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| ORIGINAL ARTICLE |
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| Year : 2022 | Volume
: 4
| Issue : 1 | Page : 51 |
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DES epidemic during COVID-19 crisis: A cross-sectional survey to emphasize education regarding ocular health
Alka Tripathi1, Richa Agarwal1, Pradip Kharya2, Imran Ahmed Khan3
1 Department of Ophthalmology, All India Institute of Medical Sciences, Gorakhpur, Uttar Pradesh, India
2 Department of Community Medicine and Family Medicine, All India Institute of Medical Sciences, Gorakhpur, Uttar Pradesh, India
3 Department of Community Medicine, BRD, Medical College, Gorakhpur, Uttar Pradesh, India
| Date of Submission | 15-Sep-2022 |
| Date of Decision | 07-Oct-2022 |
| Date of Acceptance | 17-Oct-2022 |
| Date of Web Publication | 22-Nov-2022 |
Correspondence Address:
Alka Tripathi
All India Institute of Medical Sciences, Kunraghat, Gorakhpur - 273 008 Uttar Pradesh
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/pajo.pajo_49_22
Purpose: The use of ergonomic practices and ergonomic environment should be encouraged to combat digital eye strain (DES) symptoms.
Objectives: The objective of the study was to assess the effect of online classes on ocular health of school-going children during COVID-19 crisis.
Materials and Methods: An online pretested, self-reported questionnaire with relevant details was generated through Google Forms and sent to participants.
Results: The most common symptoms associated with DES in our study were eyestrain, 27.4% (N = 82), and headache, 26.8% (N = 80) (P = 0.001). There was a positive correlation of number and frequency of symptoms with increasing age and class standard of participants (P = 0.001), usage of multiple screens as well as smartphones (P = 0.004), the time spent on digital screen (P = 0.00), and continuous screen time (P = 0.004). Increasing screen distance had a negative correlation to number and frequency of symptoms (P = 0.03).
Conclusion: COVID-19 pandemic has bought DES once again into limelight due its implications on overall physical, mental, and social health of adults as well as children. It is high time for a coordinated approach to spread education and promotion of ocular health in the community with emphasis on reduction of screen time, inculcation of ergonomic practices, and role model behavior of parents. This survey also gives an insight on the measures needed to be taken for safety of our children's ocular health, and therefore, it would reduce the stress faced by their parents.
Keywords: COVID-19, digital eye strain, online classes, risk factors, students
How to cite this article:
Tripathi A, Agarwal R, Kharya P, Khan IA. DES epidemic during COVID-19 crisis: A cross-sectional survey to emphasize education regarding ocular health. Pan Am J Ophthalmol 2022;4:51 |
How to cite this URL:
Tripathi A, Agarwal R, Kharya P, Khan IA. DES epidemic during COVID-19 crisis: A cross-sectional survey to emphasize education regarding ocular health. Pan Am J Ophthalmol [serial online] 2022 [cited 2023 Sep 29];4:51. Available from: https://www.thepajo.org/text.asp?2022/4/1/51/361717 |
| Introduction | |  |
The term “digital eye strain” (DES)[1] involves a group of ocular and nonocular symptoms among the users of visual display units; of those, ocular symptoms are more common. The most common ocular symptoms are tearing, tired eyes, blurred vision, burning sensation, redness, and double vision. Nonocular symptoms are mainly headache and those of musculoskeletal involvement (stiff neck, general fatigue, and backache). The prevalence of symptoms due to DES is estimated to range from 25% to 93%, as reported by various investigators.[2],[3],[4] In this era of digitalization, children are exposed to gadgets from a very early age, and the injudicious use of smartphones, iPads, and tablets may contribute toward the rising prevalence of eye strain in this vulnerable population.[5],[6]
COVID-19 pandemic has caused widespread school closures from March 2019, and children across the country are forced to live in confinement for an indefinite time. With encroaching threat of the third wave which is supposed to be targeting mainly the children,[7] learning through Google Classroom, Zoom, and podcasts is the need of the hour and has been accepted wholeheartedly by the entire world. While parents and teachers are adjusting to this whole new scenario, it is also important to help kids stay focused on learning and avoid the overuse of games, social media, and videos. Most schools are organizing back-to-back classes without adequate breaks; as a result, children are exhausted soon and complaining of tired eyes. The light emitted from the digital screen can strain children's eyes and could lead to vision problems throughout their lives. Watching a screen is also a passive activity that can make children lethargic and affect their thinking skills. Both prolonged near work and decreased outdoor activities can also increase myopic progression in children.[8] These factors have increased tremendously in the ongoing pandemic and are of grave concern. Online teaching is a very useful learning tool, but it has to be incorporated judiciously considering both pros and cons of the digital screen usage. While e-learning platforms have come as a relief for the education sector, especially amid the pandemic, students and parents are complaining that their screen time has surged, and therefore, they are increasingly dealing with issues like eye strain. This online survey mainly focuses on these issues and also awareness regarding ocular health. The aim of the study was to assess the effect of online classes on ocular health of school-going children during COVID-19 crisis.
