CORRELATION BETWEEN DRY EYE AND SCREEN TIME IN CHILDREN

by

Natalie Eve DeCook

This paper is submitted in partial fulfillment of the

requirements for the degree of

Doctor of Optometry

Ferris State University

Michigan College of Optometry

May, 2019
 CORRELATION BETWEEN DRY EYE AND SCREEN TIME IN CHILDREN

by

Natalie Eve DeCook

Has been approved

May 8th, 2019

APPROVED:

__________________________________________________
Faculty Advisor: Paula McDowell, OD, FAAO

ACCEPTED:

________________________________
Faculty Course Supervisor
 Ferris State University
Doctor of Optometry Senior Paper
Library Approval and Release

CORRELATION BETWEEN DRY EYE AND SCREEN TIME IN CHILDREN

I, Natalie Eve DeCook, hereby release this Paper as described above to Ferris State
University with the understanding that it will be accessible to the general public. This
release is required under the provisions of the Federal Privacy Act.

___________________________________
Doctoral Candidate

March 7, 2019
___________________________________
Date
 ABSTRACT

Background: Use of computers and other electronic devices has been shown to cause dry

eye in adults1,2. Little research, however, has been done to determine if this is also

occurring in children who use electronic devices. The main goal of this study was to

determine if there is a correlation between screen time and dry eye symptoms in children.

Additionally, our study sought to determine the average amount of screen time of the

pediatric population in the area served by the University Eye Clinic at the Michigan

College of Optometry. Methods: A survey was distributed to the parents of pediatric

patients at the University Eye Clinic. The survey asked several questions about their

children’s use of electronic devices and complaints of dry eye symptoms. The dry eye

portion of this study was adapted from the Standardized Patient Evaluation of Eye

Dryness (SPEED) Questionnaire. Student clinicians also indicated on the survey form if

and what signs of dry eye are observable in the patient. Results: Three of the 39 enrolled

subjects reported symptomatic dryness based on our adapted SPEED Questionnaire. The

average amount of screen time per week was 39.03 hours, and 31 subjects reported some

type of device use at school. Conclusions: Children show ocular signs associated with dry

eye but subjective measures are of limited use. The current amount of digital device use

is likely higher than that recommended by the American Academy of Pediatrics for

overall pediatric health and development.

iv
v
 ACKNOWLEDGEMENTS

I would like to thank my faculty advisor, Dr. Paula McDowell, for her assistance and

guidance in this research project. I also would like to thank the student clinicians for

assisting in data collection for this project.

vi
 TABLE OF CONTENTS

Page

LIST OF CHARTS, TABLES, AND GRAPHS……………………………….......… ix

CHAPTER

1 INTRODUCTION…………………………………………………...……... 1

2 METHODS………...……………………………………………………….. 3

3 RESULTS………………………………….…………………….…...…….. 5

4 DISCUSSION...…………………………………………………………….. 10

5 CONCLUSION………………………………………………………….….. 13

REFERENCES………………………………………………………….…………….. 14

vii
APPENDIX

A. IRB APPROVAL LETTER………………….……………………………... 17

B. SURVEY FORM…………………………….……………………………... 20

viii
 LIST OF CHARTS, TABLES, AND GRAPHS

Chart Page

1 Average Electronic device usage in Hours per day ….…………………… 6

Table Page

1 Categorized TBUT ……………………………………………………….... 8

2 Categorized blink rate …………………………………………………...… 8

3 Other reported signs of dry eye syndrome …………………….................... 8

Graph Page

1 Symptom score versus weekly hours of device use ….…………………… 10

ix
 CHAPTER 1

INTRODUCTION

Dry eye syndrome is a complex condition with multiple mechanisms and

associated symptoms3. Treatment methods also vary significantly, from artificial tear

drops and punctal plugs to intranasal stimulators4 and oral doxycycline. The prevalence

of dry eye syndrome in adult populations has been studied frequently and has been

reported as low as 5.7%5 and as high as 54.3%3,6, depending on the patient population

and diagnostic criteria. Several factors have been found to contribute to dry eye syndrome

including outdoor work, air conditioning, systemic health conditions, and tobacco use3.

