Dry eyes, digital devices and myopia – Q&A with Professor James Wolffsohn

Digital devices have become an integral part of everyday life. With this increasing reliance on screens has come greater attention to their potential effects on ocular comfort and visual function. Understanding the evidence behind these associations is therefore becoming increasingly relevant to everyday clinical practice.

Professor James Wolffsohn (pictured above left) is a past Director of the Tear Film & Ocular Surface Society (TFOS), and has recently become a Professor of Optometry at the University of Waterloo in Canada. In this Q&A, he discusses the TFOS definition of digital eye strain, how digital device use affects the ocular surface and vision, what we know about its relationship with myopia, and how contact lens wear may influence symptoms. 

James Wolffsohn: Tasks involving the use of digital devices often cause ocular discomfort and can reduce productivity and quality of life. While there are lots of different terms that have been used to describe the impact of digital screens on the eyes, such as “computer vision syndrome” and “ocular fatigue”, there was a consensus that “digital eye strain” was a more universal and understandable terminology. TFOS defined ‘digital eye strain’ as "the development or exacerbation of recurrent ocular symptoms and/or signs related specifically to digital device screen viewing".¹ Unfortunately, current digital eye strain symptom surveys are relatively long and do not differentiate symptoms specifically relating from digital device interaction. While signs can also occur, such as poor tear film stability, decreased blink rate and a change in critical flicker fusion frequency (noticing backlight screen flickering), these are not consistent enough to form part of the diagnosis.

A definition of any condition is essential as it is the basis that a diagnostic algorithm must fulfill, and forms a clear treatment target to assess whether management options are effective or not. 

James Wolffsohn: Digital device use has changed dramatically over time, transforming the way people communicate, work, learn and entertain themselves. In the past, digital devices were limited to desktop computers, which were mainly used in workplaces, schools and universities. Access to the internet was relatively slow and often restricted to specific locations. Mobile phones were primarily designed for making calls and sending text messages, with limited additional functions.

The development of smartphones in the late 2000s marked a major shift in digital device use. Modern smartphones combine communication, internet access, photography, navigation and entertainment in a single portable device. As wireless networks improved and became more widely available, people gained constant access to online information and services. Tablets, laptops, smart watches and other connected devices further expanded the digital ecosystem.

Today, digital devices are integrated into almost every aspect of daily life. Cloud computing allows users to access files and services from multiple devices, while artificial intelligence is increasingly incorporated into digital tools to provide personalised assistance.

Overall, digital device use has evolved from occasional and location-dependent computer access to continuous, mobile connectivity. This transformation has increased convenience and productivity, although it has also raised concerns about screen time, privacy and digital wellbeing.

James Wolffsohn: Digital device use affects the ocular surface and vision through several interconnected mechanisms. 

Under normal conditions, blinking spreads the tear film evenly across the eye, maintaining lubrication and optical quality, but also has a role in expressing the meibomian glands. Hence, reduced blinking leads to increased tear evaporation, tear film instability and symptoms of eye dryness such as irritation, burning, and fluctuating vision.²

Another mechanism involves prolonged visual concentration at near distances. Sustained accommodation and convergence can place stress on the visual system. These symptoms can be reported as eye fatigue, headaches, blurred vision and difficulty refocusing between near and distant objects. Environmental factors associated with device use also contribute to ocular surface problems. Individuals often use screens in air-conditioned or heated environments, which can lower humidity and accelerate tear evaporation.³ 

Blue light emitted from screens has received considerable attention, although current evidence suggests that its direct effect on ocular surface health is limited. However, excessive evening exposure may disrupt circadian rhythms and sleep quality, indirectly affecting ocular comfort and visual function. ⁴ 

James Wolffsohn: There is growing evidence that digital device use is associated with the development and progression of myopia in children and adolescents. However, the relationship is complex and involves several interacting factors rather than screen use alone. 

One of the primary concerns is the increase in near-work activities associated with digital devices. Prolonged viewing of smartphones, tablets and computers requires sustained accommodation and convergence, which have been proposed as potential stimuli for eye growth and myopia development. Digital devices may also encourage shorter viewing distances than traditional reading materials, increasing visual demand. However, digital device use and other near activities generally occur in indoor environments, and numerous studies have demonstrated that time outdoors is protective against myopia, making this a confounding variable. Exposure to brighter outdoor light stimulates retinal dopamine release, which appears to inhibit excessive axial elongation of the eye. During periods of lockdown during the COVID-19 pandemic, many children experienced increased screen time, remote learning and reduced outdoor exposure, coinciding with reports of accelerated myopia progression in some populations. 

Although digital device use is frequently linked to myopia, current evidence suggests that it is best viewed as part of a broader lifestyle pattern involving intensive near work and insufficient outdoor time.⁵ 

James Wolffsohn: Increased digital device use generally refers to spending prolonged periods engaging with smartphones, tablets, computers, e-readers and other screens for work, education, communication or entertainment. As digital technologies have become integrated into everyday life, most individuals now spend multiple hours each day viewing screens at near distances. This increase has important implications for ocular comfort, tear film stability and visual performance.

As a contact lens is greater than ten times the thickness of the tear film, its application to the ocular surface will disrupt the natural tear flow, which can cause contact lens discomfort, particularly in those individuals who already have signs of ocular surface disease. The reduced blink frequency and increased rate of incomplete blinking associated with digital screen use can make the already thinned tear film of the contact lens surface unstable, leading to friction with the eyelids and desiccation stress from greater tear evaporation. These changes can result in symptoms, in particular end of day discomfort, which in turn can lead to drop-out from contact lens wear and loss of all the benefits they offer. Despite these challenges, advances in contact lens materials and surface technologies have improved comfort during digital device use and so careful selection of contact lenses, particularly for those with existing ocular surface disease or an intense digital lifestyle, is warranted.⁶

James Wolffsohn: As part of the TFOS Lifestyle report on digital eye strain, a systematic review was conducted on the question “Which ocular surface disease management approaches reduce symptoms associated with digital device use?” This established that in general, interventions for digital eye strain are not well established. It advised that patients experiencing digital eye strain should be provided with a full refractive correction for the appropriate working distances and any binocular vision anomalies should be addressed. Improving blinking through blink exercises, optimizing the work environment through a workstation assessment and encouraging regular breaks such as with a reminder app may help. Current evidence suggests that blue-light blocking interventions and specific progressive addition ‘computer’ spectacles are not an effective management strategy and that many antioxidant supplements are not beneficial, despite marketing hype. There is evidence that the intake of omega-3 fatty acid supplementation and berry extracts can reduce the symptoms of digital eye strain. Regular rest breaks should be considered (such as the 20:20:20 rule) along with installing a humidifier to condition the environment surrounding the screen.