1040-5488/03/8011-0732/0 VOL. 80, NO. 11, PP.

732–739
OPTOMETRY AND VISION SCIENCE
Copyright © 2003 American Academy of Optometry

ORIGINAL ARTICLE

Is all Asthenopia the Same?

JAMES E. SHEEDY, OD, PhD, FAAO, JOHN HAYES, PhD, and JON ENGLE, BS
The Ohio State University, College of Optometry, Columbus, Ohio

ABSTRACT: Purpose. Any of several conditions can cause asthenopia. The purpose of this study was to determine
whether the particular sensations or their location vary dependent on the symptom-inducing condition. Methods.
Twenty subjects with good vision performed eight reading tasks in random order during different conditions. Each
condition used different stimuli to induce asthenopia. The eight conditions were mixed astigmatism, close viewing
distance, upward gaze, dry eyes, lens flipper, small font, glare, and flickering light. Subjects were asked to read until
attaining a level of discomfort self-defined as “barely tolerable.” After each task, subjects rated the magnitude of several
symptom descriptors (burning, ache, strain, irritation, tearing, blurred vision, double vision, dryness, and headache)
and their location. Results. Analysis of variance with repeated measures was used to determine that all of the individual
symptom sensation measures (except blur) were significantly related (p values ranged from 0.003 to <0.0001) to the
inducing condition. Principal factor analysis with orthogonal varimax rotation was used to test symptom by condition
relationships and determined two latent factors, designated external and internal symptom factors (ESF and ISF), that
related symptoms to inducing condition. The ESF pattern comprises burning, irritation, tearing, and dryness located in
the front and bottom of the eye. ESF is caused by holding the eyelid open, glare, up gaze, small font, and flickering. ESF
seems highly related to dry-eye symptoms. The ISF pattern comprises ache, strain, and headache located behind the
eyes. ISF is caused by the close viewing distance, lens flipper, and mixed astigmatism conditions and is likely related
to accommodative and vergence stress. Conclusions. Symptom descriptors and locations were able to distinguish
discomfort on the basis of causative condition. Results support two different symptom constellations and, hence, at
least two different afferent pathways for symptoms of asthenopia. (Optom Vis Sci 2003;80:732–739)

Key Words: eyestrain, asthenopia, dry eye, accommodation, convergence, glare, symptoms, eye

A
sthenopia is the formal diagnostic term (ICD-9, 368.13)1
that is nearly synonymous with the more familiar word
“eyestrain.”2 Eyestrain is very common—for example, it is
the most frequent symptom reported by computer users.3, 4 Secre-
taries, accountants, bookkeepers, draftsmen, and others with de-
manding near visual jobs have commonly experienced asthenopia.
The list of nonspecific symptom sensations most commonly asso-
ciated with asthenopia includes eyestrain, eye fatigue, discomfort,
burning, irritation, pain, ache, sore eyes, and headache. Other
more specific symptoms include photophobia, blur, double vision,
itching, tearing, dryness, and foreign-body sensation.
Asthenopia can be caused or induced by each of the following
distinct conditions: glare from lighting,5, 6 termed “discomfort
glare”; anomalies of binocular vision such as convergence insuffi-
ciency and esophoria7–9; accommodative dysfunctions such as re-
duced amplitude and accommodative infacility10 –12; uncorrected
refractive error,13, 14 including presbyopia15, 16; compromised
quality of the viewed image such as poor contrast or legibility17, 18;
less than optimal gaze angles19; flickering stimuli such as CRT
computer displays20; and dry eye.21 Because asthenopia can be
caused by many factors, the treatments can be many and often
involve treatment of visual conditions as well as of the work
environment.22, 23
Despite the fact that numerous symptom sensations have been
associated with asthenopia and numerous causative conditions
have been identified, the condition of asthenopia is known as a
single entity, and the causative factor of asthenopia cannot cur-
rently be differentiated on the basis of symptom sensation or per-
ceived location. The mechanisms that create the symptom sensa-
tions are also not known.24
Collins et al.25 studied 79 computer-using subjects and catego-
rized their symptoms as either ocular (asthenopia-type symptoms)
or visual (blur, double vision), but did not find any significant
relationship to the visual examination findings that consisted of
refractive, binocular vision, and accommodative measurements.
Likewise, Neugebauer et al.26 studied 50 young adults with asthe-
nopic symptoms of headache, ocular pain, foreign body sensation,
red eyes, photophobia, double vision, and difficulty when chang-
ing fixation distance. They found no correlation of specific symp-
toms with the refraction, binocular vision, and accommodation

