Impact of Vision Impairment and Ocular Morbidity and Their Treatment on Quality of Life in Children

TopicThis review summarizes existing evidence of the impact of vision impairment and ocular morbidity and their treatment on children's quality of life (QoL).Clinical RelevanceMyopia and strabismus are associated with reduced QoL among children. Surgical treatment of strabismus significantly improves affected children's QoL.MethodsWe conducted a systematic review and meta-analysis by screening articles in any language in 9 databases published from inception through August 22, 2022, addressing the impact of vision impairment, ocular morbidity, and their treatment on QoL in children. We reported pooled standardized mean differences (SMDs) using random-effects meta-analysis models. Quality appraisal was performed using Joanna Briggs Institute and National Institutes of Health tools. This study was registered with the International Prospective Register of Systematic Reviews (identifier, CRD42021233323).ResultsOur search identified 29 118 articles, 44 studies (0.15%) of which were included for analysis that included 32 318 participants from 14 countries between 2005 and 2022. Seventeen observational and 4 interventional studies concerned vision impairment, whereas 10 observational and 13 interventional studies described strabismus and other ocular morbidities. Twenty-one studies were included in the meta-analysis. The QoL scores did not differ between children with and without vision impairment (SMD, –1.04; 95% confidence interval [CI], –2.11 to 0.03; P = 0.06; 9 studies). Myopic children demonstrated significantly lower QoL scores than those with normal vision (SMD, –0.60; 95% CI, –1.09 to –0.11; P = 0.02; 7 studies). Children with strabismus showed a significantly lower QoL score compared with those without (SMD, –1.19; 95% CI, –1.66 to –0.73; P < 0.001; 7 studies). Strabismus surgery significantly improved QoL in children (SMD, 1.36; 95% CI, 0.48–2.23; P < 0.001; 7 studies). No randomized controlled trials (RCTs) concerning refractive error and QoL were identified. Among all included studies, 35 (79.5%) were scored as low to moderate quality; the remaining met all quality appraisal tools criteria.DiscussionReduced QoL was identified in children with myopia and strabismus. Surgical correction of strabismus improves the QoL of affected children, which supports insurance coverage of strabismus surgery. Further studies, especially RCTs, investigating the impact of correction of myopia on QoL are needed.Financial Disclosure(s)Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article. This review summarizes existing evidence of the impact of vision impairment and ocular morbidity and their treatment on children's quality of life (QoL). Myopia and strabismus are associated with reduced QoL among children. Surgical treatment of strabismus significantly improves affected children's QoL. We conducted a systematic review and meta-analysis by screening articles in any language in 9 databases published from inception through August 22, 2022, addressing the impact of vision impairment, ocular morbidity, and their treatment on QoL in children. We reported pooled standardized mean differences (SMDs) using random-effects meta-analysis models. Quality appraisal was performed using Joanna Briggs Institute and National Institutes of Health tools. This study was registered with the International Prospective Register of Systematic Reviews (identifier, CRD42021233323). Our search identified 29 118 articles, 44 studies (0.15%) of which were included for analysis that included 32 318 participants from 14 countries between 2005 and 2022. Seventeen observational and 4 interventional studies concerned vision impairment, whereas 10 observational and 13 interventional studies described strabismus and other ocular morbidities. Twenty-one studies were included in the meta-analysis. The QoL scores did not differ between children with and without vision impairment (SMD, –1.04; 95% confidence interval [CI], –2.11 to 0.03; P = 0.06; 9 studies). Myopic children demonstrated significantly lower QoL scores than those with normal vision (SMD, –0.60; 95% CI, –1.09 to –0.11; P = 0.02; 7 studies). Children with strabismus showed a significantly lower QoL score compared with those without (SMD, –1.19; 95% CI, –1.66 to –0.73; P < 0.001; 7 studies). Strabismus surgery significantly improved QoL in children (SMD, 1.36; 95% CI, 0.48–2.23; P < 0.001; 7 studies). No randomized controlled trials (RCTs) concerning refractive error and QoL were identified. Among all included studies, 35 (79.5%) were scored as low to moderate quality; the remaining met all quality appraisal tools criteria. Reduced QoL was identified in children with myopia and strabismus. Surgical correction of strabismus improves the QoL of affected children, which supports insurance coverage of strabismus surgery. Further studies, especially RCTs, investigating the impact of correction of myopia on QoL are needed. Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article. In 2020, an estimated 596 million people worldwide were affected by distance vision impairment, and a further 510 million had uncorrected near vision impairment.1Bourne R. Steinmetz J.D. Flaxman S. et al.Trends in prevalence of blindness and distance and near vision impairment over 30 years: an analysis for the Global Burden of Disease Study.Lancet Glob Health. 2021; 9: e130-e143Abstract Full Text Full Text PDF PubMed Scopus (475) Google Scholar An estimated 70 million children 0 to 14 years of age have vision impairment, among whom 1.4 million have irreversible blindness.2Burton M.J. Ramke J. Marques A.P. et al.The Lancet Global Health Commission on Global Eye Health: vision beyond 2020.Lancet Glob Health. 2021; 9: e489-e551Abstract Full Text Full Text PDF PubMed Scopus (490) Google Scholar Children with vision impairment often exhibit increased social isolation,3Gray C. Inclusion, impact and need: young children with a visual impairment.Child Care Pract. 2005; 11: 179-190Crossref Scopus (13) Google Scholar elevated risks of mental health problems developing,4Li D. Chan V.F. Virgili G. et al.Impact of vision impairment and ocular morbidity and their treatment on depression and anxiety in children: a systematic review.Ophthalmology. 2022; 129: 1152-1170Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar poor school performance,5Ma X. Zhou Z. Yi H. et al.Effect of providing free glasses on children's educational outcomes in China: cluster randomized controlled trial.BMJ. 2014; 349: g5740Crossref PubMed Scopus (159) Google Scholar and reduced quality of life (QoL).6Chadha R.K. Subramanian A. The effect of visual impairment on quality of life of children aged 3–16 years.Br J Ophthalmol. 2011; 95: 642-645Crossref PubMed Scopus (84) Google Scholar,7Pan C.-W. Wu R.-K. Wang P. et al.Reduced vision, refractive errors and health-related quality of life among adolescents in rural China.Clin Exp Optom. 2018; 101: 758-763Crossref PubMed Scopus (20) Google Scholar In ophthalmic practice, vision function traditionally has been assessed by visual acuity. However, visual acuity alone does not always convey a person's perception of his or her visual impairment and ability to perform vision-related tasks.8Elliott D.B. Hurst M.A. Weatherill J. Comparing clinical tests of visual function in cataract with the patient's perceived visual disability.Eye (Lond). 1990; 4: 712-717Crossref PubMed Scopus (159) Google Scholar,9Alexander M.F. Maguire M.G. Lietman T.M. et al.Assessment of visual function in patients with age-related macular degeneration and low visual acuity.Arch Ophthalmol. 1988; 106: 1543-1547Crossref PubMed Scopus (83) Google Scholar Quality of life is a self-rated multidimensional concept incorporating physical, functional, social, and emotional well-being.10Cella D.F. Quality of life: concepts and definition.J Pain Symptom Manag. 1994; 9: 186-192Abstract Full Text PDF PubMed Scopus (314) Google Scholar Measuring QoL provides a comprehensive overview of the affected person's experiences of an eye disease8Elliott D.B. Hurst M.A. Weatherill J. Comparing clinical tests of visual function in cataract with the patient's perceived visual disability.Eye (Lond). 1990; 4: 712-717Crossref PubMed Scopus (159) Google Scholar and satisfaction with an ophthalmic treatment.11Rayat J. Almeida D.R. Belliveau M. et al.Visual function and vision-related quality of life after macular hole surgery with short-duration, 3-day face-down positioning.Can J Ophthalmol. 2011; 46: 399-402Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar For example, strabismus surgery typically does not improve visual acuity, nor does it prevent vision loss, but it can be associated with significant emotional impact. Hence, evaluating surgical outcomes based on the patient's perspective is essential. Quality of life also supports clinical decision-making, can be used as a prognostic indicator, and may inform policy-making decisions for resource allocation.12Fallowfield L. What is quality of life.Health Econ. 2009, 1-8; 1Google Scholar Ocular conditions affect all stages of life, with young children and older people particularly at risk.2Burton M.J. Ramke J. Marques A.P. et al.The Lancet Global Health Commission on Global Eye Health: vision beyond 2020.Lancet Glob Health. 2021; 9: e489-e551Abstract Full Text Full Text PDF PubMed Scopus (490) Google Scholar During the past 2 decades, an increasing number of studies have investigated the impact of vision impairment and ocular morbidity on QoL in adults. It has been well established that vision impairment and ocular diseases can affect adults negatively, especially older people's mental health and QoL.13Assi L. Chamseddine F. Ibrahim P. et al.A global assessment of eye health and quality of life: a systematic review of systematic reviews.JAMA Ophthalmol. 2021; 139: 526-541Crossref PubMed Scopus (66) Google Scholar In 2021, Assi et al13Assi L. Chamseddine F. Ibrahim P. et al.A global assessment of eye health and quality of life: a systematic review of systematic reviews.JAMA Ophthalmol. 