Computer vision syndrome, a condition caused by prolonged use of computers and other

electronic devices, has also been shown to cause dry eye in adults1. Symptoms of

computer vision syndrome include irritation, dryness, watering, blurred vision and eye

fatigue1,7. One suggested mechanism for dry eye syndrome associated with computer use

is that decreased blink rate while using electronic devices allows the tear film to

evaporate more significantly1,8. Children use electronic devices at higher rates than they

have in the past9, but reported use varies greatly based on the location and age of

children10, 11. Research has been limited to determine if dry eye syndrome is also

occurring in children who use electronic devices. One study done in Korea found that

increased mobile phone use was a significant risk factor to dry eye disease11. A study
done in Hong Kong found that the other common symptoms of computer vision

syndrome, like neck and back pain, have been found in children12. Additionally,

increased cognitive demand has also been associated with decreased blink rate13. Since

schools are using electronic devices more frequently, the combination of electronic

device use and the increased cognitive demand of school may also contribute to dry eye.

The main goal of this study was to determine if there is a correlation between screen time

and dry eye symptoms in children. Additionally, our study sought to determine the

average amount of screen time of the pediatric population in the area served by the

University Eye Clinic at the Michigan College of Optometry.

2
 CHAPTER 2

METHODS

This study was performed among the pediatric patient population of the Michigan

College of Optometry in Big Rapids, Michigan from May 2018 through December 2018.

Our selection criteria included any children younger than 18 years old. Parental consent

and, when appropriate, patient assent was obtained for each patient. Our goal sample size

was 100 patients and we enrolled 39 patients (21 males, 18 females). A questionnaire

was given to the parents regarding their child’s dry eye symptoms and electronic device

use. The dry eye portion was adapted from the Standard Patient Evaluation of Eye

Dryness (SPEED) Questionnaire. A significant score for the SPEED Questionnaire is a

19 or higher7. The electronic device use portion of the survey asked for quantity

information on use of various electronic devices as well as information on use of

electronic device uses at school. Electronic device categories included were television,

computer, cellphone, tablet, video games, and other. The American Academy of

Pediatrics (AAP) recommends no electronic device use other than video-chatting in

children younger than 18 months, a maximum of one hour per day for children two to

five years of age, and consistent time limits on children 6 years and older that emphasizes

the importance of sleep, physical activity, and other healthy behaviors9,14. Based on this

recommendation, we considered any electronic device use significant for ages 0-18

months, more than 1 hour for children ages 2-5 years, and more than 3 hours per day on
weekends or weekdays for all older children. Student clinicians also evaluated tear break

up time (TBUT) and blink rate in 30 seconds and noted any other signs of dryness noted

during the patient’s exam. TBUT is a generally accepted sign of dry eye syndrome and

was evaluated using Fluorescein Sodium and Benoxinate Hydrochloride Ophthalmic

Solution, USP 0.25%/0.4% eye drops. TBUT was considered significantly low if it was

five seconds or less. Blink rate was measured over 30 seconds instead of the standard

one minute, due to the increased difficulty with working with some patients in this

population. Blink rate was considered significantly low if it was three or less times in 30

seconds. Other signs of dryness or other ocular surface diseases were noted by student

clinicians and the overseeing doctor, and was determined to be significant on a case-by-

case basis by the investigators of this study.

4
 CHAPTER 3

RESULTS

A total of 39 patients were enrolled in this study, 21 males and 18 females. The

average age of the subjects was 10.81 ± 4.24 years (10.88 for males, 10.72 for females)

with an age range of 3 to 17 years (3 to 17 for males, 4 to 17 for females). While the

majority of surveys were filled out completely and correctly, some were not filled out or

were filled out incorrectly in sections. Those answers were only included in the results

where the intention of the parents or student clinicians were clear and were not included

otherwise.

The average SPEED Questionnaire score was 4.58 ± 5.93. Three patients had

statistically significant SPEED Questionnaire scores of 19 or higher (two females with

scores of 20 and 24, one male with a score of 20). The average age of patients with

statistically significant SPEED Questionnaire scores was 9.00 ± 2.16 years.

