The government of Jordan imposed a strict lockdown and curfew hours for six weeks, beginning March 18, 2020 and ending April 29, 2020 to contain the COVID-19 pandemic. This study aimed to see how homebound lockdown affected the development and severity of baseline and new digital eye strain symptoms (DES).
The data revealed that young males responded to the online survey more than females, which was consistent with consumer behavior on social media platforms during the lockdown.11 This could have increased the prevalence of eye symptoms in male subjects, particularly the new onset of DES symptoms.
Females had more severe lockdown symptoms than males in this study, which were statistically significant for most symptoms such as neck/shoulder pain, photophobia, blurred vision at distance, eye redness, heavy eyelids, and difficulty focusing on near objects, as shown in Tables 4 and 5.
Correlation between gender and musculoskeletal symptoms was explored. We found that females had more neck/shoulder pain during lockdown than before. For instance, in addition to the time spent on social media; women are helping their children in online school learning. An effective policy is needed to rationalize and to impose regular breaks women use of social media and online learning platforms.12
The majority of the survey respondents declare using digital devices more than an average of 5 hours daily. In addition, this finding is consistent with the 65% (n = 957) persons that have reported an increase in their use of digital devices from which 33% of them reported 4 hours or more during the lockdown period (table 1). As people self-reported their time spent on digital devices, it could be expected that they underestimated their actual time spent on digital devices because they may not have counted internet, TV, mobile phones, or tablets. Recent studies have found a global trend toward spending more time with digital devices, particularly among younger generations. 13–15 In 2016, Common Sense Media (CSM) reported that American parents of teenagers spend about 9 hours per day on the Internet.16 Similarly, a survey conducted by CMS in 2019 revealed that teenagers spend more than 7 hours per day on media.17According to Reddy et al.(2013), using digital devices for more than 2 hours per day has a significant impact on DES symptoms.21 Blatter et al. (2002) also observed that increased computer use, with or without mouse use, was correlated with musculoskeletal pain and dysfunction. Moreover, they found positive associations with work-related upper limb disorders for both genders with computer use of more than 6 and 4 hours per day, respectively.18
In the current study, taking regular breaks was found to be statistically significant for blurred vision at a distance and difficulty focusing on near objects. However, this is not so for neck pain or dry eye symptoms, respectively. Logaraj et al. (2014) showed that students who took regular breaks were less likely to show symptoms of DES.19 Indeed, Lemma et al. (2020) studied the effect of taking regular breaks on the development of DES when compared to those who did not take frequent breaks. It was found that secretaries who took regular breaks were 72.1 % less likely to experience digital eye strain.20
Jordanian schools and universities rushed to adopt online education during the lockdown, resulting in a significant shift in the digital device usage habits of educators and students. Due to the compulsory online studies and high demand for Internet, teachers, researchers and workers were among the most affected by new DES complaints during the lockdown. This is in line with the findings of several studies conducted in Middle Eastern and Asian countries.14,15,21Contrary to the hypothesis, manual workers developed new symptoms of DES more than other occupations (OR 1.42, 95 % C.I). The reason for this is that manual workers used digital devices for communication and online services more than they did previously. Interestingly, the lockdown resulted in an increase in the severity of symptoms reported by all respondents in occupational groups, with retirement and household having the highest odds ratio (OR 6.09, 95 % C.I.) followed by university students (OR 5.6, 95 % C.I.), which highlights the importance of public awareness and early management of DES in improving the education process and helping retired people improve their vision quality as seen in table 6. Furthermore, retired people and households are at greater risk for DES because they are more likely to have chronic systemic and ocular diseases that were worsened by having to use digital devices for increased hours than they were when they first started.12
