Do you still ask patients: “Are you using a computer at all during the day?” Years ago — before digital devices took over the planet — this was a legitimate question, as responses varied. Now, however, 3-year-olds can use an iPad to navigate YouTube, and elderly patients use their smartphones to show pictures of their great-grandkids. In fact, the explosion of digital device use has resulted in 60% of Americans reporting digital eye strain symptoms, such as dry eyes, blurred vision and headaches, reports The Vision Council. So, how do we manage these patients as effectively and efficiently as possible? The answer is by addressing patient complaints related to the signs and symptoms of digital eye strain. Specifically, I use pre-presbyopic patients to illustrate.
1 START WITH THE HISTORY
On every patient, a comprehensive history, asked by a technician, should include how the patient uses his eyes and, specifically, digital devices. Areas addressed should include, according to Optometry in Practice:
- The number and types of devices being used
- Monitor sizes
- Viewing distances
- Gaze angles
- Duration of use for each device
- Type of task being performed on each device
- The size of the critical detail being observed during the task
Presented with this information, you can now identify signs of digital eye strain, and concentrate on the specific testing and treatments needed to effectively address the patient complaint(s).
2 TEST YOUR THEORY
Once it is determined from the history that the patient has symptoms related to digital eye strain, perform various tests to help diagnose causes that lead to these symptoms. For example, dry eye commonly contributes to digital eye strain, therefore, on a symptomatic patient, we may perform a dry eye workup. This would include imaging of the meibomian glands, checking for ocular surface staining and testing TBUT and tear production. Additional testing for accommodative dysfunction may be indicated, and evaluation will include minus lens amplitude test, negative relative accommodation/positive relative accommodation and vergence testing.
3 PROVIDE THE APPROPRIATE REMEDIES
The goal when prescribing contact or spectacle lenses is to address all digital eye strain symptoms.
Refraction and accommodation. Considering the time spent using digital devices, relaxing accommodation and accommodative spasm is an essential starting point for treatment. For our pre-presbyopic patients complaining of eye strain and fatigue, for example, we eliminate overcorrection and reduce their myopic prescription, while enabling them to maintain comfortable distance VA. When this is not enough, other options we frequently turn to include ophthalmic and contact lens offerings on the market that have given our patients — and more specifically, our pre-presbyopic patients — relief from their symptoms.
Spectacle lens options. Anti-fatigue spectacle lenses help to reduce accommodative demand at near. Based on our experience, pre-presbyopic patients who spend 10 to 16 hours per day on their computers, tablets and phones see a significant decrease in their digital eye strain symptoms once put into an anti-fatigue lens. You can think of these lenses as progressive-lite, as they allow the doctor to prescribe add powers less than +1.00 D, depending on the needs of the patient.
When talking about ophthalmic lenses for digital eye strain, also mention AR coatings. Reducing glare is an essential part of the treatment for a symptomatic patient, as it can significantly add to visual discomfort while viewing the screen of a digital device. Premium anti-glare coatings are built into the lens package we initially present to our patients. (Another tip: When discussing your prescription with patients, educate them about the high-quality features of their spectacle lenses and why you truly believe them to be the best possible solution.)
Patient Education Tip: Break It Up
A FEW YEARS AGO, I would complete my exam with a digital eye strain patient and rattle off the speech about the overuse of digital devices, glare reduction, dry eye, decreased blink rate, the negative effects of blue light, 20/20/20, proper posture and working distance. Then, I would bring him or her to the optical, and the optician would begin an educational speech about progressive lenses, AR coatings, occupational glasses and, well, you get the point. From a patient’s standpoint, this is overwhelming.
We now break up the information the patient is receiving throughout his/her time in the office. It starts with the front-desk staff discussing our treatments and products during the patient’s initial phone call. We provide educational material in the waiting areas. Our technicians are trained to understand a patient’s complaint, so they can ask the appropriate follow-up questions, and the opticians speak with the patient about anti-glare and other helpful options, while the patient browses in the optical prior to his exam. By the time the patient is in the exam chair, he/she has already been exposed to a few of the terms used to explain the digital eye strain diagnosis and treatment options.
By delegating the education to staff as the patient flows through our office, the patient hears the information more than once, and he/she also gets it in bits and pieces, which makes it easier to remember.
Vergence remedies. If it is determined that a patient has either convergence excess (CE) or convergence insufficiency (CI), the treatments mentioned in this entire section may be modified to improve his binocularity.
Related to the treatment of providing a near vision add to help reduce accommodative demand, this can also be mutually beneficial to reduce CE and the associated eye strain symptoms that may go along with it. As for our patients with CI, we typically prescribe at-home vision therapy training — ironically, some of it computer based — which we monitor periodically via reported scores and in-office follow-up appointments.
Blue light blocking. Blue light is at the higher energy, shorter wavelength end of the visual spectrum. It flickers more and decreases contrast, thus reducing clarity. Blue light comes largely from sunlight, but is also emitted though fluorescent lights, LED lights, LED TVs, computer monitors, tablets and smartphones. While the exposure from monitors, tablets and phones is small compared to the sun, blue light-emitting devices are in close proximity to the eyes, and blue light contributes to digital eye strain.
Research shows that changes in the light environment lead to changes in circadian rhythms that, in turn, influence sleep and contribute to alterations in mood and cognitive function, according to Nature Reviews Neuroscience. Other studies have also reported that exposure to digital devices at bedtime could negatively affect sleep and circadian rhythm, suggesting this negative impact on sleep may be due to the short-wavelength-enriched light emitted by these electronic devices, according to Proceedings of the National Academy of Sciences in the United States of America.
As a result, we recommend lenses that filter out blue light for our pre-presbyopes who frequently use screens. Put together with the premium anti-glare options and a proper refraction, our patients notice instant improvement in symptoms, as these lenses help to improve contrast and clarity and decrease glare.
Contact lens options. For the contact lens wearer, we frequently fit a contact lens that simulates positive power throughout the optic zone of the lens, again, reducing the accommodative demand. Another contact lens solution is a multifocal contact lens that has a low power add and, preferably, a distance center, so the patient is able to benefit from the near vision component of the lens with minimal disruption to their distance vision. This will require you to go through your usual multifocal adjustment steps to achieve clear distance and near vision, while reducing the accommodative demand.
It’s worth noting that improving technology in contact lens materials has reduced another common component of the digital eye strain: dry eye. When selecting a lens for these patients, keep the dry eye component in mind due to the association between digital eye strain, reduced blink rate/incomplete blinks and dry eye, according to Optometry and Vision Science.
Tried-and-true solutions. An accurate refraction and correctly selected spectacle and contact lenses do not replace patient education on how to reduce glare, practice proper posture, treatment and management of dry eye and visual hygiene. Ensure that these are part of your patient education.
Digital Eye Strain Affects All Ages
ACCORDING TO THE VISION COUNCIL, the following percentage of patient populations report using digital devices for more than two hours per day:
HERE TO STAY
Digital devices are not going away. We have to do what is best for our patients and educate ourselves on the various aspects of digital eye strain and the treatment options available. The ophthalmic and contact lens industries are responding by developing new products to help us treat our patients. Now, it is up to us to implement these products in our practice. OM