REVIEW ARTICLE

Digital Screen Use and Dry Eye: A Review

Divy Mehra, BS  y and Anat Galor, MD, MSPH  y

evaporative DE that is often seen with meibomian gland dysfunc-

Abstract: Prolonged and continuous daily use of digital screens, or visual
tion (MGD), anatomical abnormalities (eg, lagophthalmos, con-
display terminals (VDTs), has become the norm in occupational, educa-
junctivochalasis), and nerve dysfunction (peripheral or central).
tional, and recreational settings. An increased global dependence on VDTs
To complicate matters, contributors can co-exist in an individual
has led to a rise in associated visual complaints, including eye strain, ocular
patient1 and observed ocular surface and tear parameters are often
dryness, burning, blurred vision, and irritation, to name a few. The principal
disconnected from patient-reported symptoms.2 In addition, fac-
causes for VDT-associated visual discomfort are abnormalities with ocu-
tors beyond the ocular surface have been associated with DE
lomotor/vergence systems and dry eye (DE). This review focuses on the
symptoms and/or signs including blink rate3 and systemic comor-
latter, as advances in research have identified symptomology and ocular
bidities (eg, immune disorders, diabetes, chronic pain condi-
surface parameters that are shared between prolonged VDT users and DE,
tions).4,5 Furthermore, factors outside the body can affect DE,
Downloaded from https://journals.lww.com/apjoo by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdgGj2MwlZLeI= on 12/20/2020

particularly the evaporative subtype. Several mechanisms have been

including environmental factors both indoors and outdoors (eg,
implicated in VDT-associated DE, including blink anomalies, damaging
humidity, air pollution6,7), exposures (eg, light sources8), and
light emission from modern devices, and inflammatory changes. The
activities (eg, prolonged reading9). In this review, we focus on the
presence of preexisting DE has also been explored as an inciting and
relationship between screen use (eg, smartphone, computer) and
exacerbating factor. We review the associations between digital screens and
DE. We first present epidemiologic data regarding the connection
DE, mechanisms of damage, and therapeutic options, hoping to raise
between screen use and DE. We then focus on potential patho-
awareness of this entity with the goal of reducing the global morbidity
physiologic mechanisms between the 2, and finally discuss
and economic impact of screen-associated visual disability.
potential therapeutic technologies and lifestyle modifications that
may benefit individuals with symptoms and/or signs of disease.
Key Words: blink dynamics, computer use, dry eye, inflammation, tear
break-up time
Computer Vision Syndrome
(Asia Pac J Ophthalmol (Phila) 2020;9:491–497) The 21st century has given way to a global society increasingly
dependent on a variety of technologies in personal, occupational, and
institutional settings. Naturally, this has led to rising daily exposure to
INTRODUCTION digital screens, with an accompanying rise in the prevalence of ocular
complaints. Although many of these ocular symptoms fall under the
Overview of Dry Eye purview of DE, significant discussion has been had in the realm of a
related condition—computer vision syndrome (CVS).
D ry eye (DE) is a heterogeneous, multifactorial disease
characterized by a combination of ocular surface symptoms
(dryness, pain, poor, or fluctuating vision) and signs (reduced tear
CVS, or digital eye strain, refers to a spectrum of clinical
vision-related and muscular symptoms perceivably resulting from
break-up time, decreased tear production, corneal staining). The prolonged and continuous use of visual display terminals (VDTs),
DE “umbrella” is often subdivided into categories based on such as computers, smartphones, televisions, and tablets.10 Dif-
underlying contributors which include aqueous tear deficiency, ferent display device types are associated with unique profiles of
visual effects, possibly due to differences in viewing positioning
Submitted September 7, 2020; accepted September 26, 2020.
(distance and angle), patterns of use, screen resolution and
From the Surgical Services, Miami Veterans Affairs Medical Center, Miami, FL; contrast, image refresh rates, screen glare, color spectra, and
and yBascom Palmer Eye Institute, University of Miami, Miami, FL.
Support: Supported by the Department of Veterans Affairs, Veterans Health
other digital features.11 Common visual symptoms in CVS
Administration, Office of Research and Development, Clinical Sciences include dryness and irritation, sensations of burning, asthenopia,
R&D (CSRD) I01 CX002015 (Dr. Galor) and Biomedical Laboratory R&D
(BLRD) Service I01 BX004893 (Dr. Galor), Department of Defense Gulf War
epiphora, hyperemia, blurred vision, diplopia, glare sensitivity,
Illness Research Program (GWIRP) W81XWH-20-1-0579 (Dr. Galor) and and transient deceptions in color perception. Other extraocular
Vision Research Program (VRP) W81XWH2010820 (Dr. Galor), National Eye
Institute R01EY026174 (Dr. Galor) and R61EY032468 (Dr. Galor), NIH
complaints associated with CVS frequently include musculoskel-
Center Core Grant P30EY014801 (institutional) and Research to Prevent etal pain in the neck, back, and shoulders, carpal tunnel syndrome,
Blindness Unrestricted Grant (institutional).
The authors report no conflicts of interest.
and venous thromboembolism, and a higher prevalence for devel-
Address correspondence and reprint requests to: Anat Galor, MD, MSPH, Bascom oping dermatologic conditions (ie, eczema, rosacea, seborrheic
Palmer Eye Institute, 900 NW 17th Street, Miami, FL 33136. E-mail:
agalor@med.miami.edu.
dermatitis).10 Given the global burden of screen-induced visual
Copyright ß 2020 Asia-Pacific Academy of Ophthalmology. Published by Wolters discomfort, identifying and managing its underlying causes can
Kluwer Health, Inc. on behalf of the Asia-Pacific Academy of Ophthalmology.
This is an open access article distributed under the terms of the Creative
help improve physical wellbeing and workplace productivity.12,13
Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-
NC-ND), where it is permissible to download and share the work provided it is
properly cited. The work cannot be changed in any way or used commercially METHODS
without permission from the journal. Articles for this narrative review were compiled from the
ISSN: 2162-0989
DOI: 10.1097/APO.0000000000000328 National Library of Medicine MEDLINE database with a PubMed

