[Downloaded free from http://www.jcor.in on Sunday, October 20, 2019, IP: 125.163.140.

185]

Commissioned Article

Computer vision syndrome: A review

Jatinder Bali, Naveen Neeraj1, Renu Thakur Bali2

Computers and mobile computing devices are being used by increasingly larger number of people today. This has led to Access this article online
an increase in the number of patients complaining about ocular and nonocular symptoms related to computer use. Eye- Website:
strain, tired eyes, irritation, burning sensations, redness of eyes, dry eyes, blurred, and double vision reported by the www.jcor.in
visual display unit users was termed “Computer Vision Syndrome” (CVS). It is a repetitive strain disorder characterized DOI:
by one or more of the following symptoms – eyestrain, eye fatigue, burning sensations, irritation, redness, blurred 10.4103/2320-3897.122661
vision, and dry eyes when associated with operating a computer and looking at a computer monitor in a temporal Quick Response Code:
association. CVS has a multifactorial causation. Several factors have been linked to symptoms. Many treatment
modalities have been described. Treatment needs to be tailored to the individual patient. However, a large body of
work is still required to uncover gaps in our understanding of the problem. A specially designed ocular examination
for computer users and associated counseling about the current good practices in computer use would go a long way
in preventing loss of productivity and morbidity from the condition.

Key words: Computer vision syndrome, management, pathophysiology, treatment

Computer use is becoming ubiquitous. The affordable prices, at a computer monitor is generally referred to as CVS. It is a
increased productivity, and social changes have led to computers repetitive strain disorder”[11] defined by the American Optometric
and mobile computing devices being used by a large proportion Association as the combination of eye and vision problems
of population. However, it has also led to increased number of associated with the use of computers [Table 1].[13]
patients complaining about ocular and nonocular symptoms.
Table 1: Four major catagories of symptoms in computer
The initial concern about use of visual display terminals (VDTs) vision syndrome
was centered around radiation, which included X-rays, optical,
radio frequency, very low frequency, and extremely low frequency Symptom Symptoms Possible causes
category
radiation.[1] No clear evidence of any negative effects on computer
users was found in most studies.[2] There were apprehensions of Asthenopic Eyestrain Binocular vision
adverse effects on pregnant women, which were found to be Tired eyes Accommodation
incorrect by evidence.[3] Sore eyes
Ocular surface- Dry eyes
An increased number of symptoms related to rheumatology, related Watery eyes
orthopedics, psychiatry, and ophthalmology emerged in
Irritated eyes
literature.[4-7] Somatic disorders, depression, and obsessions were
reported in increased frequency in computer users especially Contact lens problems
when the operating time was more than 30 hours per week and Visual Blurred vision Refractive error
the duration of usage more than 10 years. Eye-strain, tired eyes, Slowness of focus Accommodation
change
irritation, burning sensations, redness of eyes, dry eyes, blurred,
and double vision were reported by the visual display unit Double vision Binocular vision
users and termed “Computer Vision Syndrome” (CVS).[8-11] These Presbyopia Presbyopic
correction
symptoms appeared to increase as duration of VDT exposure
increased.[12] “The ocular complaints experienced by computer Extraocular Neck pain Computer screen
location
users typically include eyestrain, eye fatigue, burning sensations,
Back pain
irritation, redness, blurred vision, and dry eyes, among others.
Shoulder pain
The condition of a person experiencing one or more of these
ocular complaints as a result of operating a computer and looking
Blehm et al. categorized the symptoms in four major categories:
Asthenopic, ocular surface-related, visual, and extraocular.[11]
Department of Ophthalmology, Hindu Rao Hospital and NDMC Medical
College, Delhi, 1Department of Ophthalmology, Swami Dayanand
Hospital, Delhi, 2Department of Medicine, Deep Chand Bandhu Hospital,
The ocular factors leading to CVS have been grouped into two
Delhi, India
major areas:
Address for correspondence: Dr. Jatinder Bali, 55-D, Third Floor,
1. Inappropriate oculomotor responses and
DDA Flats, Kalidas Road, Gulabibagh, Delhi - 110 007, India.
E-mail: drjatinderbali@yahoo.com 2. Dry eye

Manuscript received: 09.09.2013; Revision accepted: 27.09.2013. When viewing near objects miosis, accommodation and

Journal of Clinical Ophthalmology and Research - Jan-Apr 2014 - Volume 2 - Issue 1 61

[Downloaded free from http://www.jcor.in on Sunday, October 20, 2019, IP: 125.163.140.185]

Bali, et al.: Computer vision syndrome

convergence take place. Prolonged work at computer terminals can cause muscular and ocular problems. Variation in posture
has been associated with changes in both relative accommodation while sitting behind the computers can improve the symptoms
and vergence.[14] subjects over-accommodated by an average of associated with CVS. Frequent breaks with computer use have
–0.50 to –0.75 diopter (D) when stimuli were placed at 40 cm been shown to increase comfort and relax the accommodative
and by –0.75 D to colored letters on a colored background in two system.[27] Taking a smaller break for 5-10 min more frequently is
different studies.[15,16] A high prevalence of exophoria, convergence better than taking a longer break every 2 or 3 hours.[28] A 10-15 min
insufficiency and low fusional convergence have been reported break from the computer is recommended for every continuous
among VDT workers. Near point of accommodation was measured 1-2 hours of computer use[4,29] but is supported by limited evidence.
