The Ministry of Education of Saudi Arabia directed the universities and schools to shift to remote learning, so students can attend all their classes from home via electronic platforms like blackboard, ZOOM and Microsoft Teams to ensure their safety and health. But the continuation of E-learning during the COVID-19 era has several drawbacks.
High prevalence of CVS was observed. In our study, 282 students reported at least one symptom (94.0%) which is consistent with the prevalence reported during covid-19 pandemic in Pakistan (98.7%) and India (88%) [6, 7] and also similar to the prevalence in Jeddah, Saudi Arabia before the pandemic (97.3%) [12]. However, in the previous studies, there was no exclusion to students with ocular or systemic illness or to those applying medications with known visual side effects. In our study, all those confounders were eliminated.
In the current study, the most reported symptoms were neck, shoulder and back pain, headache and dry eyes which is similar to what was reported in a previous study among business and medical college students in Riyadh, Saudi Arabia [13], but with a higher percentage in our study; it could be attributed to the increasing duration of e-learning.
In our study, being female increased the risk of having three or more symptoms with a statistical significance. It is matching with what was reported in multiple studies before [3, 10, 12]. This could be attributed to the higher prevalence of dry eyes and cosmetics use among females [9] and to the gender difference in response to pain [14].
The relation between refractive errors and developing CVS has conflicting results in the literature. In our study, we found that having refractive errors as myopia, hyperopia or astigmatism were not risk factors for having more symptoms of CVS. This is almost similar to a national study conducted in Jeddah which found that myopia and hyperopia were not associated with CVS, but astigmatism showed significant association with more symptoms [10]. In contrast, in another national study in Al-Qassim region there was a significant relation between myopia and CVS, especially those corrected with contact lenses [15]. On the international level, a systematic review concluded that those who have refractive errors are at a higher risk to develop CVS or suffer from more severe symptoms of CVS [16]. Moreover, a study conducted in Nepal found that students who have myopia corrected with glasses are at higher risk to develop CVS. However, the study did not find a statistically significant difference between students who hadhigh myopia and those who had low and moderate myopia in regard to developing CVS [17].
In assessing the awareness of CVS, 76.3% of our participants never heard of the syndrome.
Similar percentage was reported by a study conducted in Nepal where 77.1% of their study population had no pre-existing knowledge of CVS [4]. This highlights the need for more awareness programmes of CVS and its risk factors.
Along with the increased dependence on online education during the pandemic, safe habits in digital device use have been recommended especially in regard to the duration of device use as we found it to be one of the most statistically significant factors in our study. We found out that students who used electronic devices for longer durations during COVID-19 (6.8+_2.8) reported 3 or more symptoms of CVS with p-value (<0.001). The ration of our respondents who reported spending 8 hours or more using electronic devices increased significantly from only 26% pre COVID-19 to 56.7% during the pandemic (p <0.001). Also, the average total studying hours increased from a mean of 5.1 hours reported pre-pandemic to a mean of 6.4 hours during this era with p-value (<0.001)
The increase in symptoms due to longer device use is matching with multiple previous studies that have reported participants experiencing more symptoms after using devices for more than six hours a day [18, 19].On the opposite side, some studies reported that there is no association between the duration of usage of the device and the number of symptoms [12].
The pattern and settings of electronic devices used by our participants remained unchanged pre and during Covid-19. In addition, the majority of the study population were not following preventive measures such as reducing hours of use, room illumination, and monitoring the brightness. In addition, using the 20-20-20 rule and locating the screen at 20-28 inch from your eyes were only applied by a minor percentage of the study population with no significant difference pre and during Covid-19.
These results could be explained by the poor level of awareness among the study participants. Even Tthough 55.3% of the respondents knew about the 20-20-20 rule, only 8% actually applied the rule pre Covid-19 and 9.7% during Covid-19.