ß 2020 Asia-Pacific Academy of Ophthalmology. https://journals.lww.com/apjoo | 491

Mehra and Galor Asia-Pacific Journal of Ophthalmology  Volume 9, Number 6, November/December 2020
search for “dry eye,” “computer vision syndrome,” “visual display
terminal,” and “screen use” with searches limited to the English
language. All published scientific articles were considered includ-
ing original research, meta-analyses, and systematic reviews. All
searches were limited to the English language. Eligible articles
were reviewed and summarized.
RESULTS
Epidemiology of Screen Exposure and DE
Modern lifestyles continue to become increasingly depen-
dent on displays, with a rising global prevalence of ownership and
daily use of handheld smartphone devices.8 The extensive use of
computers in the workplace has led to a rise in visual health
concerns and suboptimal visual function, causing significant
physical and occupational burden; an estimated 50% to 90% of
all computer users experience symptoms of CVS.14 Although
there is a significant shared cohort of symptoms among CVS and
DE, the visual manifestations of CVS may occur within and
external to the context of DE.
Screen Use Is Associated With a DE Diagnosis
Prolonged use of VDTs is associated with a DE diagnosis, as
shown in several large-scale studies.12,15–17 However, it is impor-
tant to note that DE is variably defined by a constellation of
symptoms and signs and as such, diagnostic parameters vary
between clinicians and studies.
One large-scale population-based Japanese study sought to
evaluate the association between daily hourly VDT use and DE
diagnosis in 102,582 middle-aged participants (aged 40 through
74 years). DE diagnosis was defined either as a prior clinical
diagnosis or the presence of “often” or “constant” symptoms of
both eye dryness and irritation.18 Male and female participants
were stratified into groups based on self-reported daily hourly
VDT use. Among males, a higher prevalence of DE was found
among individuals with 5 daily VDT hours (22.3%) as com-
pared to individuals with <1 daily VDT hour (16.1%). A similarly
higher prevalence of DE was found among female VDT users
with 5 daily VDT hour (36.5%) as compared to users reporting
<1 daily VDT hour (26.5%). This study demonstrated 5 daily
VDT hours as a risk factor for DE diagnosis, with an overall
greater female DE prevalence in regular VDT and non-VDT
users. Unfortunately, DE has also been shown to associate with
VDT use in younger individuals, as shown in a study of 3,549
young and middle-aged office workers (aged 22 through 60 years)
in Japan with daily computer use.17 Together, these studies
identify prolonged VDT use as a risk factor for DE (variably
defined), with the frequency of disease ranging from 22% to 27%
among males and 36% to 48% among females in Japan. Similar to
other studies,19 females were more likely to have DE than men.
Screen Use Is Associated With DE Symptoms
A range of ocular symptoms have been anecdotally associ-
ated with computer use. Some of these symptoms are presumed to
originate from tear and ocular surface dysfunction, including
sensations of irritation, burning, and dryness. Other symptoms,
such as asthenopia (ie, ocular fatigue or eye strain) and blurred
and double vision, may originate from surface issues but also from
dysfunction within the accommodative and vergence systems.
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Given the heterogeneous nature of ocular sensory processing and
the subjectivity of symptom experience and reporting, it is
important to note that, although helpful, these distinctions are
not definitive indicators of disease origin. One of the most
common computer-associated ocular complaints is asthenopia,
experienced by an estimated 55% to 81% of VDT users.10,20,21
Sensations of eye dryness, redness, burning, and blurred vision
have also been linked to screen use.8,10 In a study of 713 female
undergraduates in Saudi Arabia, questionnaires were distributed
regarding 6 CVS symptoms including headache, burning, redness,
blurry vision, dryness or tearing, and neck or shoulder pain (rated
on a scale of none, mild, moderate, and severe). The most frequent
reported ocular symptom was burning (58.3%) followed by
dryness (51.5%), blurred vision (44.6%), and redness (40.8%).
The most frequent severe symptom was dryness (5.6%).22
Similar to the findings in Japanese office workers, time on
electronic devices impacted DE symptoms, as 5 hours of screen
time was found to be a risk factor for 3 CVS symptoms.22 In
addition, DE symptoms have also been reported with short-term
device use (ie, mobile device use for 1 continuous hour).8 Overall,
