An Investigation of the Psychosocial Outcomes of Dry Eye Disease Treatment in Children with Computer Vision Syndrome

doi:10.21203/rs.3.rs-3250007/v1

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Research Article

An Investigation of the Psychosocial Outcomes of Dry Eye Disease Treatment in Children with Computer Vision Syndrome

https://doi.org/10.21203/rs.3.rs-3250007/v1

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Purpose

To examine the effects of topical eye drops treatment on the psychosocial status of pediatric patients with computer vision syndrome (CVS)-related dry eye disease (DED).

Methods

In this study, a total of 38 children (6 boys, 32 girls) with CVS-related dry eye symptoms were evaluated with the Schirmer test, tear break-up time (TBUT), and ocular surface disease index (OSDI) at the time of diagnosis and after artificial tear drops treatment. Additionally, the quality of life (QoL) levels and the anxiety and depression symptoms were assessed using self- report scales for children.

Results

The mean age and mean total screen exposure of patients were 13.95 ± 2.42 years and 5.65 ± 2.31 hours, respectively. After treatment, TBUT and Schirmer test values of the patients increased significantly, while OSDI values decreased (p < 0.001 for all). The total anxiety and the depression scores of the patients decreased (p = 0.001, and p = 0.003, respectively); whilst the physical, emotional, social and school functionality scores increased (p < 0.05 for all) with treatment. There was a significant correlation between the improvements in Schirmer test values and anxiety scores (r = -0.32, p = 0.045) and QoL total scores (r = 0.38, p = 0.016).

Conclusions

Enhanced QoL and decreased anxiety and depression scores, correlated with the amelioration of dry eye symptoms indicate that the CVS related DED has psychosocial effects, which may decrease after appropriate treatment, in pediatric patients. Future research endeavors that integrate comprehensive evaluations of dry eye and psychiatric symptoms can yield more comprehensive and precise insights into the interplay between psychiatric disorders and DED in children with CVS, as well as the outcomes of different treatment approaches.

dry eye disease

computer vision syndrome

children

quality of life

anxiety

depression

Computer Vision Syndrome (CVS) is defined as a collection of eye-related issues and visual disturbances that occur due to prolonged use of digital screens [1]. CVS is commonly associated with prolonged computer usage exceeding 3 hours per day or 30 hours per week, and it is often characterized by visual, ocular and musculoskeletal symptoms [2].

The exponential proliferation of digital devices has become an integral part of daily life, putting millions of individuals across all age groups at risk of developing CVS. Individuals spend more time on computers, laptops, smartphones, tablets, and e-readers, which contribute to CVS. Children, also spend extensive hours using digital screens for schoolwork, playing video games, and sending and receiving text messages [3]. The prevalence of CVS in children and adolescent is estimated to range from 50–70%, as reported in previous studies [4, 5].

The primary manifestation observed in CVS is the emergence of dry eye disease (DED), which exhibits a prevalence rate of approximately 60% [6]. DED is characterized by persistent symptoms such as tearing, burning or stinging sensation, ocular discomfort, blurred vision, and photophobia, which have been documented to have negative effects on the quality of life (QoL), encompassing not only vision related daily life, but also the broader aspects of general well-being [7–9]. Additionally, studies have revealed a higher prevalence of psychiatric disorders in patients with DED [10–12]. Among psychiatric diagnoses, anxiety and depressive disorders were the most frequently investigated, and findings consistently indicated that individuals with DED exhibited elevated levels of anxiety and depressive symptoms compared to those without DED [13–15].

Treatment options for DED often involve the use of artificial tear substitutes, which aim to replenish the natural tear film and provide lubrication to the eyes in order to alleviate symptoms [16]. Previous studies have reported that artificial tear treatments have been associated with improvements in overall enhancement of patients' QoL [17]. Additionally the potential of tear drops in patients with DED to mitigate symptoms of anxiety and depression has been announced [18, 19].