for VDT users and nonusers in the beginning of the day at the start
Wiggins et al. reported that there was a significant increase in
of the week. It was measured again at the end of the day 4 days
the symptoms during the computer task if there was a residual
later. the accommodative amplitude was reported to be decreased
astigmatism of up to 1D. This is a common practice while
significantly for VDT users (by 0.69 D) than nonusers (0.18 D)
prescribing soft contact lenses. The authors suggested that toric
between the first examination and the second examination
lenses or spectacle overcorrection be used in these cases.[30] For
4 days later.[17] Another longitudinal study reported that subjects
hyperopic error and high myopic error it is suggested that both be
below 40 years of age who used VDTs lost more accommodative
corrected to produce a clear retinal image and reduce the retinal
amplitude than who did not.[18] It has been suggested that an
blur to reduce the ocular stimulus for accommodation.
inaccurate accommodative response (AR) during working at the
computer terminal or a failure to relax the AR at completion of Bilton has proposed a term ‘1,2,10’ (One to Ten) to describe
the near task is at the heart of the asthenopia experienced by the commonly used distances for the current electronic forms
the users. Blurred vision at near and difficulty to shift to distant of written communication. Mobile phones at a distance of one
gaze is a common complaint in CVS and accommodative infacility foot (about 30 cm), two feet (about 60 cm) to two and a half feet
was the most common oculomotor anomaly reported.[19,20] These for desktop devices and laptops, and 10 feet (about 3 meters) for
changes are transient and workers return to baseline values by the television screens.[31] This new wave of devices has smaller
the end of workday or week. Substantial losses have not been text sizes on smaller screens necessitating a change in the usual
reported in longitudinal studies when corrected for age changes. paradigms of prescriptions. Sheedy and Shaw Mc Minn suggest
that a reserve of three times the visual acuity be present for
The comparisons between near work and computer use have
comfortable near vision tasks. Translated into real terms the usual
shown that the differences between computer and hard-copy tasks
N9 newspaper print (6/19.2 letter) would need a visual acuity of
are not compelling. Wick and Morse using an infra-red optometer
at least 6/6.4 for comfortable, prolonged viewing.[32] The working
to measure the AR in emmetropes reported an increased lag of
distances reported by workers showed that the mean distance for
accommodation of 0.33D in VDT users compared with hard copy
the small screen devices (75% people preferring distances between
users.[21] Penisten et al. using dynamic retinoscopy could not
26 and 40 cm) was lower than for hard copy use.[33] This set of
demonstrate any significant differences in printed card, VDT, or
users would need a near prescription for the reduced distances
simulated computer display when the intraobserver variability
when presenting with asthenopia.
was taken into account.[22]
Visual performance is affected by a number of display
VDT use has been associated with a small and temporary
parameters, such as character size, structure, and style; and by
myopic shift of refraction. These shifts are so small that distant
image contrast and stability.[34] The images on VDTs and liquid
visual acuity is not affected. VDT users experienced a myopic shift
crystal display (LCD) screens are composed of tiny, bright spots
of about −0.12 D after the work period compared with no change
called pixels or horizontal lines called rasters. They collectively
of refractive error of typists in a cross-sectional study.[23] Transient
form images. These images blur at the edges and lack sharp edges
myopia was reported by Luberto et al. in 20% of VDT workers at
that the printed word has. The effect is of a blurred image of hard
the end of their work shift.[24] Interestingly, all subjects exhibiting
print, which is not seen blurred because of the speed at which it
myopic change complained of asthenopia, but only 32.5% of those
is refreshed or rewritten on the screen by the beam of signals. The
with asthenopia demonstrated the transient myopic shift. This
larger the number of dots or lines displayed on a monitor to make
clearly shows that other factors are at work in the symptomatology.
the picture, the sharper and clearer is the appearance of the image.
Objective evidence is not available in the literature to suggest that
Blurred images are known to cause stimulation of accommodation.
the transient myopia acquires permanence over time or prolonged
In the case of VDT it is proposed that there is an understimulation
use when compared with other forms of near work. Standing
of accommodation resulting in a lag of accommodation behind
up, moving away, and looking away from the computer can help
the image on the screen.[35] Ziefle studied search reaction times
reduce ocular symptoms and also neck, back, and shoulder pain.
and fixation durations at resolutions of 62 dots per inch (dpi)
Levy et al. proposed an hourly break while others suggested it to
and 89 dpi and found that both increased significantly when the
be split inside of the hour up to three times. The idea remains that
resolution was lower. Visual fatigue correlated positively with
a frequent work break is taken to avoid repetitive stress disorder.[25]
search reaction times and fixation duration.[36] Conventional
In a study on 291 professional computer users, Telles et al. reported
reading differs from digital form in that the latter is dependent
that yoga practice appeared to reduce visual discomfort, while the
on “Pixels”, which result from an electron beam striking the
group who had no yoga intervention (WL) showed an increase in
phosphor-coated rear surface of the monitor screen. The pixel
discomfort at the end of 60 days.[26]
is brightest in the center and its brightness decreases toward
Maintaining a single posture over an extended period of time the outer edges unlike the print form of the word, which has

62 Journal of Clinical Ophthalmology and Research - Jan-Apr 2014 - Volume 2 - Issue 1

[Downloaded free from http://www.jcor.in on Sunday, October 20, 2019, IP: 125.163.140.185]
Bali, et al.: Computer vision syndrome
complete contrast sensitivity till the edge and fades to white next
to it. The eyes accommodate well to printed texts due to well-
defined edges. They have difficulty in sustaining focus on pixels
due to blurred margins. It relaxes to a point called resting point
of accommodation (RPA), which is normally 67 cm or behind the
screen. Then the eyes again try to focus on the pixels and a vicious
cycle starts, keeping the accommodation in a dynamic state. It
becomes more visually demanding and even small uncorrected
refractive errors become significant in computer users.