these studies illustrate that continuous VDT use, both short- and
long-term, is associated with a range of ocular symptoms, with
asthenopia, dryness, and burning among the most frequently
reported.
Screen Use Is Associated With DE Signs
Screen use has also been associated with DE signs. As above,
the Osaka study recruited 561 young and middle-aged Japanese
VDT users (aged 22–65 years, mean VDT use 7.9 hours per day)
and assessed symptoms (12-item questionnaire, answered as
"never,” “sometimes,” “often”, or “constantly”).12 Measured
ocular surface signs included Schirmer test (considered abnormal
if 5 mm in 5 minutes), Tear break-up time (TBUT) (considered
abnormal if 5 seconds), fluorescein staining (considered abnor-
mal if score of 3/9), and lissamine green staining (considered
abnormal if score of 3/9). Individuals were then separated into
groups based on the test results: “definite DE” was defined as 3 of
3 parameters—DE symptoms, tear film abnormality, and epithe-
lial damage; “probable DE” was defined as 2 of 3 parameters and
“non-DE” as 0 or 1 of 3 parameters.23 11.6% of subjects met
criteria for “definite DE,” 54.0% for “probable DE,” and the
remaining 34.4% for “non-DE.” Similar to previous studies,17,22
VDT time was a risk factor for DE, as >8 hours of use was
associated with “definite” or “probable” DE (OR 1.94). Again,
females had a higher frequency of DE than males (“definite DE,”
18.7% vs 8.0%; P < 0.05). Interestingly, contact lens use, certain
co-morbid diseases (eg, hypertension, diabetes mellitus), and
smoking were not risk factors for “definite” or “probable” DE.
A Turkish study further examined ocular surface parameters
in 53 VDT users (>6 hours of daily use) and compared these
findings to 49 controls (<1 hour of daily use).24 Fluorescein
corneal staining was assessed in 5 areas of the cornea (range 0–3)
for a total score range of 0 to 15. Tear meniscus height (TMH) and
area (TMA) were evaluated by ocular coherence tomography
twice, at 8 AM (before work) and 5 PM (after a workday). VDT
users had significantly higher DE symptoms [Ocular Surface
Disease Index (OSDI), 12.8  5.3 vs 8.7  1.6] and corneal
staining (2.04  1.86 vs 0.65  0.97) compared to controls. In
addition, VDT users had decreased baseline (8 AM) TMH and
TMA compared to controls.
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Asia-Pacific Journal of Ophthalmology  Volume 9, Number 6, November/December 2020
After working a full day, TMH and TMA were also decreased
in VDT users (5 PM measurement) as compared to their 8 AM
measurements. However, TMH and TMA did not significantly
change after a regular workday in the group of individuals who did
not use VDT in their occupation (controls).24 This study high-
lights that regular VDT users have decreased baseline tear volume
compared to non-VDT users, which further decreases after a work
day. Unfortunately, DE signs have also been related to screen use
in younger children.25 Taken together, these studies indicate that
prolonged VDT use can negatively affect tear film stability,
volume, and corneal epithelial integrity.
VDT Use Is Associated With Meibomian Gland Dysfunction
VDT use has also been associated with MGD.26,27 In Xia-
men, China, one study examined the frequency of MGD in
individuals with regular daily screen use (>4 daily hours of
VDT use, n ¼ 53) and controls (4 hours of daily VDT work
time, n ¼ 40).26 MGD was defined as the presence of lid margin
abnormalities (range 0–4), meibum quality (range 0–3), or gland
dropout on meibography (range 0–3 for each eyelid). Lid margin
abnormalities that impacted the score included irregularity, vas-
cular engorgement, gland orifice obstruction, and anterior/poste-
rior displacement of the mucocutaneous junction. All MGD
scores were higher in the regular-VDT group as compared to
controls, including lid margin abnormalities, meibum quality, and
gland dropout. Furthermore, all 3 MGD parameters also corre-
lated positively with VDT working time (all P < 0.0001). Of note,
the presence of MGD was associated with higher corneal staining
and faster TBUT.26 This study illustrates that along with abnormal
tear parameters, VDT users have a higher frequency of MGD
compared to non-VDT users. Other studies have supported these
findings.27 Overall, these studies point to relationships between
VDT use, DE symptoms, and DE signs, including MGD.
VDT Use Is Associated With Goblet Cell Dysfunction
The Osaka Study also assessed the presence of mucin 5AC
(MUC5AC), a mucin secreted by conjunctival goblet cells, in the
192 eyes of 96 young and middle-aged VDT workers (mean 8.2
daily hours of VDT use). Individuals were grouped by hours of