Drawing from the aforementioned research studies, it can be inferred that DED treatment holds the potential to yield positive effects on the psychological well-being of children who were diagnosed with CVS. The primary objective of the present study was to assess the impact of DED treatment on health-related QoL, as well as levels of depression and anxiety levels, among pediatric patients with CVS. Hence, the research study posited the following hypothesis: After topical drop treatment, children with CVS would exhibit an enhanced overall QoL and a reduction anxiety and depression levels compared to their pretreatment assessments. Additionally, there would be positive correlations between improvements in psychosocial status and dry eye measurements. Finally, it was also aimed to the examine the effects of digital screen use on the relationship between the improvement of CVS-related DED and psychosocial outcomes. To the best of our knowledge, this study represents the first comprehensive evaluation of the impact of DED treatment on the QoL, along with anxiety and depression levels, in pediatric patients with CVS.

Study Design and Participants

This prospective study was conducted at the ophthalmology department of a secondary-level hospital. The study protocol was approved by the local research ethics committee (Ethics approval number: 55-2022) and conducted in accordance with the ethical principles of the Declaration of Helsinki. Written informed consent was obtained from all children and their parents. Children with CVS between 9–18 years old who referred to the ophthalmology outpatient clinic were included. The study sample comprised 38 children with CVS. The condition known as CVS encompasses a range of ocular complaints experienced by digital screen users, including but not limited to eyestrain, eye fatigue, burning sensations, irritation, redness, blurred vision, and dry eyes, among other symptoms associated with prolonged computer use or viewing digital screens. Exclusion criteria were any other eye diseases (eg, retinal disease, uveitis, glaucoma, congenital cataract, pterygium, conjunctivitis, keratitis, blepharitis, history of ocular trauma or previous surgery, nystagmus, or orbital pathology), previous diagnosis of dry eye, use of artificial tears, any eye medication, contact lens wear, any neurological diseases (eg, cerebral palsy, epilepsy), any psychiatric diagnoses, and any other chronic illnesses (eg, type 1 diabetes). At initial assessment, 85 children with CVS were enrolled in the study. Moreover, potential factors contributing to DED symptoms, such as sun exposure, windy weather, or exposure to air conditioning, were scrutinized, and 15 patients presenting with these conditions were also excluded. Out of remaining 70 children, 50 of them had a complete ophthalmologic examination during the subsequent check-ups (20 participants did not attend the follow-up examinations), 12 of whom did not cooperate with psychiatric assessments were excluded. Finally, a total of 38 children were encompassed within the scope of this study.

To assess computer exposure time, a questionnaire was employed to determine the duration of daily computer usage, measured in hours per day. Total screen exposure time was calculated for each child before and after DED treatment.

Opthalmologic Evaluation

Dry eye evaluation tests including tear break-up test (TBUT), Schirmer test and also Ocular Surface Disease Index (OSDI) were recorded before and one month after treatment. Treatment for dry eye was administered using artificial tear drops comprising dextran and hydroxypropyl methylcellulose,

Symptomatic DED was diagnosed with the OSDI questionnaire, an OSDI value ≥ 13 was considered a diagnosis of DED. Ocular surface damage and signs of DED were assessed using TBUT and Schirmer tests. To evaluate TBUT, fluorescein was instilled into the bottom of the lower sac and the tear film was examined with a blue filter; the appearance of the first dry spots on the cornea is observed since the last blink, the average is taken in seconds of three consecutive measurements and a diagnostic value of ≤ 10 is considered. Schirmer’s test was evaluated with topical tetracaine to test basal tear secretion using a specialized Schirmer’s strip prepared from Whatman filter paper Grade 41. A value of Schirmer test ≤ 10 was considered DED. According to TBUT and Schirmer test with anterior segment evaluation, Dry Eye Workshop (DEWS) grades and Oxford scores were determined [20].

Psychiatric Measures

Following the ophthalmologic examination, all participants were asked to complete the psychiatric scales in one session (approximately 30 minutes). After one month of follow-up, the same questionnaires were repeated.

In the current study, Revised Children’s Anxiety and Depression Scale Child Version (RCADS-CV) and Pediatric Quality of Life Inventory (PedsQL) were used to assess children’s psychiatric symptoms and quality of life, respectively, based on children’s own reports.

