Current Eye Research

ISSN: 0271-3683 (Print) 1460-2202 (Online) Journal homepage: https://www.tandfonline.com/loi/icey20

Smartphone use and effects on tear film, blinking

and binocular vision

Blanka Golebiowski, Jennifer Long, Kirsten Harrison, Abigail Lee, Ngozi Chidi-
Egboka & Lisa Asper

To cite this article: Blanka Golebiowski, Jennifer Long, Kirsten Harrison, Abigail Lee, Ngozi Chidi-
Egboka & Lisa Asper (2019): Smartphone use and effects on tear film, blinking and binocular
vision, Current Eye Research, DOI: 10.1080/02713683.2019.1663542

To link to this article: https://doi.org/10.1080/02713683.2019.1663542

Accepted author version posted online: 01

Oct 2019.

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Publisher: Taylor & Francis

Journal: Current Eye Research

DOI: 10.1080/02713683.2019.1663542
Smartphone use and effects on tear film, blinking and binocular vision.
Running head: Smartphones, tear film, blinking and binocular vision

Blanka Golebiowski*, Jennifer Long, Kirsten Harrison, Abigail Lee, Ngozi Chidi-Egboka, Lisa Asper.
School of Optometry and Vision Science, UNSW Sydney, Australia.

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*corresponding author: [email protected]

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Word count: 3017

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KEYWORDS:
Smartphone
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Digital device
Blink
Binocular vision
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Accommodation
Tear function
Ocular symptoms
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Ocular surface
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ABSTRACT

Purpose: Smartphone use is now ubiquitous and is associated with a range of ocular and visual
symptoms. However, little is known about the aetiology of the symptoms which accompany
smartphone use and the relative contribution of accommodation/vergence versus that of the
ocular surface and of blinking. This study examined the effects of 60min reading on a smartphone
on ocular symptoms, binocular vision, tear function, blinking and working distance.

Methods: Twelve young adults (18-23 years; 9F:3M) with normal vision and without dry eye, or

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major accommodative/binocular vision disorders, completed this pilot study. Participants read a

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novel on a smartphone for 60min and the following were measured before and after the reading

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task: eye strain and ocular surface symptoms, non-invasive tear break-up time (NIBUT), lipid layer
appearance, tear meniscus height, horizontal fixation disparity, binocular accommodative facility.

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Spontaneous blink rate and amplitude were counted every 10min, and viewing distance was
measured at the same timepoints. Pre- and post- task comparisons were made using Wilcoxon
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signed rank test and changes during the task assessed using Friedman test. Associations were
examined using Spearman’s correlation.
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Results: Eyestrain symptoms and ocular surface symptoms increased after smartphone use,
specifically comfort, tiredness and sleepiness items (p≤0.02). Binocular accommodative facility
decreased from a median of 11.3 (IQR 6.6) cycles/min pre-task to 7.8 (2.5) cycles/min post-task
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(p=0.01), but there was no significant change in fixation disparity or working distance. There were
no changes in NIBUT, lipid layer or tear meniscus height. Number of incomplete blinks per minute
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increased from median of 6 blinks at 1min to 15 at 60min (p=0.0049). Total blink rate (complete
plus incomplete blinks) gradually increased over time, but this trend was not significant (p=0.08). A
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greater increase in incomplete blinks over 60 minutes of reading was associated with worsening of
the overall ocular surface symptoms score (ρ=-0.65, p=0.02) and of the tiredness item (ρ=0.70,
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p=0.01).

Conclusions: Extended use of smartphones appears to have important implications for ocular
surface health and binocular function.

