The methods used in this study have been described in detail elsewhere.17 In brief, a survey was developed by the lead study authors after multiple discussions to seek demographics characteristics, type of practice, and practitioners’ point of view on the future of their contact lens practice over the next five years. All international study co-authors were invited to provide comments and inputs to the survey as per the situation in their respective countries. The final survey consisted of nine questions about opportunities (i.e., 1. Managing irregular cornea; 2. Multifocal contact lenses for presbyopes; 3. Myopia control; 4. Orthokeratology for myopia correction; 5. Daily disposable for occasional wear; 6. Diagnostic, therapeutic and bionic lenses; 7. Cosmetic lenses; 8. Biocompatible materials to improve comfort; and 9. Custom soft contact lenses to control aberrations and enhance visual acuity), five about interventions (i.e., 1. Continuously updating knowledge/skills of practitioners; 2. Educating parents about the benefits for children to wear contact lenses; 3. Being competent in managing contact-related complications; 4. Making contact lenses more affordable to patients (especially daily disposable contact lenses); and 5. Marketing contact lens practice on social media), and twelve about potential threats (i.e., 1. Lack of regulation; 2. Contact lenses available online without practitioner supervision; 3. Contact lens prescriptions available via digital devices; 4. Clinics without proper instrumentation; 5. Incompetent practitioners; 6. Refractive surgeries; 7. Negative myths about contact lenses among the general public; 8. Advances in the spectacle industry; 9. Commoditization of contact lenses (i.e., not considered as medical devices); 10. Drop out from contact lens wear due to discomfort/dryness; 11. Contact lens-related infections; and 12. Unfavourable industry policies) related to contact lens practice. Each question was rated on a 0 to 10 point-scale where “0” means no concern at all and “10” represents maximum concern. As the survey was designed to quantify the rating for each opportunity, threat and intervention, it included a closed list of items to be assessed. However, at the end of the survey participants were encouraged to share additional comments. The anonymized questionnaire was constructed in English and then translated in six different languages (i.e., Spanish, Italian, French, Korean, Russian, and simplified Chinese). The survey was disseminated through social media and communication platforms (i.e., LinkedIn, Facebook, and WhatsApp) and email to ECPs worldwide. In Spain, the survey was distributed by email by the General Council of the Spanish Opticians-Optometrists to all registered Optician-Optometrists in the country. The results obtained from ECPs worldwide were grouped into six large regions (i.e., Asia, Australasia, Europe [without Spain], North America, South America, and Middle East) for analysis and comparison with Spain. Additionally, differences in opportunities, interventions and threats with regards to the type of practice in which Spanish practitioners work were also assessed, as well as the potential influence that years of contact lens fitting experience and number of contact lens fittings performed per month might have on the potential opportunities, interventions and threats reported by Spanish practitioners.

Statistical analyses were performed using SPSS 25.0 software (SPSS Inc., Chicago, Illinois, USA). The Kolmogorov-Smirnov Test of normality was used to assess whether the study variables were normally distributed. As all variables were found to be non-normally distributed, the Kruskal-Wallis and Mann–Whitney U tests were used for analysing differences between regions as well as differences in opportunities, intervention and threats reported by Spanish practitioners with regards to the type of practice, and the Spearman's rank correlation coefficient was used for assessing whether the opportunities, interventions and threats reported by Spanish practitioners were influenced by the years of contact lens experience and the number of contact lens fittings performed per month. To evaluate statistical significance, a threshold of p≥0.05 was used. For conciseness, only significant comparisons are reported.