| Materials and Methods | | |
It was an online cross-sectional survey of school-going students attending online classes. All parents/guardians/caretakers of school-going children attending online classes (class LKG to class 12) and those who could understand the purpose of survey as written in English language and willing to give consent participated in the survey. Sample size was calculated using the formula n = z2 [P × (1 − P)/d2], considering 25% prevalence of DES found in a recent study.[2] Ten percent of calculated sample size in addition was taken into consideration of incomplete response, and therefore, sample size came out to be 317. Snowball technique/chain sampling technique (nonprobability technique) where existing study participants recruit future participants from among their acquaintances with the help of online platform (that means participants will be free to forward the online questionnaire to other eligible parents/guardians/caretakers) was used. An online self-reported questionnaire with relevant details was generated through Google Forms [Supplementary Material 1]. The link to the survey form was circulated through various online platforms such as E-mail, WhatsApp, and other social media accounts to different known contacts of the investigators throughout the country. All the responses received within the time frame of 1 month were included in the study. The self-administered questionnaire generated online had details such as sociodemographic details, number of days for online classes, number of hours spent on digital screen, frequent digital screen used, common complaints after class, measures taken to overcome strain, satisfaction level with online classes, and also the stress associated with it. Participants having congenital eye disease, suffering previous eye trauma, and other pre-existing disease of eye were excluded. The institutional ethics clearance was taken before the start of the study. Data collected from the survey form were first downloaded in the Excel spreadsheet, and then, IBM SPSS Statistical Package for the Social Sciences, Chicago (Ill., USA) (latest version). was used for further analysis. Chi-square or Fisher's exact test was used to investigate the associations between the qualitative variables as per need. The associated risk factors of number and frequency of ocular health problems were analyzed by univariate and multivariate logistic regression with age, gender, device used (Smartphone, desktop, laptop/tab/multiple devices), viewing distance, and duration of screen use. P < 0.05 was considered statistically significant.
| Results | | |
A total of 350 responses were collected between April 2021 and May 2021, out of which 299 responses were found valid. 47.8% (N = 143) were female participants and 52.2% (N = 156) were male. Maximum 49.8% (N = 148) of participants were of age group 4–8 years, and 44.8% (N = 134) students belonged to primary school group grade.[1],[2],[3],[4],[5] The demographic characteristics and details of digital device usage are given in [Table 1]. | Table 1: Demographic characteristics of participants and details of digital device usage
Click here to view |
The most common symptoms associated with digital screen use in our study were eyestrain, 27.4% (n = 82), and headache, 26.8% (n = 80) [Figure 1]. Some, 12.4% (n = 37), complained of fatigue/pain, 18.1% (n = 54) suffered from frequent blinking of eyes/dry eyes, 27.1% (n = 81) from eye redness, irritation, and watering, 11.7% (n = 35) had backache/neck pain, while 37.4% (n = 112) had no symptoms. The prevalence of DES in our study was 62.5% (187/299). | Figure 1: Percentage of DES symptoms as experienced by children. DES: Digital eye strain
Click here to view |
Survey about frequency of the ocular problems revealed that 33.4% (n = 100) had symptoms occasionally (occasional/once in a week or 2 weeks), 29.8% (n = 89) often (everyday/2–3 times in a week), while 36.7% (n = 110) of participants gave consensus that they never had remarkable ocular symptoms [Figure 2]. | Figure 2: Percentage of children with the different grades of digital eye strain
Click here to view |
There was a positive correlation of number and frequency of symptoms with increasing age and class standard of participants (P = 0.001), usage of multiple screens as well as smartphones (P = 0.004), the time spent on digital screen (P = 0.00), and continuous screen time (P = 0.004). Increasing screen distance had a negative correlation to number and frequency of symptoms (P = 0.03).