Several electronic device types were reported to be used on weekdays, weekends,

and at school, as shown in Chart 1 on page 6. The average amount of electronic device

use on weekdays was 5.06 ± 0.57 hours. The device with highest reported average

amount of use on a weekday was the cellphone at 1.77 hours of use per weekday. The

average amount of electronic device use on weekend days was 6.88 ± 0.85 hours. The

device with highest reported average amount of use on a weekend day was the television
Chart 1: Average Electronic device usage in Hours per day

2.5
Number of Hours per Day

1.5

0.5

0
TV Computer Cellphone Tablet Video games
Device Type
Weekday Weekend Day

at 2.59 hours of use per weekend day. The average week total was calculated based on

the average use on a weekday and a weekend day. The average total of hours of use per

week was 39.03. The most commonly used device on a weekday was the television with

32 subjects reporting weekday use. The most commonly used device on a weekend was

the television with 30 subjects reporting use. Five device categories were reported to be

used in school to some degree: television, computer, cellphone, tablet, and video games.

The most frequently reported item used was the computer, with 26 subjects reporting

some computer use at school.

The total number of users with significantly high electronic device use was 27 (15

males, 12 females), based on the recommendations of the AAP. While we did not have

any children in 18 months of age or younger, we had six subjects in the 2-5 years of age

category. All of our subjects in that category reported a significantly higher amount of

6
use than the recommendation, with an average of 3.40 ±2.06 hours on weekdays and 6.40

± 5.24 hours on weekend days. We had a total of 33 subjects in the older child category,

21 of which reported significant electronic device use. These subjects in this category

also tended to report significantly high amounts of device use than recommended on

average, with an average of 5.17 ± 5.18 hours on weekdays and 6.86 ± 6.60 hours on

weekend days. Overall, subjects who had significant high hours of electronic device use

tended to be older, with an average age of 12.19 ± 4.59 years, but less than one standard

deviation higher than the overall average age.

The TBUT was separated in three categories as shown in Table 1 on page 8:

normal, borderline, and significant. Five subjects showed a significant TBUT, defined as

five seconds or less. TBUT was unattainable on eight patients due to their age or

cooperation and was not recorded for two patients. Blink rate was also divided into three

categories as shown in Table 2 on page 8: normal, borderline, and significant. Six

subjects had a significantly low blink rate, defined as three times or less in 30 seconds.

Blink rate was not recorded on four patients. The average blink rate was 6.69 ± 4.01

blinks per 30 seconds. Various other signs of dry eye syndrome were recorded as shown

in Table 3 on page 8 and five patients had other significant signs of dry eye syndrome. In

total, between TBUT, blink rate, and other signs, fourteen subjects had objectively

significant signs of dry eye syndrome (6 males, 8 females). Subjects with objectively

significant signs of dry eye syndrome tended to be older, with an average age of 14.27 ±

3.88 years.

7
 Of the subjects who were symptomatic, two subjects also reported high use of

electronic devices and one of those two subjects also had objectively significant signs of

dry eye syndrome. The other symptomatic patient did not have objectively significant

signs of dry eye syndrome and did not report high use of electronic devices. The average

SPEED Questionnaire score of subjects who reported high electronic device use was

4.31. The average SPEED Questionnaire score of subjects with objectively significant

Table 1: Categorized TBUT Table 2: Categorized blink rate

Number of Number of
Classification Classification
Subjects Subjects
Normal – 10 seconds or more 13 Normal – 8 times or more 10
Borderline – less than 10 but
11 Borderline – less than 8 but
more than 5 seconds 19
more than 3 times
Significant – 5 seconds or less 5
Significant – 3 times or less 6
Unable 8
Not recorded 2 Not recorded 4

Table 3: Other reported signs of dry eye syndrome

Signs Number of Subjects

Superficial punctate keratopathy 6
Capped Meibomian glands 5
Lagophthalmos 1
Papillae 5
Lash debris 1
Abnormal tear quality 3
Conjunctival staining 1
Other ocular conditions (recurrent redness, previous
2
diagnosis of dry eye syndrome)