A total of 2,408 responses were obtained from ECPs from 72 countries across the world: Africa 3.6% (n = 87), Asia 32.1% (n = 773), Australasia 2.5% (n = 60), Europe 35.2% (n = 848), Middle East 10.6% (n = 256), North America 7.0% (n = 169), and South America 8.9% (n = 215).17 Of these, 436 came from Spanish practitioners. All of the respondents from Spain were optometrists, of which 93.9% (n= 410) reported working in optometry practices [Local retail chain: 4.3% (n=19); Stand-alone practice/independent practice: 70.9% (n=309); National or regional retail chain: 18.5% (n=81); Cooperative practices: 0.2% (n=1)], 1.1% (n=5) in hospitals, 4.6% (n=20) in a university setting and 0.2% (n=1) in industry. The mean age of the Spanish optometrists who participated in the study was 42.2±10.4 years (range: 22-70). The majority were female (61.9%, n=270); male respondents accounted for about one third (36.2%, n=158); and a few participants did not report their gender (1.8%, n=8). Spanish ECPs reported having an average length of contact lens-working experience of 20.8±24.4 years (inter-quartile range (IQR): 16; range: 1-31). The average (± standard deviation (SD)) number of new contact lens fittings undertaken per month by Spanish practitioners in naïve contact lens wearers was reported to be 6.8±6.3, with most contact lenses fitted to these patients being spherical, toric and multifocal designs of soft contact lenses (Fig. 1). Spanish practitioners consider themselves proactive in fitting contact lenses (median: 8/10; range: 0-10). Around 80% of Spanish ECPs reported encouraging potential contact lens patients with no apparent contraindications for lens wear to consider contact lenses (Fig. 2). Thirty-eight percentage of Spanish practitioners indicated that they perceived their clinical practice in the next 5 years as uncertain, 15.5% as worrying, and 7.7% as very worrying. Only 33.2% and 5.7% perceived it as promising and very promising, respectively.

Fig. 1.

Types of lenses fitted by Spanish eye care practitioners in an average month to naïve contact lens wearers.

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Fig. 2.

How often do you encourage potential contact lens patients who have no apparent contraindications to consider contact lens wear?

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In Spain, daily disposable contact lens for conventional use and multifocal contact lens for presbyopes were perceived by practitioners as the most promising developments in contact lens practice for the near future (median: 9/10 in both cases). In contrast, cosmetic contact lenses and diagnostic, therapeutic and bionic contact lenses were perceived as the least favourable developments for future contact lens practice (median: 5/10 in both cases) (Fig. 3). Significant differences were found between Spain and the rest of the world regions assessed with regards to the perception of promising opportunities for future contact lens practice (p=0.02). Spanish practitioners reported a greater perception of promising opportunities in contact lens practice (median: 6.5/10) in comparison with African (median: 5.7/10; p=0.003), Middle Easter (median: 6/10; p=0.005) and Asian practitioners (median: 6.3/10; p=0.02), but no significant differences were found between Spanish and Australasian, North American, European and South American practitioners (all p>0.05). More specifically, Spanish practitioners reported managing irregular corneas with contact lenses as a significantly lower potential opportunity than African and Middle Easterpractitioners (both p≤0.05). Spanish practitioners rated the use of multifocal contact lenses for presbyopes, myopia control lenses, biocompatible materials to improve comfort and custom soft contact lenses to control aberrations and enhance visual acuity as significantly higher opportunities for contact lens practice than African, Asian and Middle Easter practitioners (all p≤0.008). The use of orthokeratology contact lenses for myopia correction was perceived as a greater opportunity for contact lens practice by Spanish practitioners in comparison with African and Middle Easter practitioners (both p<0.001). Daily disposable contact lenses for occasional wear were perceived as a greater opportunity for contact lens practice by Spanish in comparison with African and Asian practitioners (both p<0.001). In contrast, cosmetic lenses were perceived as a less favourable opportunity for contact lens practice by Spanish practitioners in comparison with African, Asian and Middle Easter practitioners (all p<0.001).

Fig. 3.

Average scores of potential opportunities for future contact lens practice (rated from 0 [lesser] to 10 [greater]) reported by Spanish practitioners. Box = 1 standard deviation, line = median, whiskers = 95 % confidence interval, o = extreme values and * = outliers. CL, Contact lens; VA, Visual acuity.