Impact of online classes
About 71.57% (n = 214) of participants agreed to the fact that their child did not have similar complaints earlier after watching the digital screen, and among those who had complaints earlier, common symptoms were also headache, 17.2% (n = 29), and eyestrain, 21.9% (n = 37) [Figure 3]. | Figure 3: Comparative data of DES symptoms as experienced by children in pre- and post-COVID-19 period. DES: Digital eye strain
Click here to view |
Awareness regarding digital eye strain
Maximum 59.5% (N = 178) of participants opted for taking break in between classes as a common remedy they advise for their child to suffice his/her problems, 43.5% (n = 130) opted for limiting the hours of screen use, while 50.5% (n = 151) of participants used nonspecific measures (washing eyes with water) or no measures at all [Figure 4]. | Figure 4: Measures used to alleviate DES symptoms. DES: Digital eye strain
Click here to view |
Majority (79.5%; n = 238) of participants agreed that online classes are causing harm to their child's eyes, and 62.5% (N = 187) of participants were of the view that problems faced by their child were giving them stress.
| Discussion | | |
In the COVID-19 pandemic, the ocular problems such as DES and myopia progression have increased by leaps and bounds. The e-learning methodology adopted by the schools is the absolute necessity, but children now spend an average of 8–12 h a day on some form of digital device.[9] The prevalence of DES in our study was 61.8%, which is on a higher side. It is an alarming situation as children are the future of the nation and their overall health is the joint responsibility of teachers, parents, eye practitioners, and policymakers.
The most common symptoms associated with digital screen use in our study were eyestrain, 27.4%, and headache, 26.8%, which is similar to findings by Reddy et al.[10] Headache and eye strain are interrelated and could be due to uncorrected refractive error, excessive glare, or improper viewing distance.
In our study, around 50% of participants were adolescents (>9 years), and DES symptoms were associated more with increasing age and higher class standard. A study by Dubey et al.[11] in Indian population revealed that 68% of adolescents have screen time for more than 2 h. Adolescents are more active on social media and have more inclination toward video games, apps, and internet surfing which might lead to increasing screen time as well as symptoms of DES.
Maximum number of participants in our study used smartphone, 45.4% (n = 136), and 20.4% (n = 61) used multiple devices. Smartphone and use of multiple devices concurrently (dual or triple screening) cause an increase in DES symptoms such as headaches, eyestrain, and sore eyes as found in our study. Decreased blink rate, increased use of accommodation and convergence as well as shorter viewing distance of smartphones have been found to be causative factors for DES.[12] The acute effect of blue light emitted from the digital devices on eye has been inconclusive; however, there is a lack of high-quality research about how the blue light from these devices might impact our eyes over the long term.[13] DES is directly related to the duration of screen time as found in several studies, which is in concordance with our survey results. In a study by Shah et al.[14] in rural western India, it was found that more than 80% of children surpassed their recommended screen time. The American Academy of Pediatrics guidelines discouraged screen time for children under age 2 and recommended limiting “screen time” to 2 h a day for children over age 2.[15] They also emphasized to focus more on digital etiquette, setting limit at a younger age, and advice to parents for cutting short their own personal digital media use (or overuse) as model behavior. A systematic review by Neza Stiglic et al. highlighted the association between screen time and adiposity/obesity, unhealthy diet, anxiety as well as depressive symptoms and poor quality of life.[16] A meta-analysis by Huang et al.[8] concluded that there is an 80% higher risk of having myopia in individuals doing near work such as reading, using a computer, or watching TV. Increased screen time and reduced outdoor activities due to COVID-19 restrictions have led to almost 400% increase in the prevalence of myopia in 2020, also known as “quarantine myopia.”[17]
Ideal distance of digital screen from an individual should be around 25 inches (arm's length) as suggested by the American Academy of Ophthalmology (AAO).[18] Visual strain on working at digital screen is stronger at 50 cm compared to100-cm distance due to increase in load on accommodation and convergence of the eye as reported by Jaschinski-Kruza et al.[19] Our survey results also pointed out that participants with increased viewing distance had less DES symptoms. Taking frequent breaks during the usage of digital device is proposed as a common remedy to alleviate symptoms of DES. However, Reddy et al.[10] suggested that taking frequent breaks alone was not very useful, but looking at far objects during breaks was associated with decrease in DES symptoms. The 20/20/20 strategy (after 20 min of digital screen use, focus at objects over 20 feet away for 20 s) is recommended by most of the researchers for management of DES.[20] In our survey too, the participants with continuous screen exposure had a greater number of symptoms (r = 0.12).
