Association Between Video Display Terminal Use

and Dry Eye Disease in School Children

Jun Hyung Moon, MD; Mee Yon Lee, MD; Nam Ju Moon, MD, PhD

ABSTRACT
Purpose: To evaluate the risk factors of dry eye disease in
school children associated with video display terminal use.
Methods: Two-hundred eighty-eight children were
classified in either a dry eye disease group or control
group according to the diagnostic criteria of dry eye
disease. The results of ocular examinations, including
best-corrected visual acuity, slit-lamp examination, and
tear break-up time, were compared between groups.
The results of questionnaires concerning video display
terminal use and ocular symptoms were also compared.
Results: Twenty-eight children were included in the
dry eye disease group and 260 children were included
in the control group. Gender and best-corrected visual
acuity were not significantly different between the two

INTRODUCTION
Dry eye disease is defined by the Report of the
Definition and Classification Subcommittee of the
International Dry Eye WorkShop as a multifactorial
disease of the tears and ocular surface, which results
in symptoms of discomfort, visual disturbance, and
tear film instability, with potential damage to the
ocular surface.1 The prevalence of dry eye disease is
estimated to be 7.4% to 33.7%, depending on the
diagnostic criteria used and population surveyed.2
Dry eye disease is known to increase with old age,

groups. Smartphone use was more common in the dry

eye disease group (71%) than the control group (50%)
(P = .036). The daily duration of smartphone use and
total daily duration of video display terminal use were
associated with increased risk of dry eye disease (P =
.027 and .001, respectively), but the daily duration of
computer and television use did not increase the risk of
dry eye disease (P = .677 and .052, respectively).
Conclusions: The results showed that smartphone use is
an important dry eye disease risk factor in children. Close
observation and caution regarding video display terminal use, especially smartphones, are needed for children.
[J Pediatr Ophthalmol Strabismus 2014;51(2):8792.]

and is not common in children because most of the

factors involved in the pathophysiology of dry eye
disease are more common in adults.3 Thus, there
have been limited studies of the prevalence and characteristics of dry eye disease in children.3-5 Children
have less ability to express discomfort than adults,
and even if they express discomfort, the diagnosis
of dry eye disease requires the cooperation of the
patient for examination and assessment of subjective symptoms.3 Additionally, the prevalence of allergic conjunctivitis is high in children, and aller-

From the Department of Ophthalmology, College of Medicine, Chung-Ang University, Seoul, Korea.
Submitted: April 23, 2013; Accepted: December 10, 2013; Posted online: February 4, 2014
The authors have no financial or proprietary interest in the materials presented herein.
Correspondence: Nam Ju Moon, MD, PhD, Department of Ophthalmology, Chung-Ang University Hospital, College of Medicine, Chung-Ang University, #224-1, Heukseok-Dong, Dongjak-Gu, Seoul 156-755, Korea. E-mail: njmoon@chol.com
doi: 10.3928/01913913-20140128-01

Journal of Pediatric Ophthalmology & Strabismus Vol. 51, No. 2, 2014

87

gic conjunctivitis commonly coexists with dry eye

disease.3,6 Thus, the differential diagnosis of allergic
conjunctivitis and dry eye disease is sometimes difficult, especially in children.7 For these reasons, the
significance and prevalence of dry eye disease in
children may be underestimated and physicians often lack awareness of dry eye disease in children and
link it with systemic diseases such as familial dysautonomia, Allgrove syndrome, Sjgren syndrome,
and juvenile rheumatoid arthritis.3,8
There has recently been an increase in the
amount of work performed using video display terminals. Use of computer, television, and portable
information terminals, including smartphones, has
increased, and these changes have been accompanied by an increase in symptoms called video display
terminal syndrome, including dry eye disease.9,10
Video display terminal syndrome is not limited to
adults because the use of video display terminals has
also increased in school children. A recent survey
concluded that 66% of children aged 8 to 17 years
in the United States preferred the Internet if they
could have only one medium of entertainment.11
Changes in lifestyle and entertainment may be risk
factors for dry eye disease in children.
In this study, we compared school children with
and without dry eye disease and evaluated the risk
factors of dry eye disease in school children associated with video display terminal use.
PATIENTS AND METHODS
Participants

