Effect of sleep quality on vision-related quality of life in a sample of Qassim University students: an ocular surface health approach

Introduction

Sleep, accounting for approximately one-third of our lives, is essential for maintaining vital physiological functions (Colten & Altevogt, 2006). The World Health Organization (WHO) has declared reduced sleep duration a public health concern (Chattu et al., 2019). Both extremes, from insufficient to excessive sleep, are related to numerous cognitive and physical comorbidities. Poor sleep quality is characterized by different factors, such as increased sleep latency, disturbances, and increased movement while sleeping. Evidence indicated a strong association between sleep quality and various chronic diseases, such as hypertension, diabetes, cardiovascular diseases, and even cancer (Berisha, Shutkind & Borniger, 2022; Lee & Lee, 2022; Miller & Howarth, 2023)

The harmful influence of sleep disorders on the quality of life related to health has been previously emphasized, highlighting the burden of prevalent poor sleep quality in modern societies (Zeidler et al., 2018). Quality of life is multifaceted, incorporating physical, social, and psychological domains, all of which are associated with and affected by sleep quality. Furthermore, sleep disorders can exacerbate existing medical conditions. For example, insomnia and daytime sleepiness can negatively impact general and mental health, though not consistently in the physical domain. While some studies have shown no impact of sleep apnea, restless leg syndrome, and snoring on overall health-related quality of life (Chen, Gelaye & Williams, 2014). This finding is not universal since controversial results were found between studies (Wanberg et al., 2021). Notably, a Japanese study of over 9,000 participants found that sleep quality and physical/mental quality of life were associated independently of sleep duration (Matsui et al., 2021). Another study done in Jordan on 1,422 young adults has shown that poor sleep quality is associated with higher levels of both anxiety and depression (Alkhatatbeh, Abdul-Razzak & Khwaileh, 2021). To subjectively evaluate the quality of sleep, the Pittsburgh Sleep Quality Index (PSQI) questionnaire is widely used due to its high validity and ease of use. It comprises 19 items, and the calculated results with higher scores indicate poorer sleep quality (Carpenter & Andrykowski, 1998).

Among the negative health outcomes affected by poor sleep quality is the high occurrence of dry eye disease. Research has established a link connecting sleep quality and both signs as well as symptoms of dry eye syndrome (He et al., 2022; Ayoubi et al., 2024). Notwithstanding, the specific association between sleep quality and quality of life related to vision requires further investigation, as no prior studies exploring this link were identified.

Vision plays a critical role in our daily activities, like driving, watching television, reading, and facial recognition. Moreover, visual impairment is a significant concern for public health, ranking as the ninth most prevalent disability in the United States, and its influence on overall life quality has been extensively studied (Vannasdale et al., 2021). To appraise the quality of life specifically related to vision, the National Eye Institute developed the Visual Function Questionnaire (NEI-VFQ). Initially consisting of 51 items (Mangione et al., 1998), followed by the development of a shortened 25-item version (NEI-VFQ25), which demonstrated strong reliability and accuracy. The NEI-VFQ25 is now a commonly implemented instrument to assess vision-related life quality (Mangione et al., 2001; Nickels et al., 2017). This questionnaire encompasses 12 domains: general health, general vision, near and distance activities, driving, peripheral vision, color vision, ocular pain, vision-related role difficulties, dependency, social function, and mental health (Mangione et al., 2001). Several studies aiming to evaluate quality of life in individuals with ocular conditions, including uveitis, glaucoma, retinitis pigmentosa, and dry eye disease, have made use of the NEI-VFQ25 (Nichols, Mitchell & Zadnik, 2002; Sainohira et al., 2018; Rossi et al., 2022).

Dry eye disease (DED) is a multifaceted condition affecting the ocular surface and tear film (Tsubota et al., 2020). Common symptoms include foreign body sensation, burning, itching, and reduced visual acuity. DED presents a substantial burden, particularly with its rising prevalence in the past years (Willcox et al., 2017).

