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How to guide patients in the use of digital devices

Optometry Times JournalOptometry Times August 2019
Volume 11
Issue 8

Glen Steele

The use of hand-held digital devices for gaming and social media has shown a marked increase in the past two years.1,2


Children who are teenagers in 2019 did not grow up having video games with the intensity, the close distance, nor the wider periphery necessary to be successful in the game as the 7- to 10-year-olds face today.

The heightened use of their “fight or flight” process, and increased engagement of peripheral awareness and scanning when following posts on social media is potentially having a significant effect on their development and function.3-6Related: Deconstructing the 20-20-20 Rule for digital eye strain

Ocular effects
Because gamers have a significantly heightened push into peripheral awareness at the closer distances, accommodation and visual acuity are diminished.

It is becoming the norm to hear vague complaints from children of not being able to see as well at distance or near and for them to show inconsistent and variable responses on testing that requires central function. The outcomes are not consistent with the refractive assessments.

Pupils show a significantly larger size than typical, are less reactive to light, and show less accommodative response to near targets on Just Look! Retinoscopy (near dynamic retinoscopy)-an observation of the manner in which a patient uses “looking” when engaged in a nearpoint task. It assesses patient response rather than refraction.

Related: How to recognize and manage digital eye strain 

The most frequent observation I see in an eye examination is an initial assessment of pupil size during near retinoscopy. It is expected to see pupil constriction during a nearpoint activity. 

This is not the observation noted in pupil size of the children who are compulsive gamers or who compulsively participate in social media activities. These children show a sustained increase in pupil size of 7 mm to 10 mm. Those who participate for longer periods of time tend to gravitate toward the larger sizes.

See Figures 1A and 1B.


Effects of devices
When a patient presents with the following signs and symptoms and shows these criteria during testing, I immediately think persistent sympathetic response:

• Playing games on the device as I come into the room
• Vague complaints of not being able to see as well at distance or near
• Responses on visual acuity (VA) or any detailed testing is not precise nor sharp
• Large pupils during near dynamic retinoscopy
• Darker retinoscopic reflex when asked to look at a central accommodative target but the pupil does not reduce in size accordingly
• Reduced fine stereo

Eckhard Hess wrote in Scientific American in 1965 that: “Dilation and constriction of the pupils reflect not only changes in light intensity but also ongoing mental activity. The response is a measure of interest, emotion, thought processes and attitudes.”7Related: Blue light: Why it matters 

These were demonstrated on a very short-term basis and were temporary. The current observations are the result of prolonged activity and are persistent rather than temporary. If this sympathetic response is shown to be persistent during testing, what else could be going on throughout the rest of the body and brain?

Social media (Facebook, Instagram, Twitter, YouTube) also leads to similar concerns as shown in gaming-a reduction of focus and increase emphasis on periphery.

For example, we have all experienced a “brief period of blur” when we look away from the screen after intense device usage.

Furthermore, the visual process in young and developing children is in a constant state of growth and sophistication. Does this lead to a disruption in vision development? A large pupil is not the cause of a problem. It is merely a reflection of what is going on internally. The patient is simply developing her own defined formed pattern of development.

Related: Virtual reality, tablet devices capture visual fields in unconventional ways 

Research results
Other things that have not been adequately investigated in the current literature include the following:

• Heart rate
• Blood pressure
• Direct and consensual pupil responses
• Respiratory responses
• Decreased sensitivities to touch, sound, and smell

During nearpoint testing, the patient will attempt to engage focusing (more than accommodation) in which case against motion will be seen on Just Look! Retinoscopy-near dynamic retinoscopy. The reflex will be even darker as the OD assesses effort. More effort will be required as the patient tries to focus from a persistent sympathetic mode.

The National Institute of Health has estimated that youth spend an average of five to seven hours per day on screens during “leisure time.” What effect does prolonged activation of the sympathetic nervous system have in infant and child development and in function and performance as children enter school?3Related: Innovative mobile technology targets low vision 

Numerous studies are beginning to show that children who utilize devices from an early age develop language more slowly, do not have the overall fine motor skills necessary for writing, and have a markedly shorter attention span when reading.4-6,8-12

Other studies show children exhibit more anxiety and depression when using the devices longer than one hour per day whereas children who use devices less than an hour a day experience less anxiety and depression.1,8,12-14

The World Health Organization now strongly suggests that limiting social media use to approximately 30 minutes per day may lead to significant improvement in well-being. This does not take into consideration required device use school and work.15

A March 2019 article in Journal of American Medical Association Pediatrics suggests that “higher levels of screen time at 24 and 36 months were significantly associated with poorer performance on developmental screening tests at 36 months.”6

The significance of this article to me is the marked increase in device use by 2- and 3-year-olds who show poorer performance on development screening tests by age 3.

Related: How artificial intelligence is changing the future of optometry 

Advice to families 

I address the increased device use trend with children by giving the patients and parents a choice: Continue in this pattern and play video games well, or limit use in order to develop central focus abilities that can be used in school and improve potential for overall development and readiness.