The study design was cross-sectional. Relative

humidity in this region of Korea during the time
of the study ranged from 45% to 67%. Exclusion
criteria were: (1) children who underwent any type
of eye surgery in the past 6 months, (2) children
who had nocturnal lagophthalmos, and (3) children
who had eyelid problems (trichiasis, districhiasis, or
epiblepharon). We performed ocular examinations
of all children in the fifth and sixth grades from
one elementary school in Dongjak-gu, Seoul, Korea, in May 2012, at the request of the school. In
addition to the ocular examination, we sent letters
explaining the purpose of the survey and requested
the participation and consent of the children. The
questionnaires were composed of questions about
dry eye disease and video display terminal use.
Twenty-eight children with dry eye disease were
included in the dry eye disease group and 260 age88

matched children with no evidence of dry eye disease were included in the control group. This study
was approved by the Institutional Review Board of
the Chung-Ang University Hospital of Korea.
Ophthalmologic Examinations

All comprehensive ocular examinations included

best-corrected visual acuity tests, slit-lamp examinations of the cornea and conjunctiva, and evaluations
of eyelid problems. Tear break-up time (TBUT) was
measured with a fluorescein strip (Haag-Streit International, Koeniz, Switzerland) coated with one drop
of balanced salt solution (BSS; Alcon Laboratories,
Inc., Fort Worth, TX). After applying the strip on
the inferior conjunctival fornix, the participant resumed normal blinking for several seconds. After
the fluorescein solution spread across the corneal
surface, the participant was asked to keep his or her
eye open until the first defect of tear film occurred.
TBUT was defined as the interval between the last
complete blink and the first appearance of a dry spot
on the pre-corneal surface of the tear film. The procedure was repeated three times for each eye tested,
with results reported as the mean value of the three
measurements.
Punctate epithelial erosions in the corneal conjunctiva were evaluated by a single examiner using a
slit lamp according to the Oxford Scheme Panel.12
The slit-lamp examiner was masked to the results of
the survey to reduce bias. In addition, we recorded
the presence or absence of papillae or follicles in
conjunctiva. Eyelid problems were also evaluated.
Rose bengal staining was performed to exclude children who had nocturnal lagophthalmos. We applied
a rose bengal strip with one drop of balanced salt
solution on the inferior fornix and confirmed conjunctival staining of nocturnal lagophthalmos.13
Questionnaires

A self-administered questionnaire was designed

for obtaining information about risk factors for dry
eye disease in school children, including video display terminal use and subjective ocular signs. The
questionnaire consisted of the following items:
(1) video display terminal use: computers, smartphones, television, and use time per day; (2) mean
duration of daily night sleep; (3) ocular symptoms
for dry eye: Do you feel dry (not wet enough?), Do
your eyes feel irritated?, Do you feel visual fatigue?,
Do you feel an itching sensation?, Do you have
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TABLE 1

Dry Eye Disease Diagnostic Criteria

Dry Eye Severity Level
Variable
Discomfort, severity,
frequency
Visual symptoms

Mild and/or episodic;

occurs under environmental stress

Moderate episodic or
chronic, stress or no
stress

Severe frequent or
constant without
stress

Severe and/or
disabling and
constant

None or episodic
mild fatigue

Annoying and/or
activity-limiting
episodic

Annoying, chronic
and/or constant,
limiting activity

Constant and/or possibly disabling

Conjunctival staining

None to mild

Variable

Moderate to marked

Marked

Corneal staining

None to mild

Variable

Marked central

Severe punctuate
erosions

Variable

10

Immediate

Tear break-up time

Data from International Dry Eye WorkShop. The definition and classification of dry eye disease: report of the Definition and Classification Subcommittee of the International Dry Eye WorkShop. Ocul Surf. 2007;5:75-92.

headaches?; and (4) whether ocular symptoms are

aggravated with the use of video display terminals
such as computers, smartphones, or television.
Diagnosis of Dry Eye Disease

Dry eye disease was defined based on the

DEWS Definition and Classification of 2007 by
symptoms evaluated with the study questionnaire:
discomfort (dryness or irritation) or visual symptoms (fatigue) associated with at least one objective
parameter (TBUT less than 10 seconds or positive
corneal and conjunctival fluorescein staining quantified according to the Oxford Scale) (Table 1).12 If
children showed unilateral dry eye disease, they were
included in the dry eye disease group.
Statistical Analysis

Statistical analyses were performed using SPSS

for Windows (version 18.0; SPSS, Inc., Chicago, IL).
Continuous variables were compared between groups
using the Students t test. The chi-square test was used
to compare noncontinuous variables between the two
groups. To assess the effects of risk factors, including
video display terminal use, on dry eye disease, Pearson rank correlation coefficients were calculated by
linear regression analysis. P values of less than .05
were considered statistically significant.
RESULTS
Baseline Characteristics of Participants