The refresh rate of a monitor refers to the number of times the
screen is painted to make an image every minute. It is measured in
Hz (times per second). Critical fusion frequency (CFF) is the refresh
rate at which humans can no longer distinguish the pulsating
beams of light as separate entities (30-50 Hz). At low refresh rates,
the characters on the screen may appear to flicker. This results
in subjective complaints of irritation, fatigue, and headache.
Berman et al. identified a synchronous electroretinogram (ERG)
response for a VDT stimulus operating at 76 Hz.[37] Other studies
also indicate that at higher refresh rates the image blur is reduced,
blink interval is decreased, and reading speed also increases.[35,38,39]
VideoElectronic Standards Association (VESA) had recommended
a minimum refresh rate of 75 Hz that minimizes flicker at all
brightness levels.[37] In today’s scenario, the upper end of refresh
rates on most high end light emitting diode (LED) LCD monitors
range from 125 to 250 Hz. Therefore this may be set to at least
80 Hz levels though on older cathode ray tube (CRT) cathode ray
tube monitors 60 Hz was a common frequency till not so long ago.
A positive correlation between associated phoria (AP) (prism
required to eliminate fixation disparity) and symptoms has been
reported by some studies in the past.[40,41] Watten et al. reported
significant decrease in positive and negative relative vergences
(vergence range) at near both at the beginning and end of an
8-hour workday. It implied that computer use decreased the
subjects’ ability to converge and diverge appropriately. [42]
However, Nyman et al. found no significant change in positive
or negative relative vergence at near, distance and near
heterophoria and near point of convergence (NPC) after 5 hours
of VDT work.[43] Yeow and Taylor found no difference between
VDT users and nonusers over 2 year period of the NPC, near
horizontal heterophoria and AP in the same office environment.
NPC declined with age in this study but no significant difference
was observed between the two groups.[18] Jaschinski reported that
near vision fatigue was associated with greater exophoria (or less
esophoria) fixation disparity as the target was brought closer to
the observer. It suggested that symptomatic subjects would tend
to prefer a longer viewing distance to minimize exophoric fixation
disparity.[44] In more recent studies, a slightly reduced vergence
response has been reported to increase subject comfort during
computer use. In a study on 20 subjects using laptop computers,
the AR to the computer screen was measured using a Grand Seiko
WAM 5500 optometer and the AP by prism to eliminate fixation
disparity, using a customized fixation disparity target (central lock)
that appeared on the computer screen. No significant changes
were reported in accommodation or vergence during the 30-min
test period. CVS symptoms were worse in subjects with zero
fixation disparity compared with subjects with exo AP thereby
implying that those who had exophoric fixation disparity at near
may be more comfortable than those with accurate vergence.[45]
Journal of Clinical Ophthalmology and Research - Jan-Apr 2014 - Volume 2 - Issue 1
Thus the minimum oculomotor response that places the image in
Panum’s fusional area may be more desirable than accurate ocular
alignment. This may have a bearing in the spectacle prescriptions
for computer users. However, larger studies are needed before this
can have direct clinical bearings on management.
Dry eye incidence of 10.1-21.5% among office workers have
been reported from different subgroups in Japan.[46] It is postulated
that dryness, burning, grittiness, or heaviness after an extended
session at the computer terminal may be attributed to ocular
surface problems. Users’ eyes sometimes even hyperlacrimate
in an attempt to restore the chemical balance and rewet the
eye.[11] Environmental factors like dry air-conditioned interiors,
draught from ventilation fans, static buildup, airborne paper, and
general office dust can have some bearing on the ocular surface
symptoms. The blink rate while working on the computer has
been reported to be significantly less than the normal. This leads
to poor tear film quality. Mean blink rate went down from 22 per
min in relaxed state to 10 per min when reading a book and 7
per min on the VDT in a study on 104 office workers.[47] However,
the tear film quality measured by tear breakup time, Schirmer I
and Jones tests was not significantly affected during computer
use.[48] Different blink patterns were described in symptomatic
patients but none of them has been proved in subsequent studies.
Blink rates have been found to decrease with reduced font size,
reduced contrast, increased cognitive demand of task, and spacing
between characters and lines.[6,49] Words with upper case and
lower case combinations are better tolerated than all upper-case
documents. It is recommended that spacing between characters
and lines should allow one-half character space between words
and one character space between lines. Dark characters against
a light background display screen are better accepted compared
to the opposite.[6] Application of elastoviscous drops has not
been associated with improvement of blink rates.[50] A study
of 112 noncontact lens using computer operators found that
68% men and 73% women reported symptoms of dry eye.[51] A
videokeratoscopy-based study has shown that the optical system
of the cornea is adversely affected by a compromised tear film.[52]
Ocular tiredness has been associated with ocular dryness in the
past.[53] Increased evaporation and decreased blinking during
computer use leads to ocular surface changes and thus was
believed to result in ocular tiredness.[47] The incidence of dry eye
has been reported to increase with age. The prevalence of dry eye
and is more common in women than in men.[54] Artificial tears may
be useful in this subgroup with dry eye conditions. Otherwise it
does nothing to reduce symptoms. Frequently, shifting gaze from
printed word to screen and vice versa is associated with eyestrain
and should be addressed.[55-57] Squinting was termed to imply
squeezing eyelids by Sheedy et al., and it was believed to reduce
the blink rate but recent studies have shown that symptoms were
less when squinting was used in laboratory conditions. Dry eye
has been reported to be a cause of eye strain and its associated
symptoms in a subset of patients.[32,58] Objective evidence is still
sketchy on the issue.
