Lecture to be given to St Jude Catholic Schools Alumni Association 28 Aug 2021, talking about Kids Eye Health this pandemic, specifically discussing digital eye strain, myopia, and myths about kids' eye health

2. Kids’ Pandemic Eyes:
Keeping Them Healthy
Alvina Pauline D. Santiago, MD
Pediatric Ophthalmology & Strabismus
28 August 2021
https://thriveglobal.com/stories/how-to-combat-zoom-fatigue-amongst-kids/

3. Some of the Materials
Brought to you by

4. Outline
Digital Eye
Strain
Myopia Myths
Dry Eye
Asthenopia
Headache
Fluctuating
Vision
Nature vs Nurture
Myopia epidemic Really???

5. https://www.facebook.com/pspos1/photos

6. Digital Device Exposure
• By age 3:
• 68% of children regularly use
computers
• 54% online activity
• 2020: Pandemic figures are
definitely higher
Shepard AL, Wolffson JS, Digital eye strain: prevalence, measurement and amelioration. BMJ Open Ophthalmol 2018 Apr 16;3(1):e000146.

7. Digital device exposure
Shepard AL, Wolffson JS, Digital eye strain: prevalence, measurement and amelioration. BMJ Open Ophthalmol 2018 Apr 16;3(1):e000146.
The Vision Council. 2016 Digital Eye Strain Report.
•Multitasking using digital devices
•use 2 or more devices simultaneously
• 87% of age 20-29 (UK)
• 70% of Americans

8. Digital Eye Strain
Synonyms
• Asthenopia
• Visual Fatigue
• Computer Vision Syndrome
• Video Terminal Display Syndrome
• Video Display Terminal Syndrome
Shepard AL, Wolffson JS, Digital eye strain: prevalence, measurement and amelioration. BMJ Open Ophthalmol 2018 Apr
16;3(1):e000146.

9. Digital Eye
Strain defined
• Physical eye
discomfort
after >2 h
using digital
screens
The Vision Council. 2016 Digital Eye Strain Report

10. Digital Eye
Strain
•Prevalence: up to 50% of
computer users
•In children, pooled prevalence
of about 20%
•Impact on learning and school
performance
• Shepard AL, Wolffson JS, Digital eye strain: prevalence, measurement and amelioration. BMJ Open Ophthalmol 2018 Apr
16;3(1):e000146.
• Vilela MAP etal. Prevalence of asthenopia in children: a systematic review with meta-analysis. J Pediatr 2015; 91-320-325.

11. Symptoms of DES
Accommodative /
Binocular Vision Stress
• Headache
• Blurred vision
• Nausea & Vomiting
• Breakdown of eye misalignment
External Eye Symptoms
• Blinking
• Tearing
• Dry eyes
• Photophobia
• Itchy Eyes
Shepard AL, Wolffson JS, Digital eye strain: prevalence, measurement and amelioration. BMJ Open Ophthalmol 2018 Apr 16;3(1):e000146.
http://www.techaddiction.ca

12. https://www.aoa.org/healthy-eyes/eye-and-vision-conditions/computer-vision-syndrome?sso=y
Figure from PSPOS Infographic
Am Optom Assoc Recommendation

13. 20.20.20

14. Vergence
anomalies
(eye
misalignment
and fusion
anomalies)
• Motor disorders
• Convergence insufficiency
• Decompensated eye misalignment
• Poor vergence facilities
• (Reduced blur points, break points)
• Patients with binocular vision problems
experience greater discomfort during
prolonged use of the eyes.
• Shepard AL, Wolffson JS, Digital eye strain: prevalence, measurement and amelioration. BMJ Open Ophthalmol 2018 Apr 16;3(1):e000146.
•

15. Digital Eye Strain
Causes Solutions
Uncorrected (mis-corrected)
refractive error
Proper correction
Altered blink Blink Awareness Exercises
Intense light exposure Reduced light luminance, reverse
polarity
Close working distance Comfortable distance 16-30 in
Small font size Increase font size
Coles-Brennan et al. Management of Digital Eye Strain. Clin Exp Optom 2019; 102: 18-29

