Dry Eye: Digital device dryness

Interaction with the digital environment is ubiquitous in our daily lives.¹ Based on online survey data, it was estimated that the average adult residing in the United States had access to at least 10 digital devices in their household² and would spend almost eight hours per day interacting with digital media.³  

Visual symptoms arise when the viewing demands of the task exceed the user’s viewing capacity.⁵ During the Covid-19 pandemic, the amount of digital screen use increased (by 20 to 30% in a self reported cross-sectional study of >3,000 adults from the USA;⁶ with an associated increased prevalence of symptoms.⁷  

The digital eye strain prevalence depends on the population studied and the questionnaire used, but has been found to affect an average around 70% of an adult population,^{8, 16} so can be expected in approximately seven out of every 10 patients attending for a routine eye examination.  

Why is addressing digital eye strain important  

Patients reporting digital eye strain have a lower quality of life⁹ and reduced work productivity compared to their colleagues with comfortable eyes.¹⁰ As digital eye strain can exacerbate or potentially trigger dry eye disease, this too is known to reduce work productivity and negatively impact an individual’s quality of life.^{11, 12} 

Work productivity loss in Japanese office workers due to dryness symptoms was valued in 2014 at $6,160/year (United States) per ^person13, while at a similar time the total annual loss due to dry eye disease in the United States of America was estimated to amount to approximately $55bn (United States).¹⁴  

In addition, discomfort with contact lenses is the leading cause of discontinuation,¹⁵ which impacts a patients quality of life and the economics of clinical practice.  

Defining digital eye strain  

The Tear Film and Ocular Surface Society recently published their impact of lifestyle of the ocular surface reports which included the digital environment as a key topic of interest.¹⁶ This defined digital eye strain as ‘the development or exacerbation of recurrent ocular symptoms and/or signs related specifically to digital device screen viewing’.  

Approximately one-third of the adult population have dry eye disease^{8, 17-19} who will have symptoms when using digital devices, but the new definition makes it clear this is not digital eye strain unless the symptoms are exacerbated when using a digital device.  

The report also advocates for the use of the terminology ‘digital eye strain’ as better representing the range of devices it encompassed rather than ‘computer vision syndrome’ and with it being more specific than alternative phrases such as ‘visual fatigue’.¹⁶  

The impact of contact lens wear on digital eye strain  

There is limited research specific to digital eye strain and contact lenses. Contact lenses are at least 10 times thicker than the tear film, so have been shown to disrupt the ocular surface.^{20, 21}  

Hence it is not surprising that contact lenses have been identified as an independent risk factor for digital eye strain (odds ratio 1.9 to 4.9 times), but these analyses did not break down aspects such as the modality of wear and the material innovations of the contact lenses worn by those surveyed.^22-24  

An older scoping review suggested the prevalence rate of symptoms when using digital devices was four times higher in contact lens wearers (95.0% to 16.9%) than non-wearers (57.5% to 9.9%),²⁵ whereas a more recent systematic review reported a slightly higher prevalence in contact lens wearers (73.1% vs 63.8%)²⁶ and a study reported slightly, but significantly, higher symptoms when using a digital device in contact lens wearers (OSDI score 34.4 versus 32.2).²⁷  

Another recent study surveying contact lens and non-contact lens wearers found that although the prevalence of symptoms when using digital devices was high (60% had symptoms more than once a week), there was no difference between the groups.²⁸ In combination, this might suggest that the impact of contact lenses on digital eye strain is reducing with modern lenses.  