Optometry and Vision Science, Vol. 80, No. 11, November 2003
 Is all Asthenopia the Same?—Sheedy et al. 733

findings. The lack of correlations in these studies supports the idea
that the symptoms of asthenopia are nonspecific and not differen-
tiated on the basis of the causative factor.
However, is it not likely that sensation differences should be
distinguishable—if measured properly— because of the differ-
ences in the primary anatomical locations of the action or stimu-
lation? The tissue that is stressed or insulted and generates the
feelings of discomfort is most likely the same tissue of the primary
action or stimulation. For example, the primary action of conver-
gence involves the medial recti, accommodation the ciliary body,
and dry eyes the anterior ocular surfaces. These are three discrete
tissues, and it is reasonable that insults to these tissues could create
different sensations. The Collins et al.25 and Neugebauer et al.26
studies used retrospective analyses of clinical data. The research
presented here is a prospective study of symptoms induced by
prespecified controlled stimuli in a laboratory setting. We investi-
gated whether the symptom sensations or their perceived locations
can be related to the causative factors. If the sensations of asthe-
nopia can be differentiated, then it is likely that the anatomical
location and/or the physiological mechanisms of asthenopia can
also be differentiated and, in individual patients, tied to the caus-
ative factor.
METHODS
Twenty adult subjects (aged 18 to 35 years) selected from stu-
dents and staff at The Ohio State University were screened to have
20/20 unaided (without glasses or contact lenses) distance visual
acuity OU, no known ocular pathology, no clinically significant
asthenopia, and no asthenopia at the beginning of the test session.
Eye examination data were not available for the subjects. Each
consented to participate in the study according to a protocol ap-
proved by the Ohio State University institutional review board.
Subjects read short stories during each of the eight discomfort-
inducing conditions listed in Table 1. Testing order was by Latin
square design. Condition parameters were selected with intent to
equalize them for difficulty. However, the absence of previous
literature or work in inducing asthenopia made such equalization
unattainable, and parameters were selected on the basis of clinical
experience and iterative preliminary testing.
The following procedures were used for all conditions unless
otherwise noted in Table 1: head and chin rest were used; subjects
silently read short stories for 15 min or until attaining a discomfort
level that was “barely tolerable”; stories were printed in 10-point
font, were selected from the works of Edgar Allen Poe, were placed
on a document holder 40 cm from the eyes, and were located so
that the paragraph was viewed with a range of 3.5° to 22° of
downward gaze. No story was ever presented more than once to a
given subject, and reading performance was not monitored. Sub-
jects completed a symptom sensation questionnaire after each con-
dition and were given 5 min of rest between tests. The symptom
sensation questionnaire contained nine identical analog scales on
which the subject recorded the magnitude of each of the following
nine symptoms: burning, ache, strain, irritation, tearing, blurred
vision, double vision, dryness, and headache. Each analog scale was
a 100-mm line with descriptors at both ends (0 ⫽ none and 100 ⫽
severe) and at each quartile location (mild, modest, and bad). The
subject indicated magnitude with a vertical line along the scale,
which was recorded as a value between 0 to 100. If the subject did
not attain a discomfort level of barely tolerable within 15 min, the
trial was stopped, the symptom sensation questionnaire adminis-
tered, and the subject reported (on a similar analog scale) the
percentage of “barely comfortable” that had been attained. For
each trial, the experimenter (JE) watched the subject and estimated
the percentage of time that the subject noticeably squinted their
eyelids.
RESULTS
Analysis of variance with repeated measures was used to test the
main effects of condition and testing order and interactions be-
tween the two on symptom sensations. Each of the individual

TABLE 1.
Asthenopia induction conditions.

Inducing Condition Induction Stimulus

Lens flipper Subject read alternate sentences through ⫾1.50 lenses using a hand-held binocular lens flipper.
Close viewing distance Subject wore glasses with ⫹6.00 DS OU; the distance between lens optical centers matched
the subject interpupillary distance within 2.5 mm. Stories were placed on a document holder
at 16.7 cm from the eyes unless a closer distance was required for clarity (to compensate
proximal accommodation) and were printed in 5-point font with reduced page width to
compensate visual angles for the closer distance.
Dry eye Subject manually held their eyelids open with thumbs and forefingers while reading.
Flickering light A strobe light (1538-A Strobotac General Radio) run at 15 cycles/sec in a dark room was
oriented to illuminate the reading material. A frosted plastic filter was placed in front of the
strobe light to evenly distribute the light onto the reading material.
Glare Two desk lamps with 60 W tungsten bulbs, 40 cm from and level with the eyes, were directed
toward the subject’s eyes.
Small font The reading material was printed in 5-point font.
Mixed astigmatism Subject wore glasses with ⫹2.00 ⫺4.00 ⫻ 180 OU; the distance between lens optical centers
matched the subject interpupillary distance within 2.5 mm.
Upward gaze The stories were placed on a document holder 40 cm from the eyes and located above eye
level to require between 20 and 35 degrees of upward gaze.