VDT use into short (<5 hours, n ¼ 38 eyes), intermediate (5–
7 hours, n ¼ 68 eyes), and long (>7 hours, n ¼ 86 eyes) categories.
Individuals in the long (5.9 ng/mg) and intermediate (6.5 ng/mg)
groups had lower mean concentrations of tear MUC5AC expres-
sion compared to the short (9.6 ng/mg) groups, with significance
between the long and short groups.28 This study shows that
beyond tear and eyelid parameters, VDT use may also effect
the health of goblet cells, with decreased mucin production on the
ocular surface.
Pathophysiology and Mechanisms of Damage
Several common mechanisms have emerged as central
causes of ocular surface damage and DE in VDT users, including
decreased blink rate,3 MGD,27 and corneal phototoxicity.29 It is
important to note, however, that the pathophysiology of screen-
associated ocular damage is multifactorial and may vary among
device type and patterns of use.22,30,31
VDT Users Have Abnormalities in Blink Rate
VDT use can affect blink rate. Specifically, a reduced mean
blink rate and incomplete blink motions have been observed
during computer use.3,32,33 In a study of 104 healthy office
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Digital Screen Use and Dry Eye
workers in Japan (age range 20–69 years), mean blink rate and
palpebral fissure widths were measured in participants in 3
conditions: during VDT work, while reading a book at table
level, and while relaxed. Blinking frequency was significantly
decreased during VDT work (7  7 blinks per minute) as com-
pared to reading (10  6; P ¼ 0.001) and relaxed conditions
(22  9; P < 0.0001). Interestingly, ocular surface exposure, as
determined by palpebral fissure width, was similar during VDT
work (2.3 cm2) and in relaxed conditions (2.2 cm2), and decreased
during reading (1.2 cm2).33 Given that ocular surface area expo-
sure is directly proportional to increased tear evaporation,34 an
increased area of exposure coupled with reduced blink frequency
is proposed to contribute to reduced tear film viability in VDT
users and may also explain why VDT use is more problematic
than reading.
VDT users also more frequently exhibit incomplete blinks. In
a study of 50 healthy individuals in Spain, participants were asked
to read on a computer screen and book. Measurements of incom-
plete blinks (defined as any visibility of the cornea on blink
completion) were recorded using video analysis. In contrast to the
study above,33 spontaneous blink rates were similar between the 2
tasks. However, incomplete blink frequency was higher during
VDT reading (median 13.5%) compared to book reading (median
5%).35 As some studies have found a correlation between incom-
plete blinks and inferior corneal staining,36,37 incomplete blinks
are one possible explanation for the noted associations between
VDT use and DE signs.
Reductions in blink frequency and blink amplitude have also
been associated with DE symptoms in VDT users.3 In a study of
21 healthy subjects in New York (age range 21–29 years), blink
frequency was measured during a 15-minute computer task, and
each blink was evaluated for completeness (no part of the cornea
being visible during the blink). A 10-item questionnaire (each
symptom ranked from 0–10, total range 0–100) was administered
at baseline and immediately after the computer session (reading
complex stories taken from the internet) to evaluate DE symp-
toms. Overall, the mean DE symptom score after the computer
task was 14.4. The mean blink rate during the task was 11.6 blinks
per minute, which correlated negatively with the total symptom
score. A mean of 16.1% blinks were incomplete, which correlated
positively with total symptom score.3 Similar to DE signs, this
study suggests that decreased blink rate and incomplete blinks are
one possible explanation for the noted associations between VDT
use and DE symptoms.
Increased task cognitive demand has also been linked to a
decreased blink rate.38,39 In a US study of 16 individuals with DE
(defined by diagnostic codes) and 16 controls, blink frequency
was evaluated during a “high cognitive demand task” (reading a
series of random letters and pressing the “space bar” when a
particular letter appeared) and a “low cognitive demand task”
(watching a movie). The blink rate was lower during the high
versus low cognitive task in both the DE (9  5 blinks per minute
vs 21  13) and control (9  5 blinks per minute vs 14  11)
groups38; however, the difference was only significant in the DE
group. This study identifies task difficulty in contributing to VDT-
associated blink rate, particularly in individuals with DE.
The above studies suggest that inadequate blinking plays an
important role in the loss of tear film homeostasis during VDT