Of 302 children who performed all examinations and returned the questionnaires, 14 children

who were diagnosed as having nocturnal lagophthalmos, trichiasis, or epiblepharon were excluded.
Twenty-eight children were included in the dry eye
disease group and 260 children were included in the
control group. The mean age was 11.00 0.61 years
(range: 10 to 12 years) in the dry eye disease group
and 10.87 0.66 years (range: 10 to 12 years) in
the control group. Eighteen of 28 children (64.3%)
in the dry eye disease group and 128 of 260 children (49.2%) in the control group were female.
The age and gender distributions did not significantly differ between the two groups (P = .31 and
.13, respectively). The mean daily sleeping time was
7.79 0.69 hours (range: 6 to 10 hours) in the dry
eye disease group and 7.80 0.90 hours (range: 5
to 10 hours) in the control group, and also did not
show significant differences between the two groups
(Table 2).
Mean logarithm of the minimum angle of resolution (logMAR) best-corrected visual acuity was
0.053 (range: 0 to 0.301) in the dry eye disease group
and 0.063 (range: 0 to 0.698) in the control group,
which was not significant (P = .66). Mean TBUT
was 7.36 1.28 (range: 5 to 10 seconds) and 9.17
1.43 seconds (range: 8 to 15 seconds) in the dry
eye disease eye group and control group, respectively.
Punctate epithelial erosion was noted in 100% of
eyes in the dry eye disease group and 36.6% of eyes
in the control group. Mean TBUT and the accompanying rate of punctate epithelial erosion showed
significant differences between the two groups (P <
.001 and < .001, respectively). In addition, allergic

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89

TABLE 2

Characteristics of the Dry Eye Disease and Control Groups

Characteristic

Dry Eye Disease

Subjects

Normal Control

28

260

Age, y (mean SD)

11.00 0.61

10.87 0.66

.31a

Gender (female) (%)

64.3

49.2

.13b

logMAR BCVA (mean SD)

0.05 0.11

0.06 0.08

.66a

Daily duration of sleep (h) (mean SD)

7.79 0.69

7.80 0.90

.92a

32.1

4.6

< .001b

Allergic conjunctivitis (%)

logMAR = logarithm of the minimum angle of resolution; BCVA = best-corrected visual acuity; SD = standard deviation
a
By independent t test.
b
By Pearsons chi-square test.

TABLE 3

Visual Display Terminal Use in the Dry Eye Disease and Control Groups
Dry Eye Disease
(n = 28)

Normal Control
(n = 260)

Odds Ratioc
(95% CI)

Use of smartphones (no. [%])

20 (71.4)

130 (50.0)

2.500 (1.0635.880)

.036a

Smartphone use per day (h)

(mean SD)

0.71 0.74

0.40 0.55

1.863 (1.0723.236)

.027b

Computer use per day (h)

(mean SD)

0.68 0.31

0.64 0.32

1.281 (0.3994.110)

.677b

Television use per day (h)

(mean SD)

0.99 0.66

0.75 0.43

1.982 (0.9943.950)

.052b

Total VDT use per day (h)

(mean SD)

2.38 0.96

1.80 0.84

1.821 (1.2602.631)

.001a

Variable

CI = confidence interval; SD = standard deviation; VDT = video display terminal

a
Single variate binominal logistic regression analysis.
b
Multivariate binominal logistic regression analysis.
c
Odds ratio greater than 1 represents an increased likelihood of dry eye disease.

conjunctivitis was present in 9 patients in the dry eye

disease group and 12 patients in the control group,
and was significantly different (P < .001).
Dry Eye Disease and Video Display Terminals

Twenty children in the dry eye disease group

(71.4%) and 130 children (50%) in the control
group reported using smartphones. The rate of smartphone use was significantly higher in the dry eye disease group. The daily duration of smartphone use was
associated with increased risk of dry eye disease. Logistic regression analysis examining the relationship
between mean daily duration of video display terminal use and prevalence of dry eye disease revealed that
duration of smartphone use and total daily duration
of video display terminal use were associated with increased risk of dry eye disease (P = .027 and .001,
respectively). However, daily duration of computer
90

and television use did not increase the risk of dry eye
disease (P = .677 and .052, respectively) (Table 3).
DISCUSSION
Dry eye disease has shown a marked increase
due to video display terminal use and has become
a significant health issue affecting the quality of life
in industrialized countries.14 Dry eye disease associated with the use of video display terminals can be
multifactorial and is still not well understood.15 Decreased blinking and increased interpalpebral ocular
surface area during use of video display terminals
may increase tear evaporation due to destabilization
of the tear film.16
A smartphone is a portable information terminal that is used not only for telephone calls but also
as a small handheld computer. In Korea, 50.41%
of the adult population uses smartphones and the
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mean duration of smartphone use is reported to