Optometry and Vision Science, Vol. 80, No. 11, November 2003
734 Is all Asthenopia the Same?—Sheedy et al.
symptom sensation measures (except blur) was significantly related
(p values ranged from 0.003 to ⬍0.0001) to inducing condition. A
summary of the mean scores by symptom is provided in Table 2.
The symptom headache was the only one to be significantly related
(p ⫽ 0.0454) to testing order—there was a cumulative effect of
testing time on headache magnitude. This is an indication that
headache is in some way different from the other symptoms or that
the subjects, in unison, scaled headache differently across the
course of the experimental session. Also, the fact that all of the
other symptoms were not related to testing order helps to validate
the methodology and the relatively short resting time (5 min)
allotted between conditions. Although some symptom carryover
seems likely, other than headache, such carryover was not statisti-
cally significant, and the Latin order testing design helped to mit-
igate remaining order effects.
There were significant simple correlations among the symptom
scores (Table 3). The simple correlations suggested the existence of
underlying primary latent variables that could reduce the dimen-
sionality of the symptom space. Principal factor analysis with or-
thogonal varimax rotation was used to take advantage of the inter-
correlations and reduce the dimensionality of the symptom space.
The number of underlying latent variables was determined by se-
lecting factors with eigenvalues ⬎1. An eigenvalue is the amount of
variance accounted for by the latent variable. An eigenvalue of one
is equal to the amount of variance accounted for by any one of the
symptom scores. An underlying latent variable reduces dimension-
ality only if it explains more variance than a single variable. The
factor analysis revealed fundamental latent factors that were used
to determine the underlying causes of eyestrain based on the re-
ported symptom sensations.
Although the individual symptom sensation measures (except
blur) were significantly related to inducing condition, a much
stronger relationship was obtained by calculating the latent factors
with principal factor analysis. Two factors accounted for 64% of
the total variance. Eigenvalues were ⬍1.0 for the remaining factors
and, thus, were dropped from consideration. For each symptom
measure, the analysis determined a coefficient by which that symp-
tom measure contributed to each calculated latent factor. Fig. 1 is
a graphical representation of the latent factor loadings for the nine
sensation measures used in this study. Two distinct groupings of
the symptom measures were evident. One group comprises burn-
ing, irritation, dryness, and tearing; and each heavily contributes to
factor 1 and not to factor 2. The other group comprises strain,
headache, ache, double vision, and (to a lesser extent) blur; and
each heavily contributes to factor 2 and not factor 1. Because the
first group, which contributes heavily to factor 1, was comprised of
symptoms that seemed related to the ocular surface, we labeled
factor 1 as “external symptom factor” (ESF), and with similar
reasoning, we labeled factor 2 as “internal symptom factor” (ISF).
After rotation, the ESF accounted for 33.7% of the total variance,
and ISF accounted for 30.3%.
Fig. 2 shows the mean value (with standard error of the mean) of
the calculated ESF and ISF for each of the eight inducing condi-
tions used in this study. The two factors were significantly different
from one another for a given condition if the error bars do not
overlap. Very clearly, the dry-eye condition shows the greatest

TABLE 2.
Summary of mean ⫾ SD symptom scores (scale of 0 to 100) by condition.

Inducing Symptom
Condition Burning Ache Strain Irritation Tearing Blur Double Vision Dryness Headache