use, and that the effects are more exacerbated in individuals with
preexisting abnormalities.
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Blue Light and Corneal Toxicity
Toxicity from blue light may be another contributor to DE
symptoms and signs in VDT users. Light emitting diode (LED)
screens have become the predominant technology used in back-
lighted displays, including smartphones, tablets, computer mon-
itors, and television sets. The peak emission wavelength of these
“white-light LEDs” falls between 400 and 490 nm (Fig. 1), which
manifests as blue light and includes the “high-energy visible”
light range (400–450 nm).40 Although more studies have exam-
ined the pathogenic effects of blue light (410–480 nm) on retinal
and circadian cycle dysregulation, some studies have examined
this question with regards to the cornea.29
Blue light can cause reactive oxygen species (ROS) forma-
tion and oxidative damage in corneal cells. In an in vitro study of
human corneal epithelial, light-emitting diodes of varying wave-
lengths (410, 480, 525, 580, 595, 630, and 850 nm) and doses (1,
2.5, 5, 10, 25, 50, and 100 J/cm2) were used to irradiate human
corneal epithelial cells, and cell viability and ROS formation (ie,
superoxide anion, hydrogen peroxide, and hydroxyl radicals)
were evaluated. Cell viability was measured as a percentage
using a colorimetric enzyme-linked immunosorbent assay.
ROS production at each LED wavelength (dose of 5 J/cm2)
was analyzed as fluorescence intensity on flow cytometry com-
pared to baseline fluorescence. Among the LED wavelengths,
only 480 nm and 410 nm wavelengths were associated with
decreased cell viability. Specifically, viability decreased in a
dose-dependent manner after 480 nm irradiation at 50 J/cm2
(60% viability at 100 J/cm2) and after 410 nm at 10 J/cm2
(10% viability at 100 J/cm2). In a similar manner, ROS produc-
tion was higher at 410 nm (363.5  3.8) and 480 nm
(454.1  10.3); no significant increases in fluorescence intensities
were found after irradiation with all other LED wavelengths.
These data show that specific wavelengths of light in the blue
spectrum (410 nm, 480 nm) are associated with corneal damage in
vitro. Furthermore, given that reactive oxygen species disrupt
DNA, protein, and lipid function at the cellular level, these data
propose oxidative stress as a mechanism for blue light-associated
ocular surface injury.29 In another study, blue wavelengths of light
were shown to damage actively mitotic corneal epithelial cells in
animal models41 in a dose-dependent manner.
A limitation of the above studies is that unlike blink dynam-
ics, no studies have demonstrated a negative effect of blue light on
corneal epithelial cells in vivo in humans. In fact, blue light-
blocking tinted glasses and “night shift” modes on VDTs have
been developed based on the available data, but there is limited
evidence supporting their clinical use for VDT-associated
DE.42,43 As such, more studies evaluating phenotypic corneal
changes in humans exposed to blue light are warranted.
VDT Use Is Associated With Ocular Surface Inflammation
and Mucin Changes
Various cytokines and chemokines, neuropeptides, and neu-
rotrophins [ie, nerve growth factor (NGF)] play a role in the
protection and viability of the ocular surface. In 1 study, cytokine
levels between 7 individuals with clinically diagnosed DE and 7
healthy controls were compared, with significantly elevated levels
of proinflammatory cytokines [eg, interleukin (IL)-1b, IL-6, IL-
10, interferon-g, and tumor necrosis factor-a, among others] in
the DE versus control tear samples.44,45 DE symptoms specifi-
cally in VDT users have also been associated with ocular surface
inflammation, including increased expression of inducible nitric
oxide synthase (iNOS, a proinflammatory and neurotoxic cyto-
kine).46–48 Given the function of iNOS in synthesizing toxic
radical nitric oxide, this demonstrates the presence of oxidative
and inflammatory ocular surface damage in VDT users.
Nerve growth factor can counteract some of these abnormal-
ities given its pleotropic functions which include regenerating
peripheral nerves and increasing corneal sensitivity, promoting
conjunctival goblet cell density and mucin production, and aug-
menting tear production.49,50 Several studies have found
increased ocular surface NGF levels in individuals with DE,51
likely due to a compensatory response to inflammation and
corneal nerve damage.50 Novel studies have even explored a
possible role for human recombinant NGF in the treatment of
DE.52 In a study of 120 VDT users in Italy, individuals with severe
symptoms expressed increased ocular NGF levels compared to