Incomplete blinks are common in computer use. A positive
correlation between the percentage of blinks considered incomplete
and the symptom score was found in recent studies.[55] Incomplete
blinking was associated with staining patterns in the inferior cornea
in some studies.[59] A higher incidence of incomplete blinks was
63
[Downloaded free from http://www.jcor.in on Sunday, October 20, 2019, IP: 125.163.140.185]
Bali, et al.: Computer vision syndrome
found with computer use as compared with hard copy of the same
task.[56,60] However, incomplete blinks are not altogether despicable.
It was found that voluntary blinking affected the concentration
on the task at hand. The partial blinks do not interrupt the
concentration on the task at hand as much as the complete blinks.[59]
Systemic diseases and systemic medications also have a
bearing on dry eye. Sjorgen’s Syndrome, rheumatoid arthritis,
collagen vascular diseases, thyroid disease, allergy, and
autoimmune disorders can have an effect on the symptoms and
dry eye. Drugs like diuretics, antihistamines, antipsychotics,
antidepressants, oral steroids, increased alcohol consumption,
and antihypertensives are associated with dry eye.[61] The ocular
condition is affected by the systemic conditions, systemic diseases,
and systemic medications. Thus all factors need to be taken into
account in assessing the patient’s symptoms.
Meibomian gland dysfunction is associated with evaporative
dry eye. This increases the symptoms reported with computer
use. Poorly applied cosmetics have similar effect by blocking the
openings of the meibomian glands.[11]
Bright illumination from large windows, over-head fluorescent
tubes, table lamps, and office lighting implements can wash out
screen character images and cause annoyance by reflection and
glare. Similarly sharp contrast between the illuminated computer
screen and hard copy written text leads to asthenopia. Glare was
found to increase the amount of time required to read relatively
easy passages but decreased the amount of time to read relatively
difficult passages.[62] For long it has been postulated that use of
antiglare filters can help alleviate the symptoms as the ambient
light passes through the glare filter two times (in and out) but the
light emitted from the monitor passes through the filter only once.
Conflicting reports on the intervention have been found. Some
small studies reported a benefit but one large study in the past
consisting of 25,064 volunteers showed that filters by themselves
did not reduce the occurrence of asthenopia.[63] The difference in
these studies was in the duration of use of the system. Most of these
studies used small times of work exposure. There was a significant
difference when the intervention was first adopted but over time
there was an adaptation to the use of filters. However, given the
fact that avoiding reflection and glare decreases annoying images, it
appears worthwhile to advocate the use of antiglare or screen filters.
Screen filters improved overall functional indices in schoolchildren
with myopia after half an hour of computer usage.[64] The accuracy
of work remains unaffected by use of screen filters. Blink rate is not
affected by use of screen filters. However, a larger body of work is
required before we can be sure of the benefits accruing from use of
antiglare screens or the type of spectral filters to employ.
It has been proposed that certain patterns of striped lines could
give rise to symptoms of eyestrain and this could be ameliorated
by use of colored lenses and overlays. Feigin et al. reported that
spectral filters in spectacles were of use.[65] However, conflicting
evidence emerged from other studies.[66,67] The studies are not
comparable because they employed different methods and
filters. Objective evidence in support of antireflective coating on
spectacles is thus limited even though they are frequently used
by computer professionals and prescribed by optometrists.
Contact lenses also show the effects of adaptation. Studies
64
revealed that use of contact lenses was associated with a higher
blink rate. York et al. examined the effect of contact lenses on
different tasks of varying difficulty. The blink rates decreased
with increasing level of difficulty. The mean blink rate was
more in the contact lens using group.[68] This effect was not
found by Pointer who allowed a one month adaptation period.
In his study, the task difficulty was the main factor deciding
blink rate.[69] However, contact lens wearers reported dry eye
symptoms 12 times more frequently than emmetropes and five
times more than spectacle users.[70] Workers on contact lenses
are more likely to suffer a higher severity of ocular discomfort.
The cause was believed to be lack of lubrication. However,
objective evidence shows that other factors may be at work,
which require more subtle tests to differentiate them from the
symptom free group. A major problem associated with contact
lens use is that the current practice of not correcting up to
1 D of astigmatism results in significant increase in symptoms.
This recommendation needs revisiting in light of the increased
amount of screen time. In borderline dry eye states the use
of soft lenses aggravates the symptoms experienced. Hence
correct patient selection is imperative when prescribing contact
lenses in computer users. Dry eye symptoms are more common
in contact lens wearers than in the general population.[71] In
a survey of U.S. eye care practitioners 18-30% of soft contact
lens wearers experienced symptoms of dry eye. The ocular
symptoms associated with dry eye varied in severity, frequency,
and intensity.[72]
Use of occupational glasses or computer glasses has been
described by some practitioners. [73] Independent objective
evidence is still not available from large studies. The use of
specialized presbyopia glasses (bifocal) has been described in
the past wherein the upper segment contained lenses focused
at the intermediate distance of the computer screen. However,
limited objective evidence limits their use. In addition the use of
laptops and mobile computing devices has changed the way we
look at the screens now.
