among the Syrian Private University students and their practices for the cleaning and care of CLs. Additionally this study evaluates possible risk factors which are possibly associated with complications and symptoms. The results would help raise awareness about the importance of adherence to proper CLs routine care which is essential in the prevention of undesirable complications.

Study design, setting and participants

This is a cross-sectional study that was conducted in the Syrian private university (SPU) during December 2022 to April 2023, in which 500 students participated.

Inclusion criteria: The Data were collected from a total of 500 student participants who wore contact lenses on almost daily bases. Students from the six main faculties of the university—the colleges of medicine, dentistry, pharmacy, engineering, business administration, and computer technology were included in the study.

Exclusion criteria: Data from students who don't use contacts nearly every day were eliminated.

Data collection instruments and procedures

Random data sampling was done to compile information from the students in the aforementioned faculties. In the SPU, there are about 5,000 students. 500 of the 1,700 students we were able to recruit for this study were contact lens wearers.

Prior to collecting data from the students, we ran a pilot study with 50 students to make sure the survey was valid and reliable. It had a satisfactory Cronbach's alpha score of 0.68 to 0.74.

After the participants in the study were informed about the aim of the study, where and the data would be used and the confidentiality of the answers, they were given an informed consent form on paper. They were individually requested to submit an anonymous paper questionnaire. To lessen the possibility of mistakes, our data collection team gave the participants a brief explanation of the medical terms used in the questionnaire.

The questionnaire consisted of three sections. Participants’ age, gender, family income, work statues, smoking statues, and medical conditions were covered in the first section. The second section involved the Contact lenses-hygienic practises reported by the students. The last section consisted of the reported contact lenses-related complications by the students. The Appendix contains attachments for each of the sections’ questions. The Syrian private university ethics committee gave its approval to this study methodology.

Statistical Analysis

The Statistical Package for Social Sciences (SPSS) for Windows, Version 25.0, was used to analyze the data. Frequencies and percentages were used to report categorical variables. Chi-square test was used to determine the association between different hygienic practices and various complications. A p-value of < 0.05 was regarded as statistically significant.

In order to obtain a sample of 500 participants, the present investigation utilized well-defined inclusion and exclusion criteria. The study population consisted of 56 male individuals (11%) and 444 female individuals (89%), with a mean age of 22.41±3.11 years. The majority of participants were enrolled in a medical program. Table 1 presents a detailed overview of the demographic characteristics of the participants, encompassing their age, gender, and other relevant features.

Table 1. Demographics characteristics of participants

Age, mean (SD)	22.41 (±3.11)
Gender	N (%)
Male	56 (11)
Female	444 (89)
Smoking
Yes	167 (33)
Negative smoking	117 (23)
No	216 (43)
Family income
Very good	150 (30)
Good	296 (59)
Moderate	54 (11)
Working
Yes	96 (19)
No	404 (81)
Faculty
Business	93 (19)
Pharmacy	88 (18)
Medicine	131 (26)
Engineer	73 (15)
Dentist	73 (15)
IT	42 (8)
Do you have any of these medical conditions
Rheumatoid diseases	15 (3)
Diabetes	8 (2)
Sjogren’s syndrome	1 (0.2)
Crohn’s disease	2 (0.4)
PCOs	1 (0.2)
Nothing	473 (95)

It was found that a considerable proportion of the student cohort, comprising 323 individuals (65%), had utilized contact lenses without a valid prescription. Out of this group, 221 students (44%) had engaged in this practice for a duration exceeding 3 years, while the remaining students had worn the lenses for varying periods, ranging from less than a month to 3 years. The primary incentive for utilizing contact lenses among the student cohort was for aesthetic purposes, with the largest proportion of students, comprising 244 individuals (44%), reporting wearing them for this reason. However, the remaining motives for wearing lenses were linked to visual acuity problems, with myopia being the most prevalent issue (reported by 214 students, 39%), followed by astigmatism (57 students, 10%), and hyperopia (22 students, 4%).