be 1.9 hours per day. There are no data regarding
smartphone use in children, but it is known to be
increasing. In the current study, 52.1% of children
among 288 elementary school children aged 9 to 11
years reported using smartphones.
We evaluated the characteristics and risk factors of dry eye disease in children. Dry eye disease
is more commonly found in females with adult dry
eye disease,17 but there were no significant differences in gender distribution between the dry eye
disease group and control group in our study. Mean
daily duration of sleep, also known as a risk factor
for dry eye disease in adults,4,18 did not show significant differences between the two groups in our
study, but this may be due to lack of variation in
sleeping duration in children. The characteristics of
dry eye disease in children may be similar to or may
have different features than dry eye disease in adults.
Among our participants, all of the children used
computers and televisions and 52.1% used smartphones. The results revealed that the use of smartphones, the mean duration of smartphone use, and
the mean duration of total video display terminal
use were risk factors for dry eye disease in children. Interestingly, the daily duration of computer
and television use alone was not associated with
increases in dry eye disease, but children who used
both smartphones and computers reported more
ocular symptoms, including visual fatigue, dryness,
and headache.
The significance of smartphone use as a risk factor for dry eye disease in children has not previously
been recognized. Our results indicate that dry eye
disease in children is a clinically significant problem. All of the children in the dry eye disease group
complained of visual fatigue, and more than half
complained of dryness, headache, and burning sensations. Such subjective symptoms may affect quality of life. Punctate epithelial erosions were found in
100% of the dry eye disease group; such ocular surface complications require treatment and decrease
visual acuity. In addition, surface irregularities on
the cornea can aggravate tear film instability.19
Limitations of our study include the following.
Children and their parents who answered the
questions regarding duration of sleep and video display terminal, television, and computer use assumed
a correlation between video display terminal use and
ocular problems. A research bias was that parents

may have guessed the reason for our study before

answering the questionnaire. Additionally, the age
range was limited to 9 to 11 years, and therefore
our study results may not represent the full extent of
dry eye disease in children. We also did not evaluate
all types of video display terminals, only the video
display terminals most commonly used by children.
In our study, allergic conjunctivitis was significantly more common in the dry eye disease group,
confirming previous findings in the literature.20
However, this finding may reflect a limitation of our
study in that children with allergic conjunctivitis
were included. Allergic conjunctivitis aggravates
ocular dryness by exacerbating the inflammatory
reaction on the ocular surface. Spring and fall are
peak allergic season in Korea, and would include
confounding anterior segment problems for these
eyes. Ocular allergy was noted to be a risk factor for
dry eye disease in the Beaver Dam Study, although
the concomitant use of systemic medications such
as antihistamines was recognized as a potential contributor.4,9 However, there was no statistically significant clinical aggravation in our study between
participants with dry eye disease and allergic conjunctivitis and participants with dry eye disease
only. There was no statistically significant difference
between the two groups regarding time of video
display terminal use. There were no children with
severe allergic conjunctivitis in our study, but allergic conjunctivitis may have biased evaluations of the
relationship between video display terminal use and
dry eye disease.
The prevalence of dry eye disease in children is
known to be lower than in adults, but should not
be dismissed as a minor problem.2,17 Many children
express ocular discomfort such as dryness, irritation,
and fatigue, but it can be challenging to obtain samples of tears from children and is difficult to distinguish these symptoms from those caused by allergic
conjunctivitis.
In our study, 9.7% of children were diagnosed
as having dry eye disease and video display terminal use was more common in the dry eye disease
group. Although the children in our study felt that
computer use resulted in greater experiences of subjective symptoms than the use of smartphones, our
results showed that smartphone use is a greater risk
factor than computer use in children.
Close observation and caution when using video
display terminals, especially smartphones, is needed

Journal of Pediatric Ophthalmology & Strabismus Vol. 51, No. 2, 2014

91

for children. Smartphones are used not only for telephone calls, but also for gaming, Internet searches,
and entertainment, and use time per day may increase as children become older. Increased use of
smartphones could result in other ocular problems
due to near visual tasking. Long-term use of near
visual tasking may affect accommodation and lead
to progression of myopia.21,22 Transient myopia induced by near work may contribute to the development and progression of permanent myopia.21,23,24
Thus, children with high levels of video display terminal use should undergo routine examinations and
treatment to preserve ocular health. Dry eye disease
in children must be detected early, and should be
treated with appropriate medical and environmental
manipulations and education.
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