Dr. Fiza Tariq, acting coordinator of Primary Eye Care/Ocular Disease residencies and assistant professor of the Pennsylvania College of Optometry at Drexel University, shares how how increasing screen usage is affecting children's vision from myopia to digital eye strain and what families can do about it.
I almost think we're living in this post-COVID era. And during COVID, because everything went virtual at the time and school had to be done at home since then, we're still living in this hybrid model where we realize a lot of things that we could do at home. Children's homework could be done online, people could do work from home. And since then, we're still going through the after effects of having things be virtual. Over the last five to six years, we've had a much more increased screen time or screen use.
Sometimes morning appointments are challenging for children. They're coming in and they're very sleepy and they're tired. And especially during the summertime when they don't have a regular school routine. What happens is a lot of times these children have unsupervised screen time, especially at night and they're scrolling. I had one of my colleagues tell me a parent went in to wake up the child at 5 a.m. and the child was still up. They had just been using screen time and playing video games all night. Apart from that, children are coming in complaining that when they're looking far away or a distance, things are blurry. And so you would expect that they have a prescription. And when you complete a full eye exam, they don't have a prescription.
So part of the reason they're blurry is because they're looking at things up close and over-focused for so long and it's causing them to almost have a fake prescription or be truly blurry far away. Those are kind of two things we're seeing.
Absolutely. The closer you hold a screen, the closer your eyes are working more, in essence. Your focusing system, your accommodative system, it's in overdrive. And the closer you bring it and the longer period you do it for, it can be more eye straining. Whether or not it truly leads to myopia or needing a glasses prescription, because myopia is so multifactorial, it's difficult to say for sure at this time, but there's absolutely a correlation between the two.
Myopia is nearsightedness. It means that things far away are blurry or hard to see. For adults, you would notice it when you're driving and you're trying to look at signs, especially at nighttime and that would be difficult. For children, it's mostly when they're looking at the chalkboard at school or watching TV. Those screens, those are going to be a little bit more difficult to see for a person who has myopia and they do not have the appropriate glasses prescription.
The other big thing is when you're looking at screens or looking at something up close, your blinking rate significantly decreases. So, when you're keeping your eyes open for long periods of time, it's also causing your eyes to feel dry or gritty. And you're also causing excessive tearing. It can also cause headaches or eye strains. A lot of up-close work is causing a lot more side effects than just your prescription changes. It can cause them a lot more symptoms.
There's been so much meta analysis and so much research done trying to figure out what exactly is the reason when you're outside. It not only stops the progression of myopia, but also the initial development of myopia, which is truly what we're trying to accomplish, just to not have any nearsightedness.
There's a couple of reasons. One is the amount of light that's out there, just higher amounts of light can be protective. It can stop your eye length from growing too quickly. It's not that it stops growing, but from growing too quickly. Also, something called peripheral defocus, which is present when you're doing screen time or up close work, but it's not present when you're outside.
Another thing is your circadian rhythm is much more your melatonin, which is suppressed when you see light when you're outside. And when you come in, your melatonin is increasing and it helps your circadian rhythm so children have a regular sleep schedule, which is so important. And screen time disrupts that.
And last but not least, when you're outside, you're not inside, you're not using screens. So, the reason you're encouraged being outside is because inadvertently you're also stopping near work or screen time use. As for the actual science behind it, there's so many theorized reasons. We don't know exactly what the protective factor is, but there's been a strong correlation with children who are outside and outdoor use and the decrease not only of the progression of myopia, but also the initial starting of myopia, which is what we're trying to stop in the first place.
If they need glasses and they need them to see, of course we give them the glasses. But the big thing is how quick the change is. There's so many multifactorial factors to cause myopia. If both your parents wear glasses for distance, the likelihood of you needing glasses for distance is high. However, in those cases, the big thing we're seeing is how quickly year by year you're changing. There's an expected change in myopia as children grow, their prescription changes. But if it's too quick or too fast, that's when we want to intervene and we want to intervene as early as we can.
I'm definitely biased being an eye doctor because they'll come see us at least once a year. But it depends on age. The babies, get pediatrician screenings and they are adequate. We're looking for large things, large eye turns, make sure there's not large prescriptions. So that happens early, but then we check at the age of three. But before they start school, we really recommend they have an eye exam, make sure they have all the tools they need to be able to be successful in their first year of the classroom. And then yearly after that, we want to see them at least once a year and just make sure there's no big changes in their prescription. Make sure everything is stable and healthy.