This research showed that individuals with chronic eye problems are at a higher risk of developing new DES complaints and increasing the severity of their symptoms, even if they spend less time using digital. The results of Ranasinghe et al. (2012) indicated that chronic eye diseases were the greatest risk factor for DES development among Sri Lankan computer workers.12 As well, both new and severe eye symptoms were associated with the presence of chronic systemic diseases such as hypertension, diabetes mellitus, dyslipidaemia, neurological disorders, and allergy, as shown in Tables 4 and 5. The ocular symptoms of DES syndrome are classified into two groups, with the first being comprised of symptoms that are related to accommodation and that include blurred vision of near objects, blurry vision at a distance after using the computer, focusing difficulties between different distances, double vision, headaches, and neck and shoulder pain. The second is associated with dry eyes, burning sensation, irritation, discomfort, sensitivity to bright light, eyestrain, and headaches.1 Eyestrain and headaches are linked to binocular visual stress and accommodation, in addition to their connection to dryness.13,22
The most common symptom was neck and/or upper shoulder pain, followed by symptoms of accommodative dysfunction and to a lesser extent dry eyes. Prior to the lockdown, approximately 201 out of 250 respondents (n = 250) reported neck and/or shoulder pain; however, during the lockdown, this number nearly doubled to 390 (n = 489). This is in line with similar studies that found neck pain to be a common symptom among computer users, ranging from 19–70%.7–9,23,24 Touch screen devices, according to Kargar et al., necessitate more hand and head movements, resulting in arm/neck pain.25 Another study found that 68% of participants experienced musculoskeletal pain as a result of using touch screens, with neck pain and upper shoulder pain reported at 84.6% and 65.4 %, respectively, due to unnatural sitting positions without adequate back support.26 Logaraj et al., who found that 60.7 % of medical students reported neck pain as the most common symptom of DES, reported similar findings.19Workers who used computers for more than 6 hours per day were more likely to report upper limb disorders, according to Blatter and Bongers.18 As an unexpected mechanism to explain musculoskeletal pain is the oculomotor accommodative, and vergences dysfunction due to DES; electromyography has shown that ciliary muscle contraction is associated with head and neck muscle activation. The stabilization of gaze by head and neck muscles during accommodation was studied by Richter et al.27 They noticed increased trapezius muscle activity in a dose-dependent manner when subjects were given different lenses in front of their eyes to stimulate the ciliary body. More head and neck muscle activity was observed, as accommodation was activated.27
As expected, blurred vision, both near and far, was the second most common symptom reported at baseline and during the lockdown.6,19,28,29Rosenfield et al. (2011) attributed it to an incorrect accommodative response, as well as a failure to relax the ciliary body after the visual demand was completed.3The use of smart phones and handheld devices, according to Jaiswal et al. (2019), cause symptoms that are similar to DES because they stimulate the accommodative facility, resulting in decreased amplitude when the eye is fatigued. Despite the fact that no definitive evidence has been found linking smartphones to accommodative facility dysfunction, additional research is required to uncover the actual impact of digital devices on long-term users.29
Figure 2 depicts the most commonly reported dry eye symptoms in this study population before and during lockdown are shown. The most common complaints were photophobia, burning sensation, and heaviness. Research studies provide similar findings, but the symptoms occur in a different order that is reflective of sampling and geographical variations.15,21,30,31
Dry eye symptoms might not be a legitimate component of DES, as dry eye disease may aggravate accommodative symptoms, especially in elderly men and women, as well as those who have ocular surface disease. However, DES affects people under the age of 18 who use digital devices; this necessitates the need to develop a more specific and precise definition of DES.32Many patients who use dry eye treatments and increase their rate of blinking did not notice an improvement in their digital eye strain symptoms. Rosenfield and Jaiswal examined various factors that affect dry eye disease and its relation to DES in their reviews.3,29 They identified that various environmental factors, such as humidity, ambient lighting, fans, blinking rate, corneal exposure to air, gender, age, medications, systemic diseases, contact lenses, tear film volume, osmolality, and tear film composition, all affect the development of dry eye disease. Nonetheless, DES is still affecting normal people who are not at risk for dry eye disease.13,14,33,34
The major drawback of this study is that it is cross-sectional and uses convenient sampling methods. The participants may exaggerate or under exaggerate their symptoms due to the self-reporting nature of the survey.