8
signs of dry eye syndrome was 4.57. Neither of these are significant according to the

SPEED survey or in comparison to the overall average SPEED Questionnaire score (4.58

± 5.93). Of the subjects who reported high use of electronic devices, 9 subjects also had

objectively significant signs of dry eye syndrome. The average TBUT in subjects who

reported high electronic device use was 6.59 seconds, which is a borderline value. The

average TBUT in subjects who had a significant SPEED Questionnaire score was use

was 9.83 seconds, which is also a borderline value. The average blink rate in subjects

who reported high electronic device use was 9.09 blinks in 30 seconds, which is in the

normal value category. The average blink rate in subjects who had a significant SPEED

Questionnaire score was 6.67 blinks in 30 seconds, which is a value in the borderline

category.

9
 CHAPTER 4

DISCUSSION

Our primary goal was to determine if there was a correlation between screen time

and dry eye symptoms in children. Very few subjects reported significant symptoms in

the adapted SPEED Questionnaire. However, there were objectively significant signs of

dry eye syndrome in more than a third of patients. When evaluating the overall trends,

there was not a correlation between screen time and symptoms or dry eye in children, as

shown in Graph 1. This may be due to two reasons. First, it is possible that the amount

and severity of dry eye symptoms was underreported because the parents were

completing the survey based on their child’s complaints. The children may not be

Graph 1: Symptom score versus total weekly hours of device use

180

160

140

120
Hours per Week

100

80

60

40

20

0
0 5 10 15 20 25 30
SPEED Score
reporting all their symptoms to parents either because they are afraid to lose out on

something they enjoy, like electronic device use, or because they do not realize that the

symptoms they are experiencing are abnormal. Unfortunately, due to the population

being studied, it may be particularly difficult to get subjective findings of dry eye

experiences. Second, it is possible that the signs of dryness that we marked as clinically

significant may not be clinically significant due to lack of established normative values of

dry eye syndrome in children. Further study into the tear film quality and stability in

children should be done to determine if this is significantly different than that of adults.

Our secondary goal for this study was to determine the average amount of screen

time of the pediatric population in the area served by the University Eye Center at the

Michigan College of Optometry. The average weekly use, 39.03 hours, was

significantly higher than that recommended by the AAP for young children. While there

are no specific numerical values listed for teens or adolescents, this number is just one

hour shy of what would be a full time job for a working adult. This was comparable to

the urban value found by Moon et al11. This is significant as the area surrounding the

University Eye Center at the Michigan College of Optometry is typically considered a

relatively rural area. Rural areas typically have less electronic device usage, suggesting

that these numbers may even be lower than the general population11.

The American Academy of Pediatrics (AAP) warns against significant electronic

device usage, particularly unsupervised usage9. The first reason given by the AAP to

caution parents is the importance of an active life to prevent obesity and other conditions

that are associated with sedentary activity. The second is to ensure that children have

minimal exposure to alcohol, sex, and tobacco usage on social media, minimizing the

11
effects of cyberbullying, and maximizing privacy and safety. The AAP recognizes the

benefits of increased socialization through social media and video-chatting but

recommends that first priorities should be given to ensuring children have adequate sleep

and physical activity. The American Academy of Pediatrics recommends no electronic

device use other than video-chatting in children younger than 18 months, a maximum of

one hour per day for children two to five years of age, and consistent time limits on

children 6 years and older that emphasizes the importance of sleep, physical activity, and

other healthy behaviors9,14. The majority of our subjects failed to meet these guidelines.

One limitation of our study was the small study size, which limited the

significance of the findings of the study. Finally, while there were several signs of dry

eye syndrome in the pediatric population, correlation does not necessarily equate to cause

in this case. There were several children who may have had ocular allergies, or pre-

existing dry eye separate from their device use. Some or all of this study should be

performed again on a larger population to determine if these findings can be applied to

larger populations.