The study found that a proportion of approximately 4.2% of contact lens users had renewed their lenses every 3-8 months, while 17% used daily disposable lenses, as presented in Table 2. Furthermore, 39% of users reported exceeding the recommended renewal period for their contact lenses. In terms of cleaning habits, just 0.4% of users reported never cleaning their lenses, while 96% reported cleaning their lens with contact lenses solution. A few proportions of users, approximately 1%, reported sharing their contact lenses with others. Regarding water exposure, 8% of users reported exposing their lenses to water during showering, while 9% reported doing so while swimming.

Table 2: Contact lenses-hygienic practices reported by students’ users.

Does ophthalmologist prescribe lenses for you?	N (%)
Yes	177 (35)
No	323 (65)
Do you use lenses in
Both eyes	489 (98)
One eye	11 (2)
How long have you been using lenses?
Less than a month	48 (10)
More than a month and less than a year	85 (17)
More than a year and less than 3 years	146 (29)
More than 3 years	221 (44)
Reasons for using contact lenses
Keratoconus	8 (2)
Astigmatism	57 (10)
After surgery	4 (1)
Cosmetic reasons	244 (44)
Myopia	214 (39)
Abrasion comae	1 (0.2)
Hyperopia	22 (4)
Type of lens
Rigid	17 (3)
Soft	285 (57)
Colored	177 (35)
Simi-rigid	9 (2)
Do not know	12 (2)
Renewing contact lenses
Daily	86 (17)
From week to month (wearable during sleep)	51 (10)
From week to month (unwearable during sleep)	210 (42)
3 months	5 (1)

6 months	17 (3)
8 months	1 (0.2)
Annually	25 (5)
Exceeding the recommended period of renewal
Yes	194 (39)
No	182 (36)
Sometimes	124 (25)
Cleaning contact lens
With contact lenses solution	482 (96)
With water	5 (1)
Never	2 (0.4)
Do not know	11 (2)
Using soap when washing hands using lenses
Yes	396 (79)
No	46 (9)
Occasionally	58 (12)
Showering with lenses
Yes	41 (8)
No	420 (84)
Occasionally	39 (8)
Swimming with lenses
Yes	44 (9)
No	433 (87)
Occasionally	23 (5)
Sharing lenses
Yes	20 (4)
No	473 (95)
Occasionally	7 (1)

The principal complications observed among contact lens wearers were red eye, which was reported in 68% of cases, followed by dacryorrhea (63%), dry eye (58%), burning sensation with eye congestion (50%), and blurred vision (43%). Less frequently occurring complications included keratitis and corneal ulcer, with respective incidences of 4% and 6%. Diagnoses of conjunctivitis were made in 25% of participants, with diverse pathogenic origins such as allergic, bacterial, and viral. Meibomianitis was the least common complication, as it was reported in only 1% of the sample. Additionally, 144 students (29%) experienced a reduction in visual acuity as a result of contact lens use. Table 3.

Table 3: Reported contact lenses-related complication(s) by students’ users

Dry eyes	N (%)
Yes	292 (58)
No	208 (42)
White purulent secretions
Yes	85 (17)

No	415 (83)
Eyelid swelling
Yes	99 (20)
No	401 (80)
Conjunctival redness
Yes	178 (36)
No	322 (64)
Eyelid adhesion when waking up
Yes	65 (13)
No	435 (87)
Watery secretions
Yes	120 (24)
No	380 (76)
A burning feeling with eye congestion
Yes	251 (50)
No	249 (50)
Painful vesicles on the eyelid
Yes	14 (3)
No	486 (97)
Eye itch
Yes	169 (34)
No	331 (66)
Red eye
Yes	341 (68)
No	159 (32)
Pain
Yes	204 (41)
No	296 (59)
Dacryorrhea
Yes	317 (63)
No	183 (37)
Blurred vision
Yes	215 (43)
No	285 (57)
Photophobia
Yes	69 (14)
No	431 (86)
Corneal ulcer
Yes	32 (6)
No	468 (94)
Chalazion
Yes	18 (4)
No	482 (96)
Stye
Yes	54 (11)

