The Role of Digital Devices and Myopia

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August 1, 2024

By Monica Jong, PhD

As we navigate the digital landscape, understanding the nuanced relationship between digital devices and myopia is paramount.

In today’s technology-driven era, the extensive use of digital devices has become an integral part of daily life, revolutionizing the way we work, learn, and communicate. However, as the world becomes increasingly interconnected through screens, concerns are emerging about the potential impact of digital device use on eye health, particularly in relation to the global surge in myopia. 

Myopia is the leading cause of distance vision impairment with younger age of onset^1,2 and a rise in severity.³ The prevalence of myopia is on the rise worldwide, with projections indicating that half of the global population may be affected by 2050.³ The advanced form of myopia, high myopia, has been linked to a higher risk of sight-threatening ocular conditions such as myopic macular degeneration, glaucoma, cataract, and retinal detachment.^4-6 Environmental risk factors such as insufficient time spent outdoors and increased engagement in near-vision activities including the use of digital devices have been identified as significant contributors to the myopia epidemic.^7,8  

Digital Devices and the Possible Risk for Myopia
As digital devices become ubiquitous in our lives, the question arises: could their usage be contributing to the escalating myopia epidemic? 

Two recent meta-analysis studies explored the association between digital device use and the risk for myopia to help better answer the question for patients and parents.^9,10 Wang et al. found that there was no significant association, but a closer examination reveals limitations to the studies analyzed, including that most studies did not investigate smartphone and tablet use independently of other near-vision tasks.⁹  Smart devices, introduced over the past 15 years, may induce longer viewing durations and closer distances than traditional near-vision tasks.^11-13 A second systematic review and meta-analysis focused on studies with smart devices.¹⁰ Of the 35 studies evaluated, 11 with mixed findings were included in the final analysis. The analysis showed that smart devices used in combination with a computer were associated with myopia (odds ratio: 1.77, 95% CI: 1.28 – 2.45).¹⁰ A limitation of this meta-analysis is that most of the studies were done in Asian populations, hence, limiting the generalizability of findings to all populations. Despite this, when asked the question if screen time impacts myopia, the evidence-based answer is: “It may not have been directly demonstrated, but it may likely in the future.”

Promoting Digital Wellness
In response to the potential risks associated with prolonged digital device use, the 20/20/2 rule emerges as a practical guideline for myopia management, particularly in children.¹⁴ Klaver et al. recommend that for every 20 minutes spent on any near task, including digital device use, children should take at least a 20-second break as well as at minimum spend two hours outdoors daily.¹⁴ Not only does this provide a rest for the eyes, but it also encourages children to engage in outdoor activities. Outdoor experiences play a crucial role in myopia management by exposing the eyes to varying focal distances and daylight, factors associated with reduced myopia risk. Encouraging children to adopt the 20/20/2 rule not only promotes ocular health but also fosters a more active and balanced lifestyle, addressing both the digital and physical dimensions of well-being — something all practitioners should be able to embrace.

Digital wellness extends beyond the 20/20/2 rule and encompasses a holistic approach to mitigate the potential risks of digital device use. Additionally, understanding the distinct impact of various digital devices, such as smartphones and tablets, is crucial in developing targeted interventions. As children increasingly adopt digital devices at younger ages, exploring the effects of these devices on eye health in diverse populations is imperative. Installing apps on children’s devices to track real-time use and employing objective measurements of face-to-screen proximity, ambient light, posture, and viewing angle can enhance the precision of investigations.¹⁵ Apps on digital devices that monitor and alert children and their parents to develop good visual habits may play an increasing role in the future.¹⁵

Conclusion
As we navigate the digital landscape, understanding the nuanced relationship between digital devices and myopia is paramount. While the 20/20/2 rule offers a practical strategy for managing screen time, digital wellness practices and an early diagnosis and management of myopia are equally crucial. This evolving field of research calls for ongoing evaluation of the specific impact of different digital devices, which can provide insights that can then better inform policies, parenting practices, and education strategies. By adopting a comprehensive approach, we can pave the way for a healthier and more balanced integration of digital technology into our lives, safeguarding the visual health of current and future generations.

• Digital devices have yet to be shown to cause myopia.^8,9
• Prolonged digital screen use may be associated with developing myopia.^8,9 
• The ‘20/20/2 rule’ is easy for parents to remember and may be a useful strategy to minimize risk factors for myopia such as intense near work while encouraging more time outdoors.¹⁴
• The availability of sensor technologies on digital devices may be useful for promoting better near work behaviors in children and adolescents.¹⁵

 

Dr. Monica Jong serves as the Global Director of Professional Education, Myopia, at Johnson & Johnson Medtech, spearheading practitioner education worldwide to bolster evidence-based myopia management. Formerly, she held the position of Executive Director at the International Myopia Institute, where she played a pivotal role in co-founding the organization and leading the development of white papers and key initiatives aimed at fostering consensus in myopia management through collaboration with leading experts. Monica has contributed significantly to the field with numerous peer-reviewed articles in esteemed journals, placing her among the top 0.056% of authors in myopia. Additionally, she co-created the first global online education program in myopia at the Brien Holden Vision Institute and played integral roles in WHO meetings on myopia and the International Agency for the Prevention of Blindness (IAPB) Refractive Error Working group. With diverse experience in optometry across various settings, Monica is deeply committed to research, education, and mentorship. She has presented at over 400 global scientific and practitioner meetings and maintains a passion for physical fitness through practicing Muay Thai while spending time with her two children.