PedsQL was developed by Varni et al. to assess health-related quality of life in children [21]. The PedsQL TM 4.0 General Core Scales includes 23 items and four subscales: (1) physical functioning, (2) emotional functioning, (3) social functioning, and (4) school functioning. A 5-point response scale with scores ranging from 0 to 4 was used to assess child self-reports. Items were reverse scored and linearly transformed to a 0 to 100 scale (0 = 100%, 1 = 75%, 2 = 50%, 3 = 25%, 4 = 0%), so that higher scores indicated better quality of life. The range of measurement was based on the percentage of the total summary and subscale scores on the PedsQL [22]. The Turkish version of the PedsQL was found to be valid and reliable for the age group from 7 to 18 years [23, 24].

RCADS-CV was developed to screen for anxiety, depressive, and obsessive-compulsive symptoms in children and adolescents. This self-report questionnaire consists of six subscales and 47 items: generalized anxiety disorder (GAD), separation anxiety disorder (SAD), panic disorder (PD), obsessive-compulsive disorder (OCD), social phobia (SP), and major depressive disorder (MDD). Additionally, there exist two comprehensive subscales referred to as "Total Internalizing" and "Total Anxiety. Each item is scored between 0 and 3 (0 = never, 1 = sometimes, 2 = often, 3 = always) [25]. The validity and reliability of the Turkish version were conducted by Görmez et al. [26].

Statistical Analysis

A statistical power analysis was conducted to estimate the required sample size for sample size determination through the utilization of a paired sample t-test. In order to achieve an 80% power level (alpha = .05) [27] for the detection of a "medium" effect size, the anticipated sample size required, as determined by G*Power 3.1, was approximately 34 [28, 29]. Statistical analyses were performed using SPSS 24.0. Comparisons of psychiatric scale measures and dry eye evaluation tests between pre- and post-treatment were reported using paired samples t test and Wilcoxon signed-ranked test according to the normality of the data. Pearson’s correlation analyses were conducted to determine the associations between the improvements in ophthalmic measurements and in psychiatric scales.

Of 38 children with CVS, 84.2% (n = 32) were female and 15.8% (n = 6) were male. The mean age was 13.95 ± 2.42 years. The mean duration between two consecutive assesments was 35.36 ± 8.62 days. Demographic and clinical characteristics of the patients are shown in Table 1.

Table 1

Sociodemographic and Clinical Characteristics of Patients
Characteristic	Value
Age (years)	13.95 ± 2.42
Sex (male/female), n (%)	6 (15.8) / 32 (84.2)
BCVA	0.97 ± 0.05
Spherical equivalent, D	-0.09 ± 0.55
IOP, mmHg	15.7 ± 3.1
Screen time exposure (hour per day)	5.65 ± 2.31
SD: Standard Deviation; BCVA: Best corrected visual acuity; D: Diopter; IOP: Intraocular pressure

Values are presented as mean ± SD, unless otherwise noted.

Table 2

Comparison of dry eye evaluation tests and psychiatric scale scores before and after treatment
Dry eye evaluation tests	Pre-treatment Mean ± SD / Median (IQR)	Post-treatment Mean ± SD / Median (IQR)	p	t / Z
TBUT *	7.45 ± 3.43	9.92 ± 2.89	< .001	-6.04
Schirmer test *	11.84 ± 6.50	15.66 ± 6.40	< .001	-4.84
Oxford **	0 (0)	0 (0)	.014	-2.44
DEWS *	2 (1)	2 (1)	< .001	-4.91
OSDI *	45.99 ± 15.47	25.46 (13.37)	< .001	8.20
Scales
PedsQL *
Physical functioning	72.44 ± 19.28	82.15 ± 14.40	< .001	-3.98
Emotional functioning	64.86 ± 21.03	73.94 ± 18.16	.006	-2.89
Social functioning	84.86 ± 21.73	90.13 ± 13.87	.04	-2.07
School functioning	68.28 ± 18.82	75.65 ± 17.09	.003	-3.16
Total	72.76 ± 16.94	80.47 ± 12.61	< .001	-3.92
RCADS-CV *
GAD	49.08 ± 10.97	43.07 ± 11.24	.002	3.30
SAD	53.29 ± 11.37	49.36 ± 10.35	.03	2.13
PD	57.24 ± 13.07	52.44 ± 10.91	.01	2.73
OCD	53.21 ± 11.52	47.78 ± 10.94	.004	3.08
SP	48.16 ± 13.10	40.39 ± 10.88	.001	3.80
MDD	49.55 ± 14.09	44.47 ± 12.25	.003	3.22
Total Anxiety	52.94 ± 13.22	45.05 ± 12.25	.001	3.76
Total Internalizing	52.36 ± 13.58	44.73 ± 12.40	.001	3.76

