In this day and age of extremely conscientious and even helicopter parenting, it is shocking that many parents allow children to use telephones, tablets, and computers; often, without imposing time restrictions. According to the American Optometric Association’s (AOA) 2015 American Eye-Q® survey, 41% of parents say their kids spend 3+ hours per day using digital devices, and 66 % of kids have their own smartphone or tablet. It is estimated that 25 % of children between the ages of 2 and 5 have a smartphone. Children spend an average of 3+ hours sedentary and staring at a screen that illuminates artificial light, instead of playing outdoors or with their toys.
Dr. Stephen Cohen, one of the national leaders in the diagnosis and treatment of dry eye and a member of the TFOS DEWS II Public Awareness & Education Subcommittee, spoke to me about the catch-22 of technology. “We should be careful of what we wish for,” he claims, “Because our advances in technology have led to incredible access to information while simultaneously forcing a more sedentary lifestyle that results in a number of health repercussions: increases in obesity, ADD, diabetes, and dry eye, just to name a few.” He continued to explain that, more specifically to sight, humans aren’t designed to stare at a screen all day; if that were the case we would have one eyeball in the middle of our head since we don’t use our peripheral vision the way we did in the past.
Related, is the pernicious issue of artificial light. Richard Stevens, a cancer epidemiologist, first wrote in 1996, that evidence linking artificial light exposure to poor health was “sparse but provocative.” Over time, other researchers have joined him to produce a fast-growing body of research linking artificial light exposure to disruptions in circadian rhythms, the light-triggered releases of hormones that regulate bodily function. In turn, circadian disruption has been linked to a host of health problems, from cancer to diabetes, obesity and depression, in children as well as in adults. When parents read that artificial light can provoke obesity or cancer, they are most likely to panic. Why don’t they have the same reaction when hearing that artificial light can trigger dry eye?
Humans, particularly parents, tend to see things in absolutes. Something is either hot or cold, far or near, and good or bad. However, in terms of mobile device use, parents are confused as to the long-term effects usage might have on their children: many parents consider mobile devices to be akin to a portable-babysitter-teacher-and-friend whereas other parents find them to be atrocious-addictive-malicious-beeping-evil chunks of metal. The reason for parents’ confusion is that research is both limited and often conflictive. For example, whereas a study by S.R.I. International found that game-based play could raise cognitive learning for students by as much as 12 % and improve hand-eye coordination, problem-solving ability and memory, whereas researchers at Boston University published comments in Pediatric magazine arguing that using a tablet or smartphone to divert a child’s attention could be detrimental to their social-emotional development.
Dr. Cohen argues parents might be less reactive because there is not yet wide awareness about dry eye, especially not with respect to children. He has found that, even though the condition is considerably more rare in children, dry eye may be both under-diagnosed and undertreated in children and in fact, there has been a huge recent uptick in dry eye diagnosis for children. He parallels the fairly blasé attitude associated with mobile device use to that society once had with respect to sun exposure: remember seeing people in the 1970s lathered in vegetable oil frying themselves in the sun, whereas in 2016, you would be shocked to know that someone is walking along the street without sunscreen, let alone tanning on the beach.
Just as in adults, dry eye in children can be irritating and painful and, can affect vision. Fluctuations in vision is fairly common and an often missed symptom of dry eyes. These symptoms can have a particularly strong impact on children’s lives by making it more difficult for them to perform at school.
The first step in reducing the impact of dry eye in children is developing a greater awareness of the condition and its possible causes. For example, one pro-active response would be to limit a child’s use of mobile devices, compelling children to shift to more manual activities. Playing with building blocks may help a toddler more with early math skills than interactive electronic gadgets, since devices often replace the hands-on activities important for the development of sensor-motor and visual-motor skills, which is imperative for the learning and application of math and science. How can we ask our children to develop their small motor skills before they have developed their gross motor skills? Second, if we limit children’s screen time, they will blink more and lessen the chance for dry eye to develop: when children are looking at the screen, their eyes are open wider and as a result, more surface area is open to the eye, not only making the eye more vulnerable to environmental factors but also resulting in blinking half as much. It is the blinking process that recoats the eyes with new tears about 6-8 times per minute.
Dr. Cohen deems this constant battle with children not a “war on attrition” but a battle that needs to be fought. In addition to being more aware and limiting access, he strongly encourages parents to step away from a constant and focus on getting their children tested more thoroughly and more frequently. However, diagnosing dry eye in children is not as straightforward as it is in adults for several reasons: first, children are simply challenging to examine because they struggle to express their symptoms, and second, the Schirmer and other tests do not work because children instinctively rub or scratch their eye during the process, and lastly, because eye care professionals and parents typically think of dry eye disease as an adult condition.
Going forward, Dr. Cohen hopes that doctors can overcome diagnostic and management challenges in young patients. He is positive that TFOS DEWS II will have even further positive impact helpful in further developing industry protocol and guidelines.
Dr. Cohen believes there are particular points we can follow when dealing with ocular disease globally and dry eye specifically. First, define dry eye as a big thing rather than just as a mild problem or nuisance so that we can predict its development process and adjust our lifestyle or those of our children. Second, paying attention now to symptoms will reap enormous benefits later. And third, Dr. Cohen believes the “introduction of technology is a shining example of the law of unintended consequences because while the advent of technology is amazing, there are a number of unanticipated issues and challenges associated with technology.”
He leaves us with two powerful quotes to consider: changes in lifestyle don’t come without price tags, and vision doesn’t just happen by divine inspiration so we need to protect it.
TFOS Staff Writer