In our survey, there were questions pertaining to awareness of DES spectrum as well as use of protective measures to combat the problem. 56.2% (n = 168) of participants did not use any protective measure, and association between the use of protective measures and DES symptoms was not found to be significant (P = 0.76). Shantakumari et al.[21] stated that the use of screen filters causes less DES; however, Scullica et al.[22] and Reddy et al.[10] found that screen filters have no role in reducing DES. The AAO[23] does not recommend any eyewear for computer use due to lack of any scientific evidence. A recent study by Singh S et al.[24] reported that blue-blocking lenses have no role in management of DES although many researchers encourage its use.[25] However, ergonomic practices such as use of appropriate lighting in room, adjusting digital screen parameters (resolution, text size, contrast, and luminance), and taking frequent breaks have been found to be effective in reducing DES symptoms.[26],[27] In our study, 59.5% (N = 178) of participants opted for taking break in between classes as a common remedy for DES; however, around 50.5% (n = 151) of participants used nonspecific (washing eyes with water) or no measures at all.
Limitation
It was a questionnaire-based survey, so obvious limitations were: (i) recall bias, (ii) almost 50% of participants belonged to <9-year age group, and this could question their credibility (desirable answers rather than the true answers), (iii) online platform and questions in English language could confine the survey to educated masses, (iv) undiagnosed refractive error and other ocular surface disorders could not be ruled out as no objective assessment was done. Although the study had several limitations, still it gives an idea about the burden of disease (DES) and its management. Our study targeted <18 years' children who are very vulnerable, and very few research has been done in this potentially at-risk population which makes our study unique and one of its kind.
| Conclusion | | |
DES is a very well-known entity around the globe and multiple researches have been done regarding its symptomatology and management. However, COVID-19 pandemic has again bought DES into limelight due its implications on overall physical, mental, and social health of adults as well as children. It is high time for a coordinated approach for education and ocular health promotion in the community with emphasis on reduction of screen time, inculcation of ergonomic practices, and role model behavior of parents. The “PRAGYATA” guidelines, for digital education introduced by HRD Minister of India,[28] recommend that online classes for preprimary students should not be for more than 30 min. Two online sessions of up to 30–45 min each should be conducted for classes 1–8 and four sessions for classes 9–12. The caregivers should be vigilant enough to assess their child problems and consult an ophthalmologist even on the slightest doubt. Our study proposes regular eye screening of school-going children even at the community level as gadgets nowadays are easily accessible to children living in rural area. Screens are recommended to be 10–20 below eye level, viewing distances of 35–40 inches for computers and >40 cm for smartphones, adjusting the background illumination to decrease glare and reflection, antiglare filters, protective computer eyewear, and appropriate posture.[29],[30] The role of 20–20–20 rule, limiting screen time to <4 h, and physical activity should be emphasized for well-being of children.
Acknowledgment
The authors are grateful to volunteers who participated in the study.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| Supplementary File | | |
Supplementary Material 1
Impact of online classes on ocular health during COVID-19 crisis
The COVID-19 pandemic has threatened the humanity at a global level to a large extent by the burden of the disease with significant mortality and to a certain extent as a byproduct of the necessary efforts to contain the same. In India, the country was in a complete lockdown since 25th March, and then, there has been a phasic opening up of various necessary commodities. The schools and colleges have been completely closed till date, and online classes have taken the driver seat in the form of e-learning. While e-learning platforms have come as a relief for the education sector, especially amid the pandemic, students and parents are complaining that their screen time has surged, and therefore, they are increasingly dealing with issues like eye strain. This questionnaire mainly focuses on these issues and also awareness regarding ocular health.
Filling the form will take approximately 5–10 min.
*Required
Consent
Parent/Guardian has to fill the form; you can fill separate form for each of your child attending the online class.
1. Knowing and understanding the purpose of survey, are you willing to participate in the survey and give your consent for use of information given by you in understanding the eye problems faced by children due to online classes during covid-19 crisis *
Mark only one oval.
{INLINE:1] Yes
{INLINE:1] No
DEMOGRAPHIC PROFILE
2. Age of the child*
Mark only one oval.
{INLINE:1] 4-8 years
{INLINE:1] 9-13 years
{INLINE:1] 14-18 years
{INLINE:1] >18 years
3. Gender of the child*
Mark only one oval.
{INLINE:1] Male
{INLINE:1] Female
4. Class/standard in which the child is studying *
Mark only one oval.
LKG, UKG
Primary school (class1-5)
Middle school (class 6-8)
Senior school (class 9-12)
5. What is your relationship with the child?
Mark only one oval.
Father
Mother
Grandparent
6. How would you describe the area in which you are living *
Mark only one oval.
Urban
Suburban
Rural
Other: __________________________________________
7. What is the highest educational level completed by the person filling the form? *
Mark only one oval.
Profession or Honors
Graduate
Intermediate or diploma
High school certificate
Middle school certificate
Primary school
Certificate illiterate
Other: __________________________________________
8. Occupation of the person filling the form
Mark only one oval.