SD: Standard Deviation; IQR: Interquartile Range; TBUT: Tear Break-Up Time; DEWS: Dry Eye Workshop; OSDI: Ocular Surface Disease Index; PedsQL: Pediatric Quality of Life Inventory; RCADS-CV: Revised Child Anxiety Depression Scale; GAD: Generalized Anxiety Disorder; SAD: Social Anxiety Disorder; PD: Panic disorder; OCD: Obsessive-Compulsive Disorder; SP: Social Phobia; MDD: Major Depressive Disorder.

The characteristics of normally distributed variables are represented by Mean ± SD, and for non-normally distributed variables, Median (IQR) serve as representative measures.

^* Paired samples t test

^** Wilcoxon signed-ranked test

Bold values indicate statistical significance.

According to the analyses of the children’s dry eye evaluation tests, comprising TBUT, Schirmer test and OSDI values before and after the artificial tear drops treatment, statistically significant differences were identified. Additionally, significant improvements in the QoL and anxiety, depression and OCD symptoms were found among children with CVS following the treatment (Table 2). There was a significant difference between the pre- and post-treatment evaluations in terms of screen exposure time as hours per day (M_pre= 5.65 ± 2.31, M_post= 4.88 ± 2.56; t(37) = 3.11, p = .004).

Upon assessing the associations using Pearson’s correlation test, between reductions in screen time measures (hours per day) and the improvement in DED evaluation test results, no statistically significant correlations were identified (p = 0.33, p = 0.16, p = 0.12 for TBUT, Schirmer and OSDI, respectively.). Additionally, no significant correlation was detected between the reductions in screen usage prior to and following treatment, and the subsequent decrease in scores on the RCADS-CV (p = 0.76), and QoL total scales (p = 0.61).

While investigating the associations between the improvements in DED and psychosocial outcomes, the statistically significant differences were detected in only Schirmer test values. As the comparisons for TBUT (p = 0.27 for RCADS-CV internalizing and p = 0.32 for QoL total) and for OSDI (p = 0.59 and p = 0.64, respectively) were performed, yielding results did not demonstrate significant differences. Statistically significant correlations were found between the magnitude of increase in Schirmer test values and the increase in quality of life scores (total and emotional functioning domain), as well as the decrease in generalized anxiety, total anxiety and total internalizing scores. Additionally, QoL scores were negatively correlated with anxiety and internalizing scores (Table 3).

Table 3

Correlations between improvement in psychiatric scale scores and Schirmer tests
	Schirmer	RCADS-Anxiety	RCADS- Internalizing	RCADS-GAD	PedsQL-Total
RCADS-Anxiety	-0.32*
RCADS-Internalizing	-0.30	0.99***
RCADS-GAD	-0.32*	0.89***	0.88***
PedsQL-Total	0.38*	-0.48**	-0.47**	-0.39*
PedsQL- Emotional Functioning	0.32*	-0.29	-0.30	-0.27	0.79***
RCADS: Revised Child Anxiety Depression Scale; PedsQL: Pediatric Quality of Life Inventory; GAD:Generalized Anxiety Disorder

Pearson’s correlation test

Bold values indicate statistical significance.

*p < .05

**p < .01

***p<. 001

In the present study, we aimed to examine the effects of DED treatment on the improvements of QoL as well as depression and anxiety symptoms. Each hypothesis is further elaborated and examined in the following, providing detailed discussion.