FIGURE 1. High-energy visible blue light damages the corneal epithelium. Typical industry light emitting diode display screens exhibit a peak light
emission amplitude between 400 and 490 nm wavelengths. This range includes high energy visible (HEV) light from 400 to 450 nm. Several in vitro
models have identified HEV light as a pathogenic contributor to corneal damage, including increased levels of local reactive oxygen species
(superoxide anion, hydrogen peroxide, and hydroxyl radicals), decreased cell viability, and decreased mitotic activity.

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Asia-Pacific Journal of Ophthalmology  Volume 9, Number 6, November/December 2020 Digital Screen Use and Dry Eye

those with moderate symptoms, although not compared to mild or
no symptoms.47 Thus, DE symptom severity relates to local NGF
changes in VDT users, although the relationship may be nonlinear
and dependent on compensatory mechanisms as demonstrated in
other disease states.53,54
Prevention and Treatment of Screen-Associated DE
DE symptoms are a significant component of CVS. As such,
the identification and management of DE is a necessary measure
in minimizing the negative consequences of CVS. Multiple treat-
ments for VDT-associated DE have been advocated, particularly
lifestyle adaptations (Fig. 2). Any approach plan must be individ-
ualized to the patient and practical for their work environment.
Treating the Underlying Components of DE to Prevent
Compound Damage
The treatment of DE begins with artificial tears (AT) of
various composition and viscosity.55 Individuals are advised to
apply a lubricant eye drop periodically throughout the day if they
experience ocular surface discomfort associated with VDT use.
Although effective in combating signs and symptoms of DE, a
study of 20 volunteers in Spain showed that topical lubricants may
not prevent decreases in VDT-associated blink rate.56 This sup-
ports a central neural mechanism for VDT-associated reduction in
blink rate, influenced by such factors as the difficulty required to
complete the task,57 that may persist after treatment with AT.
Beyond AT, given associations between VDT use, inflam-
mation, and MGD, anti-inflammatories (eg, topical cyclosporine)
and lid therapies (eg, antibiotics and intense pulse light therapy)
can also be considered in appropriate individuals.27 The purpose
of these interventions is to decrease the severity of preexisting DE
and minimize factors contributing to VDT-associated ocular
discomfort. However, more work needs to be done to demonstrate
that therapies often used to treat DE have an effect on VDT-
associated DE.
Improving VDT Device Position
With a goal of reducing asthenopia and symptoms of ocular
discomfort while optimizing comfort, studies have determined a
preferred VDT viewing distance of 90 cm and slight downward
gaze of 10 degree with some personal variations.58,59 In a study of
38 healthy VDT users in Germany, subjective ocular comfort and
symptoms were evaluated at differing screen positions (varying
distances and angles). An analysis of subjects’ preferred screen
positioning, representing the most comfortable individual screen
position, resulted in a mean distance of 90.1  8.9 cm and gaze
declination of 11.3  3.4 degrees. Overall, this study identified
that a VDT distance of 90 cm and downward gaze angle of 108
were associated with the lowest ocular discomfort scores and the
highest favorability.59 Although other studies have corroborated
these findings,58,60 it is important to note that interpersonal
variability is expected. Users are encouraged to evaluate various
working distances and inclinations to see whether this can reduce
ocular discomfort symptoms.
Limiting Screen Time and Blink Modifications
With increasing evidence of the deleterious effect of contin-
uous VDT usage, the obvious solution, although often impracti-
cal, would be to limit prolonged screen time. The American
Academy of Ophthalmology and American Optometric Associa-
tion thus make such recommendations as resting from computer
work for 15 minutes for every 2 hours of use, and the “20–20-20
Rule” (after every 20 minutes of computer viewing, refocus on an
object over 20 feet away for 20 seconds).61,62
Blinking exercises have shown modest efficacy in reducing
DE symptoms and signs. In a study of 41 individuals with signifi-
cant DE symptoms, as identified by questionnaires, participants
were instructed to follow a blinking exercise protocol every 20
minutes during waking hours for a 4-week period. The exercise
consisted of gently closing eyes for 2 seconds, opening eyes, again
gently closing eyes for 2 seconds, followed by squeezing eyes
closed for 2 seconds. The average number of daily blinking exercise
cycles completed over the 4-week period was 25.6  17.7. After the
4-week period, significant reductions were found compared to
baseline in symptom questionnaires (Dry Eye Questionnaire-5:
11  4 to 7  3, and OSDI: 36  18 to 22  17) and TBUT
(6.5  2.4 to 8.1  4.8 seconds). This study shows a mild alleviating
effect of routine blinking exercises on DE symptoms and signs.63