 

References 

1. Dirani M, Chan YH, Gazzard G, et al. Prevalence of refractive error in Singaporean Chinese children: the strabismus, amblyopia, and refractive error in young Singaporean Children (STARS) study. Invest Ophthalmol Vis Sci 2010; 51: 1348–55. https://doi.org/10.1167%2Fiovs.09-3587.
2. Chen Z, Gu D, Wang B, Kang P, Watt K, Yang Z, Zhou X. Significant myopic shift over time: Sixteen-year trends in overall refraction and age of myopia onset among Chinese children, with a focus on ages 4-6 years. J Glob Health. 2023 Nov 9;13:04144. http://doi.org/10.7189/jogh.13.04144.
3. Morgan IG, French AN, Ashby RS, et al. The epidemics of myopia: aetiology and prevention. Prog Retin Eye Res 2018; 62: 134–49. https://doi.org/10.1016/j.preteyeres.2017.09.004.
4. Holden BA, Fricke TR, Wilson DA, et al. Global prevalence of myopia and high myopia and temporal trends from 2000 through 2050. Ophthalmology 2016; 123: 1036–42. https://doi.org/10.1016/j.ophtha.2016.01.006.
5. Chua SY, Sabanayagam C, Cheung YB, et al. Age of onset of myopia predicts risk of high myopia in later childhood in myopic Singapore children. Ophthalmic Physiol Opt 2016; 36: 388–94. https://doi.org/10.1111/opo.12305 
6. Wong TY, Ferreira A, Hughes R, Carter G, Mitchell P. Epidemiology and disease burden of pathologic myopia and myopic choroidal neovascularization: an evidence-based systematic review. Am J Ophthalmol 2014; 157: 9–25. https://doi.org/10.1016/j.ajo.2013.08.010.
7. Pan CW, Ramamurthy D, Saw SM. Worldwide prevalence and risk factors for myopia. Ophthalmic Physiol Opt 2012; 32: 3–16. https://doi.org/10.1111/j.1475-1313.2011.00884.x.
8. Lyu Y, Zhang H, Gong Y, et al. Prevalence of and factors associated with myopia in primary school students in the Chaoyang District of Beijing, China. Jpn J Ophthalmol 2015; 59: 421–29. https://doi.org/10.1007/s10384-015-0409-x.
9. Wang J, Li M, Zhu D, Cao Y. Smartphone Overuse and Visual Impairment in Children and Young Adults: Systematic Review and Meta-Analysis. J Med Internet Res. 2020 Dec 8;22(12):e21923. http://doi.org/10.2196/21923.
10. Foreman J, Salim AT, Praveen A, Fonseka D, Ting DSW, Guang He M, Bourne RRA, Crowston J, Wong TY, Dirani M. Association between digital smart device use and myopia: a systematic review and meta-analysis. Lancet Digit Health. 2021 Dec;3(12):e806-e818. http://doi.org/10.1016/S2589-7500(21)00135-7. 
11. Cuéllar JM, Lanman TH. “Text neck”: an epidemic of the modern era of cell phones? Spine J. 2017 Jun;17(6):901-902. http://doi.org/10.1016/j.spinee.2017.03.009.
12. Bababekova Y, Rosenfield M, Hue JE, Huang RR. Font size and viewing distance of handheld smart phones. Optom Vis Sci. 2011 Jul;88(7):795-7. http://doi.org/10.1097/OPX.0b013e3182198792. 
13. Enthoven CA, Polling JR, Verzijden T, Tideman JWL, Al-Jaffar N, Jansen PW, Raat H, Metz L, Verhoeven VJM, Klaver CCW. Smartphone Use Associated with Refractive Error in Teenagers: The Myopia App Study. Ophthalmology. 2021 Dec;128(12):1681-1688. http://doi.org/10.1016/j.ophtha.2021.06.016. 
14. Klaver CCW, & Polling JR; Erasmus Myopia Research Group. Myopia management in the Netherlands. Ophthalmic Physiol Opt 2020; 40: 230–240. https://doi.org/10.1111/opo.12676
15. Wang J, Shen Y, Zhao J, Wang X, Chen Z, Han T, Huang Y, Wang Y, Zhao W, Wen W, Zhou X, Xu Y. Algorithmic and sensor-based research on Chinese children’s and adolescents’ screen use behavior and light environment. Front Public Health. 2024 Feb 22;12:1352759. http://doi.org/10.3389/fpubh.2024.1352759.

This article is sponsored by Johnson & Johnson Vision.

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