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INTRODUCTION

The use of handheld digital devices has risen rapidly over the past decade, and smartphone use is
now ubiquitous. In Australia, for example, almost 90% of those aged 18-75 years owned a
smartphone in 2018.1 Usage of smartphones has been associated with a range of symptoms of
ocular discomfort,2 and some studies suggest smartphones and tablets induce greater symptoms
than desktop computers3 or reading from printed text.4 A study of Korean primary-school children,
for example, and another of adolescents, found ocular discomfort and visual symptoms to be
higher with greater exposure to smartphone use.5, 6

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There is little information, however, regarding aetiology of the reported symptoms.2 The limited

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literature available suggests use of smartphones may impact blink rate, tear function,
accommodative/binocular function and promote shorter working distances.6-12 The relative

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contributions of the accommodative/vergence system and the ocular surface (including blinking)
to these collective symptoms is not clear, and both components have not previously been
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considered in the one study. It is not understood what effect prolonged viewing of a smartphone
at a short working distance has on the accommodative/vergence system and symptoms reported
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by smartphone users.
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Smartphones are used differently to both printed material and computers, in terms of viewing
position and distance, and patterns of use, and consequently are likely to have a unique profile of
effects on the visual system and ocular surface. The widespread use of smartphones and the
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pervasive nature of their use, especially amongst frequent users such as children and
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adolescents,13 drives the need for an improved understanding of their ocular effects. This will
enable clinicians to provide timely advice for mitigating potential short and long-term adverse
effects, which could potentially include effects on accommodative and binocular function as well
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as function of the tear film and meibomian glands resulting in ocular surface disease such as dry
eye.

To better understand the aetiology of symptoms which occur with smartphone use, this study
examined the effects of 60 minutes of smartphone use on ocular symptoms, binocular vision, tear
function, blinking and working distance.

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METHODS
Twelve young adults with normal vision, and without dry eye or major accommodative/binocular
vision disorders, were recruited for this longitudinal pilot study comparing the effects of
smartphone use over time (60 minutes), with baseline measurements serving as the control.
Exclusion criteria included reduced visual acuity at near or distance, multifocal spectacle use, and
contact lens wear within 48 hours of the study. Ocular surface and visual abnormalities were ruled
out using the Ocular Comfort Index questionnaire,14-16 the Convergence Insufficiency Symptoms

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Survey,17 visual acuity testing at distance and near, cover test at near, near point of convergence,
near point of accommodation and slit-lamp examination. The study adhered to the Declaration of

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Helsinki for research on human subjects and was approved by the UNSW Human Research Ethics
Advisory panel. Each subject gave written informed consent to participate in the study.

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Participants read an extract from a novel (“Saving Wishes” by G.J Walker-Smith) on a smartphone
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(IPhone 5, Apple Inc.) for 60 minutes. The reading level of the text was calculated by inserting an
extract from the book into an online tool (http://www.readabilityformulas.com/freetests/six-
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readability-formulas.php); the tool rated the book as having a Flesch Reading Ease Score of 70.7.
The experimental conditions were the same for each participant. Participants were instructed to
hold the smartphone where they would normally hold it while reading (Figure 1A), to use one
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finger to scroll and to not alter the screen brightness or font size. The smartphone screen
measured 4” (10.2 cm) diagonally and was set to maximum brightness (luminance measured 458
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cd/m2). The font was black Times New Roman, with a capital letter height of 2 mm. The room
illuminance was 403 lux. Comprehension of the reading material was tested with a short quiz after
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the task completion to confirm that participants had been reading the novel during the task.
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Ocular symptoms, tear function and binocular vision were assessed prior to the reading task and
after 60 minutes of reading. The Eyestrain Symptoms Questionnaire (ESQ)9 and Numerical Ratings
Scale (NRS)18 were completed by participants. Items were scored individually, and a total score of
all items was calculated. Tear function was assessed using the Keratograph 5M (Oculus, Arlington
WA, USA) to measure non-invasive tear break-up time (NIBUT) and tear meniscus height;
Keratograph images were also assessed for lipid layer pattern as described by Guillon et al.19 Tear
function measurements were conducted approximately 10-15 minutes after completion of the
reading task. Horizontal fixation disparity (primary gaze, Saladin Near Point Balance Card, (Bernell,
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Mishawaka, IN, USA) with polarised lenses) and binocular accommodative facility (BAF)
(downgaze, ±1.50D flippers) were assessed at 40 cm.