It has been announced that the widespread use of digital screens such as computers, tablets and smartphones has significantly contributed to the spread of DED in children and adolescents [30, 31]. A recent study explored the correlations between computer exposure time and DED Evaluation tests, including Schirmer, TBUT and OSDI, indicating that a longer exposure time results in greater visual symptoms [32]. In contrast, a literature review indicated that electronic devices do not cause organic damage to the visual system [33]. Additionally, children comprising our sample group may not have undergone sustained exposure to screens, nor have they been professionally exposed to screens or computers for a prolonged duration at a chronic level. This aligns with the findings of the present study, which revealed no correlations between screen exposure time measures and DED evaluation tests. The limited size of our sample may present a significant constraint or limitation. And also, it is important to note that our study lacked a control group (non-DED), limiting our ability to make comparisons. Therefore, we were only able to assess these factors within a single group consisting of pediatric patients with DED associated with CVS.

It is well known that DED has a detrimental impact on the patient's daily life. The unpleasant symptoms of dry eye, such as burning or stinging, ocular grittiness, foreign body sensation, blurred vision, and photophobia could contribute to the impaired QoL [34]. In addition to the alterations in visual performance and ocular functioning, chronic pain may also play a role in the poor QoL of patients with DED [8, 9, 35]. Topical eye drop treatments were found to be associated with improved QoL compared to baseline, as a significant number of patients reported relief from symptoms [36, 37]. Our study revealed that statistically significant improvements in QoL were observed across all domains during the post-treatment assesment. Furthermore, positive correlations between QoL scores, specifically emotional functioning and total summary, and the Schirmer test results. These findings provide further support for prior research.

In terms of the depression and anxiety levels of children, we detected statistically significant reductions in depression, all subtypes of anxiety, and total internalized symptoms following the treatment. Additionally, there were significant associations between the increase in Schirmer test values and the decreases in generalized anxiety and total anxiety scores. This is consistent with previous studies which have revealed that the severity of DED symptoms impacted on the depressive symptoms in youthful [35] and elderly populations [38]. While the observational nature of the present study prevents drawing causal inferences, it is conceivable that the reported associations may stem from multiple factors [35]. Dry eye symptoms may trigger or intensify symptoms of anxiety and depression. For example, ocular pain and discomfort could result in psychosocial stress, depression and anxiety [39, 40]. On the contrary, depression, stress, and anxiety, may influence subjective ocular symptoms and pain perception, contributing to the formation of a cyclic relationship [41, 42]. Depressive individuals may have a lower threshold for perceiving physical discomfort and pain [38]. Likewise, anxiety can also arise from patients' concerns regarding their symptoms and the possibility of occurence of DED [15]. Additionally, it has been suggested that patients with depression exhibit an increased susceptibility to DED due to the elevation of proinflammatory cytokines [43], and alterataions of neurotransmitters and neuropeptides [44]. Finally, depressive disorder and DED may have a common pathophysiology. Shared risk factors and increased production of inflammatory cytokines may contribute to the pathogenesis of both diseases [13, 38]. In summary, while our study aligns with previous research, it is important to acknowledge that our findings may be limited due to the exclusion of patients with psychiatric disorders such as anxiety and depression. Additionally, the psychiatric assessments in our study were solely based on self-report scales, focusing on symptom levels. Therefore, these findings may not provide a comprehensive understanding of the relationship between DED and depression and anxiety.

A notable association has been indicated between the severity of DED and the presence of depression and anxiety symptoms, suggesting that the successful management of DED may have a beneficial effect on alleviating symptoms of depression and anxiety [18]. A recent study showed the association between the eye drop frequency and depression, anxiety scores, suggesting that topical eye drops potentially plays a significant role in psychosocial status of patients with DED [19]. Concurrently, in our study, we found statistically significant associations between the improvement of DED symptoms, as measured by the Schirmer test, and reduced levels of anxiety and depression when comparing pre- and post-treatment outcomes. These findings suggest a relationship between psychological symptoms and the burden of DED [18], indicating that anxiety and depression may improve with the relief of dryness. Moreover, the observed decrease in symptoms of anxiety and depression may be attributed to the improvement in sleep quality [45], which has been reported to be compromised in patients with DED [14, 46]. Although we found statistically significant differences in DED screening tests, including Schirmer, TBUT and OSDI between pre- and post-treatment assesments, a significant correlation was observed between the improvement in psychological well-being, including QoL and symptoms of depression and anxiety, and the amelioration in the Schirmer test results exclusively. These outcomes may be due to the low levels of correlation among objective dry eye tests that might reflect the diverse aetiology and complex pathophysiology of DED [47]. Furthermore, it is important to note that artificial tears do not address the underlying causes of DED [48]. As a result, additional treatment strategies are necessary for certain patients. However, our study solely focused on conditions related to a specific type of treatment, without conducting comparisons with alternative treatment options.

