How digital device usage is affecting youth
The time we are spending on digital devices is on the rise, and it’s unlikely to slow down any time soon. With more and more apps, games, and social media options, we have all become more dependent on smartphones, tablets, and other electronic devices.
The time we are spending on digital devices is on the rise, and it’s unlikely to slow down any time soon. With more and more apps, games, and social media options, we have all become more dependent on smartphones, tablets, and other electronic devices.
This increased time is trickling down to children and teens as well. American teens use nine hours of media per day, in addition to time spent on homework and schoolwork.1 A 2014 study (n=288) showed that increased time on smartphones was significant for dry eye disease; however, interestingly, time spent watching television and using computers were not factors.2
Meibomian gland dysfunction (MGD) and dry eye disease (DED) are thought to primarily affect the older population. However, data shows that digital device use is an important dry eye disease risk factor in children.2
Previously from Dr. Schachter: Demodex update: 4 things you need to know
Devices and blink rate
Blink quality and quantity suffer when focused on near tasks. When blink rates decline, problems ensue.
The tear film will likely begin to break up prior to the blink response. This lack of protection from the tear film leaves the surface of the eye vulnerable, resulting in damage to cells of the cornea and conjunctiva and impaired functional visual acuity of dry eye patients.3 This damage leads to inflammation, causing goblet cell death, lacrimal gland inflammation, and MGD, which results in decreased tear quantity and poor quality.
With digital device usage increasing, long-term effects on the lacrimal unit of the eye need to be considered. MGD has been defined as “a chronic, diffuse abnormality of the meibomian glands, commonly characterized by terminal duct obstruction and/or qualitative/quantitative changes in the glandular secretion.”4 In addition, MGD “may result in alteration of the tear film, symptoms of eye irritation, clinically apparent inflammation, and ocular surface disease.”4
While the exact mechanism of MGD and dry eye is not known, there are some prevailing theories. Meibum from the meibomian glands is drawn out by the full force of a blink. With less blinking and partial blinking, the meibum stagnates.
Related: How digital devices are affecting vision
Think of it like an open tube of toothpaste that is not squeezed. The meibum begins to thicken, which causes obstruction. Blocked glands then atrophy and ultimately disappear completely.
In addition, the increased demand placed on the glands by evaporative stress (created by reduced blink rates while staring at devices) causes meibocyte proliferation, increased production of meibum, duct dilation, and then obstruction. Suhalim et al suggested that “continued exposure to desiccating stress may therefore potentially deplete meibocyte stem cells and lead to early aging changes and gland atrophy.”5
The classic MGD patient is a post-menopausal female; therefore, dry eye screenings in eyecare practices may to be skewed toward older women.
Children and dry eye
In my practice, we have been screening younger and younger people for ocular surface disease (OSD) over the last few years. We began because many of our younger patients spend so much time looking at devices and take medications with dry eye side effects, such as antihistamines, ADD/ADHD medications, birth control, and antidepressants. Many of our younger patients were complaining of contact lens intolerance and fatigue at the computer.
We screen with Standard Patient Evaluation of Eye Dryness (SPEED) surveys, tear volume (Zone Quick Phenol Red Thread test, Menicon), MMP-9 (InflammaDry, Rapid Pathogen Screening), osmolarity, and meibography (depending on findings). When we put this protocol in place, we started finding a great deal of dry eye and MGD in this younger group, and we are now screening all patients.
Screen your younger patients in the same way as your older patients with surveys, imaging, and gland expression.
Related: Parents underestimate time kids spend on electronic devices
Surveys
Use a survey such as SPEED. We prefer this survey to others because it’s brief, easy to interpret and score, and easy for patients to understand. Eight questions are scored.
Another common survey to use for dry eye screening is the Ocular Surface Disease Index (OSDI), which consists of 12 questions. It is more cumbersome to score than SPEED.
Related: Why you should offer children’s eyewear
Imaging
There are several ways to view the meibomian glands.
Transilluminating the glands is the simplest, fastest way to see them. This will allow you to view only the lower glands. Position the patient behind the slit lamp with the light off. Ask the patient to look up, then evert the lower lid with the transilluminator. The glands will be dark, and appear as tiger stripes.
