Digital eye strain – there is more to come & more to explore! Part-2

Dr. Jameel Rizwana Hussaindeen, M.Phil, PhD, FAAO, FCOVD-I

Head of Academy, Rivoli Vision

Clinical Diplomate – Binocular vision, Perception & Pediatric Optometry Section,

American Academy of Optometry (AAO)

President, Optometric Association of Tamil Nanbargal (OATN) & AAO India chapter

Assessment protocol for DES

Due to the surge in DES across all age groups, it is very much likely that eyecare professionals would be encountered with this symptomatic population every single day in their practice. Based on the available evidence, the recommendations towards assessing DES should include ^{(1,2, 3-5)}

1. A detailed history taking using a structured inventory to elicit symptoms of asthenopia and dry eyes, and task specific questions to understand the visual demands specific to the occupation or job that the patient is engaged in. This should also include
   1. The number of digital devices used
   2. The viewing distance and angle
   3. Number of hours of digital device use
   4. Breaks taken during digital device use
   5. Details of the digital device and screen
2. Details regarding Ergonomic aspects of the workplace, lighting, and related Musculo-skeletal complaints
3. Comprehensive eye examination including assessment for refractive errors
4. Detailed binocular vision assessment to evaluate parameters of accommodation and vergence
5. Dry eye evaluation that includes the assessment of blink rate, quality of blinking, tear film height, quality of tear film, evaluation of the eyelids and ocular surface, and clinical measurements of the tear film including Schirmer’s test, Tear break-up time, etc

Management of DES ^(6,7)

Management of digital eye strain is primarily aimed at ameliorating the symptoms and improving the vision comfort and quality associated with the use of digital devices. This would include prescription of appropriate refractive correction, management of presbyopia, occupation specific glass prescription and coatings, management of binocular vision anomalies, counseling regarding the use of digital devices, environmental modifications, and ergonomic aspects, and management of dry eyes. In addition to managing any existing ocular and visual dysfunctions, preventative approaches should also focus at incorporating appropriate lifestyle changes such that the precious sense of sight is preserved and protected for improved productivity and overall quality of life.

The preventative approaches should include

• Frequent breaks and following the 20-20-20 rule
• Ensuring frequent and complete blinking, following lid-hygiene measures
• Taking care of environmental factors that can precipitate or aggravate symptoms such as lighting, placement of air-conditioning unit
• Maintaining appropriate viewing distance and angle based on the type of digital device that is used
• Ergonomic considerations such as using a chair with appropriate back rest
• Regular eye examinations
• Education and awareness on a routine basis regarding digital eye strain for all ages
• Teachers and school authorities to be educated regarding the need for frequent breaks and reduced workload with e-learning. To supplement learning through other off-line modalities
• Engaging in outdoor activities, and regular physical activity
• Managing stress and anxiety
• Taking care of one’s overall health as systemic diseases can increase the risk for ocular diseases

A paradigm shift required

Now that we have explored DES and CVS from the standpoint of its etiology, clinical presentation and understanding. What if these conditions are looked through the lenses of an occupational eyecare expert?

Dr. Krishna Kumar, Freelance Educationist & Optometrist/ Former Principal, Elite School of Optometry shares the following nuggets of wisdom from his close to 3 decades of experience in the clinical and occupational eyecare sector.

A recent study⁽⁸⁾ explored the prevalence of dry eyes among a large sample of 40,501 employed individuals working ≥8 hours a week included from the population-based Lifelines cohort in the Netherlands. This study explored the association between the different occupations based on the ISCO-08 classification and the prevalence of dry eyes. This study with a robust methodology concluded that people who work indoors, with high screen use, and high-risk occupations such as building workers are at an increased risk for symptomatic dry eye compared to people who work outdoors. This study brings out the importance of understanding the visual demands pertinent to the occupational profile, and to approach this issue from a potential protective perspective.

So, this adds the following key points to the above checklist of proposed preventative approaches.

• Dry eye evaluation in occupations that are based indoor, and with a high screen use
• Understanding the external factors and occupational hazards in the workplace and advocate towards improving the workplace environment
• Evaluating the visual profile of an individual to understand if it matches the visual demands required at work
• Understanding the internal and external risk factors that increases the risk of digital eyestrain and dry eyes, and catering to an individual’s workplace productivity through a customized approach

Digital eye strain is not going to go away!