Spontaneous blink rate and amplitude, and working distance were assessed at 10 minute intervals
during the reading task. A video camera (Sony Alpha NEX-5 SLR, 1080p, 60 frames/sec) was
positioned approximately 1 m in front and lateral to the participant, so as to best capture eyelid
movement. Blink rate was manually counted from a video recording for one minute every 10
minutes, starting with the first minute. Both partial (incomplete) and complete blinks were

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counted. Blinks were considered to be complete when downward movement of the upper eyelid
covered more than approximately 75% of the cornea, as estimated by the observer.20 Counts were

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randomly repeated to improve reliability. Working distance was measured from a still digital
image (PixelStick, Plum Amazing Software LLC), using a spot on a headband as a scale reference;

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this is similar to the method described earlier (Figure 1B).9
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Statistical analysis:
Pre- and post-task comparisons were assessed using Wilcoxon signed rank test. Change over task
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duration was assessed with Friedman test, and post-hoc comparisons were made with Wilcoxon
signed rank test with a Bonferroni correction. Associations between changes in variables were
examined using Spearman’s bivariate correlation. Analyses were conducted using Prism GraphPad
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Software version 7 and 95% confidence intervals were calculated in R version 3.6.1 (www.R-
project.org, R Core Team, 2019).
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RESULTS
Twelve young adults (median age 18.5 years, range 18-23 years; 9 females, 3 males) completed
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the study. All participants scored 75% or more on the comprehension test.

Total ESQ and NRS symptoms scores were significantly worse after 60 minutes of reading on the
smartphone (p=0.002 and 0.001 respectively, Figure 2). Specifically, the items for tiredness
(p=0.02 for ESQ and NRS) and comfort (p=0.004 for ESQ, p=0.01 for NRS) became worse on both
symptoms scales, as did the ESQ sleepiness item (p=0.02) (Figure 2).

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Almost two-thirds of the recorded blinks were incomplete. The number of incomplete blinks per
minute increased over the duration of the reading task (p=0.0049), whereas the number of
complete blinks remained unchanged (p=0.42) (Figure 3B). Post-hoc analysis showed significantly
more incomplete blinks after 10-60 minutes compared to the first minute of reading from a
smartphone (Figure 3C), and after 30, 40 and 60 minutes compared to after 10 minutes of reading.
Total blink rate (complete plus incomplete blinks) gradually increased over time, but this trend
was not statistically significant (p=0.08) (Figure 3A).

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Binocular accommodative facility was significantly reduced post-task (p=0.01, Figure 4), but there
was no significant change in fixation disparity. Mean viewing distance did not change significantly

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over 60 minutes of reading (Figure 5), nor were there significant changes in any of the tear film
variables NIBUT, lipid layer appearance or tear meniscus height, which is supported by the

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confidence intervals for the pre-post differences (Table 1).
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A greater increase in the rate of incomplete blinks over the 60 minute reading task was associated
with worsening of the overall ocular surface symptoms score (ρ=-0.65, p=0.02) and of the
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symptom of tiredness (ρ=0.70, p=0.01) (Figure 6). There were no other significant associations
between changes in variables between the two time points (Table 2).
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DISCUSSION
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This is the first investigation of smartphone use that examines ocular surface, blinking, and
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binocular vision parameters together in the one study. After one hour of reading from a
smartphone, increased symptoms were found to occur alongside reduced binocular
accommodative facility and were associated with an increased rate of incomplete blinks.
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The increase in eye symptoms after smartphone use is consistent with earlier findings.2, 6, 8-11, 21 In
the current study, the symptoms of tiredness and discomfort increased after one hour of reading
from a smartphone. Interestingly, there was no change in symptoms that are commonly attributed
to binocular / accommodative anomalies (for example symptoms of headache, blur or diplopia) or
to tear dysfunction (the symptoms of dryness, foreign body sensation, stinging or watery eyes).
The exception was the symptom of sleepiness which has been associated with binocular vision