Legislators, Senior Officials, & Managers
Professionals
Technicians and Associate Professionals
Clerks
Skilled Workers and Shop & Market Sales
Workers Skilled Agricultural & Fishery workers
Craft & Related Trade Workers
Plant & Machine Operators and Assemblers Elementary Occupation
Unemployed
Other: __________________________________________
9. Who is accompanying the child during online classes *
Check all that apply.
Mother
Father
Sibling (sister/brother)
Other: __________________________________________
Skip to question 10
QUESTIONNAIRE
10. Is your child on any medication/undergone surgery for any ocular problem (acute/chronic/congenital)? *
Mark only one oval.
Yes
No
11. If yes, please specify
__________________________________________
12. Does your child have any h/o eye allergy (acute/seasonal/chronic)? *
Mark only one oval.
Yes
No
13. Does your child wear glasses? *
Mark only one oval.
Yes
No
14. Does your child use a contact lens? *
Mark only one oval.
Yes
No
15. What is the number of days for online classes per week? *
Mark only one oval.
<3 days
3-5 days
>5 days
16. What is the frequent digital screen on which your child is attending the online class? *
Check all that apply.
Ordinary computer
Screen/desktop laptop
Tablet/iPad/note
Smartphone
Other: __________________________________________
17. What is the number of hours the child is spending on a digital screen per day? *
Mark only one oval.
<2 hours
2-4 hours
>4-6 hours
>6 hours
18. Has the screen time of your child increased during the COVID-19 crisis? *
Mark only one oval.
Yes
No
19. The hours your child spends on digital screen are?
Mark only one oval.
Continuous
Interrupted
20. Does your child use any precaution/special arrangement like blue filter/plain glass/room lights/brightness of the screen while attending the online class? *
Mark only one oval.
Yes
No
21. If the answer of the above question is yes, please mention the measure taken-
Check all that apply.
Plain/antiglare glass
Screen filter
Increasing illumination of room
Decreasing screen brightness
Other: __________________________________________
22. What is the illumination of the room in which your child is studying?
Mark only one oval.
Good
Fair
Poor
23. What is the viewing distance of your child from the screen?
Mark only one oval.
Less than 25 cm
Within 25-40 cm
At an arm's distance
24. What is the common complaint of your child after online classes? *
Check all that apply.
Headache
Fatigue/pain
Frequent blinking of eyes/dry eyes
Blurred vision
Eye strain
Double vision
Eye redness and irritation
Watering Backache/neck pain
Vertigo/dizziness
No symptoms Other: __________________________________________
25. What is the frequency of the ocular problems as addressed by your child? *
Mark only one oval.
Almost everyday
Almost 2-3 times in a week
Once in a week
Once in 2 weeks
Occasionally
Never
26. Does your child earlier have similar complaints after watching the digital screen?
*
Mark only one oval.
Yes
No
27. If yes, what was the common complaint of your child after watching the digital screen?
Check all that apply.
Headache
Fatigue/pain
Frequent blinking of eyes/dry eyes
Blurred vision
Double vision
Eye strain
Eye redness and irritation
Watering
Back pain/neck pain
Vertigo/dizziness
Other: __________________________________________
28. Have the ocular problems faced by your child aggravated during the pandemic?
*
Mark only one oval.
Yes
No
29. If yes, what according to you can be a probable cause?
Check all that apply.
Nonavailability of medical care
Online classes
Increased screen time due to restriction of outdoor activities
Other: __________________________________________
30. What is the common remedy you advise for your child to suffice his/her problems? *
Check all that apply.
Take breaks in between classes
Frequent blinking of eyes
Wash your eyes with water
Keep your eyes closed for few seconds in
Between change your focus from near to far in
Between limit the hours of screen use
Have no idea of any measure
31. Are you using any eye drop/medication for the symptoms? *
Mark only one oval.
Yes
No
32. If yes, please mention the name of eye drop/medication (allopathic/ayurvedic/homeopathic preparation)?
33. Have you ever thought of consulting an eye specialist for your child's problems?
*
Mark only one oval.
Yes
No
Problem is not grave enough
34. Do you think that online classes are causing harm to your child's eyes? *
Mark only one oval.
Yes
No
35. Have the problems faced by your child giving you stress? *
Mark only one oval.
Yes
No
36. What is your satisfaction level with online classes in terms of learning for your child?
*
1-Not at all satisfied, 2-Slightly satisfied, 3-Moderately satisfied, 4-Very satisfied, 5-Completely satisfied
Mark only one oval.
1 2 3 4 5
Not at all satisfied Completely satisfied
37. Do you think that online classes could be a good alternative for classroom teaching? *
Mark only one oval.
Yes
No
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1]
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