DED is a frequent complaint in eye care clinics, with prevalence estimates spanning from 5% to 50% (Alkhaldi et al., 2023; Papas, 2021). The disruption of tear film homeostasis in DED can be caused by various factors, such as age, gender, and certain medications (Craig et al., 2017; Gomes et al., 2023). Prior research has indicated a relationship between sleep quality and DED, highlighting the detrimental effects of dry eye syndrome on general health and quality of life related to vision (Li et al., 2012; Erøy, Utheim & Sundling, 2023). In this sense, several validated questionnaires to assess dey eye symptoms are available and widely used; The Ocular Surface Disease Index (OSDI) is among the most used self-reporting methods to measure the severity of dry eye symptoms due to its rapid diagnosis of ocular surface disease (Aljarousha et al., 2024; Schiffman et al., 2000).

The rising prevalence of dry eye disease in the Middle East has become pronounced, according to a recent systematic review and meta-analysis, which has highlighted a significant regional variation in dry eye disease; the results showed that dry eye prevalence in the Middle East was higher than the global estimate (Mohamed et al., 2024).

This study aims to explore the association connecting self-reported sleep quality and vision-related quality of life, specifically concerning the signs and symptoms of ocular surface disorders.

Materials and Methods

Results

Discussion

This study investigated the relationships between dry eye signs and symptoms, quality of life related to vision, and sleep quality. The results indicated a significant association between ocular symptom severity, as measured by the Ocular Surface Disease Index (OSDI) questionnaire, and quality of life related to vision, sleep efficiency, and sleep disturbances. Furthermore, the established association between sleep quality and quality of life related to vision was corroborated. These findings present both similarities and differences when compared to previous research. Published data shows that sleep problems are becoming an increasing problem globally (Lund et al., 2010). For instance, a study done in Australia revealed that between 41% and 42% of young adults with a mean age of 22.2 years suffered from sleep issues, with males scoring significantly higher than females (McArdle et al., 2020). University students usually experience numerous factors to cope with and keep with their academic responsibilities, and often they suffer from several factors affecting their quality of life, sleep is among the reported factors (Schlarb, Friedrich & Claßen, 2017). Higher percentages were reported in a study population of university students in Jordan where sleep quality was found to be poor in 74% of a total of 1,308 subjects (Albqoor & Shaheen, 2021). A similar study with the same population group (University students) was done in Germany and revealed that 48.7% suffered from poor sleep quality (Schmickler et al., 2023). In the current sample, poor sleep quality obtained by PSQI scores higher than five accounted for 52%.

Dry eye symptoms are not necessarily reflected by the signs seen in the clinic; therefore, numerous questionnaires were developed to self-report dry eye symptoms. One of the most used questionnaires is the Ocular Surface Disease Index (OSDI), specifically designed for dry eye patients to assess dry eye-related symptoms, functional limitations, and environmental factors (Dana et al., 2019). Aligned with the results obtained here, only the NIKBUT test was related with increasingly poor dry eye symptoms. Moreover, results in the present work showed an association with dry eye symptoms and only two components of the sleep quality questionnaire: sleep efficiency and sleep disturbances. These results are in part contradictory to previous work where OSDI scores correlated with all PSQI components except the use of sleep medication (Ayoubi et al., 2024). These differences could be due to the difference in the age group and the population studied since they examined veterans with a mean age of 56 ± 5 years, whereas our population mean age was 22.25 ± 1.38, which highlights the importance of testing different age groups due to plausible differences. Unlike the present study, another study showed that Schirmer test results were correlated with PSQI score, indicating that further studies are necessary to elucidate the question regarding dry eye signs and sleep quality (Kawashima et al., 2016).

Among the questions that authors wanted to clarify in the current manuscript was the association between sleep quality and quality of life related to vision. A question was raised because it is well established in the literature that dry eye has a negative influence on the quality of life, in addition to the fact that both measurements of interest are subjective and dependent on the sole answer of the participant. Moreover, only one study that correlated sleep quality and NEI-VFQ-25 and it was in a geriatric population, yet similar results were seen in the current study. Worse sleep quality scores are reported to be significantly associated with poor vision-related quality of life.

Conclusions

This research highlights an association between sleep quality, quality of life related to vision, and dry eye disease. Nevertheless, the study has limitations, and still, more studies are required to highlight the capacity of healthy and good sleep quality in promoting better ocular surface health. The population recruited in the study was healthy and young, which established a base for future studies. However, increasing the sample and dividing the subjects into categories with the degree of dry eye present would be beneficial. This was not done since only profound results were observed between the symptomatology of dry eye and the aspects of interest.

Supplemental Information