Since the COVID-19 pandemic lockdown measures, there has been a dramatic increase in applications of digital screen time particularly with children in their learning environments.
For example, in our clinical locations we are regularly hearing from parents of children in elementary school that their children are on digital devices about 5-8 hours a day. This translates to 35-40 hours per week or about the same amount of time spent by an adult in a full time job, but in this case it is elementary school children in front of a digital screen. These same children are coming into our clinics because they are experiencing visual-based symptoms. Some are showing increases in distance blur and refraction changes toward progressive myopia (nearsightedness).There is also another, seemingly greater set of children who are not having distance blur, but instead, near vision blur, headaches, eye strain and difficulty with visual efficiency issues involving binocular vision (eye teaming) and accommodation (focusing) and oculomotor (tracking) abilities. There is another smaller group that are manifesting more serious binocular disorders involving an acquired form of esotropia.
Those in the field of developmental and rehabilitation optometry recognize the genius of one of developmental optometry’s pioneers, Dr. A.M. Skeffington, who suggested that the “socially compulsive, near-centered visual tasks” common in an educationally oriented society triggers an autonomic stress response that can be clinically measured. This condition, defined as Nearpoint Visual Stress has been documented in multiple sources of the optometric literature as a response of the visual system to excessive near point demands resulting in a mismatch between binocular vision and accommodation. While these two components of visual efficiency function, binocular vision and accommodation should work together in harmony, when experiencing Nearpoint Visual Stress the result can be excessive binocular convergence in response to an apparent lag of accommodation (focussing) and vice versa.
This condition is discussed in excellent detail by another one of developmental optometry’s pioneers, Dr. Martin Birnbaum. In his seminal book entitled, Optometric Management of Nearpoint Vision Disorders, Birnbaum outlines the demands of extended near work, such as reading, requires concentration and attention which sets the stage for an autonomic “fight or flight” response of the visual system. This can lead to the following adaptations to Nearpoint Visual Stress.
- Refractive anomalies particularly Myopia, Nearsightedness
- Binocular dysfunction, ex. Convergence Insufficiency and Convergence Excess
- Accommodation dysfunction, ex. Accommodative Insufficiency and Accommodative Excess
Additionally, with Nearpoint Visual Stress there typically are behavioral and emotional related conditions triggering anxiety, reduced self esteem and even depression. Another common behavior side-effect is a significantly reduced attention and concentration for reading related activities.
Moving this now into the year 2020, the COVID pandemic has rapidly accelerated Nearpoint Visual Stress by societally imposed excessive digital screen time. This has accelerated these visual conditions to an even greater concern than ever before. One example of this was published in the American Journal of Ophthalmology July 29, 2020 entitled: Digital Screen Time During COVID-19 Pandemic: Risk for a Further Myopia Boom.
Another example was published in the Journal of Pediatric Ophthalmology and Strabismus August 2020 entitled: Acute Acquired Concomitant Esotropia from Excessive Application of Near Vision During the COVID-19 Lockdown.
What can be done?
First, it’s important to realize that there are many educational benefits to having access to digital technology for enhanced learning opportunities. These new virtual learning platforms have expanded access to information and methods to stay connected as well as a plethora of knowledge-based resources. At the same time, if unaddressed, there can be a host of visual consequences.
Therefore, to help offset the impact of Nearpoint Visual Stress, an important common sense approach is to recommend “visual stress relief” from digital devices as part of the Nearpoint Visual Stress management strategy. One such example is applying the 20/20/20 rule for visual breaks every 20 minutes by looking 20 feet away (or more) for 20 seconds.
Furthermore, it is important for parents to have their children with signs and symptoms of Nearpoint Visual Stress to have a Comprehensive Eye Health and Vision Evaluation. For those children who are progressing in nearsightedness, or showing sensorimotor dysfunctions, such as convergence insufficiency or excess and accommodative insufficiency or excess, should be seen by a Developmental Vision/Rehabilitation Optometrist. The application of nearpoint stress relieving lenses, often with “blue blocking” filters can be a critically important preventative tool for Nearpoint Visual Stress. When visual conditions that involve binocular and accommodative dysfunction go beyond what can be managed with lenses alone OR the patient has more extreme forms of binocular vision failure such as acquired esotropia, a consult for office-based vision therapy should be prescribed as an important management of Nearpoint Visual Stress.
In this era of excessive application of digital screen time we need a more collaborative approach, ophthalmology, primary care and developmental/rehabilitative optometry; working together to find solutions, to end the senseless struggle that affects so many children from induced Nearpoint Visual Stress.
Dan L. Fortenbacher, O.D., FCOVD