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problems.22,23 Earlier studies have reported changes in a wide range of symptoms, including “blur”
and “irritation”.2, 9, 24

Binocular accommodative facility (BAF) reduced after reading from a smartphone for 1 hour, and
for 2 participants this fell to below the accepted cut-off for normal BAF.25 The finding of reduced
BAF is in agreement with one study26 which found a small (1.5 cycles/min) but statistically
significant decrease in BAF after reading from a tablet for 30 minutes. In contrast, another group11
did not find a significant effect on monocular or binocular accommodative facility after 30 minutes

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of viewing a film on a smartphone. The difference in these two studies is likely to be due to the
difference in the tasks performed on the devices. The current study and Kim et al26 both involved

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reading and both found reduced BAF. BAF results can be strongly influenced by vergence ability, so
any change found could be secondary to a change in vergence facility or ranges of vergence.

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Further study into the effect of smartphone use on accommodative facility should include
vergence testing as well as both monocular and binocular accommodative facility testing.
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Monocular accommodative facility testing would allow an assessment of the ability to change
focus without any confounding effects due to vergence skills.
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To our knowledge, fixation disparity has not been studied in relation to smartphone use. No
change in fixation disparity was found in this study, indicating that vergence, if affected, can adjust
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to maintain the original vergence state over 60 minutes or that the vergence returns very quickly
to normal after cessation of the smartphone task. Further investigation is warranted in people
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who have existing binocular vision problems because these people may be less able to cope with
the demands on vergence and accommodation required by smartphone use.
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The study found that the rate of incomplete blinks increased over the first 1-30 minutes of reading
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from a smartphone and then plateaued, but the rate of complete blinks was unchanged during the
reading task. Blink rate in the context of smartphone use has been examined only in one previous
study, but blink amplitude, or completeness, has not yet been studied.2 The unchanged rate of
complete blinks in the present study agrees with findings in a group of university students who
used a smartphone for 60 minutes to play a game or watch a film, where the rate of complete
blinks was stable throughout the task.10 The rate of complete blinks in that study was reduced
compared to the (non-reading) rate measured before the smartphone task was started. In the
present study, blink rate was measured and compared over the 1-60 minute duration of the task,
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rather than comparing to the pre-task blink rate, which is difficult to control for as it can vary due
to cognitive demand and type of activity.27-29 “Spontaneous” blink rate is known to be dependent
on conditions such as sitting quietly, reading or having a conversation.30 Of note is that all blink
rates observed by Park et al,10 are high relative to previous reports of blinking at baseline or while
concentrating on a task.28

Three earlier studies have investigated blink rate while reading from other types of hand-held
digital devices, which are held in a similar posture as a smartphone. Differing study designs make it

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difficult to compare these finding with ours. Blink rate over the course of the reading task was
observed in only one study, which found no change during 10 minutes of reading from a tablet,

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but the authors do not report blink amplitude.29 An increased blink rate and a higher proportion of
incomplete blinks is reported after reading from a tablet for 6 minutes, but the comparison is

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made with printed text.31 In contrast, another study found blink rate to be decreased after reading
for 1 hour from an LCD E-reader, when compared to printed text.32 A third study showed no
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difference between tablet and printed text when reading for 10 minutes.29
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Notably, the increase in incomplete blinks found in this study was associated with a worsening of
symptoms. This is consistent with earlier findings in the context of computer use.33,34 The
alteration in blink amplitude may be a compensatory response to ocular surface discomfort
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induced by prolonged reading from a smartphone, and could be viewed as a marker of ocular
surface disturbance. Increased blink rate is reported in dry eye where it is associated with ocular
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surface discomfort.28, 35
The association of incomplete blinks with the symptom of tiredness in
particular, is interesting in light of a previous study of 6 hours computer use, which showed that
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reduced blink amplitude (incomplete blinking) is a marker of general (not eye-specific) fatigue.36
The increased rate of incomplete blinks in our study may also reflect a reduced concentration with
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prolonged reading time, similar to the inverse relationship between total blink rate and cognitive
demand of the task reported elsewhere.20, 27-29