No	446 (89)
Meibomianitis
Yes	6 (1)
No	494 (99)
Do you have loss of visual acuity
Yes	144 (29)
No	229 (46)
Do not know	127 (25)
Did you diagnose with any of the following
Allergic conjunctivitis	63 (13)
Bacterial conjunctivitis	42 (8)
Viral conjunctivitis	20 (4)
No	375 (75)
Did you diagnose with any of the following
Bacterial keratitis	12 (2)
Fungal keratitis	3 (1)
Viral keratitis	4 (1)
No	481 (96)

The ocular health of contact lens wearers has been found to be significantly associated with various factors. Specifically, statistical significance was observed in the relationship between the incidence of dry eye and two factors: showering (P= 0.0098) and swimming with lenses (P= 0.0065). Additionally, sharing lenses was found to be significantly associated with a burning sensation accompanied by eye congestion (P= 0.0036). Moreover, our investigation into the impact of hygienic practices on the development of red eye and dacryorrhea in contact lens wearers revealed statistically significant correlations between exceeding the recommended renewal period and these conditions (P= 0.014, 0.0038), as well as cleaning contact lenses with contact lens solution and these conditions (P= 0.0017, 0.0020).
Table 4-5-6-7.

Hygiene practices	Dry eyes		P value
Hygiene practices	Yes	No	P value
Exceeding the recommended period of renewal			0.050
Yes	110 (60)	72 (40)
No	101 (52)	93 (48)
Sometimes	81 (65)	43 (35)
Cleaning contact lens			0.085
With contact lenses solution	285 (59)	197 (41)
With water	2 (40)	30 (60)
Never	2 (100)	0 (0.00)
Do not know	3 (27)	8 (73)
Using soap when washing hands using lenses			0.273
Yes	233 (59)	163 (41)

No	30 (65)	16 (35)
Occasionally	29 (50)	29 (50)
Showering with lenses			0.0098*
Yes	30 (73)	11 (27)
No	233 (55)	187 (45)
Occasionally	29 (74)	10 (26)
Swimming with lenses			0.0065*
Yes	33 (75)	11 (25)
No	241 (56)	192 (44)
Occasionally	18 (78)	5 (22)
Sharing lenses			0.590
Yes	13 (65)	7 (35)
No	276 (58)	197 (42)
Occasionally	3 (43)	4 (57)

Hygiene practices	A burning feeling with eye congestion		P value
Hygiene practices	Yes	No	P value
Exceeding the recommended period of renewal			0.771
Yes	88 (48)	94 (52)
No	101 (52)	93 (48)
Sometimes	62 (50)	62 (50)
Cleaning contact lens			0.073
With contact lenses solution	247 (51)	235 (48)
With water	2 (40)	3 (60)
Never	0 (0.00)	2 (100)
Do not know	2 (18)	9 (82)
Using soap when washing hands using lenses			0.438
Yes	193 (49)	203 (51)
No	26 (57)	20 (43)
Occasionally	32 (55)	26 (45)
Showering with lenses			0.172
Yes	26 (63)	15 (37)
No	204 (49)	216 (51)
Occasionally	21 (54)	18 (46)
Swimming with lenses			0.448
Yes	26 (59)	18 (41)
No	213 (49)	220 (51)
Occasionally	12 (52)	11 (48)
Sharing lenses			0.0036*
Yes	17 (85)	3 (15)
No	232 (49)	241 (51)

Occasionally

2 (29)

5 (71)