2021; 139: 526-541Crossref PubMed Scopus (66) Google Scholar conducted an umbrella review and found an association among vision impairment, eye disease, and lower QoL across the lifespan. However, most of the included systematic reviews focused on vision impairment and eye diseases that are common among older adults, but not children, such as age-related macular degeneration, glaucoma, and diabetic retinopathy. Additionally, chronic ocular conditions exist that do not impair vision, but do have other negative impacts that can reduce the QoL of affected children. For example, strabismus affects 5.0% to 6.8% of otherwise healthy children,14Lin S. Congdon N. Yam J.C. et al.Alcohol use and positive screening results for depression and anxiety are highly prevalent among Chinese children with strabismus.Am J Ophthalmol. 2014; 157: 894-900.e1Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar,15Fu J. Li S.M. Liu L.R. et al.Prevalence of amblyopia and strabismus in a population of 7th-grade junior high school students in Central China: the Anyang Childhood Eye Study (ACES).Ophthalmic Epidemiol. 2014; 21: 197-203Crossref PubMed Scopus (79) Google Scholar causing physical, educational, and socioemotional difficulties in their daily lives.16Buffenn A.N. The impact of strabismus on psychosocial health and quality of life: a systematic review.Surv Ophthalmol. 2021; 66: 1051-1064Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar,17McBain H.B. Au C.K. Hancox J. et al.The impact of strabismus on quality of life in adults with and without diplopia: a systematic review.Surv Ophthalmol. 2014; 59: 185-191Abstract Full Text Full Text PDF PubMed Scopus (45) Google Scholar A narrative review conducted in 2021 found that strabismus can impact the well-being of children and adults negatively, and strabismus surgery can improve ocular alignment, psychosocial health, and QoL. However, the authors did not conduct a meta-analysis because of the high heterogeneity of included studies across the life course.16Buffenn A.N. The impact of strabismus on psychosocial health and quality of life: a systematic review.Surv Ophthalmol. 2021; 66: 1051-1064Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar To our knowledge, no systematic reviews or meta-analyses have assessed comprehensively the effect of vision impairment and ocular morbidity on QoL in children. In addition, results from available studies regarding eye health and QoL in children are not consistent. Some studies reported no significant difference in QoL between children with vision impairment and those without.18Wong H.B. Machin D. Tan S.B. et al.Visual impairment and its impact on health-related quality of life in adolescents.Am J Ophthalmol. 2009; 147: 505Abstract Full Text Full Text PDF PubMed Scopus (76) Google Scholar, 19Wang Y. Wang H. Adverse influences of nonstrabismic amblyopia on quality of life of teenagers in China.Comput Math Methods Med. 2022; : 2621991PubMed Google Scholar, 20Wen G. McKean-Cowdin R. Varma R. et al.General health-related quality of life in preschool children with strabismus or amblyopia.Ophthalmology. 2011; 118: 574-580Abstract Full Text Full Text PDF PubMed Scopus (64) Google Scholar However, several other studies found that vision impairment or refractive error had a detrimental effect on children's QoL.6Chadha R.K. Subramanian A. The effect of visual impairment on quality of life of children aged 3–16 years.Br J Ophthalmol. 2011; 95: 642-645Crossref PubMed Scopus (84) Google Scholar,7Pan C.-W. Wu R.-K. Wang P. et al.Reduced vision, refractive errors and health-related quality of life among adolescents in rural China.Clin Exp Optom. 2018; 101: 758-763Crossref PubMed Scopus (20) Google Scholar,21Hsieh M.-H. Lin J.-C. Association of refractive error with vision-related quality of life in junior high school students.Taiwan J Ophthalmol. 2016; 6: 32-35Crossref PubMed Scopus (6) Google Scholar Therefore, this systematic review examined the impact of vision impairment and ocular morbidity on children's QoL and the effectiveness of ophthalmic interventions in improving QoL. We performed a systematic review and meta-analysis in accordance with the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) checklist (Appendix 1). A protocol was registered and published on the International Prospective Register of Systematic Reviews (identifier, CRD42021233323). This is a systematic review and meta-analysis using de-identified participant data from all included studies. Informed consent was not obtained, and the Queen's University Belfast Ethics Committee agreed that approval was not required for this study. All research adhered to the tenets of the Declaration of Helsinki. Li et al4Li D. Chan V.F. Virgili G. et al.Impact of vision impairment and ocular morbidity and their treatment on depression and anxiety in children: a systematic review.Ophthalmology. 