During Covid-19, a high prevalence (92%) of digital eye strain was reported in medical students, but while there was an association between contact lens wear and symptoms there was a similar trend with spectacle lens wear.²⁹  

Patients swapped to a polyvinyl pyrrolidone embedded silicone hydrogel lens who were classed as intensive (defined as >3 hours as day) digital device users reported being more satisfied.³⁰  

Another study found an aspheric lens design decrease accommodative microfluctuations when reading from a smartphone for 20 minutes, which the authors suggested indicated reduced ciliary muscle stress and so may be of benefit to patients experiencing digital eye strain.³¹

Contact lenses with a low (+0.50 D) add decreased the accommodative response (made the response less accurate) compared to monofocal contact lenses at near distances (25 and 40cm) and with really low contrast conditions (20%, but not a 40% contrast), but no details of the digital device viewed were given.³² 

Another study suggested there was a statistical difference between a prism and aspheric contact lens addition on symptoms and binocular accommodative facility, but only eight participants were involved.³³  

Managing digital eye strain in contact lens wearers  

It has been suggested that special consideration is needed for people at a high risk of digital eye strain, such as contact lens wearers,³⁴ principally due to a contact lenses impact on the tear film. Digital eye strain has also been associated with accommodative and oculomotor alterations as well as musculoskeletal effects of using digital devices.¹⁶  

These can be altered with contact lenses compared to spectacles (the oculomotor response in pre-presbyopes³⁵ and musculoskeletal effects in presbyopes wearing progressive lenses.³⁶  

However, a recent cross-over study showed that wearing a modern disposable contact lens (Dailies Total1, Alcon) had no additive effects on signs and symptoms of dry eye when using digital devices for a short (20 minute) periods and that instillation of artificial tears was an effective strategy for reducing the impact of display use in contact lens wearers.³⁷  

Although not specific to contact lens wear, based on the available academic evidence, the TFOS lifestyle report on the digital environment recommended:³⁸  

Differential diagnosis:  

• Dry eye versus digital eye strain: check whether the patient has symptoms during non-digital tasks and if so, do they get worse when they are performing digital tasks.³⁸  
• Infection/allergy: if the symptoms are largely unilateral, include itchiness, are associated with pain rather than discomfort or are of sudden onset, be suspicious of other possible causes and ask whether there has been any discharge from the eyes.^{38, 39} A detailed slit lamp biomicroscope examination is warranted. 

Assessment:  

• Ocular surface disease: check for poor tear film stability and any ocular surface staining  
• Binocular vision: check for any dissociating phoria or poor accommodative facility  
• Refraction: check the refraction compared to the currently worn refractive correction  

Management:  

• Optimise the contact lenses^{40, 41} (figure 1):  
  • Reduce the replacement frequency, ideally to a daily disposable as this will remove any involvement of the cleaning solutions.^{37, 42} 
  • Change to contact lenses with a more lubricious surface to reduce the mechanical stress between the lens and ocular surface with each blink.^{43, 44}  
  • Use a non-preserved artificial tear at times when the eyes can become uncomfortable, to manage any associated dry eye symptoms.³⁷  
  • Ensure the contact lenses fully correct the refractive error, including even low levels of astigmatic error.^{45, 46} If eye focus is limited, the refraction should be appropriate to the screen distance.  

• Other advice:³⁸  
  • Optimise binocular vision with eye exercises. 
  • Add oral omega-3 fatty acid supplementation to the diet. 
  • Try blink exercises. 
  • Take regular breaks from intense screen-based tasks. 
  • Ergonomic considerations – avoid reflections from the screen and position it lower than the eyes. 
  • Screen considerations – increase screen and font size; switch to e-paper. 
  • Environment considerations – increase humidity and decrease air conditioning. 
• Task considerations – limit screen time to four to five hours a day and reduce task demand if possible. 

Figure 1: Reducing digital eye strain in contact lens wearers

While digital eye strain is highly prevalent for all digital device users and it is recognised that contact lenses can further exacerbate the condition, with dryness (digital device dryness) one of the more pervasive symptoms.  

For all, simple steps like recommending the use of non-preserved artificial tears, and for contact lens wearers including prescribing a daily disposable contact lens with a lubricious surface which fully corrected the sphero-cylindrical refractive error, for when patients are conducting intense tasks for long durations, can minimise the impact on your patients.  

References  

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