Elastoviscous lubricating eye drops and eye ointments have
been prescribed to computer users frequently to alleviate dry eye
or as a placebo. Initially some studies reported that use of such
drops reduced the symptoms of CVS but this fact was refuted by
other studies later, which stated that the users were dissatisfied
with the therapeutic effects. Guillon et al. in their study on 20
subjects reported that use of povidone 2% preservative-free
eyedrops was associated with an improvement in symptoms
during sustained computer use.[74] Several studies based on
objective parameters have shown that topical instillation of
elastoviscous drops does not increase the blink rate. Acosta
et al. have reported that blowing a hot air stream onto the face
in the middle of playing a computer game did not increase the
blink rate.[75] In contrast, Portello et al. reported that increased
blink rate induced by using a metronome which is any software
or device that produces regular, metrical ticks or beats or clicks
during computer use did not result in difference in posttask
symptoms in computer users.[76] Looking down while reading a
mobile computing device reduces the exposed corneal surface and
negates the effect of reduced blinking rate. In desktop computers
this is not the case. Thus an evaporative dry eye condition can
occur. It was postulated that polyvinyl alcohol (PVA), dextran,
Journal of Clinical Ophthalmology and Research - Jan-Apr 2014 - Volume 2 - Issue 1
[Downloaded free from http://www.jcor.in on Sunday, October 20, 2019, IP: 125.163.140.185]
Bali, et al.: Computer vision syndrome
poly vinyl pyrollidine would be better in this subgroup rather
than carboxymethylcellulose. However, convincing objective
evidence is still awaited.[47]
Limiting the computer and screen time is postulated to have
a dramatic impact on symptoms of CVS. Other workers have
suggested the 20/20/20 rule. After working on a computer for 20
min the computer user should gaze into the distance in excess of
20 feet for at least 20 s. It is believed that this will improve the
work efficiency and prevent eye strain.[77,78] However, any break
from work is as good as this rule. In fact, moving around between
tasks reduces the musculoskeletal symptoms experienced.
However, objective evidence is still awaited. Children often do not
notice discomfort or other symptoms and hence their computer
use should be regulated.[77]
In the USA, National Institute of Occupational Safety and
Health (NIOSH) suggests that computer users should have a
detailed ocular examination at the beginning of taking up the
computing job and then repeat it annually.[79]
Suggestions about ergonomic positioning of the computer and
its chair include the following:[79-81]
Use the computer monitor in an ergonomic position - one arm
distance or 40 inches away with a downward gaze of 14° or more
appears to help relieve the symptoms of CVS.[79] This is achieved
by placing the monitor so that the top line of screen is at or below
eye level Figures 1 and 2.
Prefer to use a chair specially designed for computer use so
that it provides necessary support to the back, legs, buttocks,
and arms. It should help avoid awkward postures, contact
stress, and forceful exertions. A height adjustable lumbar
support can be appropriately placed to fit the lower back. The
outward curve of the backrest should fit into the small of the
back. The adjustment should allow the user to recline at least
15° from the vertical. The backrest should lock in place or be
tension adjustable to provide adequate resistance to lower back
movement. Use the keyboard in such a position that the arms
and wrist are in neutral position. Avoid screen reflections, glare
from window, or overhead lights.
According to Occupational Safety and Health Administration,
Figure 1: Incorrect monitor position
Journal of Clinical Ophthalmology and Research - Jan-Apr 2014 - Volume 2 - Issue 1
the preferred viewing distance is 20-40 inches and the letter size
may be increased for smaller monitors. In the older guidelines for
work with VDTs the safe distance from the computer screen was
between 45 and 70 cm. The monitor should be kept directly in front
of the user’s chair so that the head, neck and body face forward
when viewing the screen. It should not be farther than 35° to the
left or right. It is recommended that while working from printed
material, the monitor should be placed slightly to the side and the
printed material kept directly in front. The printed material and
monitor should be kept as close as possible to each other. Viewing
the computer screen from a distance (48.42 and 65.33 cm) causes
more accommodation and convergence among people working
with computers than those who do not work behind computer
screens.[82] Visual strain in computer users was reported to be more
at 50 cm than 100 cm with characters twice as large. Therefore a
longer distance is more favorable than the reverse.
Single-vision lenses with a focal length designed for computer
work are to be preferred over bifocals in symptomatic computer
users. Bifocal presbyopic glasses are designed for near work in the
lower segment of the glasses thereby forcing the users to view
the monitor by tilting the head backward to see an appropriately
placed monitor through the bottom portion of their lenses. This
stresses the neck muscles, improved lighting quality, screen
design, ergonomically designed keyboard and mouse, alternative
input methods like touch, speech, stylus, etc., may go a long way
in preventing the symptoms related to CVS and computer-related
injuries (CRIs).[57,83,84]
The monitor should not be tilted too much. Excessive tilting
may distort the letters and alter their form by affecting contrast.
The monitor should be perpendicular to line of sight.
Desks and computer equipment with hard, angled leading
edges impacting a user’s arm, or wrist should be avoided. The
contact stress can affect soft tissues, nerves and blood vessels
resulting in tingling and sore fingers. One way to overcome it
can be padding edges of the sharp edged furniture with pipe
insulation or other such material. Furniture with rounded desktop
edges should be preferred.[79-82]
Adjustable setups where different family members especially
children can modify the setup for themselves is preferable in
Figure 2: Correct monitor position
65
[Downloaded free from http://www.jcor.in on Sunday, October 20, 2019, IP: 125.163.140.185]
Bali, et al.: Computer vision syndrome
households having kids.
The lighting intensity should be half of normal room
illumination when computers are used. The brightness of the
monitor should be turned up to the levels of the surroundings.
Lighting requirements vary with tasks at hand. In general, lighting
levels between 200 and 700 lux (approximately 20-70 foot candles)
measured at the workstation are recommended. More than 500
lux will usually be needed only to read poor quality documents.
Glare and reflections on computer screens should be avoided.
An antiglare cover and use of flat screens has been advocated
by workers.[85]
Dust can affect clarity of screen and cause glare, so all
monitors or screens should be free of dust.[84] Avoid turning the
air conditioning too high or direct draughts to the face.