Lens flipper 15.8 ⫾ 19.3 35.9 ⫾ 31.3 52.2 ⫾ 27.1 19.2 ⫾ 19.8 9.7 ⫾ 15.9 15.5 ⫾ 27.2 20.2 ⫾ 32.8 18.3 ⫾ 22.1 32.3 ⫾ 31.2
Close viewing 26.7 ⫾ 29.7 44.1 ⫾ 31.3 70.8 ⫾ 16.8 27.4 ⫾ 29.2 12.6 ⫾ 18 20.1 ⫾ 31.2 30.1 ⫾ 39.6 23.7 ⫾ 26.9 36.1 ⫾ 36.4
Dry eye 63.3 ⫾ 35.7 19.8 ⫾ 29.6 23.8 ⫾ 25.1 50.7 ⫾ 35.2 58.8 ⫾ 36 13.9 ⫾ 29.4 6.5 ⫾ 17.7 53.2 ⫾ 42.8 11.2 ⫾ 19.9
Flickering light 26.4 ⫾ 31.2 33.7 ⫾ 31.5 43.4 ⫾ 29.7 30 ⫾ 31.2 17 ⫾ 26.4 16.3 ⫾ 24.9 12.9 ⫾ 22.9 29.7 ⫾ 32.2 35.4 ⫾ 40
Glare 35.2 ⫾ 29.9 35.1 ⫾ 32.3 45.4 ⫾ 29.1 31.8 ⫾ 31 12.9 ⫾ 20.4 19.8 ⫾ 29.2 10.9 ⫾ 23 31.7 ⫾ 25.8 31.9 ⫾ 32.1
Small font 33.5 ⫾ 29.5 30.9 ⫾ 27.5 52.7 ⫾ 28.3 28.5 ⫾ 30 15.8 ⫾ 24 26.3 ⫾ 32.3 23.1 ⫾ 31.5 23.2 ⫾ 26.1 28.5 ⫾ 33.7
Mixed astigmatis 22.3 ⫾ 23.4 49 ⫾ 31.5 63.8 ⫾ 25.4 30.9 ⫾ 28.1 14.5 ⫾ 19.5 17.3 ⫾ 27.8 38.2 ⫾ 43 23 ⫾ 26.6 35.5 ⫾ 31.3
Upward gaze 39 ⫾ 26.4 49.7 ⫾ 27.8 55.3 ⫾ 25.9 27.7 ⫾ 26.2 22.6 ⫾ 24.7 17 ⫾ 28.1 15.5 ⫾ 24.8 31.7 ⫾ 24.4 34.9 ⫾ 31.8

TABLE 3.
Pearson correlation coefficients between symptom scores.

Ache Strain Headache Double Vision Blur Tearing Burning Irritation Dryness

Ache — 0.66a 0.59a 0.46a 0.56a 0.27b 0.38a 0.41a 0.26b

Strain — — 0.60a 0.43a 0.37a 0.04 0.21b 0.23b 0.10
Headache — — — 0.32a 0.28b 0.13 0.17 0.17 0.13
Double vision — — — — 0.62a 0.17 0.25b 0.29b 0.25b
Blur — — — — — 0.31 0.39a 0.44a 0.43a
Tearing — — — — — — 0.66a 0.56a 0.43a
Burning — — — — — — — 0.79a 0.65a
Irritation — — — — — — — — 0.64a
Dryness — — — — — — — — —
a
p ⬍ 0.0001.
b
p ⬍ 0.01.