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Significant differences were found in the perception of opportunities with regards to the type of optometric practice (p=0.002). Spanish practitioners who work in a hospital setting reported a lower perception of opportunities (median: 5.8/10) compared to those working in a stand-alone practice/independent practice (median: 6.3/10; p<0.001), university setting (median: 6.2/10; p=0.014) or in national or regional retail chains (median: 6.4/10; p<0.001) (Table 1). Additionally, practitioners who work in local retail chains also reported a lower perception of opportunities (median: 6/10) compared to those working in a stand-alone practice/independent practice (median: 6.3/10; p=0.025) or in national or regional retail chains (median: 6.4/10; p=0.007) (Table 1).

Although statistically significant, it is unlikely that years of contact lens fitting experience was correlated with the overall perception of promising opportunities for future contact lens practice reported by Spanish practitioners (r=0.045; p=0.026). More specifically, fitting experience was unlikely to be correlated, despite statistical significance, with the perception of opportunities related to managing irregular cornea (r=0.106; p<0.001), multifocal contact lenses for presbyopes (r=0.185; p<0.001), myopia control lenses (r=0.082; p<0.001), cosmetic lenses (r=0.269 p<0.001), biocompatible materials to improve comfort (r=0.155; p<0.001) and custom soft contact lenses to control aberrations and enhance visual acuity (r=0.095; p<0.001). Although statistically significant, it is also unlikely that the number of contact lens fittings performed per month was correlated with the perception of promising opportunities related to the overall perception of future contact lens practice (r=0.223; p<0.001). More specifically, the number of fittings per month was unlikely to be correlated, despite statistical significance, with the perception of opportunities related to managing irregular cornea (r=0.286; p<0.001), multifocal contact lenses for presbyopes (r=0.082; p<0.001), myopia control (r=0.177; p<0.001), orthokeratology for myopia correction (r=0.184; p<0.001), diagnostic, therapeutic and bionic lenses (r=0.187; p<0.001), biocompatible materials to improve comfort (r=0.130; p<0.001) and custom soft contact lenses to control aberrations and enhance visual acuity (r=0.180; p<0.001).

Spanish practitioners considered it important to update knowledge skills; to proactively recommend the use of contact lenses to potential patients; to educate parents about myopia control methods; to create an efficient recall system for follow-up examinations; and to be able to manage ocular-related complications associated with contact lens wear (median: 9/10 in all cases). In contrast, the use of marketing campaigns in social media and making contact lenses more affordable to patients were perceived as less relevant interventions (median: 6/10 and 7/10, respectively) (Fig. 4).

Fig. 4.

Average scores of potential interventions (rated from 0 [lesser] to 10 [greater]) reported by Spanish practitioners. Box = 1 standard deviation, line = median, whiskers = 95 % confidence interval, o = extreme values and * = outliers. CL, Contact Lens.

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Significant differences were found between Spain and the rest of the regions with regards to potential interventions (p<0.001). Overall, Spanish practitioners reported a greater perception of potential interventions (median: 8.1/10) in comparison with Middle Easter (median: 7.8/10; p=0.04) and North American practitioners (median: 7.7/10; p=0.007); lower perception of interventions in comparison with South American practitioners (median: 8.8/10; p<0.001); and no significant differences in the perception of potential interventions in comparison with Australasian, African, European and Asian practitioners (all p>0.05). Making wearers aware of the importance of safe contact lens wear was reported as a more and less relevant intervention by Spanish practitioners in comparison with North American and South American colleagues, respectively (both p<0.001). Constant updating of knowledge/skills, creating an efficient recall system for follow-up examinations and managing contact lens-related complications were reported as more relevant potential actions by Spanish practitioners in comparison with Middle Easter and North American colleagues, but less relevant in comparison with South American practitioners (all p<0.05). Staff training was considered less important by Spanish in comparison with South American practitioners (p<0.001). Recommending contact lenses to potential patients as well as educating parents about the benefits of contact lens wear in children were reported as more and less interesting interventions by Spanish in comparison with Middle Easter and South American practitioners, respectively (all p<0.001). Making contact lenses more affordable to patients and using social media for marketing contact lenses online were found as less attractive interventions by Spanish in comparison with Middle Easter and South American practitioners (all p≤0.01).