No clinically or statistically significant changes were observed in tear volume or stability after 60
minutes of smartphone reading. Only a small handful of studies have investigated tear function
with handheld devices. Interestingly, the only study of tear volume with smartphone use found an
increase in tear volume after one hour of playing a game and viewing a film,10 and these authors
speculated that this was a result of reflex tearing. No effect on tear volume was shown after
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reading from a tablet for one hour.24 Reduced tear stability after 60 minutes of viewing a movie or
playing a game on a tablet is reported by a single study.21 This is in line with improved tear stability
in a group of children with dry eye one month after they stopped smartphone use.6 Of note,
measurements in the present study were conducted approximately 15 minutes after the task was
completed, thus any short-term tear film changes would not have been detected. However, it is
possible to conclude that any effect on tear function induced by a one hour period of smartphone
use is transient.

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The mean viewing distance adopted by participants in this study ranged from 338mm at 50
minutes (furthest mean viewing distance) to 295 mm at the end of the experiment (closest mean

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viewing distance), which represents a retinal image angular size of approximately 20 minutes of an
arc (‘) and 23’ respectively. This angular size is a comfortable size for viewing an electronic display

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and is consistent with recommendations that visual displays should be capable of providing a
character height of 20’ to 22’.37 These data are similar to data reported in an earlier study9 and
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consistent with viewing distances reported by others for smartphone use.12 It has also been
proposed that tasks can be performed efficiently and comfortably if the angular size of detail
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within a task is more than twice the resolving power of the viewer’s eye.38 In this experiment the
inclusion criteria for participation was 6/7.5 binocular visual acuity (logMAR 0.1). Font size 2mm
high viewed at 338mm (20’ retinal image angular size) corresponds to a Snellen letter size of 6/24.
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This is at least 3 times larger than the resolving power of the participants’ eyes. Therefore,
participants would have been able to clearly see the text at this viewing distance.
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There was no significant decrease in working distance over the course of the experiment. One
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possible explanation for the difference between these results for viewing distance and those
reported in an earlier study by our group, where a reduced working distance was observed over
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time,9 is that participants completed different tasks while reading. In our 2017 study, participants
were asked to identify non-English words in the text, which requires vigilance throughout the task.
However, it is not impossible that participants scanned the text for non-English words without
actually reading the text. To address this issue, in the current study participants read
uninterrupted from a novel of average cognitive demand (Flesch Ease Score 70.7) and their
comprehension was tested at the conclusion of the task. Easy reading material was selected to
reduce the likelihood that fatigue-related changes could be attributed to reading of difficult
material. Although participants scored well on the comprehension test, indicating that they did
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indeed read the material, it is possible that the earlier vigilance task required greater
concentration from participants than the current uninterrupted reading, and may have manifested
as increased accommodation with a reduced viewing distance over time as the visual system
became fatigued, similar to the nearpoint visual stress model described by Birnbaum.39 In future
experiments it may be valuable to include both a vigilance task and comprehension test to ensure
that participants actively read the text throughout the experiment.

The strength of this study is that multiple aetiologies of symptoms were examined within the one

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experiment. Eye strain and discomfort symptoms are evident after 60 minutes of smartphone use
and are accompanied by reduced binocular accommodative facility and an increased rate of

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incomplete blinks. Reduced binocular accommodative facility may result in difficulty changing
focus between near and far targets. Incomplete blinks may disrupt tear homeostasis and increase

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risk of development of dry eye, which has important implications for ocular surface health. These
findings are important for all users of smartphones, especially those in younger age groups who
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use smartphones frequently and for extended durations. Importantly, this study has also identified
directions for further research to be conducted with expanded study design, including automated
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blink detection methods and further investigation of tear film and ocular surface integrity,
accommodative function and working distance. An improved understanding of the effects of
smartphone use will guide effective remediation strategies and clinical management to reduce
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symptoms.
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Declaration of interest: The authors report no conflicts of interest.

