Dry eye in the digital age

With the increased usage of digital devices in both adults and children, ODs should be actively searching for dry eye in their practices and screen all patients. ODs are able to do this with the tools already available to them.

The days when computer use was restricted to office work are long past. Modern computer use has extended to the classroom, home, and for most all activities. Excessive computer use has led to an increase in health-related problems in video display terminal (VDT) users, particularly in students and younger age groups. Foremost of concern for optometrists is digitally-related dry eye disease (DED).

Related: How to create an ocular surface disease treatment protocol

I am sure ODs are seeing more dry eye in their offices, reaching veritable epidemic proportions, and the patients suffering from dry eye disease are growing ever younger. So let’s discuss dry eye in this cohort. Most of what you will read you have likely already seen. I want to emphasize the prevalence of dry eye and why all ODs should be actively searching for dry eye in their practices.

Rise of digital device use
Since the advent of the internet, there has been an almost viral expansion of accessibility to it. Consider the percentage of global population with internet access:¹

16 percent in 2005
30 percent in 2010
51 percent in 2017
58.8 percent in 2019

More by Dr. Bowling: Hope in the time of COVID-19

Digital dry eye is directly tied to digital device use. Ninety percent of American adults report using digital devices greater than two hours a day.² Sixty percent of Americans use digital devices for at least five hours a day.3 Some 71 percent of Americans use digital devices for over seven hours a day.⁴ Some 67 percent of people use three or more devices simultaneously.² Some 27 percent of users report experiencing dry eye.³ Older subjects and people spending more than four hours a day on VDTs are at major risk for developing DED.⁵

Related: The importance of updated Glaucoma, OSD and dry eye treatments

ODs see the effects of digital use on our younger patients. Starting in infancy, children gravitate to the glowing screen in their parents’ hands; school-aged children are required to complete assignments online; and adults shop, socialize, and work using screens. Add in entertainment, and the hours people spend in front of a screen are staggering.

It is not a surprise that current research suggest that screen time may play a significant role in dry eye. Children are raised with digital devices. About 70 percent of adults report their children spend more than two hours a day on digital devices.² Some 23 percent of children report playing on digital devices as their favorite activity.³ Teens spend more than eight hours per day on digital devices.6 Children age eight to 12 are getting six hours a day of screen time.⁶

Approximately 10 percent of youth report dry eye symptoms.³

A 2016 study found that children who spend more time on their smartphones have more dry eye symptoms.⁷ This same study also found outdoor activity appeared to be protective against pediatric dry eye disease.

Related: Your glaucoma patients also have ocular surface disease

Effects of device use
Research shows ocular pathophysiologic effects from digital device use.

Both book reading and computer use result in decreased blink rates and increases in partial blinks. ODs have known that reading reduces the normal blink rate, but digital device use reduces that blink rate even further.

Related: Remember the basics as dry eye treatments expand

Ocular dryness is often accompanied by alteration in conjunctival epithelial cell morphology and conjunctival goblet cell density.⁸ Digital device use reduces blink rate to five to six blinks per minute vs normal of 14 blinks per minute.⁹ Patients have higher incomplete blink rates when reading from digital devices (7 percent) vs. 4 percent when reading from hard copy.¹⁰ Blink rate, blink amplitude and tear film stability are compromised during VDT use.11 Visual fatigue is greater with LCD displays vs. e-ink and hard copy.¹² Eye dryness is common after prolonged computer use with the prevalence ranging from 30 percent to 68.5 percent.¹³ Low mucin 5AC concentration in the tears with prolonged VT use.¹⁴ The oxidative stress marker hexanoyl lysine (HEL) was significantly increased at four hours of smartphone use than at baseline and at one hour of smartphone use.¹⁵

Contact lenses and devices
Contact lens wear is a risk factor for abnormal tear physiology, and contact lens wearers are 12 times more likely than emmetropes and five times more likely than spectacle wearers to report dryness symptoms.¹⁶

Add in computer use and the numbers increase even further. Some 83 percent of male and 87 percent of female contact lens wearers reported at least one dryness symptom compared to 68 percent of male and 73 percent of female non-contact lens wearers among computer users.¹⁷ And those dryness symptoms were more prominent among contact lens wearers using digital devices for three to six hours than among those using devices for less than three hours.¹⁷

Related: Why patient occupation matters with dry eye disease

Dry eye diagnosis
ODs understand the differences between the 2007 and 2017 DEWS definitions of dry eye.¹⁸ Hyperosmolarity is one common component of the two definitions. The etiophysiologic distinction between aqueous deficiency and evaporative dry eye is not included in the 2017 definition of dry eye, but inflammation is. The new definition reflects research showing an inflammatory component to dry eye disease, and tear film osmolarity and neurosensory abnormalities play significant roles.