FIGURE 2. Lifestyle modifications to prevent screen-associated dry eye. This simplified image depicts the appropriate viewing distance (90 cm or
35 inches) and downward gaze angle (108) correlated with improved subjective comfort and dry eye parameters. A desktop humidifier and
blinking exercises (gently closing eyes for 2 seconds, opening eyes, again gently closing eyes for 2 seconds, followed by squeezing eyes closed for 2
seconds) are further measures evidenced to prevent screen-associated ocular damage.

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Mehra and Galor
Given the impact of blink changes on VDT-associated DE, blinking
exercises may be incorporated into clinical care recommendations
as a protective or therapeutic measure.
Optimizing Workplace Humidity
Given the long hours spent by VDT users in an occupational
or home setting, the indoor environment may play a role in
development of DE. Alterations in humidity have been associated
with DE, particularly in the indoor setting.6,64 Both low and high
humidity have been associated with DE, likely due to low
humidity causing tear evaporation and thinning of the tear
film,64,65 and high humidity environments favoring the survival,
transmission, and growth of microorganisms.64,66 Optimal rec-
ommended humidity ranges from 40% to 55%, primarily due to
effects on upper airway health and respiratory function.64,67
Using a humidifier has been found to modestly alleviate DE
signs and symptoms in VDT users, and may be particularly useful
in workplaces with low relative humidity.68,69 In a study of 44
young VDT users in New Zealand, individuals were asked to
complete a 1-hour computer task without a humidifier and again
with a USB-powered desktop humidifier.69 As compared to
completing the computer task without humidifier, humidifier
use resulted in greater ocular comfort scores and a higher TBUT,
with no changes in tear-film lipid layer grading or TMH measure-
ments. Thus, a desktop humidifier may be beneficial in the
prevention of VDT-associated ocular damage.
CONCLUSIONS
VDT use has been associated with a number of DE symptoms
and signs, most notably tear film instability. This instability may
be driven by blink abnormalities, Meibomian gland and goblet
cell dysfunction, corneal effects of the peak emission wavelength
in modern LEDs, and ocular surface exposure. Individuals with
preexisting ocular surface abnormalities seem to be more suscep-
tible to VDT-associated DE. As such, we stress the management
of underlying contributors to ocular surface dysfunction and
modifiable DE parameters for preventing development and pro-
gression of VDT-associated DE. Optimizing VDT positioning,
lifestyle modifications, blinking exercises, and workstation
humidifiers serve as further ancillary treatments.
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