Significant differences were found in potential interventions with regards to the type of optometric practice (p<0.001). Spanish practitioners who work in a hospital setting reported a lower perception of potential interventions (median: 7.8/10) compared to those who work in a local retail chain (median: 8.0/10; p=0.021), in a national or regional retail chain (median: 8.3/10; p<0.001) or in a stand-alone practice/independent practice (median: 8.1/10; p=0.002). Additionally, practitioners who work in national or regional retail chains reported a higher perception of potential interventions (median: 8.3/10) compared to those working in a stand-alone practice/independent practice (median: 8.1/10; p=0.006), university practice (median: 7.9/10; p=0.001) or in a local retail chain (median: 8.0/10; p=0.019) (Table 2).

No significant correlation was found between the years of fitting experience and overall potential interventions reported by Spanish practitioners (r=-0.019; p=0.354). Although statistically significant, it is unlikely that the number of fittings performed per month was correlated with the overall perception of potential interventions (r=0.144; p<0.001). More specifically, the number of fittings performed per month by Spanish practitioners was unlikely to be correlated, despite statistical significance, with the perception of potential interventions related to continuously updating practitioner's knowledge/skills (r=0.120; p<0.001), educating parents about the possibility for children to wear contact lenses (r=0.133; p<0.001), being competent in managing contact lens-related complications (r=0.116; p<0.001), making contact lenses more affordable to patients (especially daily disposables) (r=0.041; p<0.001), and marketing contact lens practice on social media (r=0.102; p<0.001).

Significant differences were found in the perception of threats between Spain and the rest of the regions assessed, with the exception of South America (p<0.001). Overall, Spanish practitioners reported a greater perception of threats (median: 7.3/10) in comparison with Middle Easter (median: 6.2/10; p<0.001), North American (median: 6.3/10; p<0.001), African (median: 6.7/10; p=0.002), Asian (median: 6.9/10; p<0.001), Australasian (median: 6.0/10; p<0.001) and European practitioners (median: 6.5/10; p<0.001). In Spain, practitioners reported to be very concerned about threats related to the lack of regulation, contact lenses being available online without professional supervision, and contact lens prescriptions being available via digital devices (median: 10/10 in all cases); these three threats were reported to be more concerning by Spanish practitioners in comparison with practitioners from the other regions assessed, with the exception of South American practitioners (Table 3). Technological advances in ophthalmic lenses and ocular infections caused by contact lens wear were perceived as less worrying threats (median: 5/10 in both cases) (Table 3).

Significant differences were found in perceived threats with regards to the type of optometric practice (p=0.039). Spanish practitioners who work in a university setting reported a lower perception of threats (median: 6.6/10) compared to those working in a stand-alone practice/independent practice (median: 6.9/10; p=0.014) or in national or regional retail chains (median: 6.9/10; p=0.020) (Table 4).

Although statistically significant, it is unlikely that fitting experience was correlated with the overall perception of threats reported by Spanish practitioners (r=0.064; p=0.002). More specifically, the number of years of fitting experience was unlikely to be correlated, despite statistical significance, with the perception of threats related to the lack of regulation (r=0.192; p<0.001), contact lenses being available online without professional supervision (r=0.108; p<0.001), contact lens prescriptions being available via digital devices (r=0.115; p<0.001), clinics without proper instrumentation (r=0.058; p=0.005), incompetent practitioners (r=0.067; p<0.001), commoditization of contact lenses (r=0.158; p<0.001), drop out due to discomfort/dryness (r=0.096; p<0.001), unfavourable industry policies (r=0.107; p<0.001), negative myths about contact lenses among the general public (r=-0.079; p<0.001), advances in the spectacle industry (r=-0.080; p<0.001) and contact lens-related infections (r=-0.077; p<0.001). Although statistically significant, the number of fittings performed per month was unlikely to be correlated with the overall perception of threats (r=0.042; p=0.040). More specifically, the number of fittings performed per month was unlikely to be correlated, despite statistical significance, with perceptions of threats related to clinics without proper instrumentation (r=0.056; p=0.006), incompetent practitioners (r=0.095; p<0.001) and negative myths about contact lenses among the general public (r=0.048; p=0.004).