It is fair to believe that digital advances do support the achievement of the United nations’ each of the 17 sustainable development goals. ⁽⁹⁾ Especially given the disruption to education and healthcare needs imposed by the COVID-19 pandemic, technology and digital devices have become a matter of basic lifestyle needs. But it is also important to balance the use of digital devices such that they do not impact the quality of life by affecting the health of the eye and visual system. It is the moral responsibility of every eyecare professional to spread awareness regarding digital eyestrain and also to equip themselves with the necessary skillset and knowledge to provide appropriate preventative and management approaches to curb this condition. Further explorations in this field includes optimizing the digital screen for improved visual comfort, ⁽¹⁰⁾ novel spectacle lens technologies to reduce visual fatigue associated with longer hours of screen viewing, and inbuilt filters to optimize visual comfort. Most importantly, consider the paradigm shift that may be required in our understanding of looking at the issue as man/instrument made, so that customized solutions can be explored accordingly.

References

1. Barabino S. A Narrative Review of Current Understanding and Classification of Dry Eye Disease with New Insights on the Impact of Dry Eye during the COVID-19 Pandemic. Ophthalmol Ther. 2021 Sep;10(3):495-507. doi: 10.1007/s40123-021-00373-y. Epub 2021 Jul 17. PMID: 34275088; PMCID: PMC8286160.
2. Sheppard AL, Wolffsohn JS. Digital eye strain: prevalence, measurement and amelioration. BMJ Open Ophthalmol. 2018 Apr 16;3(1):e000146. doi: 10.1136/bmjophth-2018-000146. PMID: 29963645; PMCID: PMC6020759.
3. Coles-Brennan C, Sulley A, Young G. Management of digital eye strain. Clin Exp Optom. 2019 Jan;102(1):18-29. doi: 10.1111/cxo.12798. Epub 2018 May 23. PMID: 29797453.
4. Mohan A, Sen P, Mujumdar D, Shah C, Jain E. Series of cases of acute acquired comitant esotropia in children associated with excessive online classes on smartphone during COVID-19 pandemic; digital eye strain among kids (DESK) study-3. Strabismus. 2021 Jul 5:1-5. doi: 10.1080/09273972.2021.1948072. Epub ahead of print. PMID: 34223812.
5. Jaiswal S, Asper L, Long J, Lee A, Harrison K, Golebiowski B. Ocular and visual discomfort associated with smartphones, tablets and computers: what we do and do not know. Clin Exp Optom. 2019 Sep;102(5):463-477. doi: 10.1111/cxo.12851. Epub 2019 Jan 21. PMID: 30663136.
6. Rosenfield M. Computer vision syndrome: a review of ocular causes and potential treatments. Ophthalmic Physiol Opt. 2011 Sep;31(5):502-15. doi: 10.1111/j.1475-1313.2011.00834.x. Epub 2011 Apr 12. PMID: 21480937.
7. Munshi S, Varghese A, Dhar-Munshi S. Computer vision syndrome-A common cause of unexplained visual symptoms in the modern era. Int J Clin Pract. 2017 Jul;71(7). doi: 10.1111/ijcp.12962. Epub 2017 Jun 8. PMID: 28594459.
8. Bazeer S, Jansonius N, Snieder H, Hammond C, Vehof J. The relationship between occupation and dry eye. Ocul Surf. 2019 Jul;17(3):484-490. doi: 10.1016/j.jtos.2019.04.004. Epub 2019 Apr 2. PMID: 30951831.
9.   (accessed 9th August, 2021)
10. Yuan K, Zhu H, Mou Y, Wu Y, He J, Huang X, Jin X. Effects on the Ocular Surface from Reading on Different Smartphone Screens: A Prospective Randomized Controlled Study. Clin Transl Sci. 2021 May;14(3):829-836. doi: 10.1111/cts.12933. Epub 2021 May 3. PMID: 33202098; PMCID: PMC8212737.

Additional sources:

1. Sánchez-Brau M, Domenech-Amigot B, Brocal-Fernández F, Seguí-Crespo M. Computer vision syndrome in presbyopic digital device workers and progressive lens design. Ophthalmic Physiol Opt. 2021 Jul;41(4):922-931. doi: 10.1111/opo.12832. Epub 2021 May 4. PMID: 33945635.
2. Additional link to access professional resources related to Digital eyestrain: https://www.skoptics.org/post/digital-eye-strain-ools (accessed 9th August, 2021)

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