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From first thing in the morning until the last thing at night, people are tethered to their smartphones. Screen time is ubiquitous throughout the day, whether at work or play. Computer vision syndrome (CVS) is as pervasive as the devices for which it is named, having been described as the number one occupational hazard of the 21st century.1
Extended exposure to computer screens and digital devices, such as smartphones and tablets, is associated with symptoms of CVS and digital eye strain (DES), including dry eyes, blurred vision, eye fatigue, and headache. According to a 2016 report from The Vision Council, 65% of Americans experience symptoms of DES, and the highest rates of DES are found in younger people, with almost 75% of adults younger than 30 years of age reporting symptoms.2 The report, which was based on a survey of more than 10,000 adults, suggests that prolonged use of digital devices appears to worsen the symptoms of DES, as 96% of Americans who experience DES report spending 2 or more hours each day using devices.2 The report also suggests that proximity to the screen, frequency and duration of device use, and the amount of exposure to high-energy visible (HEV) and blue light all play roles in DES symptoms.2
MORE THAN A NUISANCE
In an interview, Andrew S. Morgenstern, OD, FAAO, chief medical editor of AOC, pointed out that human beings were not built to look at tiny print on a computer or phone screen all day long. “We were built to hunt and gather and care for our young; focusing on an unnatural target takes a toll,” he said. Dr. Morgenstern is past chairman of the American Optometric Association New Technology Committee and a member of the association's Evidence-Based Care Committee.
Ocular surface disorder (OSD) expert Richard W. Yee, MD, said it is becoming increasingly clear that DES is more than a nuisance that can be addressed solely with artificial tears. Prolonged exposure to digital devices and video screens contributes to OSD, particularly meibomian gland dysfunction (MGD), according to Dr. Yee, formerly a clinical professor of ophthalmology at the University of Texas and now in private practice. Dr. Yee and colleagues performed a study examining the relationship between frequency of screen use and ocular surface health.3 They found that individuals who had exposure to device screens for 3 or more hours daily were more likely to have OSD symptoms and complaints. Additionally, they found that patients who were asymptomatic had significantly less advanced MGD, and those patients who were most symptomatic had significant MGD.3
“I think this presents a clear association of OSD with computer vision complaints, and that those complaints actually relate to surface problems and perhaps even more specifically to meibomian gland problems,” Dr. Yee said.
A BLINK IN TIME
Both Drs. Morgenstern and Yee noted the well-documented association between screen time and reduced blink rate as a culprit in the symptoms associated with DES.4,5 Studies have found that there is a reduction in blink rate by approximately 60% in individuals using computers.6
“When you stare at a computer screen or handheld device, your blink rate goes down dramatically, and you decrease tear production,” Dr. Morgenstern said. “When you have decreased tear production, you have a poor ocular surface, and when you have a poor ocular surface that leads to a decrease in quality of vision. Staring at a computer screen or video screen for hours at a time can also affect the focusing mechanism; it is going to fatigue the muscles inside the eye that control the ability to accommodate.”
• Physician Recommended Nutraceuticals (PRN)
• Micro-Environment Glasses (MEGS)
worn as a protective measure on a regular basis to keep eyes lubricated
APPS TO REDUCE BLUE LIGHT
designed to filter blue light and make smartphone screens adapt to the time of the day
• NightShift (Apple iOS 9.3)
• Twilight (Urbandroid)
may improving the quality of expressed meibum available from Greenpark compounding pharmacy, Houston, Texas
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Dr. Morgenstern added that he doubts that dependence on smartphones or computers will wane, so the goal of eye care providers should be to help patients avoid the deleterious effects. A simple way to reduce the severity of symptoms, he said, is to take a break and look away.
“First, increase your blink rate; second, vary your focus. We tell our patients who report symptoms of DES that every 20 minutes they should take a 20 second break and look at something 20 feet away. This 20-20-20 rule can help make a difference,” he said.
Dr. Yee, too, recommended a specialized method of increasing the blink rate to improve the health of the ocular surface. He said a correlation between decreased blink rate and MGD can be extrapolated from the documented relationship between increased screen time and OSD symptoms.