The spectacle prescription needs to be customized to the
individual for computer users taking into account the working
distance. Bifocals or progressives if not properly customized may
not be optimal for computer distances. The direction of gaze is
important when making decisions on spectacle prescription. In
desktops it is important to bear in mind that there is a straight
ahead gaze focused at intermediate range and the downgaze at
near working distance may have to be explained to the user. The
refocusing from screen to print and vice versa can be avoided by
document holders attached to the screen. But the prescription has
to be understood by the patient and the usage understood by the
prescriber. Laptops and mobile devices are used at closer distances
than the standard desktop. Hence the concept of working distance
is important. A study of 79 VDT users reported that computer
glasses reduced the symptoms over the 15-week period[83] but
larger studies are required.
The children have to be educated about how far they should sit
from the screens and for how long. They usually tend to adapt to
poorer working conditions and overlook somatic complaints.[86] A
large body of work is required to address gaps in our knowledge.
In the absence of large studies it is only reasonable to assume
that children should spend only as much time as is absolutely
necessary before the devices. This will address the epidemic of
childhood obesity also. At a later date, we may realize that our
fears were ill founded but till the time we have made technology
absolutely safe for the children we should progress with caution.
Conclusion
CVS is a repetitive stress disorder characterized by a symptom
complex of eye-strain, tired eyes, irritation, burning sensations,
redness of eyes, dry eyes, blurred, and double vision apart
from nonocular complaints like neck, shoulder, and back pain
experienced by computer users. Several factors have been linked
to these symptoms. Many treatment modalities have been
described in literature and still more in anecdotes. Objective
evidence favors a multifactorial causation. The treatment needs
to be tailored to the individual patient. However, a large body of
work is still required to uncover gaps in our understanding of the
problem. A specially designed ocular examination for computer
users and associated counseling about the current good practices
in computer use would go a long way in preventing loss of
productivity and morbidity from the condition. The computers of
66
today are like the automobiles at the beginning of the twentieth
century. A lot of work needs to be done to make them like the
comfortable and safe automobile rendering service on our roads
today. The current knowledge needs to be shared along with the
relevance and importance that it deserves. The ophthalmologists
need to approach the syndrome complex scientifically to educate
his patients to make best possible use of the digital systems, which
are here to stay in a big way.
References
1. Scalet EA. VDT health and safety: Issues and solutions. Lawrence,
KS: Ergosyst Associates; 1987.
2. Abelson MB. How to fight computer vision syndrome. Rev
Ophthalmol 1999;114-6.
3. Delpizzo V. Epidemiological studies of work with video display
terminals and adverse pregnancy outcomes (1984-1992). Am J Ind
Med 1994;26:465-80.
4. Wang W, Li C, Zhan C, Long Y.. Study on the psychological status
of video display terminal operator. Wei Sheng Yan Jiu 1998;27:233-6.
5. Collins MJ, Brown B, Bowman KJ.Visual discomfort and VDTs.
National Occupational Health and Safety Commission, Worksafe,
Australia, 1988. p. 1-37.
6. Costanza MA. Visual and ocular symptoms related to the use of
video display terminals. J Behav Optom 1994;5:31-6.
7. Dain SJ, McCarthy AK, Chan-Ling T. Symptoms in VDU operators.
Am J Optom Physiol Opt 1988;65:162-7.
8. Berg M, Bengt A. An occupational study of employees with VDT-
associated symptoms—The importance of stress. Stress Med
1996;12:51-4.
9. Bergqvist UO, Knave BG. Eye discomfort and work with visual
display terminals. Scand J Work Environ Health 1994;20:27-33.
10. Cole BL, Maddocks JD, Sharpe K. Effect of VDUs on the eyes: Report
of a 6-year epidemiological study. Optom Vis Sci 1996;73:512-28.
11. Blehm C, Vishnu S, Khattak A, Mitra S, Yee RW. Computer vision
syndrome: A review. Surv Ophthalmol 2005;50:253-62.
12. Travers PH, Stanton BA. Office workers and video display
terminals: Physical, psychological and ergonomic factors. AAOHN
J 2002;50:489-93.
13. American Optometric Association. Computer Vision Syndrome
(CVS). Available from: http://www.aoa.org/x5374.xml. [Last
accessed on 2011 Mar 21].
14. Trusiewicz D, Niesluchowska M, Makszewska-Chetnik Z. Eye-
strain symptoms after work with a computer screen. Klin Oczna
1995;97:343-5.
15. Bockelmann WD. Optimal ocular correction for computer
operators. Klin Oczna 1995;97:95-7.
16. Raasch TW, Bailey IL, Howarth PA, Greenhouse DS, Berman S.
Visual performance at video display terminals — effects of screen
color and illuminant type. Optom Vis Sci 1991;68:924-9.
17. Gur S, Ron S, Heicklen-Klein A. Objective evaluation of visual
fatigue in VDU workers. Occup Med (Lond) 1994;44:201-4.
18. Yeow PT, Taylor SP. Effects of long-term visual display terminal
usage on visual functions. Optom Vis Sci 1991;68:930-41.
19. Birnbaum MH. Optometric Management of Near Point Disorders.
Boston: Butterworth-Heinemann; 1993. p. 121-60.
20. Sheedy JE, Parsons SD. The visual display terminal eye clinic:
Clinical report. Optom Vis Sci 1990;67:622-6.
21. Wick B, Morse S. Accommodative accuracy of visual display
monitors. Optom Vis Sci 2002;79:218.
22. Penisten DK, Goss DA, Philpott G, Pham A, West RW. Comparisons
of dynamic retinoscopy measurements with a print card, a
Journal of Clinical Ophthalmology and Research - Jan-Apr 2014 - Volume 2 - Issue 1
[Downloaded free from http://www.jcor.in on Sunday, October 20, 2019, IP: 125.163.140.185]
Bali, et al.: Computer vision syndrome
visual display terminal and a PRIO system tester as test targets.
Optometry 2004;75:231-40.
