Screentime eyes: talking to screen-based workers about dry eye and (dis)comfort

The scenario

Post-pandemic, it seems screentime usage has only risen as people continue to work from home and spend more time in front of their devices on Zoom and Teams meetings. As a result, I’m seeing more patients with dry eyes than ever before. However, patients don’t always acknowledge their discomfort. Do you have any advice for locum optometrists on raising and educating patients about dry eye symptoms and healthy at home screen habits? 

Freya, locum optometrist

The advice

Clair Bulpin, optometrist and Johnson & Johnson MedTech faculty member

It is amazing how accepting we can be when considering something as a ‘new normal.’ The COVID-19 pandemic changed so much about optometry, and arguably enhanced our role and how we are perceived by the public. As clinicians, we are dealing with a whole new scope of work and have accepted this readily. 

These changes can be observed all around us, with statistics reporting that there has been a significant jump in hybrid and home working, with around 5% of the workforce reporting periods of time spent working from home in 20191 to around 40% in 2023.²  Whilst this may bring flexibility for individuals, it undoubtably also brings the potential for eye concerns.

Whilst the job descriptions of hybrid workers have probably not changed much, the time they spend on screens certainly has. Previous face-to-face meetings now have the option of being remote, and let’s not forget, our use of technology far surpasses that of even 10 years ago.

Even in ‘non-office’ based employment, screentime use is growing. As an optometrist, in my early years practising, I spent little time on a screen. Paper records and hand-written referrals were the norm, and whilst I am not suggesting we should regress, even in our highly practical and clinical role, we spend far more time on a screen than ever before. 

A knowledgeable clinician can advise on options that really suit the patient, a modality that works for them, all in conjunction with material properties which meet their anatomical and physiological needs, rather than generic recommendations

  

Screens and vision impact

The main symptoms of Digital Eye Strain (DES) are considered to be: ocular pain (including tiredness, soreness and dryness), blurred vision, burning, photophobia and eye strain.³  

DES has also been reported to occur as rapidly as within 20 mins of device use,⁴ so it is undoubtably having an impact on a large proportion of our patients. If we consider this alongside the fact that we also know that these changes will have a more significant impact on our contact lens wearers,⁵ it is clear to see why our patient-centred advice is being directed more frequently into areas other than simply vision correction. 

Alongside the increasing prevalence of DES, data demonstrates that around one third of the UK population also have dry eye disease.⁶

The clinician’s crystal ball has always been a useful tool. When signs are seen ahead of symptoms, advice is critical

A lack of presenting symptoms

We know that this ‘new normal’ increases the potential for discomfort and dryness. I also see it on the slit lamp, noting an increased prevalence of meibomian gland dysfunction, tear film instability and corneal staining. However, despite the apparent increase in signs, this doesn’t necessarily directly correlate with an increase in symptoms. So why not? 

A lack of presentation could be for a number of reasons. It may be for fear that practitioners will confiscate a patient’s beloved contact lenses if they voice any concerns around comfort; maybe they are ‘self-managing’ with reduced wearing times or lubricating eye drops? However, we should also consider that quite simply, patients have come to accept this as their new normal, and therefore it isn’t worthy of reporting.

The clinician’s crystal ball has always been a useful tool. When signs are seen ahead of symptoms, advice is critical. Compliance in an asymptomatic patient may not be as guaranteed, but can be encouraged with careful explanations.

While you can adopt the ‘if it isn’t broke, don’t fix it’ approach, it will break eventually. Therefore, it is beneficial for practitioners and patients alike to prevent the breaking in the first place.

In my experience, the first thing is to advise the patient that you are seeing these clinical signs. I often explain that in the early stages, they may not perceive the subtle changes these signs bring but my goal is to keep them comfortable in the long term. I like to remind a patient that the reason they come for an appointment is to allow us to check their vision and eye health, and that prevention is arguably better than cure.

I would advise approaching every patient with the assumption that they will be experiencing either digital eye strain or dry eye to some degree

  

One of the things I have learnt over time is that dryness presents in a myriad of ways.  Some patients will volunteer that their eyes feel dry, but what does this actually mean?  I like to ask patients to describe what they experience that makes them feel this is the case.  Not everyone describes a feeling of dryness, some describe tiredness, itching, heavy eyelids or often, blurry vision.

Contact lens wearers may also, on the face of it, be symptomless, but any change in wearing habits necessitates additional questions and investigations. It is possible that their needs have changed, but could the comfort of their lenses have driven them to change their wearing times? Are they now symptomless simply because reducing days of wear, or wearing hours has ‘solved’ their issues? 

Raising awareness

As eye care professionals, we have the knowledge that this is ever more prevalent and therefore it is easy to begin a conversation around the risk of experiencing digital eye strain and dry eye. 

I would advise approaching every patient with the assumption that they will be experiencing either digital eye strain or dry eye to some degree. It is estimated that nearly half of contact lens wearers experience discomfort,⁷ so you have a high chance of being right.

I like to explain that their environments and lifestyle, through no particular fault of their own, may make them more susceptible to experiencing some discomfort. I may go on to explain that dryness could manifest in a variety of ways, and that this could be changes in their vision, maybe their eyes looking different, a little redder perhaps, or their eyes just feeling heavy and tired. Most importantly, I can advise them that they don’t have to accept this, and that this doesn’t have to be their new norm.

Promoting healthy screen habits is an interesting notion. It is all very well telling someone to take regular breaks, but anyone who works with a screen knows that the hours just fade away and the 20-20-20 rule turns into every 20 hours reminding yourself 20 times about the 20 breaks you didn’t take.

I’m not a huge fan of generic recommendations, any advice that you give needs to be perceived as practically possible and individualised. If it doesn’t fit somehow into a patient’s busy day, it can be a real effort to make something new a habit. Whilst the 20-20-20 rule is commonly cited, there is little evidence base to support this,⁷ and realistically this is a stringent timescale to stick to. I may discuss this with a patient, but I will equally discuss that breaking every hour is better than not taking a break at all.  Finding something realistic for the patient, I believe, enhances the chances of this happening.

A final area that eye care professionals absolutely need to consider is that for some individuals, nothing about their world has changed over the last few years. Our younger patients are growing up in this ever-changing world – it’s not new to them, it simply is their normal. Gone are the days where a classroom shared a single computer – screens feature heavily in their life from an early age. Tear film related disorders are becoming more common in the younger generation, and it is estimated that over 40% of four–17-year-olds may show some evidence of meibomian gland atrophy.⁸

These patients may be less able to articulate their symptoms, so signs become invaluable. They can definitely accept their discomfort as normal, especially if they have never known any different. Conversations around healthy screen habits and eye health should happen regularly with patients, almost regardless of age.