“We offer blinking exercises to offset some of this stasis,” Dr. Yee said. “Patients are told to close their eyes firmly nine times in a row three times throughout the day. In this way, they are using the Riolan muscle mechanism to force a jetting of the oil. This reduces the chance of stoppage and blockage and keeps the oil flowing.”
Dr. Yee said lid massages and warm compresses applied to the lids are also effective, but he prefers to recommend the “9-3” blinking exercises because he has seen better compliance with this method. In fact, he said, he has stopped recommending use of warm compresses because he has seen that his patients are more likely to follow through with the blinking exercise regimen.
“Patients tend to be compliant with compresses for about 2 weeks, but you need a constant flow of oil to maintain patency, so a method to which they are more likely to adhere is preferred,” he said.
Dr. Yee also recommended use of the drug spironolactone, a drug primarily used as a diuretic, which he has developed in a topical formulation for treatment of DES. In a retrospective study aimed at evaluating the efficacy of topical spironolactone in the treatment of OSD, Dr. Yee and colleagues identified the drug’s potential antiinflamatory properties and found that spironolactone may play a role in improving the quality of expressed meibum, among other things.7 In the study, 20 patients with moderate to severe MGD were evaluated, and self-reported global assessment scores revealed a 23% improvement in MGD symptoms with use of the drug.
Other interventions that are effective in modifying symptoms associated with DES include supplements such as HydroEye (ScienceBased Health), containing omega-3 fatty acids and antioxidants, which has been shown to be helpful in improving evaporative dry eye disease,8 and other omega-3 fatty acid formulations.
In the first study to demonstrate an induced change in fatty acid saturation concentration content in meibum as a result of dietary supplementation with omega-3 fatty acids, patients who took omega-3 dietary supplements had improvements in Ocular Surface Disease Index, tear breakup time, and meibum scores.9
OTHER FACTORS IN PLAY
Blink rate and ocular surface health are not the only factors in play in DES. For instance, Dr. Yee pointed out, MGD and metabolic status are related, and a higher rate of MGD has been seen in patients with high cholesterol.10
“The implication,” Dr. Yee said, “is that, if you already have characteristics associated with metabolic syndrome, such as obesity and a sedentary lifestyle, and you are spending additional time being inactive while using a smartphone, tablet or computer, then there is a chance that your predisposition to MGD may be even higher than in the [healthy] population,” he explained.
Increased rates of nearsightedness are another alarming connection to frequent screen time, Dr. Morgenstern said. “The pervasive use of these devices in our younger populations is associated with increasing rates of myopia,” he said. “Myopia studies suggest that, the more people use these near stimulus devices, the more these devices are stimulating the eye to become nearsighted. Human beings learn to adapt to the stimuli with which they are faced. So we are essentially creating a large generation of young people who are nearsighted. That is a big problem because, when you have elongation of the eye due to axial myopia, that increases the rate of diseases such retinal detachment. For these reasons, eye care providers need to pay a significant amount of attention to CVS and DES,” he said.
Statistics and anecdotal evidence suggest that people are spending more time than they should looking at screens; nearly 60% of Americans use digital devices for 5 or more hours each day.2
“Everyone should be given the talk about giving the eyes a rest, using supplemental tears, and trying far stimulus and blinking exercises; and everyone should be made aware that digital eye strain is real,” Dr. Morgenstern said. This message is of even greater importance in the pediatric population, he said: “While in some patients excessive screen time may cause eye strain and discomfort, that does not necessarily equal harm, but in the pediatric population, where the eye is still developing, it can cause long-term harm.”
The optical industry has responded to overuse of digital devices by introducing specialized computer spectacles that provide protective properties. For instance, Micro-Environment Glasses, or MEGS (SeeFit), the brainchild of Dr. Yee, are specially designed to relieve and protect eyes from the symptoms associated with chronic dry eye and DES. He says these computer glasses can play a role, along with other effective interventions, in mitigating the symptoms of DES.11
BLUE LIGHT AND SLEEP
As digital device use becomes pervasive, concerns are growing about the light-emitting diodes (LED) that they use, which radiate blue wavelength light. The literature suggests that ongoing exposure to blue light emitted from backlit displays can damage retinal cells, and that it can also disrupt sleep by suppressing the natural release of melatonin.12,13 According to a survey, more than 75% of Americans use their smartphone within 1 hour of going to sleep.2
In response to this concern, Apple has released iOS 9.3, “NightShift,” a way of modifying Apple computers, iPhone, and iPad displays so that less blue light is emitted. Users can go into their settings to enable the modification. Dr. Morgenstern explained that this modification is designed to reduce DES symptoms and offset the effect of blue light on circadian rhythms to help users fall asleep easier.