Hygiene practices	Red eye		P value
Hygiene practices	Yes0.0	No	P value
Exceeding the recommended period of renewal			0.014*
Yes	114 (63)	68 (37)
No	130 (67)	64 (33)
Sometimes	97 (78)	27 (22)
Cleaning contact lens			0.0017*
With contact lenses solution	336 (70)	146 (30)
With water	2 (40)	3 (60)
Never	0 (0.00)	2 (100)
Do not know	3 (27)	8 (73)
Using soap when washing hands using lenses			0.411
Yes	266 (67)	130 (33)
No	31 (67)	15 (33)
Occasionally	44 (76)	14 (24)
Showering with lenses			0.536
Yes	25 (61)	16 (39)
No	288 (69)	132 (31)
Occasionally	28 (72)	11 (28)
Swimming with lenses			0.416
Yes	27 (61)	17 (39)
No	300 (69)	133 (31)
Occasionally	14 (61)	9 (39)
Sharing lenses			0.346
Yes	14 (70)	6 (30)
No	324 (69)	149 (31)
Occasionally	3 (43)	4 (57)

Hygiene practices	Dacryorrhea		P value
Hygiene practices	Yes	No	P value
Exceeding the recommended period of renewal			0.0038*
Yes	100 (55)	82 (45)
No	126 (65)	68 (35)
Sometimes	91 (73)	33 (27)
Cleaning contact lens			0.0020*
With contact lenses solution	313 (65)	169 (35)
With water	2 (40)	3 (60)
Never	0 (0.00)	2 (100)
Do not know	2 (18)	9 (82)

Using soap when washing hands using lenses			0.310
Yes	247 (62)	149 (38)
No	28 (61)	18 (39)
Occasionally	42 (72)	16 (28)
Showering with lenses			0.345
Yes	23 (56)	18 (44)
No	266 (63)	154 (37)
Occasionally	28 (72)	11 (28)
Swimming with lenses			0.241
Yes	23 (52)	21 (48)
No	278 (64)	155 (36)
Occasionally	16 (70)	7 (30)
Sharing lenses			0.863
Yes	12 (60)	8 (40)
No	300 (63)	173 (37)
Occasionally	5 (71)	2 (29)

This study determines the prevalence of contact lenses users among a sample of the Syrian private university students as well as their compliance and related complications to CLs use.

Our results revealed a predominance of female contact lens users (89%). The rising use of CLs for cosmetic purposes may be the cause of this. This result coincides with another study conducted in Saudi Arabia. (27) We also found that 323 individuals (65%) had used CLs without a valid prescription. On the contrary, a study conducted among adults in Sudan showed that only 31% of used contact lenses were self-prescribed. This may be due to the availability of CLs in Syria without a prescription. (28) Additionally, our study found that the main purpose of using CLs was for cosmetic purposes (44%), which is consistent with findings from another study conducted in India. (29). A higher rate (58.9%) was reported in the study done in Saudi Arabia. (27) The most common type of CL used among the participants in our study was soft contact lenses, which is in line with other findings from several other studies. (30)

Regarding the hygienic practise 0.4% of users in our study reported never cleaning their lenses, which is far lower than the 12.9% reported in the Saudi Arabian study. (27) We hypothesised that the awareness of the importance of rinsing CLs among the participants in our study might be because the majority of participating students are enrolled in medical colleges. In contrast, 96% of respondents said they cleaned their lenses using contact lens solution; however, a smaller proportion (78.27%) of participants in a survey among university students in Thailand said they rinsed their CLs with lens solution. (30) As an encouraging finding, 79% of the participants used soap while washing their hands before wearing CLs. While another study that was held in the Maldives among soft CLs wearers revealed that 60% of the participants in their study followed inadequate hand-washing behaviour. (31) The disparity in the target demographics might be the cause of this mismatch.