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Funding sources: This research did not receive any specific grant from funding agencies in the
public, commercial, or not-for-profit sectors.
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TABLES

Table 1: Binocular vision and tear film variables pre- and post- 60 minutes of reading on a
smartphone (median and range) and 95% confidence intervals for the difference between
timepoints. *For fixation disparity, the 90% CI is reported as due to ties in the difference value, the
95% CI was not computable.

pre-task post-task difference p

(95% CI) value

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Binocular accommodative facility (cycles/min) 11.25 (6.5-18.0) 7.8 (4-12) -3.0 (-5.7, -0.5) 0.01

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Fixation Disparity (min of arc) 0 (-2-1) 0 (-3-0.5) -0.2 (-1.0, 0.5)* 0.56
Tear Meniscus Height (mm) 0.25 (0.22-1.03) 0.25 (0.18-0.81) 0.00 (-0.08, 0.10) 0.97
Non-Invasive Tear Break Up Time (NIBUT) (s) 8.3 (5.1-21.3) 8.7 (4.7-23.6) 0.6 (-2.4, 3.6) 0.73

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Lipid Layer Appearance (grade) 3 (2-5) 3.5 (1.5-5.5) 0.3 (-0.7, 1.5) 0.57

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Table 2: Associations between changes in variables which differed significantly between baseline
and after 60 minutes of reading from a smartphone. BAF, Binocular accommodative facility; ESQ,
Eyestrain Symptoms Questionnaire; NRS, Numerical Rating Score.
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Symptoms BAF Total Blink Rate Incomplete Blink Rate

ρ p ρ p ρ p
ESQ comfort 0.02 0.96 -0.28 0.38 -0.45 0.14
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ESQ tired -0.05 0.88 -0.40 0.20 -0.70 0.01

ESQ sleepy -0.13 0.68 0.20 0.53 -0.04 0.91
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ESQ total score -0.06 0.85 0.31 0.32 0.49 0.11

NRS comfort -0.31 0.32 0.20 0.53 -0.27 0.38
NRS tired -0.35 0.26 0.47 0.13 0.00 0.99
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NRS total mean -0.14 0.65 -0.11 0.74 -0.65 0.02

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FIGURES

Figure 1:
A) Experimental set-up for smartphone reading task.
B) Working distance measurement for smartphone reading task (PixelStick, Plum Amazing Software
LLC).

Figure 2:
A) Eyestrain Symptoms Questionnaire scores (median and IQR) pre- and post- 60 minutes of

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reading on a smartphone. Significantly different findings are indicated with an asterisk. A higher

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score on the ESQ indicates worse symptoms.
B) Numerical Rating Score (NRS) (median and IQR) pre- and post- 60 minutes of reading on a

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smartphone. Significantly different findings are indicated with an asterisk. A lower score on the NRS
indicates worse symptoms.

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Figure 3: Blink rate (median and IQR) over the course of 60 minutes of reading from a smartphone.
There was no significant change in blink rate over time, when (A) all blinks (complete and
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incomplete) were counted, or (B) when only complete blinks (more than 75% of corneal coverage
by eyelids) were considered. (C) An increasing number of incomplete blinks (less than 75% of
cornea covered) were counted over time (p=0.0049). Post-hoc comparisons (marked with bars)
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show significantly more incomplete blinks after 10-60 minutes compared to the first minute of
reading, and after 30, 40 and 60 minutes compared to after 10 minutes of reading. When these
comparisons were corrected for multiple comparisons, a significant difference was only observed
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between the first and 20th minutes of reading (p=0.045, indicated with an asterisk), with a trend
evident between the first and the 40th and 50th minutes (p=0.08 and p=0.09 respectively).
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Figure 4: Binocular accommodative facility (BAF) (median, IQR) pre- and post- 60 minutes of
reading on a smartphone.
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Figure 5: Working distance (median and IQR) over the course of 60 minutes of reading from a
smartphone.
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Figure 6: Significant associations between increase in the rate of incomplete blinks over the 60
minute reading task and (A) worsening in total symptoms (Numerical Rating Score, NRS) (ρ=-0.65,
p=0.02), and (B) worsening of the symptom of tiredness (ESQ, Eyestrain Symptoms Questionnaire)
(ρ=0.70, p=0.01). (Note that worse symptoms are indicated by a higher ESQ score but a lower NRS
score.)