Look for signs of incomplete glands, dilation, and tortuosity. The more you look, the more you will become familiar with what is normal. Grade them based on scales such as Pult, Arita, or Meiboscore.
Transillumination is the easiest method for younger patients because it is quick, easy, and performed during biomicroscopy. If you see gland loss, then consider imaging with an instrument.
Oculus Keratograph features a dry eye module, the Jenvis report, part of which can be used to image upper and lower glands. In addition, it can measure noninvasive tear film break-up time (TFBUT), conjunctival redness, tear meniscus, and lipid layer interferometry.
I have found that TearScience LipiView II images upper and lower glands more clearly than the Keratograph. It also measures blink rate, partial blinks, and lipid layer thickness.
TearScience LipiScan incorporates dynamic meibomian imaging (DMI) technology to produce high-definition images of meibomian glands. LipiScan allows eyecare practitioners to assess meibomian gland structure during routine workups in any practice setting; however, it does not measure blinks.
The newest player in the game, Meibox from Box Medical Solutions, is a versatile, portable, cloud-based meibographer that provides high-quality images with a small footprint. Its ease of use, mobility, and low cost make it an easy product to work toward the goal of “image everyone.” Like LipiScan, Meibox is a pure meibography unit.
Express glands
Glands can be diagnostically expressed manually or via TearScience Meibomian Gland Evaluator (MGE), a device that mimics the pressure of the blink.
Gentle therapeutic manual expression (one soft side, one hard side) can be done in-office. Heat up the lids with warm compresses for five to 10 minutes, then press on the glands. Use caution with pressure; glands may be damaged by vigorous pressure. A device such as the Mastrota paddle can aid in expression.
Look at the functionality of the glands and the viscosity of the oil that comes out. Oil will range in consistency from clear olive oil to cloudy toothpaste. The thinner the oil, the better.
Related: Examining pediatric eyes
Treatment
Treating meibomian dysfunction due to digital device overuse can range from changing patient habits to pharmaceutical therapy.
Takebreaks. Tell patients to look 20 feet away from devices every 20 minutes for 20 seconds.
Usewarmcompresses. For example, Bruder masks offer consistent heat and can be used for about seven minutes per day.
Thin the meibum. If the meibum is thickened, TearScience LipiFlow is the best option. Effects of this warming/compression device appear to last as long as three years in thinning out the oil.6
Keep the meibum moving. Recommend that your patients squeeze their eyes shut for about 10 seconds four times per day. This will keep the meibum moving, limiting stagnation.
Useanti-inflammatorieswhenappropriate. It is important to recognize that inflammation is usually present in MGD.7 Measure for tear film inflammation with InflammaDry. It measures MMP-9, which is a non-specific biomarker for inflammation, most closely associated with dry eye. Restasis (cyclosporine, Allergan) is FDA approved to treat dry eye caused by inflammation for patients age 16 and older. Recently approved Xiidra (lifitegrast, Shire), another anti-inflammatory medication for dry eye, is an option. Safety and efficacy in patients below the age of 17 have not been established.
Decrease desiccating stress. Artificial tears can increase TFBUT, which can protect against decreased blink rates while staring at devices. I recommend patients instill a non-preserved tear every two hours during periods of intense near work.
Consider nutraceuticals. The results of the ongoing Dry Eye Assessment and Management (DREAM) study will tell us more about the impact of fish oil on dry eye disease. In the meantime, gamma linoleic acid, or GLA, was shown to improve signs and symptoms in MGD patients.8
Related: Why patients are choosing eyecare apps over you
Patient education
Once you have made a diagnosis, counsel your patients. Treatment starts with education, and it will be the same for kids as adults.
Educate them by letting them know that they need to take frequent breaks from extended time on their electronic devices, playing video games, or just playing on their phone and social media.
Other suggestions:
• Teach them how to effectively blink.
• Ask them to set a reminder every hour to blink, close, squeeze, relax, and open.
• Recommend lid hygiene to keep the lids and lashes clean and decrease bacterial load and inflammation.
We use checklists explaining our recommendation, and put them in a folder for the patient. We have found this to improve compliance.