Optometry and Vision Science, Vol. 80, No. 11, November 2003

FIGURE 1.
Graphical representation of the loading factors for the external symptom
factor and the internal symptom factor for each of the nine symptom
sensation measures used in this study.
FIGURE 2.
Mean ⫾ SEM of the external symptom factor (ESF) and internal symptom
factor (ISF) for each inducing condition.
separation between the two symptom factors with a high ESF and
low ISF. Therefore, the ESF component sensations (burning, irri-
tation, dryness, and tearing) were related to dry eyes. The dry-eye
condition was also the only condition with a significantly high
ESF. ISF (strain, headache, ache, double vision, and blur) was
significantly higher than ESF for the accommodative stress, con-
vergence, and mixed astigmatism conditions.
The large contribution of the dry-eye condition to ESF and to
the separation between ESF and ISF led to a concern that the
symptoms elicited by this one condition overwhelmed the analysis.
For this reason, statistical analysis was reperformed with the dry-
Optometry and Vision Science, Vol. 80, No. 11, November 2003
Is all Asthenopia the Same?—Sheedy et al. 735
eye data removed. Analysis of variance with repeated measures
determined that burning (p ⫽ 0.0005), ache (p ⫽ 0.048), strain (p
⫽ 0.0111), and headache (p ⫽ 0.03) were significantly related to
inducing condition. Principal factor analysis without the dry-eye
condition revealed the same two latent factors for which the load-
ing factors of the component symptom sensations are graphed in
Fig. 3 and for which the mean values for each condition are shown
in Fig. 4. Without the dry-eye condition, the overall factor model
accounted for 63% of the variance with 34% being accounted for
by ESF and 29% accounted for by ISF. Again, factors with eigen-
values ⬍1 were not considered.
Figs. 3 and 4 are the same as Figs. 1 and 2, respectively, except
that data from the dry-eye condition have been removed from the
analysis. The ESF and ISF clusters of symptoms in Fig. 3 are nearly
the same as in Fig. 1. Burning, irritation, and dryness were still
associated with ESF, and strain, headache, and ache were still as-
sociated with ISF. The symptoms of tearing, blur, and double
vision were not as well associated with the latent factors with re-
moval of the dry-eye data.
Likewise, the relationships between the two latent factors and
the inducing conditions were similar in Figs. 2 and 4. Lens flippers,
close viewing distance, and mixed astigmatism continued to have
significantly greater ISF than ESF weightings despite absence of
data from the dry-eye condition. However, after the strong effects
of the dry-eye data were removed, the data in Fig. 4 show that other
conditions are related to ESF. Glare had significantly greater ESF
compared with ISF, and flickering, small font, and up gaze also
showed higher ESF than ISF. These effects were seemingly over-
whelmed by the very strong ESF effects of the dry-eye condition
shown in Fig. 2. The remarkable similarities between the factor
analysis results with (Figs. 1 and 2) and without (Figs. 3 and 4) the
influential dry-eye data strengthens the validity of the two latent
factors (ESF and ISF). Table 4 contains the same raw data means of
FIGURE 3.
Graphical representation of the loading factors for the external symptom
factor and the internal symptom factor for each of the nine symptom
sensation measures used in this study, but with data from the dry-eye
condition removed from analysis.
736 Is all Asthenopia the Same?—Sheedy et al.
with ISF and a negative relationship with ESF. “Between” the eyes
has a negative relationship with ESF.
The percentage estimate of squinting time was significantly re-
lated to condition (p ⬍ 0.0001), values are displayed in Table 5.
The glare, refractive error, and convergence stress conditions had
the greatest amount of squinting. Squinting provides a visual ben-
efit by reducing blur for uncorrected refractive error and reducing
retinal illumination for glare, and, hence, the high level of squint
during these conditions is reasonable.27 The visual benefit of
squinting during the close viewing condition is less clear, although
it is possible that blur occurred due to inappropriate accommoda-
tive response to the close viewing condition.
The mean amount of time required to reach barely tolerable and
the mean percentage of barely tolerable attained are presented in
Table 6. The latter mean was determined by using 100% when the
subject attained barely tolerable within 15 min and using their
percentage estimate on the analog scale when they didn’t reach that
level. The dry-eye condition was much faster to threshold than the
other conditions. The values in Table 6 calibrate the symptom-
FIGURE 4. inducing conditions used in this study as reported in Table 1 and
Mean ⫾ SEM of the external symptom factor (ESF) and internal symptom can help to equalize the difficulty of discomfort-inducing condi-
factor (ISF) for each inducing condition, but with data from the dry-eye tions for future study.
condition removed from analysis.

symptom ratings as shown in Table 2, however, in Table 4, the
inducing conditions and symptoms are segregated into ESF and
ISF categories. Inspection of data in Table 4 shows the categorical
(ISF and ESF) differences in the magnitudes of specific symptoms
based on the category (ISF or ESF) of the inducing condition.
ESF (p ⫽ 0.0013) and ISF (p ⫽ 0.0033) were also significantly
related to perceived location with all of the data and still have good
relationships with the dry-eye data removed (ESF, p ⫽ 0.0016;
ISF, p ⫽ 0.0549). Fig. 5 A and B shows the mean factor scores with
and without the dry-eye data, respectively. “Bottom” of the eyes
bears a strong positive relationship with ESF and a negative rela-
tionship with ISF in both Fig. 5 A and B—“front” of the eyes has
the same relationships but only with inclusion of the dry-eye data.
“Behind” the eyes shows the opposite—i.e., a positive relationship
DISCUSSION
The symptom sensations were significantly related to the induc-
ing conditions. The relationships were determined to be strongest
by calculating two factor groups herein named external symptom
factor (ESF) and internal symptom factor (ISF). ESF continues as
a separate identifiable factor even when data from the dry-eye-
inducing condition are removed from the analysis. This strongly
supports ESF and ISF as fundamentally identifiable and different
factors. The relationships of these two factors to the symptom
sensations, inducing conditions, and perceived locations are sum-
marized in Table 7.
The data analysis demonstrates at least two constellations of
subjective symptoms that are differentiated by sensation type, sen-
sation location, and inducing condition. The fact that the subject