Related: 6 steps to establish an OSD advocate in your practice

Perhaps the most powerful part of the current definition is the reference to the loss of homeostasis of the tear film. Because the eye is so critical to survival, much of its function centers around maintaining or regaining the physiologic balance necessary for sustained stable vision, such as protecting and repairing the ocular surface from damage or disruption. When the delicate homeostatic balance of the ocular surface system is disturbed, it triggers an activation of a progressive stress response resulting in the production of pro-inflammatory cytokines and matrix metalloproteinases.¹⁹
Meibomian gland dysfunction (MGD) is recognized as both a cause and a contributor to dry eye.²⁰ It is an obstructive and inflammatory disease resulting in insufficient and abnormal production of tear lipids. While most associate MGD with excessive tear evaporation, its role in tear dysfunction is far more complicated. Meibomian gland lipids have tear stabilizing functions beyond serving as an evaporative barrier.²¹

Related: Minimize symptoms of dry eye disease in refractive surgery patients

An unstable tear structure leads to surface exposure and, in more severe cases, frank damage. Maintaining integrity and function of the ocular surface is so critical that the eye is equipped with mechanisms such as increased mucin production to maintain and regain homeostasis.

Obstruction is the most recognized cause of MGD and resulting tear lipid insufficiency.²² As meibum stagnates and becomes saturated and thickened, pressure within the glands mounts and production is down-regulated. Gland clearance has long been recognized as a treatment for MGD.²³ Performed appropriately, this includes the application of heat to help melt congealed meibum and mechanical expression.

Related: Better manage nocturnal lagophthalmos for dry eye patients

Although DEWS II offers the most comprehensive view of dry eye to date, its complexity can be daunting for many clinicians, especially in diagnosing and managing the condition. So, let’s back up for a moment.

In 2006, a group met to discuss the state of dry eye disease. The results of their work was published in August 2006 and preceded the DEWS report.²⁴ This group, often referred to as “The Delphi Panel” or the “Dysfunctional Tear Syndrome Study Group” was polled for its most commonly used tests for evaluating a patient with probable dry eye. Their top four: fluorescein staining, tear break-up time, Schirmer’s test, and rose bengal staining. These are tests any clinician can perform in her office and are part of any dry eye protocol.

Related: Managing dry eye key to patient satisfaction after cataract, refractive surgeries

Since 2006, there has been an explosion of dry eye testing. How have testing patterns changed over a decade later?
A 2017 study surveyed 101 ophthalmologists, including 43 corneal specialists, regarding dry eye diagnosis.²⁵ Their top three most common ”traditional” dry eye tests performed and the percent of each test performed by the doctors:

Corneal fluorescein staining (8 percent)
Tear break-up time (78 percent)
Anesthetized schirmer’s test (51 percent)
Conjunctiva lissamine green and/or rose bengal staining (<25 percent)
The top three most common “newer” dry eye tests performed:
Tear osmolarity assessment (23 percent)
MMP-9 testing (17 percent)
LipiView (Johnson & Johnson Vision, 13 percent)

Note the same top four tests identified by the 2007 group were still the top four tests performed in 2017. This survey also added three “newer tests,” but the same tests are still being used a decade after the first TFOS report. Guess what? These top four tests and two of the newer tests can be incorporated into any practice, no matter the size, with a minimal investment.

