Environmental Vision (OPT 6051)

Computer Vision Syndrome I

Reference: Sheedy JE, Shaw-McMinn PG. Diagnosing and Treating Computer-Related Vision Problems.
Butterworth Heinemann, 2003. ISBN 0-7506-7404-0.

OVERVIEW (Chapter 1)
Sheedy defines computer vision syndrome (CVS) as, the complex of eye and vision
related problems associated with computer use. The primary symptoms are eyestrain,
blurred vision, dry and irritated eyes, tired eyes, and headaches. Neck and backaches
can also be related to the way that we use our eyes at the computer.
CVS is common among the patients we see because computer use is so widespread. Older
references books or articles on CVS used to estimate the percentage of people who use
computers in the workplace, but today we can safely assume that essentially 100% of our
patients use computers either at work, in school or at home.
Computers have become the primary medium through which we receive informationand we
receive it through our eyes and visual system. (Sheedy p. 1)
Estimates state that 25% to 93% of computer users experience visual symptoms associated
with CVS, yet many optometrists find the diagnosis and treatment of CVS challenging. This
may be because a variety of visual or eye problems, plus various ergonomic factors can
contribute to CVS. By understanding both the visual and ergonomic aspects of CVS, doctors
can better care for their patients.
Note that the problems that lead to CVS are not necessarily unique to computers, but are the
same problems patients encounter in other near-point tasks. Therefore, the same basic
principles used to prescribe for near-point problems can be applied to computer users if you
keep in mind the specifics such as working distance, viewing angle, lighting etc.
The causes of CVS are a combination of individual visual problems and poor
visual ergonomics. The symptoms occur whenever the visual demands of the
task exceed the visual abilities of the individual. For example, many individuals
have marginal vision disorders such as uncorrected refractive errors,
accommodative disorders, or binocular vision disorders that do not cause
symptoms when performing less demanding visual tasks. (p. 2)
In Chapter 2, Positioning Your Practice to Care for Computer-User Patients, Sheedy describes
practice management principles that will attract patients to your office as a place that provides
care for computer-related eye problems. He includes office literature or examination forms
specifically geared toward CVS, including:
Welcome-to-the-office brochures
CVS history and symptoms forms
CVS optometric exam form
Treatment routing slip
CVS case summary form
Patient education brochures about computer glasses

SIGNS AND SYMPTOMS OF CVS (Chapter 3)

Some of the symptoms associated with CVS are vague or can be attributed to other causes.
How can you tell if the problems are computer-related? One way is to ask the patient if the
symptoms (eye strain, headache, blurred vision, etc.) are closely correlated with computer use.
Do the symptoms increase with computer use? Do the symptoms decrease or go away on
weekends or vacations, when the patient is not using computers? CVS symptoms are dose
related.
If they appear to be computer related, a closer history of specific symptoms can lead you to
diagnose a specific visual/ocular or ergonomic etiology. This will then lead you to a specific
treatment or recommendation. Sheedy categorizes the various symptoms into one of the
following groups:
Visual symptoms
Ocular symptoms
Asthenopia
Sensitivity to lights
Musculoskeletal symptoms
Visual symptoms include:
Blurred vision or squinting (constant, intermittent, or when changing viewing distance)
Frequently losing place
Diplopia
Visual symptoms may be caused by an uncorrected refractive error (or incorrect far or near
correction), an accommodative problem, binocular alignment problem, or dry eye.
Non-visual ocular symptoms include:
Irritated eyes (itching, burning, dry, aching or red eyes)
Excessive tearing
Excessive blinking
Contact lens intolerance
These symptoms in a computer user are usually an indication of dry eye that is caused by a low
blink rate or high angle of gaze.
The patient may complain of a more general asthenopia (eyestrain, headaches or fatigue). A
variety of refractive, accommodative, binocular or lighting problems can lead to asthenopia.
Sensitivity to lights includes symptoms such as:
Glare, or annoying brightness
Flickering sensation (less common, especially with modern computer displays)
These symptoms are usually due to incorrect workplace lighting (including windows) relative to
the computer. This problem is much more common than you might thinkI estimate that 90%
of computer users have incorrect lighting that can lead to these symptoms.
Musculoskeletal symptoms:
Neck, shoulder or back pain
Shoulder, arm or wrist pain

Quoting from Sheedy (p. 41, 42):