Since digital screens are widely used, the age to meet digital screens is gradually decreasing. Studies have reported digital screen usage rates of up to 92.7% in the pediatric population [49], and DED is among the prevalent eye disorders in CVS [6].

In this study, decreased anxiety and increased functionality scores, correlated with dry eye severity, were found after dry eye treatment. It is thought that dry eye disease has psychosocial effects, which may decrease after appropriate treatment, in pediatric patients.

The consultation-liaison psychiatry service involves a collaborative effort between psychiatrists and other medical specialists. Traditionally, ophthalmology and psychiatry have not had a close interface. However, our findings suggest a new possibility that liaison psychiatry could offer benefits to certain patients with ocular diseases, particularly those with CVS-related DED.

This study has several limitations that should be acknowledged. Firstly, the study sample was limited to children with CVS, which may not be representative of the broader population. The generalizability of the results to children without CVS or other age groups could be limited. Secondly, the study relied on self-report measures to assess quality of life, anxiety, and depression levels, which may be subject to recall bias or subjective interpretation. Additionally, it is plausible that a noteworthy placebo effect may be present, potentially contributing to the observed results. Future studies could benefit from incorporating objective measures or clinical assessments to enhance the validity of the findings. While our study established a relationship between the amelioration of dry eye symptoms, improvements of psychiatric symptoms and QoL using a moderator regression model, the absence of a control group without DED hinders our ability to compare relevant variables. Since hypotheses of causality would require evaluations at different time points, longitudinal studies with a control group could provide more robust evidence in this regard. Moreover, the study did not extensively investigate the specific effects of digital screen use on the relationship between DED improvement and psychosocial outcomes. Lastly, it is important to note that there was no control group without any treatment for DED due to ethical considerations, as it is not appropriate to withhold eyedrop prescriptions from DED patients. Further research with a more focused approach on this aspect is warranted to provide a comprehensive understanding of these associations.

In the available literature, limited research has focused on the impact of topical treatment on quality of life and psychosocial well-being, including anxiety and depression symptoms, in children with CVS-related dry eye disease. The present study presented a significant reduction in anxiety levels and improvement in QoL functionality scores following treatment for DED. These findings suggest that pediatric patients with DED experience psychosocial effects that can potentially be mitigated through appropriate treatment. Additional research endeavors are warranted to elucidate the relationship between psychiatric disorders and DED symptoms among children and adolescents with CVS.

CVS

Computer vision syndrome

DED

Dry eye disease

TBUT

Tear break-up test

OSDI

Ocular surface disease index

DEWS

Dry Eye Workshop

RCADS-CV

Revised Children’s Anxiety and Depression Scale Child Version

PedsQL

Pediatric Quality of Life Inventory

Availability of data and materials

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.

Funding

The authors declare that no funds, grants, or other support were received during the preparation of this manuscript.

Competing Interests

The authors have no relevant financial or non-financial interests to disclose.

Author Contributions

All authors contributed to the study conception, design, material preparation, data collection and analysis. The first draft of the manuscript was written by Rahime Duygu Temeltürk and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Ethics Approval

This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committee of Haseki Training and Research Hospital (23.03.2022 / 55-2022).

Consent to Participate

Written informed consent was obtained from the children and their parents.

Consent To Publish

All authors have given consent for the study to be published in European Journal of Pediatrics.

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No competing interests reported.

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An Investigation of the Psychosocial Outcomes of Dry Eye Disease Treatment in Children with Computer Vision Syndrome

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Abstract

Purpose

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Conclusions

Introduction

Methods

Study Design and Participants

Opthalmologic Evaluation

Psychiatric Measures

Statistical Analysis

Results

Discussion

Abbreviations

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References

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