This is the parent or family choice in preparing the child for ensuing stages of development that require a more sophisticated use of vision. I do not recommend totally taking the device away but suggest guidelines to help the child gain control of the pattern of device use.

In consultation with the parent, I use pupil size to compare what happens in school versus gaming. It is then the parent’s choice to choose intervention and guidance. I suggest tighter guidelines for parents to use with kids who are on their devices for lengthy periods per day.

Related: Upgrading your patients to new technology 

Though there is little research to provide guidance for parents, it is imperative that all professionals, including optometrists, become involved.

In late 2018, I began using guidelines for young kids on hand-held devices. (See “Guidelines for parents” box.)

In my former practice and in the college clinic today, I saw a large number of patients diagnosed with Down syndrome, on the autism spectrum, and generally delayed in development. The use of music and video were the most common types of entertainment provided to these kids, and they were used continually. Often, the parent would have to take this entertainment away in order for me to complete the examination.

This presented a problem then and it is more prominent in typical kids today. I offer advice to parents of all children with any developmental delays, especially those noted above. (See “Device usage guidelines” box.)

Finally, babies and young children need a solid foundation in visual development, and digital devices seem to be a disruptor in the process of overall development. I recommend beginning at the first visit providing advice on family/parent responsibility with games and device use.

Optometrists have a responsibility to be in a guidance role with patients and families in order to raise the awareness of the concerns involved in social media and gaming to even include the “addiction” to such devices.

Read more technology content here 

About the authorDr. Steele cofounded InfantSEE in 2005. He has served as president of College of Optometrists in Vision Development (COVD), chair of the AOA InfantSEE and Children's Vision Committee, and international ambassador of Southern Educational Congress of Optometry (SECO) International. In 2012, SCO established the Developmental Vision Endowed Scholarship in his name, which recognizes students who are dedicated to working with vision therapy and amblyopia patients.



1. Hunt MG, Marx R, Lipson C, Young J. No More FOMO: Limiting Social Media Decreases Loneliness and Depression. J Social Clin Psychology. 2018;37(10):751-768.
2. Bush, S. Screen time in the pediatric population: a review of its effects on refractive error, attention and learning, and ocular health. Vision Dev and Rehab. 2018; 4(3):120-9.
3. Twenge, JM, Campbell, WK. Associations between screen time and lower psychological well-being among children and adolescents: Evidence from a population-based study. Prev Med Rep. 2018 Oct 18;12:271-283.
4. Seo HS, Jeong EK, Choi S, Kwon Y, Park HJ, Kim I. Neurotransmitters in young people with internet and smartphone addiction: A comparision with normal controls and changes after
cognitive behavioral therapy. Presented at the Radiological Society of North America Annual Meeting, Chicago, IL, Nov. 26-Dec. 1, 2017.
5. Heffler KF, Oestricher, LM. Causation model of autism: Audiovisual brain specialization in infancy competes with social brain networks. Med Hypotheses. 2016 Jun;91:114-122.
6. Madigan S, Browne D, Racine N, Mori C, Tough S. Association between screen time and children’s performance on a developmental screening test. JAMA Pediatr. 2019 Mar 1;173(3):244-250.
7. Hess EH. Attitude and Pupil Size. Scientific American. 1965;212(4):46-54.
8. Han DH, Kim MS, Bae S, Renshaw PF, Anderson JS. Brain connectivity and psychiatric comorbidity in adolescents with internet gaming disorder. Addict Biol. 2017 May;22(3):802-812.
9. Ra CK, Cho J, Stone MD, De La Cerda J, Goldenson NI, Moroney E, Tung I, Lee SS, Leventhal AM.Association of digital media use with subsequent symptoms of attention-deficit/hyperactivity disorder among adolescents. JAMA. 2018 Jul 17;320(3):255-263.
10. Rechichi CR, De Mojà G, Aragona P. Video game vision syndrome: A new clinical picture in children? J Pediatr Ophthalmol Strabismus. 2017 Nov 1;54(6):346-355.
11. Ma J. Is handheld screen time linked with speech delays in young children? Pediatric Academic Societies Meeting 2017.
12. Kadaras N. Glow kids: how screen addiction is hijacking our kids-and how to break the trance. St. Martin’s Press, 2016.
13. McDaniel, BT, Radesky, JS. Technoference: longitudinal associations between parent technology use, parenting stress, and child behavior problems. Pediatr Res. 2018 Aug;84(2):210-218.
14. Christakis DA. The Challenges of Defining and Studying “Digital Addiction” in Children. JAMA. 2019 Jun 18;321(23):2277-2278.
15. World Health Organization. Guidelines on physical activity, sedentary behaviour and sleep for children under 5 years of age. Available at: https://apps.who.int/iris/bitstream/handle/10665/311664/9789241550536-eng.pdf?sequence=1&isAllowed=y. Accessed 8/7/19.

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