The most common symptoms reported with CLs use were red eye (68%), dacryorrhea (63%) and dry eyes (58%). Similarly, another study conducted in coastal Karnataka (32) revealed that dry eyes and watering eyes were among the commonest symptoms. Such symptoms are associated with factors like dry weather conditions and dusty environments.(32) In specification, showering and swimming while wearing CLs were found to be significantly associated with dry eyes, having (P value = 0.0098) and (P value = 0.0065) respectively. Water exposure is associated with several CLs infections, such as Acanthamoeba keratitis. Similarly, short-term swimming in a chlorinated pool significantly increases the frequency of CL colonisation with the same bacterial organisms found in the pool water (25). …

However, Exceeding the recommended period of CLs renewal practise showed a significant reason for acute red eyes and dacryorrhea with P-value = 0.014 and P-value = 0.0017 respectively. Bacterial colonisation of CLs has been implicated in CL-induced inflammation, specifically, CL acute red eye. (33) Finally, keratitis (4%) was among the least frequently occurring complications. High hygienic performance among the participants would explain the low incidence of keratitis.

Implementations:

Due to the significant prevalence of CLs use and its related complications at the Syrian Private University, as revealed by our study, CLs wearers are recommended to follow proper hygienic practices given by the ophthalmologist. In order to correctly analyse the fit of the CLS, the patient's compliance with the care system, and general CLS-related cleanliness, regardless of the kind of CLS, it is imperative to see an ophthalmologist prior to wearing CLS. The patient's wearing habits, wearing duration, and how the CLs measure up to expectations should all be evaluated by the optometrist. Wearers of CLs must also check up with their ophthalmologist frequently in order to catch issues including dry eyes, keratitis, and corneal neovascularization early. It is important to emphasise that people who wear CLs for aesthetic reasons should also contact an ophthalmologist before doing so in order to do any necessary tests based on their medical history and risk factors. Above all, patients should be open and honest with the ophthalmologist about their hygiene routines and eyewear usage. Proper CLs practices and awareness of CL-related complications should be explained to all students under the supervision of the college’s Department of Ophthalmology through awareness campaigns organised and held by the students to help minimise preventable visual damages in the young population. However, this is the first study handled in Syria to assess the practice of CLs and common discomfort symptoms and complications. Therefore, more hypothesis-driven studies of a wider Syrian population should be encouraged in order to validate and broaden our findings.

To comprehensively address the significant findings from the study on contact lens (CL) use and related complications at the Syrian Private University, a multifaceted approach is recommended. Firstly, educational campaigns should be launched to raise awareness about the risks of using CLs without a valid prescription and emphasize the importance of consulting with ophthalmologists before wearing CLs, regardless of the type. These campaigns should target individuals who seek to use CL for both aesthetic and vision-related causes. Secondly, regular follow-up appointments with optometrists should be encouraged to assess wearing habits, fit, and early detection of complications. Individuals planning to use CLs for aesthetic reasons must undergo pre-approval tests based on their medical history. Open and honest communication with healthcare providers about hygiene routines is vital. The college's Department of Ophthalmology should organize awareness campaigns led by students to disseminate information about proper CL practices. Additionally, this study represents the first investigation of CL use and complications in Syria to the best of our knowledge. Therefore, more hypothesis-driven studies of a wider Syrian population should be encouraged to validate and broaden our findings. This comprehensive strategy aims to promote responsible CL use, reduce preventable visual damages, and safeguard the ocular health of students at the university while contributing to the broader understanding of CL practices in Syria.

Acknowledgments:

We are thankful to the management of the Syrian Private University for their support in the field of medical training and research.

Funding:

This research received no specific grant from SPU or any other funding agency.

Availability of data and materials:

All data related to this paper’s conclusion are available and stored by the authors. All data are available from the corresponding author at a reasonable request.

Conflict of interest:

The authors declare that they have no conflict of interest.

Author’s contributions:

Omar Halawani and Sedra Alhabal conceptualized the study, participated in the design, wrote the study protocol, participated in data collection, and drafted the manuscript. Omar Halawani performed the statistical analysis. Yusra Haddeh did a literature search and revision of the draft. All authors read and approved the final draft.

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Studying the prevalnce, habits and outcomes of using contact lenses among students in the Syrian Private University

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