See more: Eyecare practitioners urged to provide emergency care only amid COVD-19

But what about optometrists’ choice of diagnostic testing? A poll fielded on the Optometry Times® website26 asked ODs what objective test for dry eye they think is the most important. In first place-but not overwhelmingly so-was tear film break-up time with fluorescein as the most important objective dry eye test with 33 percent of respondents making this choice. After a sharp drop, corneal staining was second choice. Only 17 percent of respondents felt it was the most important objective test. Third and fourth place were close: 12 percent of ODs held tear osmolarity testing to be most important, and 11 percent voted for non-invasive tear break-up time. Conjunctival staining was fifth with 9 percent of respondents, and Schirmer was sixth with 7 percent. Meibography follows in seventh place with 5 percent. Tied for last as the most important objective dry eye test were MMP-9 and phenol red thread test with 1 percent of respondents. Compare the results of this small survey with how you diagnose dry eye in your practice.

Learn more: Contact lens wear still safe amid COVID-19

Treatment considerations
General treatment considerations in dry eye caused by digital devices include:
Drink water
Avoid excess caffeine
Quit smoking
Turn off overhead fans at night and consider a humidifier
Digital device specific recommendations include remembering to blink, the 20-20-20 rule, adjust device brightness, and consider changing background color from bright white to cool grey.

Most optometrists have heard of the 20-20-20 rule for preventing and relieving digital eye strain. The catchphrase suggests taking a 20 second break every 20 minutes by looking 20 feet away. Numerous sources now refer to it, including the American Optometric Association27 and the American Academy of Ophthalmology.²⁸

Other treatment considerations in dry eye caused by digital devices include:²

Adjust the screen directly in front of the face below eye level. Do not tilt screen.
Check the distance from you to screen: Extend a hand; it should lie flat against the VDT. Lessen overhead and surrounding light. Increase font size on the device. Keep handheld devices at a safe distance and below eye level. Most children hold devices at 5 to 6 inches from face. Increase distance.

More: 5 facts about contact lens wear with COVID-19

Blinking exercises can be beneficial, and the importance of reestablishing normal blink patterns must be reinforced. Dry eye expert Donald Korb, OD, FAAO, has long been a proponent of blink training, and it is an essential part of restoring function to the meibomian glands. I encourage patients to download a blinking app created by Dr. Korb. It is available for iOS for free in the App Store. Patients can set their own blinking reminders for their desired frequency.

Related: How to build a lifestyle and nutritional firewall against viruses like COVID-19

Conclusion
The purpose of this article was simply to alert ODs to the ubiquitous nature of digital dry eye disease and therefore to encourage them to look for the disease in their patient population. ODs don’t need to spend thousands of dollars or go to weekend workshops to diagnose and treat dry eye. However, those are options available.

ODs have the tools in their offices and the knowledge to conduct a cursory dry eye evaluation. They just need to be doing them. Dry eye is optometry’s golden goose. Think about it: Skills and the tools necessary are already available. ODs don’t need to refer it for surgical considerations. And patients deserve help with this condition. Take a few moments to probe for dry eye. Your patients will thank you for it.

More by Dr. Bowling: Coronavirus: A quick summary for optometrists

References:

1. Internet Growth Statistics. Available at: https://www.internetworldstats.com/emarketing.htm. Accessed 3/30/20.
2. The Vision Council. Digital Eye Strain. Available at: https://www.thevisioncouncil.org/content/digital-eye-strain. Accessed 3/30/20.
3. WebMD. Dry Eye and Screen Use. Available at: https://www.webmd.com/eye-health/dry-eye-screen-use#1. Accessed 3/30/20.
4. American Optometric Association. Kids’ prolonged smartphone use could trigger dry eye. Available at: https://www.aoa.org/news/clinical-eye-care/kids-prolonged-smartphone-use-could-trigger-dry-eye. Accessed 3/30/20.
5. Rossi GCM, Schudeller L, Bettio F, Pasinetti GM, Bianchi PE. Prevalence of dry eye in video display terminal users: a cross-sectional Caucasian study in Italy. Int Ophthalmol. 2019 Jun;39(6):1315-1322.
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26. Bailey G. The most important objective dry eye test is TBUT with fluorescein, ODs say. Available at:  https://www.optometrytimes.com/dry-eye-awareness/most-important-objective-dry-eye-test-tbut-fluorescein-ods-say. Accessed 3/30/20.
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