TABLE 4.
Mean symptom ratings for symptoms and inducing conditions categorized as ESF or ISF.a

Symptoms
Inducing Conditions ISF ESF Neither
Ache Strain Headache Burning Irritation Dryness Tearing Blur Double Vision

ISF
Lens flipper 36 52 32 16 19 18 10 16 20
Close viewing 44 71 36 27 27 24 13 20 30
Mixed astigmatism 49 64 36 22 31 23 15 17 38
ESF
Dry eye 20 24 11 63 51 53 59 14 7
Glare 35 45 32 35 32 32 13 20 11
Small font 31 53 29 34 29 23 16 26 23
Upward gaze 50 55 35 39 28 32 23 17 16
Flickering light 34 43 35 26 30 30 17 16 13
a
ESF, external symptom factor; ISF, internal symptom factor.

Optometry and Vision Science, Vol. 80, No. 11, November 2003
 Is all Asthenopia the Same?—Sheedy et al. 737

TABLE 5.
Mean estimate, by condition, of the percentage time sub-
jects squinted during testing.

Squint
Condition
(%)

Glare 56.5
Mixed astigmatism 53.1
Close viewing distance 51.8
Lens flipper 22.8
Small font 18.9
Upward gaze 5.5
Flickering light 5.0

TABLE 6.
The mean amount of time for symptoms to become “barely
tolerable” and the mean magnitude attained relative to
barely tolerable.

Mean Time Barely Tolerable

Condition
(sec) (%)

Mixed astigmatism 336.6 100

Dry eyes 26.5 99.6
Close viewing distance 409.6 90.8
Upward gaze 571.0 83.6
Small font 604.6 79.6
Lens flipper 599.8 77.6
Flickering light 605.3 76.0
Glare 672.0 73.3

TABLE 7.
Summary of the ISF and ESF symptom/condition/location
relationships.a

Factor Symptoms Inducing Conditions Location

ESF Burning Dry eye Bottom of eyes

Irritation
Glare Front of eyes
Dryness Up gaze
FIGURE 5. Small font
Mean scores of the two factors (external symptom factor and internal Flicker
symptom factor) for each location. Mean scores were calculated for (A)
ISF Strain Lens flipper Behind the eyes
analyses of all data and (B) analysis without data from dry-eye condition.
Ache Close viewing distance
Headache Mixed astigmatism
a
ISF, internal symptom factor; ESF, external symptom factor.
population could differentiate asthenopia demonstrates at least
two different afferent pathways that are involved in asthenopia.
The composition of the two constellations is rational based on Manually holding open the eye lids will clearly create a dry-eye
current understanding of anatomy and physiology, i.e., ESF seems condition and ESF symptoms. The up-gaze condition also seems
clearly related to dry eye and ISF is most likely related to other reasonably related to dry eyes and symptoms of ESF because supe-
visual functions such as accommodation and convergence. rior gaze results in a greater exposed ocular surface.31 Blinking is
The sensations of ESF (burning, irritation, and dryness) are retarded in up gaze because of fusion of the fibrous sheaths of the
similar to the most common symptoms considered related to dry superior rectus and levator palpebrae superioris muscles.32 The
eye (gritty, burning, red, and dry) in a population-based study of other ESF-inducing conditions (glare, small font, and flicker) seem
elderly subjects28 and is also consistent with clinical reports of not as directly related to dry eyes. However, each of these condi-
symptoms associated with dry eyes.29, 30 Also, one of the signs of tions commonly exist at computer workstations, and work at a
dry eye is staining in the lower cornea and conjunctiva,30 which is computer has been shown to significantly reduce blink rate.33, 34
essentially the same location as the perceived location of ESF (front These conditions could in some manner reduce blink rate and
and bottom of the eye). result in dry-eye conditions. It is also possible that they operate by