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FIGURES

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Figure 11A: Experim
mental set-u
up for Figurre 1B: Workking distancce measuremment
smartphone readin ng task. for smartphone reading tassk (PixelSticck, Plum
Ama azing Softwa
are LLC).

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an
M
ed
pt
ce
Ac

15
5
 *

*
* *

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Figure 2A: Eyestrain Symptoms
S Questionnai
Q ire scores (mmedian and IQR) pre- aand post- 60 0 minutes
of reading on a smarttphone. Sign
an
nificantly diffferent find
dings are ind
dicated withh an asteriskk. A higher
score on th
he ESQ indiccates worsee symptoms..
M
ed

*
*
pt
ce

*
Ac

Figure 2B: Numerical Rating Scorre (NRS) (meedian and IQR) pre- an nd post- 60 minutes off reading on
a smartphoone. Significcantly differrent findinggs are indica
ated with an
n asterisk. A lower scorre on the
NRS indica
ates worse symptoms.
s

16
6
 Figure 3: Blink
B rate (m
median and d IQR) over
A)
p=0.08 the course e of 60 minuutes of read ding from a
smartphon ne.
There wass no significaant change in blink ratte
over time, when (A) aall blinks (co omplete and d
incomplete e) were couunted, or (B)) when onlyy
complete blinks
b (moree than 75% of corneal
coverage by b eyelids) w were considdered. (C) Ann
increasing number off incompletee blinks (lesss
than 75% of cornea coovered) were counted
over time (p=0.0049).. Post-hoc comparisons
c s

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ip
(marked with
w bars) shhow significcantly more
B)
incomplete e blinks afteer 10-60 minutes
n/s compared to the first minute of reading,
r andd

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after 30, 40
4 and 60 m minutes com mpared to
after 10 minutes
m of reeading. Wheen these

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compariso ons were corrrected for multiple
compariso ons, a signifificant differeence was
only obserrved betweeen the first and a 20th
an minutes off reading (pp=0.045, ind dicated withh
an asteriskk), with a trrend evident between
nd the 40th and 50th minutes
the first an m
M
(p=0.08 an nd p=0.09 reespectively)).
C) p=
=0.0049
ed

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pt
ce
Ac

17
7
 p = 0.01

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Figure 4: Binocular accommodative facility (BAF) (median, IQR) pre- and post- 60 minutes of
an
reading on a smartphone.
M
ed
pt
ce
Ac

18
 t
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an
M
Figure 5: W
Working disttance (mediian and IQR
R) over the course
c of 60
0 minutes off reading frrom a
smartphon ne.
ed
pt
ce

ρ=-0.65 ρ=0..70
p=0.02 p=0..01
Ac

Figure 6: Siignificant associations

s between
b inccrease in the rate of inccomplete bllinks over th
he 60
minute reaading task anda (A) worssening in tootal symptom ms (Numeriical Rating SScore, NRS) (ρ=-0.65,
p=0.02), annd (B) worsening of thee symptom of tirednesss (ESQ, Eyesstrain Sympptoms Questtionnaire)
(ρ=0.70, p==0.01). (Notte that worsse symptomms are indica ated by a hiigher ESQ sccore but a lower NRS
score.)

19
9