12
 CHAPTER 5

CONCLUSION

Dry eye syndrome due to computer use may be occurring in children in the same

way as it is happening in adults but subjective measurements may be less useful in

children. Subjective measures are of limited use and do not always correlate with

objective signs of dryness. Some children, like those in the area surrounding the

University Eye Center at the Michigan College of Optometry, are using electronic

devices in a week almost as much as adults spend at a full time job. This is more than the

recommended limit of electronic device use put forward by the AAP to prevent overall

poor health and development. More research is needed on this topic to determine how

children are using electronic devices, and how that use is contributing to their ocular

health.
 REFERENCES

1. Gowrisankaran S, Sheedy JE. Computer vision syndrome: a review. Work

2015;52(2):303-14.

2. Klamm J, Tarnow KG. Computer vision syndrome: a review of literature.

MedSurg Nursing 2015;24(2):89+.

3. Shah S, Jani H. Prevalence and associated factors of dry eye: our experience in

patients above 40 years of age at a tertiary care center. Oman J Ophthalmol

2015;8(3):151-56.

4. Intranasal Stimulator Improves Dry Eye Symptoms. Medscape, 2018. Available

at: https://www.medscape.com/viewarticle/904205 Accessed February 5, 2019.

5. Shaumberg DA, Sullivan DA, Buring JE, Dana MR. Prevalence of dry eye

symptoms among US women. Am J Ophthalmol 2003;136(2):318-326.

6. Lee AJ, Saw SM, Gazzard G, Koh D, Widjaja D, Tan DTH. Prevalence and risk

factors associated with dry eye symptoms: a population based study in Indonesia.

Br J Ophthalmol 2002;86(12):1347-51.

7. Ngo W, Situ P, Keir N, Korb D, Blackie C, Simpson T. Psychometric properties

and validation of the standard patient evaluation of eye dryness questionnaire.

Cornea 2013;32(9);2005-10.

8. Portello JK, Rosenfield M, Chu CA. Blink rate, incomplete blinks and computer vision

syndrome. Optom Vis Sci 2013;90(5):482-487.

 9. American Academy of Pediatrics. Media use in school-age children and

adolescents. Pediatrics 2016;138(5).

10. Christakis DA, Ebel BE, Rivara FP, Zimmerman FJ. Television, video, and computer

game usage in children under 11 years of age. J Pediatr 2004;145(5):652-656

11. Moon JH, Kim KW, Moon NJ. Smartphone use is a risk factor for dry eye diease

according to region and age: a case control study. BMC Ophthalmol 2016;16.

12. Sui DCH, Tse LA, Yu ITS, Griffiths SM. Computer products usage and

prevalence of computer related musculoskeletal discomfort among adolescents.

Work 2009;34:449-54.

13. Abelson MB et all. It’s time to think about the blink. Review of Ophthalmology.

Published online June 13, 2011. Accessed February 23, 2019. Available at:

www.reviewofophthalmology.com/article/its-time-to-think-about-the-blink

14. American Academy of Pediatrics. Media and young minds. Pediatrics 2016;138(5).

15. State Education Reforms: Table 5.14. Number of instructional days and hour in the

school year, by state: 2018. National Center for Education Statistics. Accessed February

23, 2019, Availible at: https://nces.ed.gov/programs/statereform/tab5_14.asp

16. Jago R, Stamatakis E, Gama A, Carvalhal IM, Nogueira H, Rosado V, Radez C. Parent

and child screen-viewing time and home media environment. Am J Prev Med

2012;43(2):150-158

17. Kozeis N. Impact of computer use on children’s vision. Hippokrati 2009;13(4):230-231

18. Al Rashidi SH, Alhumaidan H. Computer vision syndrome prevalence, knowledge and

associated factors among Saudi Arabia university students: is it a serious problem. Int J

Health Sci 2017;11(5):17-19.

15
 19. Munshi S, Varghese A, Dhar-Munshi S. Computer vision syndrome – a common cause of

unexplained visual symptoms in the modern era. Int J Clin Pract 2017;71(7):e12962.