Optometry and Vision Science, Vol. 80, No. 11, November 2003
738 Is all Asthenopia the Same?—Sheedy et al.
different mechanism (e.g., glare could stress the retina, iris, or
visual pathway35) that were not distinguishable by the testing in
this study.
The ISF symptoms of strain, ache, and headache seem categor-
ically distinct from those associated with dry eyes—and more re-
lated to those commonly described as occurring with accommoda-
tive or binocular vision disorders. Headaches, eyestrain, and eye
fatigue are reported as symptoms commonly related to conver-
gence insufficiency36 and to minor disorders of ocular vergence.37
Blur, headache, and asthenopia were the most common symptoms
noted in a retrospective study of patient records containing a diag-
nosis of accommodative insufficiency.38 In a paper on vergence,
Tyrell and Leibowitz39 state: “A common complaint associated
with prolonged near work is of a vague discomfort, which may
seem to be localized in either the head or the eyes.” ISF symptoms
are similar to those previously reported for accommodative and
binocular vision problems.
Two of the ISF-inducing conditions, the lens flipper and the
close viewing conditions, primarily stressed the accommodative
and vergence mechanisms. It is possible that the mixed astigmatism
condition likewise stressed accommodation and convergence if the
large astigmatic range (4.00 D) resulted in accommodative uncer-
tainty and fluctuation. The location of ISF (behind the eyes) is
consistent with the description by Tyrell and Leibowitz39 and is
also close to the locations of the oculomotor and ciliary muscles
that are responsible for binocular alignment and accommodation,
respectively.
CONCLUSIONS
Symptom descriptors and locations were able to distinguish dis-
comfort on the basis of causative condition, indicating at least two
different afferent pathways for the symptoms of asthenopia. Re-
sults support two different symptom constellations herein labeled
external symptom factor (ESF) and internal symptom factor (ISF).
The ESF pattern comprises burning, irritation, tearing, and dry-
ness located in the front and bottom of the eye. ESF is caused by
holding the eyelid open, glare, up gaze, small font, and flickering.
ESF seems highly related to dry-eye symptoms. The ISF pattern
comprises ache, strain, and headache located behind the eyes. ISF
is caused by the close viewing distance, lens flipper, and mixed
astigmatism conditions and is likely related to accommodative
and/or binocular vision stress.
ACKNOWLEDGMENTS
Supported, in part, by National Eye Institute, National Institutes of Health
grant T35-EY07151.
Received October 19, 2002; revision received June 25, 2003.
REFERENCES
1. International Classification of Diseases, 9th Revision, Clinical
Modification: Physician ICD-9-CM, 2003. Hyattsville, MD: Na-
tional Center for Health Statistics, Division of Data Services, 2002.
2. Schapero M, Cline D, Hofstetter HW. Dictionary of Visual Science,
2nd ed. Philadelphia: Chilton, 1968:267.
3. Sheedy JE. Vision problems at video display terminals: a survey of
optometrists. J Am Optom Assoc 1992;63:687–92.
Optometry and Vision Science, Vol. 80, No. 11, November 2003
4. Nilsen E, Salibello C. Survey of US optometrists regarding prevalence
and treatment of visual stress symptoms. In: Salvendy G, Smith MJ,
Koubeck RH, eds. Design of Computing Systems: Proceedings of the
7th International Conference on Human-Computer Interaction
(HCI International ’97), San Francisco, CA, August 24–29, 1997.
New York: Elsevier, 1997;24–30.
5. Guth SK. Prentice memorial lecture: the science of seeing-a search for
criteria. Am J Optom Physiol Opt 1981;58:870–85.
6. American National Standards Institute. American National Standard
Practice for Office Lighting, ANSI/IESNA RP-1-1993. New York:
American National Standards Institute, 1993.
7. Sheedy JE, Saladin JJ. Phoria, vergence, and fixation disparity in
oculomotor problems. Am J Optom Physiol Opt 1977;54:474–8.
8. Sheedy JE, Saladin JJ. Association of symptoms with measures of
oculomotor deficiencies. Am J Optom Physiol Opt 1978;55:670–6.
9. Grisham JD. Visual therapy results for convergence insufficiency: a
literature review. Am J Optom Physiol Opt 1988;65:448–54.
10. Hennessey D, Iosue RA, Rouse MW. Relation of symptoms to ac-
commodative infacility of school-aged children. Am J Optom Physiol