16. Dry Eye Disease (DED) in Children
• Longer daily duration of digital device use
increased DED in Children
• Cessation of use (4wks!) in 7-12 y improved DED
• Improved tear break up time
• Improved punctate corneal epithelial
erosions
Moon JH et al. Association between video display terminal use and dry eye disease in school children. J Pediatric Ophthalmology &
Strabismus 2014; 51: 87-92.
Moon JH et al. Smartphone use is a risk factor for pediatric dry eye disease according to region and age: a case control study. BMC
Ophthalmol 2016; 16: 188

17. https://www.mother.ly/zoom-fatigue-kids https://community.today.com/parentingteam/post/how-to-help-kids-with-zoom-fatigue

18. Digital Eye Strain
• Neck & shoulder pain
• Poor posture
https://www.aoa.org/healthy-eyes/eye-and-vision-conditions/computer-vision-syndrome?sso=y

19. Recommendations
• Top of monitor at eye
level
• Monitor at arm’s length
• Use a document stand
https://ssep.com.au/best-posture-for-sitting-at-a-desk-all-day/

20. Proper Posture
https://www.aoa.org/healthy-eyes/eye-and-vision-conditions/computer-vision-syndrome?sso=y

21. Digital Eye Strain
•Bigger screens
• TV > desktops > laptops > mobiles
•Spreadsheets compromise
Figure from PSPOS Infographic

22. Distancing
• Improper viewing distance
https://encrypted-tbn0.gstatic.com/

23. Digital Eye Strain
• Improper lighting
• Glare from digital screen
Figure from PSPOS Infographic

24. Blinking
• Squinting to see better increased blink
rates if conditions can be improved by
squint
• Pinhole effect for refractive errors
• Reduce glare
• If squinting will not cause an
improvement, (small font size, low
contrast), patient squints more and with
reduced blink rates
Patel et al. Effect of visual display unit use on blink rate and tear stability. Optom Vis Sci 1991; 68: 888-92.
Freudenthaler N et al. Characteristics of spontaneous eyeblink activity during video display terminal use in healthy volunteers. Graefes
Arch Clin Exp Ophthalmol 2003; 241: 914-920
Sheedy et al. What are the visual benefits of eyelid squinting? Optom Vis Sci 2003; 80: 740-44.
• Reduced blink rates observed with
computer use
• Patel: 18.4 to 3.6 blinks
• Nakamori: 22 to 7 blinks
• Increased cognitive demand
exacerbates visual stressors, like
refractive errors and low contrast
https://img.wonderhowto.com/img

26. Night Mode
Ang night mode ay isang
feature na makikita sa mga
gadget. Ito ay nakakatulong
upang mabawasan ang
liwanag na nagmumula sa
screen ng iyong cellphone,
tablet o computer. Ang ilaw
mula sa iyong screen ang
sanhi ng eye strain,
panunuyo ng mata at iba pa.
#EyeCare #NightMode

27. https://www.medicinatv.com
MYOPIA EPIDEMIC

28. Definition: Myopia
spherical
equivalent
objective refractive
error is -0.50 or
worse
Joint report WHO-BHVI, 2017
https://img.webmd.com

29. Definition: High Myopia
• Uncorrected acuity 6/172
• Worse than blindness
threshold of <3/60 (6/120) in
better eye Joint report WHO-BHVI, 2017
spherical equivalent objective
refractive error is -5.00 or
worse
◦ Axial length > 26 mm
Cannot see even
the biggest letter
on chart

30. Definition: Pathologic Myopia
(degenerative myopia, malignant myopia)
vPresence of vision
threatening changes in
retina
vPosterior staphyloma
vHigh myopia + myopia-
related fundus
abnormalities such as
myopic macular
degeneration or glaucoma
Joint report WHO-BHVI, 2017
https://webeye.ophth.uiowa.edu