Available at https://doi-org.ezproxy.ferris.edu/10.1111/ijcp.12962

20. Bogdanici CM, Sandulache DE, Nechita CA. Eyesight quality and computer vision

syndrome. Rom J Ophthalmol 2017;61(2):112-116

16
 APPENDIX A

IRB APPROVAL FORM

 Date: May 18, 2018

To: Paula McDowell

From: Gregory Wellman, R.Ph, Ph.D, IRB Chair

Re: IRB Application IRB-FY17-18-164 Computer Vision Syndrome in Kids

The Ferris State University Institutional Review Board (IRB) has reviewed your application for

using human subjects in the study, Computer Vision Syndrome in Kids(IRB-FY17-18-

164) and approved this project under Federal Regulations Exempt Category 2. Research

involving the use of educational tests (cognitive, diagnostic, aptitude, achievement), survey

procedures, interview procedures or observation of public behavior, unless: (i) information

obtained is recorded in such a manner that human subjects can be identified, directly or

through identifiers linked to the subjects; and (ii) any disclosure of the human subjects'

responses outside the research could reasonably place the subjects at risk of criminal or civil

liability or be damaging to the subjects' financial standing, employability, or reputation.

Approval has an expiration date of three years from the date of this letter. As such, you may

collect data according to the procedures outlined in your application until May 18,

2021. Should additional time be needed to conduct your approved study, a request for

extension must be submitted to the IRB a month prior to its expiration.

Your protocol has been assigned project number IRB-FY17-18-164. Approval mandates that

18
 you follow all University policy and procedures, in addition to applicable governmental

regulations. Approval applies only to the activities described in the protocol submission;

should revisions need to be made, all materials must be reviewed and approved by

the IRB prior to initiation. In addition, the IRB must be made aware of any serious and

unexpected and/or unanticipated adverse events as well as complaints and non-compliance

issues.

Understand that informed consent is a process beginning with a description of the study and

participant rights, with the assurance of participant understanding followed by a signed

consent form. Informed consent must continue throughout the study via a dialogue between

the researcher and research participant. Federal regulations require each participant receive

a copy of the signed consent document and investigators maintain consent records for a

minimum of three years.

As mandated by Title 45 Code of Federal Regulations, Part 46 (45 CFR 46) the IRB requires

submission of annual reviews during the life of the research project and a Final Report Form

upon study completion. Thank you for your compliance with these guidelines and best wishes

for a successful research endeavor.

Regards,

Gregory Wellman, R.Ph, Ph.D, IRB Chair

Ferris State University Institutional Review Board

Office of Research and Sponsored Programs

19
APPENDIX B

SURVEY FORM
 Study: Correlation Between Screen Time and Dry Eye in Children Number:_____
Parents: Please fill out the following questions about your child

Current age of Child ____________ Gender: □Male □Female

Please indicate any of the following eye symptoms that your child has experienced. For all symptoms
that your child has experienced, please also indicate when those symptoms have occurred.*
*Adapted from the Standardized Patient If YES: When
Evaluation of Eye Dryness (SPEED™) No Today Within last 72 hrs Within last 3 months
Questionnaire
Dryness, Grittiness, or Scratchiness
Soreness or Irritation
Burning or Watering
Eye Fatigue
Please indicate the frequency that your child has experienced the following symptoms.

Never Sometimes Often Constant

Dryness, Grittiness, or Scratchiness
Soreness or Irritation
Burning or Watering
Eye Fatigue
Please indicate the severity of the symptoms your child has experienced.

None Tolerable Uncomfortable Bothersome Intolerable Unknown

Dryness, grittiness, or
Scratchiness
Soreness or Irritation
Burning or Watering
Eye Fatigue

The next several questions are related to screen time. Please list the number of hours your child uses
each of the devices on an average weekday or weekend day. Please also indicate if any of these devices
are used by your child while at school.

Hours on a weekday Hours on a weekend day Use at school

Television
Computer
Cellphone
Tablet
Video games
Other (please describe)

For Student Clinician: Please fill out the following information:

TBUT: ______________ Blink rate: _____________

Other Signs of Dry Eye: _________________________________________________________________

21