Meibomian gland dropout
A 22-year-old female graduate student presented to the clinic with complaints of decreased contact lens-wearing time, increased awareness, and blurry vision later in the day. She was wearing monthly silicone hydrogel lenses, usually from 8 a.m. until removal at 5 p.m. when lenses became uncomfortable. The symptoms had been worsening over the past year, and she was taking no medications.
The patient refracted to 20/20 in each eye with a low myopic correction. Her SPEED score was 11, Zone Quick phenol red thread test was 15 mm, MMP-9 was negative OU. TFBUT was five seconds in each eye. Fluorescein staining was negative, but there was moderate lissamine green staining nasally and temporally OU. Mild papillae were present on the upper tarsal plate OU.
Meibomian gland expression was difficult, and the meibum was mildly cloudy. Imaging with the K5 Keratograph (Oculus) revealed meibomian gland dropout and tortuosity. The meiboscore was one for all four lids, indicating gland dropout between one and 25 percent.
The following treatment plan was proposed:
• Education about the potential harm of excessive device use. Blink exercises and the need for periodic breaks were explained.
• Lipid-based artificial tears prescribed for four times per day.
• Refit patient into a daily disposable contact lens.
• Lipiflow administered to evacuate thickened meibum.
• Gamma linolenic acid (GLA) supplements were recommended.
Two months later, her SPEED score was seven, down from 11. Meibum expressed easily and was the consistency of olive oil. TFBUT was seven seconds OD, eight seconds OS. Comfortable contact lens wearing time was now 6 a.m. to 6 p.m. There was no fluorescein staining, and I saw mild lissamine green staining 360 degrees around the limbus.
She reported increased awareness of blinks and had been taking more breaks from electronic devices.
Related: Contact lenses can be a positive option for some kids
Take a closer look
It is important to screen and intervene early. Once glands have “dropped out,” they cannot recover. While anecdotal clinical evidence supports MGD trending among younger patients, more research is required to provide firm validation.
We owe it to our patients to be thorough in our assessment of their ocular health. Keep the potential impact of increasing digital device use in mind when evaluating younger patients.
References
1. Rosenfield M. Computer vision syndrome: a review of ocular causes and potential treatments. Ophthalmic and Physiol Opt. 2011 Sep;31(5):502-15.
2. Moon JH, Lee MY, Moon NJ. Association between video display terminal use and dry eye disease in school children. J Pediatr Ophthalmol Strabismus. 2014 Mar-Apr;51(2):87-92.
3. Baudouin C, Messmer EM, Aragona P, Geerling G, Akova YA, Benítez-del-Castillo J, Boboridis KG, Merayo-Lloves J, Rolando M, Labetoulle M. Revisiting the vicious circle of dry eye disease: a focus on the pathophysiology of meibomian gland dysfunction. Br J Ophthalmol. 2016 Mar;100(3):300-6.
4. Nichols KK. The international workshop of meibomian gland dysfunction: introduction. Invest Ophthalmol Vis Sci. 2011 Mar 30;52(4):1917-21
5. Suhalim JL, Parfitt GJ, Xie Y, De Paiva CS, Pflugfelder SC, Shah TN, Potma EO, Brown DJ, Jester JV. Effect of desiccating stress on mouse meibomian gland function. Ocul Surf. 2014 Jan;12(1):59-68.
6. Greiner JV. Long-Term (3-Year) Effects of a Single Thermal Pulsation System Treatment on Meibomian Gland Function and Dry Eye Symptoms. Eye Contact Lens. 2016 Mar;42(2):99-107.
7. Solomon A, Dursun D, Liu Z, Xie Y, Macri A, Pflugfelder SC. Pro- and anti-inflammatory forms of interleukin-1 in the tear fluid and conjunctiva of patients with dry-eye disease. Invest Ophthalmol Vis Sci. 2001 Sep;42(10):2283-92.
8. Sheppard JD, Pflugfelder SC, Sing R, McClellan AJ, Weikert MP, Scoper SV, Joly TJ, Lago DM, Whitley WO. Long-term Treatment with Nutritional Supplements Containing Gamma Linolenic Acid and Omega 3 Fatty acids Improve Moderate to Severe Keratoconjunctivitis Sicca. Invest Ophthalmol Vis Sci. 2012 Mar;53(14): 581-581.