31. Consequences of High Myopia
MYOPIC MACULAR
DEGENERATION
MYOPIC CHOROIDAL
NEOVASCULARIZATION
RETINAL
DETACHMENT
GLAUCOMA CATARACTS
https://www.researchgate.net https://imagebank.asrs.org https://www.thelancet.com https://journals.plos.org https://endmyopia.org/

32. https://www.eyetrusteyecare.ca
https://www.verywellhealth.com
https://www.reviewofophthalmolo
gy.com
https://www.researchgate.net

34. Causes of Myopia
Optical:
Peripheral
Defocus
Intense
near work
Not enough
time spent
outdoors
Genetics
https://www.ahaparenting.com
http://www.pointsdevue.com
https://s3-ap-southeast-
1.amazonaws.com
https://ugc.futurelearn.com

35. MYOPIA OCULAR MORBIDITY
AMBLYOPIA STRABISMUS HEAVY EYE
SYNDROME
https://m4.healio.com

36. Conventional
Treatment
for Myopia
Single vision spectacle correction
(Concave lenses)
Contact Lenses
Refractive Surgery
https://www.aao.org
https://ae01.alicdn.com

37. Causes & Treatment of Myopia
Optical 20.20.20 Go out! Genetics
Modification?
https://www.ahaparenting.com
http://www.pointsdevue.com
https://s3-ap-southeast-
1.amazonaws.com
https://ugc.futurelearn.com

38. http://cdn.coverstand.com/55224/571097/article_assets/2c24c81b54d706a59fbd2d4d3752cc5ab1dc27bc.jpg

39. The promise is not to stop PROGRESSION per se but retard the rate of progression.

40. https://www.neotaos365.top/ProductDetail.aspx?iid=248981332&pr=58.99

41. https://www.mykidsvision.org/blog/contact-lens-options/

42. https://www.aoa.org/healthy-eyes/eye-and-vision-conditions/computer-vision-syndrome?sso=y
Figure from PSPOS Infographic

43. 20.20.20

44. https://www.facebook.com/pspos1/photos

45. https://www.facebook.com/pspos1/photos
•Bright Light
•UV
•Dopamine
•Vitamin D
•Eliminates
defocus
•Pupil
constriction

46. Historical
Manage-
ment
•Undercorrecting myopia:
•believed to slow down myopia
due to reduced accommodation
•Studies show undercorrecting
ACCELERATED myopia progression
•Optical blur
•SHOULD NOT be used to slow
progression
•RGPs no evidence of effect on
myopic eye growth
1.Walline JJ, Lindsley K, Vedula SS, Cotter SA, Mutti DO, Twelker JD. Interventions to slow progression of myopia in children. Cochrane Database Syst Rev. 2011 Dec
7;(12):CD004916. doi: 10.1002/14651858.CD004916.pub3. Update in: Cochrane Database Syst Rev. 2020 Jan 13;1:CD004916. PMID: 22161388; PMCID: PMC4270373.

47. STOP Myopia Progression
https://media.istockphoto.com
www.aao.org

48. effects of atropine for both myopia
progression and axial elongation
• dose-dependent for the concentration
0.025% to 1%.
• Results for 0.01% atropine are still
equivocal.
Sau, S. A., Santiago, A. P., Peralta, M. D., Lo, J. J., & Vera Cruz, A. (2021). Efficacy of atropine eyedrops in reducing myopia progression and axial elongation in myopic
children: a meta-analysis. Asian Journal of Ophthalmology, 18(1), 75-91. https://doi.org/10.35119/asjoo.v18i1.593

49. Atropine for Myopia
Progression
•Commitment:
Daily for 2 years
•Side effects with
higher doses
•Rebound on cessation
•Use till 18?