A lot of times patients come in with symptoms of some gritty feeling. They feel like there's some things inside the eye, but there's actually nothing there. We have a natural lubrication system. We have an oil layer, a water layer, and like a mucus layer, those three layers. And basically in dry eyes, one of those layers is disrupted.
Dry eye can be caused by many reasons. But if your oil layer is not there, your water layer is evaporating too quickly. If your water layer is not being produced, the oil layer is protective, but there's not enough water to protect it in the first place and provide that lubrication. The dry eye is basically that the natural lubrication of the eye isn't there. And there could be for many reasons for that.
That's where when you're blinking, you're looking at something up closer because your blink rate is decreasing, your eyes are open for a longer period of time, and their natural lubrication isn't meant to last for as long as with fewer blinks. If you're outside day-to-day, you're about 20 to 25 blinks per minute versus when you're focusing on something up close in screen time, you're about seven to nine blinks. So less than half. That can have a significant impact and your eyes feeling dry.
With video games, it's really important to ask the distance of how far something is. But TV and even video games, they're a little bit of a farther distance away. That’s so impactful, especially if you're doing it for multiple hours in a day. But more important is how close the closer screens, the iPads, the mobile phones, the tablets, the screen time that's closer and your entire eye and your side vision is exposed to that amount of light. Those tend to be a little bit worse for the child. And not only are their eyes feeling dry, but they're also using their focusing system. So they can feel symptoms a lot more quicker than at distance.
We have two eyes and the challenging part is both those eyes have to point in the same direction to make sure we look at an image. That image shouldn't be double, that image shouldn't be blurry, that image shouldn't be jumping around. And our brain actually does a lot of work to make sure our eyes are pointing in the same direction. That's where eye teaming comes in.
For eye teaming skills, one of the most common ones is they're going to end up seeing double because their eyes are now misaligned. So instead of seeing a single image, they're seeing two separate images. So that's why a lot of times they'll see double, maybe even shadowing they might say.
Another one is headaches. Now children, you have to dive into it a little bit. Sometimes they might not complain, but if they're holding their head down or if they're avoiding schoolwork, there can be so many reasons. I always say children compensate, they don't complain. So they're going to modify their behavior instead of outright complaining. If a child is getting a headache, one thing they might do is avoid doing the schoolwork or avoid doing the reading or be unable to do it for a long period of time. Got it. Another one is eye strain that is common as well.
There's so much recognition of dry eyes being a very debilitative disease, especially in adults, but it's present in children as well. There's a lot of interventions now than there were previously. More palliative care, you can have over-the-counter eye drops, you can use cool compresses. It's just a cold washcloth over the eyes. You can use a mask over the counter as well. And if over-the-counter medication or palliative care isn't there, there's also prescription medication. There's also fish oil, omega-3. Those also help improve the oil production in our eyelids. Eat your eggs if you like them. Omega-3s naturally also help as well. So all these things, there's a lot of intervention for dry eyes. Now we can use contact lenses to help with dry eyes, keep a reservoir of fresh tears.
And then for eye teaming and eye focusing skills, there's something called vision therapy or eye therapy. I call it gym for the eyes. It's 45 minutes of intense workout, but it's simply for the eyes. It's PT, it's OT. But kids come in and afterwards their symptoms are improving, the more therapy sessions they do, and by the end of it, their symptoms can definitely be improved.
Under the age of one, we don't recommend any screen time. Especially because your development system is so early. You want them to be exposed to natural colors, natural lighting, faces of people and recognized faces. So that point and when you're too young, no screen time.
Of course, by the time you're six and after you're in school, it's been difficult to do no screen time, but you almost can break down screen time into recreation or entertainment screen time versus school. And so the recreation entertainment should be two hours or less than that for even six to afterwards. Again, with teenagers, we recognize that they would need more school time, screen time.
And that of course, as long as it's supervised and it's not entertainment for a long period of time, those can be what they need to be. But entertainment or recreation should be around two hours a day at the most.
If I could tell parents one thing that they can implement today: no screen time an hour before bed. And so I almost want to change that and say that you should spend that time reading a book with the child.
In addition to the reading part, it's a time to bond with the child. And one of the things that happens during that time is your melatonin kicks in and they naturally can fall asleep. So use that time, especially the hour before bedtime. Close the day, read to them, recap with them, and then also just have conscious bonding time with the child as well. And that naturally will take away that screen time. And then you have a fresh start to the next day.