These musculoskeletal symptoms result from assuming a less than optimal
position for extended periods of time, which causes tonic stress in the
musculature.
These problems are often related to the eyes. It is commonly recognized that
the eyes lead the body. For visually intensive tasks, the body locates the eyes
at a position where they can comfortably and efficiently perform the job; this is
often accomplished by creating awkward posture that results in musculoskeletal
problems.
We will discuss later how this can often be due to the use of a bifocal, progressive or near
spectacle design that is inappropriate for use with computers for an extended length of time.
Sheedy has incorporated these CVS symptoms into a handy patient questionnaire (p. 44-46),
which includes many of the key questions youll want to ask your patients who use computers.
REFRACTIVE ERRORS AND CVS (Chapter 4)
Blurred vision, squinting or eyestrain can be caused by an uncorrected refractive error, so an
obvious place to begin a CVS eye exam is with an accurate refraction.
Q. Which do you think is more visually demanding, reading printed text or computer text? For
example, would you rather read a software manual on the computer or as a printed book?
A.
As we will discuss later, the quality of computer text is worse than printed text. It is therefore
more visually demanding. Long hours of reading low-visibility text, with a small, uncorrected
refractive error can lead to some of the CVS symptoms. Because of the visual demands, even
small refractive errors, that we might otherwise overlook, can become significant.
For example, even 0.50 diopters of uncorrected astigmatism, 0.50 diopters of hyperopia, or a
slightly incorrect binocular balance can cause problems.
Myopia
In theory, a well-corrected myope with adequate accommodation should have no difficulty
viewing a computer. How about a patient with about -1.00 to -2.00 diopters (D) of uncorrected
myopia? This patient should be able to see the computer screen well without any correction
since his eyes are in focus for a working distance of 1 meter to 50 cm, the normal working
distance for most computers. Quoting from Sheedy (p. 47, 48):
There is a problem, however, that a low to moderate myope can experience at a
computer. The person with 2.00-3.00 D of myopia who is used to taking his or
her glasses off for normal reading is unable to see the computer screen clearly
with his or her glasses off because it is located farther away than the usual
reading distance. The patient may need to assume an awkward posture to
obtain a shorter distance to the computer screen. Wearing the distance glasses
may enable the patient to see the screen clearly, but sometimes he or she
cannot comfortably use his or her accommodation through the glasses.
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So, for any patient who complains of blurred vision or eyestrain when using a computer, first
measure and correct his distant refractive error.
Consider how would you manage each of the patients described in Appendix 4-1, on page 60.
ACCOMMODATION IN NON-PRESBYOPES (Chapter 5)
Sheedy points out (p. 61) that Viewing a computer can be demanding on the accommodative
mechanism so if the patient experiences one of the following symptoms, accommodation may
be the problem, even though he is not yet presbyopic.
Near blur
Blur when looking from far to near
Other intermittent blur that does not correlate with the blink
Eyestrain or headaches when using a computer
The majority of young emmetropes or well-corrected young ametropes should have no difficulty
accommodating on a computer monitor located 50-60 cm away, a common working distance.
Another reason computer viewing should pose little problem for the accommodation of most
patients is the normal dark focus of accommodation. Most eyes tend to accommodate
slightly when relaxed, or when there is no specific accommodative stimulus. On average, this
dark focus of accommodation is about 1.50 D (corresponding to a working distance of 67 cm),
although this can vary greatly among individuals from 0.00 to 3.50 D. It has been proposed,
and with some supporting evidence, that the greatest visual comfort is attained when working at
the dark focus or dark vergence position of the eyes. (Sheedy p. 63)
Why should accommodation be a problem for non-presbyopes? Some patients are not capable,
or are marginally capable of comfortably accommodating on poor-quality computer text, over
long periods of time. While they might be asymptomatic when reading a book, the demands of
computer viewing may be too much and lead to symptoms. Sheedy (p. 68) reported that nearly
a third of the young patients he sees have a problem with accommodation.
Amplitude of accommodation
If the young patient has a lower-than-normal amplitude of accommodation, he may have
eyestrain when viewing the computer monitor.
Patients younger than 40 years of age should have at least 5-6 D of accommodative amplitude,
but this can vary from person to person. Some patients may start showing early symptoms of
presbyopia in their late 30s, while other patients may have no difficulty accommodating for near
in their late 40s.
Q. What amplitude of accommodation should be necessary to view a computer located at a
working distance of 50 cm?
A.
Reduced amplitude of accommodation relative to age, in the presence of symptoms, should be
considered a possible source of those symptoms. (Sheedy p. 69)
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Accommodative fatigue
In addition, some studies suggest that computer work may fatigue the accommodative system
faster than printed text. Sheedy (p. 66) describes an interesting study that may explain why this
occurs.
Although it might be intuitively thought that accommodative fatigue responses are
due to muscular fatigue, this may not be the case. First of all, the ciliary muscle
is smooth muscle, which is generally considered not to fatigue. An alternative
explanation has been provided by the work of Lunn and Banks (1986). They
found that, after reading text on a VDT, there was a significantly decreased
sensitivity to medium spatial frequenciesthat is, the detection thresholds were
significantly increased. This is apparently the result of the spatial frequency
content of the repeating text patterns on the screen. These medium spatial
frequencies are critical for proper accommodative response (Charman and
Tucker, 1977; Owens, 1980). If, as a result of their tasks, workers become
desensitized to the spatial frequencies that drive accommodation, it helps to
explain decreased accommodative responses.
Lag of accommodation
It is not necessary that the eye accommodate exactly for the working distance. In fact a lag of
accommodation of 0.50-0.75 diopters is normal. However, accommodative lags of +1.00 D or
more can indicate problems.
Values of +1.00 or greater indicate an excessive lag and accommodative
difficulty, perhaps combined with an esophoria (accommodation lags to reduce
esophoria). Values of plano or negative indicate an over-accommodation,
possibly combined with convergence insufficiency (accommodation used to
provide convergence). (Sheedy p. 73)
Q. How do you measure lag of accommodation?
A.
The Prio Corporation has researched the lag of accommodation, and they believe that this is a
major problem among computer users. One of the fundamental principles underlying the Prio
system is that computer text is made up of pixels that have a Gaussian luminance profile,
whereas printed text has a square-wave profile. The square-wave profile of printed text
provides a sharper image that is a better stimulus to accommodation, so most eyes can
accommodate better when viewing printed text. On the other hand, the Gaussian profile of
computer text is a poorer stimulus to accommodation, and this leads to greater lags of
accommodation, more blur and eyestrain.
Even if a patient does not show an excessive lag of accommodation with standard optometric
tests (using a printed near-point card), he may have a problematic lag with the computer. To
correctly diagnose the lag of accommodation that users experience with their computers, Prio
proponents say that you must measure the lag of accommodation with a near target that uses a
simulated computer screen with Gaussian pixels. They manufacture and sell a device designed
for this specific purpose. (See Figure 5-2 on p. 74).
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Several studies, written by doctors closely associated with the Prio Corporation, have been
published that support the Prio theory, and the importance of using their device to correctly
prescribe the appropriate near correction for computer users.
On the other and, a study published by student researchers at NSU and Dr. Penisten did not
find that the Prio device did a better job of measuring the lag of accommodation with computers
than a standard near-point card with near retinoscopy.
From the viewpoint of Fourier optics, there is a fundamental problem with the Prio logic about
computer Gaussian text versus printed square-wave text. It turns out that there is not as much
of a difference in the luminance profile between printed and computer generated text as they
describe. The sharp edges of the square-wave luminance profile of printed text contains high
spatial frequencies, but because the eyes optics act as a low-passing filter, the highest spatial
frequencies are not transferred to the retinal image. Therefore, although the printed text may
have a sharp square-wave profile, the retinal image has a more rounded (blurred) profile that is
not so different from a Gaussian profile. The difference between text on a near-point card and
text on the Prio device is not as great as the company claims. In addition, recall that in the
paragraph above, Sheedy quoted a study by Charman, which found that the eye uses medium,
not high spatial frequencies to drive accommodation.
This may explain why, (quoting from Sheedy, p. 67), Most research does not support that
viewing a computer screen creates any more of a problem for accommodation that viewing hard
copy.
This does not mean that the Prio device is without merit. It does more closely resemble a
computer screen than a near-point card, and may therefore do a better job of simulating vision
at computers during an eye exam. In addition its high-tech appearance may bolster the
patients confidence his doctors knowledge of computer-related eye problems.
Accommodative facility
Accommodative facility is the ability to quickly change focus for different distances. Even if a
patient has an adequate amplitude of accommodation, or a normal lag of accommodation, he
may have problems with accommodative facility. This is especially relevant for workers that
must change viewing distances between printed copy and the computer monitor or between
distant viewing and the computer.
Q. How can you test accommodative facility? (Note: there may be an error in Sheedys
description of the test on p. 70.)
A.
Q. What is a normal value for a binocular accommodative facility test using 1.50 D flippers?
A.