Opt 1984;61:177–83.
11. Levine S, Ciuffreda KJ, Selenow A, Flax N. Clinical assessment of
accommodative facility in symptomatic and asymptomatic individu-
als. J Am Optom Assoc 1985;56:286–90.
12. Jaschinski-Kruza W, Schweflinghaus W. Relations between dark ac-
commodation and psychosomatic symptoms. Ophthalmic Physiol
Opt 1992;12:103–5.
13. Wiggins NP, Daum KM. Visual discomfort and astigmatic refractive
errors in VDT use. J Am Optom Assoc 1991;62:680–4.
14. Wiggins NP, Daum KM, Snyder CA. Effects of residual astigmatism
in contact lens wear on visual discomfort in VDT use. J Am Optom
Assoc 1992;63:177–81.
15. Bachman WG. Computer-specific spectacle lens design preference of
presbyopic operators. J Occup Med 1992;34:1023–7.
16. Butzon SP, Sheedy JE, Nilsen E. The efficacy of computer glasses in
reduction of computer worker symptoms. Optometry 2002;73:221–30.
17. Sheedy JE. Reading performance and visual comfort on a high reso-
lution monitor compared to a VGA monitor. J Electronic Imaging
1992;1:405–10.
18. Sheedy JE, McCarthy M. Reading performance and visual comfort
with scale to gray compared with black and white scanned print.
Displays 1994;15:27–30.
19. Sheedy JE, Kang JM, Ota WT. Vertical eye gaze position: effect on
task performance and visual comfort. In: Sheedy JE, Shaw-McMinn
P, eds. Diagnosing and Treating Computer-Related Vision Prob-
lems. Boston: Butterworth-Heinemann; 2002;190–1.
20. Wilkins AJ, Nimmo-Smith I, Slater AI, Bedocs L. Fluorescent light-
ing, headaches and eyestrain. Lighting Res Tech 1989;211:11–8.
21. Toda I, Fujishima H, Tsubota K. Ocular fatigue is the major symp-
tom of dry eye. Acta Ophthalmol (Copenh) 1993;71:347–52.
22. Sheedy JE, Parsons SD. The Video Display Terminal Eye Clinic:
clinical report. Optom Vis Sci 1990;67:622–6.
23. Aaras A, Horgen G, Bjorset HH, Ro O, Thoresen M. Musculoskeletal,
visual and psychosocial stress in VDU operators before and after multi-
disciplinary ergonomic interventions. Appl Ergon 1998;29:335–54.
24. Watten RG. Reinvention of visual fatigue: accumulation of scientific
knowledge or neglect of scientific history? Ophthalmic Physiol Opt
1994;14:428–32.
25. Collins MJ, Brown B, Bowman KJ, Carkeet A. Vision screening and
symptoms among VDT users. Clin Exp Optom 1990;73:72–8.
26. Neugebauer A, Fricke J, Russmann W. Asthenopia: frequency and
objective findings. Ger J Ophthalmol 1992;1:122–4.
27. Sheedy JE, Truong SD, Hayes JR. What are the visual benefits of
eyelid squinting? Optom Vis Sci 2003;80:740–744.
 Is all Asthenopia the Same?—Sheedy et al. 739
28. Bandeen-Roche K, Munoz B, Tielsch JM, West SK, Schein OD. 36. Grisham JD. Visual therapy results for convergence insufficiency: a
Self-reported assessment of dry eye in a population-based setting. literature review. Am J Optom Physiol Opt 1988;65:448–54.
Invest Ophthalmol Vis Sci 1997;38:2469–75. 37. Grisham JD. Treatment of binocular dysfunctions. In: Schor CM
29. Donnenfeld E, Thimons JJ. How to ease the symptoms of dry eye in and Ciuffreda KJ, eds. Vergence Eye Movements: Basic and Clinical
computer users. Review Optom 1999;June 15:85–92. Aspects. Boston: Butterworths, 1983;605–46.
30. Lemp MA, Chacko B. Diagnosis and treatment of tear deficiencies. 38. Daum KM. Accommodative insufficiency. Am J Optom Physiol Opt
In: Duane DT, Tasman W, Jaeger EA, eds. Duane’s Clinical Oph- 1983;60:352–9.
thalmology, Vol 4. Philadelphia: Lippincott, 1994:chapter 14. 39. Tyrrell RA, Leibowitz HW. The relation of vergence effort to reports
31. Rupp BA, Greeson JC. Eyeball surface area as a function of gaze of visual fatigue following prolonged near work. Hum Factors 1990;
declination angle. Insight 1995;17:5–7. 32:341–57.
32. Lockhart RD, Hamilton GF, Fyfe FW. Anatomy of the Human
Body, 2nd ed. Philadelphia: Lippincott, 1969;472.
James Sheedy
33. Patel S, Henderson R, Bradley L, Galloway B, Hunter L. Effect of
visual display unit use on blink rate and tear stability. Optom Vis Sci
The Ohio State University
1991;68:888–92. College of Optometry
34. Tsubota K, Nakamori K. Dry eyes and video display terminals. 320 West Tenth Ave.
N Engl J Med 1993;328:584. PO Box 182342
35. van den Berg TJ. On the relation between glare and straylight. Doc Columbus, OH 43218
Ophthalmol 1991;78:177–81. e-mail: sheedy.2@osu.edu

Optometry and Vision Science, Vol. 80, No. 11, November 2003