50. Other Drugs for
Myopia Control
• Pirenzipine gel: study protocol, not yet
available for commercial use
• Cyclopentolate: no FDA submission for
therapeutic use
• Latanoprost: studied in guinea pigs
Walline JJ, Lindsley K, Vedula SS, Cotter SA, Mutti DO, Twelker JD. Interventions to slow progression of myopia in children. Cochrane Database Syst Rev. 2011 Dec
7;(12):CD004916. doi: 10.1002/14651858.CD004916.pub3. Update in: Cochrane Database Syst Rev. 2020 Jan 13;1:CD004916. PMID: 22161388; PMCID: PMC4270373.

51. https://www.ridgevieweyecare.com/blog/what-is-orthokeratology.html

52. https://www.ridgevieweyecare.com/blog/what-is-orthokeratology.html
CORNEAL INFECTION
CORNEAL DISTORTION
EPITHELIAL DEFECTS

53. https://i.ytimg.com/vi/NuuIoJGPjBA/maxresdefault.jpg
https://neptuneprime.com.ng/wp-
content/uploads/2021/03/foot-binding.jpg
https://metro.co.uk/wp-
content/uploads/2015/11/cwk52x.jpg?quality=90&strip=all

54. • Myopic parents
• Retinopathy of Prematurity
• Indoor
• Near work
• Higher Education

55. Experimental
Evidence
Optical
Coherence
Tomography
•Choroid
becomes 16 um
thinner reading
black text on
white
background
•Choroid
becomes
10um thicker
reading white
text on black
background
THINNER CHOROID =
MYOPIA

56. MYTHS VS TRUTHS

58. https://www.facebook.com/pspos1/photos

59. Blue light
(400-500
nm) and
Digital Eye
Strain
Harmful to retina
• suprathreshold acute doses
• Peak damage at 440 nm
• Longer duration, even if less intense
also cause damage
Ham et al, Retinal sensitivity to damage from short wavelength light. Nature 1976; 260: 153-155.
Jaedane et al. Retinal damage induced by commercial light emitting diodes (LEDs) Free Radical Bio Med 2015; 84: 373-
384

60. How much blue?
• ICNIRP Luminance Cut off Value 10.4 cd m2
• Incandescent lamp (14%)
• Domestic Lamps including LEDs exceed limit by 10-20%
(assuming intentional viewing)
• Screens even at maximum brightness (Computers,
smartphones, tablets) lower than “natural” exposures
• Highest luminance from white screen
O’Hagan et al. Low energy light bulbs, computers, tablets and the blue light hazard. Eye 2016; 30: 230-233.
International Commission on Non Ionizing Radiation Protection. Guidelines on limit of exposure to incoherent
visible and infrared radiation. Health Phys 2013; 105: 75-96
https://www.learnreligions.com/angel-colors-blue-light-ray-123860

61. Blue light and digital screens
• Low levels of blue light from digital screens NOT
a biohazard
• More blue light from low energy light bulbs (LED
lights)
O’Hagan et al. Low energy light bulbs, computers, tablets and the blue light hazard. Eye 2016; 30: 230-233.
International Commission on Non Ionizing Radiation Protection. Guidelines on limit of exposure to incoherent visible and
infrared radiation. Health Phys 2013; 105: 75-96
https://images.theconversation.com

62. O’Hagan et al. Low energy light bulbs, computers, tablets and the blue light hazard. Eye 2016; 30: 230-233.
International Commission on Non Ionizing Radiation Protection. Guidelines on limit of exposure to incoherent visible and infrared radiation. Health Phys 2013; 105: 75-96

63. O’Hagan et al. Low energy light bulbs, computers, tablets and the blue light hazard. Eye 2016; 30: 230-233.
International Commission on Non Ionizing Radiation Protection. Guidelines on limit of exposure to incoherent visible and infrared radiation. Health Phys 2013; 105: 75-96
None of the computer monitors,
laptops, tablets, and smartphone
screens exceeded 0.39% of ICNIRP blue
light exposure limit
Blue light from these screens DO NOT
present a biohazard even with
prolonged viewing