2022; 129: 1152-1170Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar described the search methods in detail. In brief, a comprehensive search was conducted using Medical Literature Analysis and Retrieval System Online (MEDLINE), Embase, Web of Science, PsycINFO, Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials in the Cochrane Library, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Chinese databases WANFANG MED ONLINE and China National Knowledge Infrastructure from inception through February 18, 2022, without language restriction. We repeated the search strategy on August 22, 2022. This search strategy was developed under an information specialist's guidance and was tested through an iterative process before finalizing the combination of terms (Appendix 2). Studies meeting the following criteria were considered eligible for inclusion: (1) enrolled children or young adults, as long as the mean age of participants was younger than 18 years; (2) defined vision impairment according to the International Classification of Diseases, Eleventh Revision (2018), (presenting visual acuity, < 6/12); (3) observational studies should include a comparison group, such as normally sighted children; and (4) reported QoL outcomes (including generic, health related, or vision related). Studies using visual function questionnaires were also included, as long as the questionnaire contained subscales related to QoL or could be used to measure QoL, and (5) used either observational or intervention design, including randomized controlled trials (RCTs) and before-and-after studies with no control group. Only original studies published in peer-reviewed journals were included. Studies were excluded if they met any of the following criteria: (1) the interventions were not ophthalmic; (2) the study compared different kinds of interventions without a placebo or control group; (3) the studies concerning retinoblastoma, retinopathy of prematurity, and uveitis were excluded because of potential complications other than vision; and (4) the study used a qualitative design. Two reviewers (D.L. and one of the following: P.P., S.M., H.H., and S.P.) independently screened all titles and abstracts for eligibility. Reviewers read the full-text articles for potentially eligible studies to determine final inclusion or exclusion. Two reviewers (D.L. and S.P.) extracted data independently into Excel version 2201 software (Microsoft Corporation). For observational studies, the extracted data consisted of the authors' names, publication year, study design, country, diagnosis, sample size, demographic characteristics of participants, instruments used to measure QoL, and a summary of findings. For interventional studies, beyond the characteristics listed above, we also recorded the type of intervention in each group. Any disagreement was resolved by discussion within the research team. The risk of bias and quality of studies was assessed using the National Institutes of Health quality assessment tool for the before-and-after study without a control group and corresponding Joanna Briggs Institute critical appraisal checklists for cross-sectional and RCT study designs. Two reviewers (D.L., S.P., and H.H. worked as the second) appraised the studies independently. Data analyses were conducted using Stata version 17.0 statistical software's meta suite of commands (StataCorp LLC). As described previously,4Li D. Chan V.F. Virgili G. et al.Impact of vision impairment and ocular morbidity and their treatment on depression and anxiety in children: a systematic review.Ophthalmology. 2022; 129: 1152-1170Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar we reported vision impairment and strabismus separately. We expected that different studies would use a variety of tools to measure QoL; thus, standardized mean differences (SMDs) were used in the pooled analyses. A negative pooled SMD indicates that the eye disease is detrimental to QoL of children and vice versa. A random-effects model was used because of heterogeneity between studies, and data were displayed using a forest plot. To minimize heterogeneity, we included only self-reported QoL studies and excluded proxy-reported outcomes from the meta-analysis. A leave-one-out sensitivity analysis was conducted to evaluate the relative impact of studies on the meta-analytic outcomes. Studies not eligible for meta-analysis were included in a narrative description. Of the 29 118 references identified (28 992 via the first search and 126 after repeating the search strategy on August 22, 2022), 71 full-text articles (0.24%) were reviewed, and 44 studies (0.15%) were identified as eligible for systematic review (Fig 1). A list of excluded studies with reasons for exclusion is provided in Table S1 (available at www.aaojournal.org). Among the 44 studies, 17 observational studies concerned vision impairment,6Chadha R.K. Subramanian A. The effect of visual impairment on quality of life of children aged 3–16 years.Br J Ophthalmol. 2011; 95: 642-645Crossref PubMed Scopus (84) Google Scholar,7Pan C.-W. Wu R.-K. Wang P. et al.Reduced vision, refractive errors and health-related quality of life among adolescents in rural China.Clin Exp Optom. 2018; 101: 758-763Crossref PubMed Scopus (20) Google Scholar,18Wong H.B. Machin D. 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