23. Saito S, Sotoyama M, Saito S, Taptagaporn S. Physiological indices
of visual fatigue due to VDT operation: pupillary reflexes and
accommodative responses. Ind Health 1994;32:57-66.
24. Luberto F, Gobba F, Broglia A. Temporary myopia and subjective
symptoms in video display terminal operators. Med Lav
1989;80:155-63.
25. Levy B, Wagner G, Rest K, Weeks J. Preventing Occupational
Disease and Injury. American Public Health Association. 2nd ed.
Washington DC, USA, 2005.
26. Telles S, Naveen KV, Dash M, Deginal R, Manjunath NK. Effect of
yoga on self-rated visual discomfort in computer users. Head Face
Med 2006;2:46-52.
27. Fenety A, Walker JM. Short-term effects of workstation exercise on
musculoskeletal discomfort and postural changes in seated video
dis-play unit workers. Phys Ther 2002;82:578-89.
28. Thomson WD. Eye problems and visual display terminals-the facts
and the fallacies. Ophthal Physiol Opt 1998;18:111-9.
29. Anshel J. Visual Ergonomics Handbook. In: Anshel J, editor. New
York: Taylor and Francis; 2005.
30. Wiggins NP, Daum KM. Visual discomfort and astigmatic refractive
errors in VDT use. J Am Optom Assoc 1991;62:680-4.
31. Bilton N. I live in the future and here is how it works? New York:
Crown Business; 2010:1-293.
32. Sheedy JE, Shaw McMinn PG. Diagnosing and treating Computer-
related vision problems. Burlington, MA: Butterworth Heinemann;
2003:1-288.
33. Bailey IL. Visual acuity. In: Benjamin WJ, editor. Borisch’s Clinical
Refraction. 2nd ed. St. Louis: Butterworth Heinemann; 2006.
p. 217-46.
34. Rinalducci EJ. Chairman, Video displays, work, and vision.
National Research Council, Committee on Vision. Washington
DC: National Academy Press; 1983.
35. Jaschinski W, Bonacker M, Alshuth E. Accommodation,
convergence, pupil diameter and eye blinks at a CRT display
flickering near fusion limit. Ergonomics 1996;39:152-64.
36. Ziefle M. Effects of display resolution on visual performance. Hum
Factors 1998;40:554-68.
37. Berman SM, Greenhouse DS, Bailey IL, Clear RD, Raasch TW.
Human electroretinogram responses to video displays, fluorescent
lighting, and other high frequency sources. Optom Vis Sci
1991;68:645-62.
38. Costanza MA. Visual and ocular symptoms related to the use of
video display terminals. J Behav Optom 1994;5:31-6.
39. Montegut MJ, Bridgeman B, Sykes J. High refresh rate and
oculomotor adaptation facilitate reading from video displays. Spat
Vis 1997;10:305-22.
40. Pickwell LD, Kaye NA, Jenkins TC. Distance and near readings
of associated heterophoria taken on 500 patients. Ophthal Physiol
Opt 1991;11:291-6.
41. Jenkins TC, Pickwell LD, Yekta AA. Criteria for decompensation
in binocular vision. Ophthal Physiol Opt 1989;9:121-5.
42. Watten RG, Lie I, Birketvedt O. The influence of long-term visual
near-work on accommodation and vergence: A field study. J Hum
Ergol (Tokyo) 1994;23:27-39.
43. Nyman KG, Knave BG, Voss M. Work with video display
terminals among office employees. Scand J Work Environ Health
1985;11:483-7.
44. Jaschinski W. The proximity-fixation-disparity curve and the
preferred viewing distance at a visual display as an indicator of
near vision fatigue. Optom Vis Sci 2002;79:158-69.
Journal of Clinical Ophthalmology and Research - Jan-Apr 2014 - Volume 2 - Issue 1
45. Collier JD, Rosenfield M. Accommodation and convergence during
sustained computer work. Optometry 2011;82:434-40.
46. Uchino M, Schaumberg DA, Dogru M. Prevalence of dry eye disease
among Japanese VDT users. Ophthalmology 2008;115:1982-98.
47. Tsubota K, Nakamori K. Dry eyes and VDTs. N Engl J Med
1993;328:584-5.
48. Schlote T, Kadner G, Freudenhaler N. Marked reduction and
distinct patterns of eye blinking in patients with moderately
dry eyes during VDT use. Graefes Arch Clin Exp Ophthalmol
2004;2422:306-12.
49. Himebaugh NL, Begley CG, Bradley A, Wilkinson JA. Blinking and
tear break up during four visual tasks. Optom Vis Sci 2009;106:114.
50. Acosta MC, Gallar J, Belmonte C. the influence of eye solutions
on blinking and ocular comfort at rest and during work at visual
display terminals. Exp Eye Res 1999;68:663-9.
51. Hagan S, Lory B. Prevalence of dry eye among computer users.
Optom Vis Sci 1998;75:712-3.
52. Thibos LN, Hong X. Clinical applications of the Shack-Hartmann
aberrometer. Optom Vis Sci 1999;76:817-25.
53. Toda I, Fujishima H, Tsubota K. Ocular fatigue is the major
symptom of dry eye. Acta Ophthalmol 1993;71:347-52.
54. Salibello C, Nilsen E. Is there a typical VDT patient? A demographic
analysis. J Am Optom Assoc 1995;66:479-83.
55. Portello JK, Rosenfeld M, Chu CA. Blink rate, incomplete blinks
and computer vision syndrome. Optom Vis Sci 2013;90:482-7.
56. Chu CA, Rosenfield M, Portello JK, Benzoni JA, Collier JD. A
comparison of symptoms after viewing text on a computer screen
and hardcopy. Ophthalmic and Physiological Optics 2011; 31: 29-32.