However, he said, although NightShift may alleviate some DES, Apple does not make clear what wavelengths are being cut, nor is it clear what the optimal level of blue light is with respect to avoiding DES symptoms and circadian rhythm disruption. Given that the modification is adjusted by the user, with no explanation of how high the filter must be set to be useful or what wavelengths are being filtered out, at this point there are more questions than answers about the therapeutic value of this option. n
1. Akinbinu TR, Mashalla YJ. Knowledge of computer vision syndrome among computer users in the workplace in Abuja, Nigeria. Journal of Physiology and Pathophysiology. 2013;4(4):58-63.
2. The Vision Council. Eyes Overexposed: The Digital Device Dilemma. 2016. http://www.thevisioncouncil.org/digital-eye-strain-report-2016. Accessed August 19, 2016.
3. Dao AH, Spindle JD, Harp BA, et al. Association of dyslipidemia in moderate to severe meibomian gland dysfunction. Am J Ophthalmol. 2010;150(3):371-375.
4. Acosta MC, Gallar J, Belmonte C. The influence of eye solutions on blinking and ocular comfort at rest and during work at video display terminals. Exp Eye Res. 1999;68(6):663-669.
5. Patel S, Henderson R, Bradley L, et al. Effect of visual display unit use on blink rate and tear stability. Optom Vis Sci. 1991;68(11):888-892.
6. Blehm C, Vishnu S, Khattak A, et al. Computer vision syndrome: A review. Surv Ophthalmol. 2005;50(3):253-262.
7. Yee RW, Wong BW, DeJesus M. Topical spironolactone in the treatment of meibomian gland dysfunction. Poster presented at: Association for Research in Vision and Ophthalmology Annual Meeting; May 1-5, 2016; Seattle.
8. Sheppard JD Jr, Singh R, McClellan A, et al. Long-term supplementation with n-6 and n-3 PUFAs improves moderate-to-severe keratoconjunctivitis sicca: a randomized double-blind clinical trial. Cornea. 2013;32(10):1297-1304.
9. Macsai MS. The role of omega-3 dietary supplementation in blepharitis and meibomian gland dysfunction. Trans Am Ophthalmol Soc. 2008;106:336-356.
10. Dao AH, Spindle SD, Harp BA, Jacob A, et al. Association of dyslipidemia in moderate to severe meibomian gland dysfunction. Am J Ophthalmol. 2010;150(3):371-375.
11. Yee RW, Sperling HG, Kattek A, et al. Isolation of the ocular surface to treat dysfunctional tear syndrome associated with computer use. Ocul Surf. 2007;5(4):308-315.
12. Chamorro E, Bonnin-Arias C, Pérez-Carrasco MJ, et al. Effects of light-emitting diode radiations on human retinal pigment epithelial cells in vitro. Photochem Photobiol. 2013;89(2):468-473.
13. Blue Light Has a Dark Side. Harvard Health Letter. May 2012. http://www.health.harvard.edu/staying-healthy/blue-light-has-a-dark-side. Accessed August 19, 2016.
Andrew S. Morgenstern, OD, FAAO
• Optometric subject matter expert, Booz Allen Hamilton
• Chief Medical Editor, AOC
• Contract support, Vision Center of Excellence, Walter Reed
•ational Military Medical Center, Bethesda, Maryland
• Past Chairman, American Optometric Association New Technology Committee
• Financial interest: none acknowledged
NOTE: The opinions expressed in this article by Dr. Morgenstern are his own and do not reflect the view, opinion or recommendation of Walter Reed National Military Medical Center, Vision Center of Excellence, US Department of Defense, US Department of Veterans Affairs, Booz Allen Hamilton or the United States government.
Richard W. Yee, MD
• Corneal, refractive, cataract surgeon in private practice, Houston, Texas
• (832) 289-2020; firstname.lastname@example.org
• Financial disclosure: patent pending for spironolactone and consultant to SeeFit