64. Performance of Blue
Blocking Lenses
• Commercially available blue light filtering spectacles
reduced calculated phototoxicity only by 10.6-23.6%
• Blue Control (Hoya), BlueProtect (Zeiss), Crizal
Prevencia (Essilor), StressFree and Noflex (Swisslens)
• Reduced scotopic sensitivity 2.4-9.6%
• Melatonin suppression by 5.8-15.0%
Leung TW et al. Blue light filtering spectacle lens: optical and clinical performances. PLoS One
2017; 12: e0169114

65. Performance of Blue Blocking Lenses
Leung TW et al. Blue light filtering spectacle lens: optical and clinical performances. PLoS One 2017; 12:
e0169114

66. Blue light and DES
• Need for high quality
research (RCTs) for blue
blocking spectacles and
its effects on eye health

67. https://www.facebook.com/pspos1/photos

70. Glasses or Contact Lenses can cure myopia.
No.
Glasses and Contact Lenses can provide clear vision but will not
change the need for glasses.

71. https://nycancer.com/media/images
Eye exercises or vision therapy
will improve vision.
MYTH

72. https://nycancer.com/media/images
1. Orthoptics work for convergence insufficiency
2. Behavioral vision therapy scientifically unproven.
3. No evidence that VT improves or retards myopia
.
FACTS
https://aapos.org/glossary/vision-therapy

73. References
1. Coles-Brennan et al. Management of Digital Eye Strain. Clin Exp Optom 2019; 102: 18-29
2. Computer vision syndrome. https://www.aoa.org/healthy-eyes/eye-and-vision-conditions/computer-vision-syndrome?sso=y
3. Freudenthaler N et al. Characteristics of spontaneous eyeblink activity during video display terminal use in healthy volunteers. Graefes Arch Clin Exp
Ophthalmol 2003; 241: 914-920
4. Leung et al. Filtering spectacle lenses: Optical and Clinical Performances. PLoS One 2017; 12: e0169114.
5. Moon JH et al. Association between video display terminal use and dry eye disease in school children. J Pediatric Ophthalmology & Strabismus 2014; 51:
87-92.
6. Moon JH et al. Smartphone use is a risk factor for pediatric dry eye disease according to region and age: a case control study. BMC Ophthalmol 2016; 16:
188
7. O’Hagan et al. Low energy light bulbs, computers, tablets and the blue light hazard. Eye 2016; 30: 230-233.
8. Patel et al. Effect of visual display unit use on blink rate and tear stability. Optom Vis Sci 1991; 68: 888-92.
9. Sheedy et al. What are the visual benefits of eyelid squinting? Optom Vis Sci 2003; 80: 740-44.
10.Shepard AL, Wolffson JS, Digital eye strain: prevalence, measurement and amelioration. BMJ Open Ophthalmol 2018 Apr 16;3(1):e000146.
11.Vilela MAP etal. Prevalence of asthenopia in children: a systematic review with meta-analysis. J Pediatr 2015; 91-320-325.
12.The Vision Council. 2016 Digital Eye Strain Report. https://visionimpactinstitute.org/wp-content/uploads/2016/03/2016EyeStrain_Report_WEB.pdf
13.Walline JJ, Lindsley K, Vedula SS, Cotter SA, Mutti DO, Twelker JD. Interventions to slow progression of myopia in children. Cochrane Database Syst Rev.
2011 Dec 7;(12):CD004916. doi: 10.1002/14651858.CD004916.pub3. Update in: Cochrane Database Syst Rev. 2020 Jan 13;1:CD004916. PMID: 22161388;
PMCID: PMC4270373.
14.American Association of Pediatric Ophthalmology and Strabismus. Vision Therapy. https://aapos.org/glossary/vision-therapy
15.Philippine Society of Pediatric Ophthalmology and Strabismus. Myths. https://www.facebook.com/pspos1
16.Joint report WHO-BHVI, 2017