57. Office Ergonomics Handbook. 5th ed. Occupational Health Clinics
for Ontario Workers. 2008:46-53.
58. Butzon SP, Sheedy JE, Nilsen E. The efficacy of computer glasses in
reduction of computer worker symptoms. Optometry 2002;73:221-30.
59. Harrison WW, Begley CG, Liu H, Chen M, Garcia M, Smith
JA. Menisci and fullness of the blink in dry eye. Optom Vis Sci
2008;85:706-14.
60. Koslowe KC, Hadas W, Biner-Kaplan M. The Blink Frequency
Relationship between Reading from a Computer Screen and
Reading from a Printed Page. Optometry and Vision Development
2011;42:168. Rinalducci EJ. Video displays, work, and vision.
Chairman, Committee on Vision, National Research Council.
Washington DC: National Academy Press; 1983.
61. Garcia KD, Wierwille WW. Effect of glare on performance of a VDT
reading-comprehension task. Hum Factors 1985;27:163-73.
62. Scullica L, Rechichi C, De Moja`CA. Protective filters in the
prevention of asthenopia at a video display terminal. Percept Mot
Skills 1995;80:299-303.
63. Gumener PI, Kaisina OV, Koval’kova SL. Hygienic problems in the
use of computers by school children with refractive disorders. Gig
Sanit 1996;4:19-22.
64. Feigin AA. Role of spectral filters for refraction dynamics in
computer users. Vestn Oftalmol 2003;119:39-40.
65. Ciuffreda KJ, Scheiman M, Ong E, Rosenfield M, Solan HA. Irlen
lenses do not improve accommodative accuracy at near. Optom
Vis Sci 1997;74:298-302.
66. Simmers AJ, Gray LS, Wilkins AJ. The influence of tinted lenses
upon ocular accommodation. Vision Res 2001;41:1229-38.
67. York M, Ong J, Robbins JC. Variation in blink rate associated with
contact lens wear and task difficulty. Am J Optom Arch Am Acad
Optom 1971;48:461-7.
68. Pointer JS. Eyeblink activity with hydrophilic contact lenses. A
concise longitudinal study. Acta Ophthalmol 1998;66:498-504.
69. Nichols JJ, Ziegler C, Mitchell GL, Nichols KK. Self- reported dry
67
[Downloaded free from http://www.jcor.in on Sunday, October 20, 2019, IP: 125.163.140.185]
Bali, et al.: Computer vision syndrome
eye disease across refractive modalities. Invest Ophthalmol Vis Sci
2005;46:1911-4.
70. Orsborn GN, Robboy M. Hydrogel lenses and dry eye symptoms.
J Br Contact Lens Assoc 1989;6:37-8.
71. Orsborn GN, Zantos SG. Practitioner survey: Management of dry
eye symptoms in soft lens wearers. Contact Lens Spectr 1989;4:23–6.
72. Butzon SP, Sheedy JE, Nilsen E. The efficacy of computer
glasses in reduction of computer worker symptoms. Optometry
2002;73:221-30.
73. Guillon M, Maissa C, Pouliquen P, Delval L. Effect of povidone 2%
preservative-free eyedrops on contact lens wearers with computer
visual syndrome: Pilot study. Eye Contact Lens 2004;30:34-9.
74. Acosta MC, Gallar J, Belmonte C. The influence of eye solutions
on blinking and ocular comfort at rest and during work at video
display terminals. Exp Eye Res 1999;68:663-9.
75. Portello JK, Rosenfield M, Chu CA. Blink rate, incomplete blinks
and Computer Vision Syndrome. Optom Vis Sci 2013;90:482-7.
76. Anshel J. Visual Ergonomics Handbook. In: Anshel J, editor. New
York: 1st Edition. Taylor and Francis; 2005. p. 1-232.
77. Misawa T, Yoshino K, Shigeta S. An experimental study on the
duration of a single spell of work on VDT (visual display terminal)
performance. Sangyo Igaku 1984;26:296-302.
78. Izquierdo JC, Garcıa M, Buxo C, Izquierdo NJ. Factors leading
to the computer vision syndrome: An issue at the contemporary
68
work-place. Bol Asoc Med P R 2007;99:21-8.
79. Sheedy JE. The bottom line on fixing computer-related vision and
eye problem. J Am Optom Ass 1996;67:512-7.
80. Guidelines for work with VDUs. Occupational Health
Department,Ministry of Labour, Singapore, 2001:1-33.
81. Piccoli B, Braga M, Zambelli PL, Bergamaschi A. Viewing distance
variation and related ophthalmological changes in office activities
with and without VDUs. Ergonomics 1996;39:719-28.
82. Wan L. Task-specific computer glasses: Under-standing needs,
reaping benefits. Occup Health Saf 1992;61:50-2.
83. Wallin JA, Zhu Z, Jacobsen JL, Jacobsen SD. A preliminary study of
the effects of computer glasses on reported VDT user symptoms:
A field study. J Saf Res 1994;25:67-76.
84. Grosso D, Bellini A, Zambelli P, Troiano P, Di Bisceglie M,
Bergamaschi A, et al. Work efficiency and lighting conditions: An
experimental study. G Ital Med Lav Ergon 2007;29:256-8.
85. Kozeis N. Impact of computer use on children’s vision. Hippokratia
2009;13:230-1.
Cite this article as: Bali J, Neeraj N, Bali RT. Computer vision syndrome: A
review. J Clin Ophthalmol Res 2014;2:61-8.
Source of Support: Nil. Conflict of Interest: None declared.
Journal of Clinical Ophthalmology and Research - Jan-Apr 2014 - Volume 2 - Issue 1