Treatment of accommodative problems

The easiest and most direct way to treat accommodative problems is to prescribe low plus
lenses over the distance prescription. Sheedy suggests +0.75 to +1.25. Keep in mind that most
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people view their computers at distances greater than 40 cm, so you cannot assume that 40-cm
vision tests will give you the correct near prescription. It is best if you know the exact distance
that the patient uses.
The Prio Systems suggests that you cannot assume a common power for most patients (such
as +0.75), but you must individually measure each patients lag of accommodation using the
Prio device and prescribe based on that data.
When prescribing a near Rx for computers, (just as you do when prescribing for reading)
remember that distance vision will be blurred with the near Rx. Depending on how the patient
uses his eyes, this may or may not be a problem with a single-vision computer Rx. In some
cases other options may be better, such as:
A bifocal designed for computer use (higher-than-normal seg height; lower-than-normal
add)
Progressive lenses designed specifically for computer use (Sola Access, etc.)
Half-eye glasses
Flip-down lenses clipped to the distance Rx
Plus inserts
Vision training may also be used to increase the amplitude of accommodation or
accommodative facility, but this will require motivation and discipline by the patient.
Spectacle treatment is often the quicker and less expensive option, especially considering that
many computer workers do not have the time to commit to a training program. (Sheedy p. 75)
BINOCULAR ANOMALIES (Chapter 5, p. 75-88)

Binocular vision problems can lead to eyestrain with computers. As with some of the problems
described above, subtle binocular anomalies that would not be a problem for normal reading
can be a problem with computers because of the greater visual demand or extended time used
with computers.
Binocular problems include:
Esophoria with inadequate divergence ability
Exophoria with inadequate convergence ability
Vertical phoria
Incorrect binocular balance
Anisometropia
We can test for these problems by the usual clinical tests, including the von Graffe technique,
cover test, fixation disparity or vectograph testing. Sheedy suggests the following approaches
to correcting near-point binocular problems.

Near exophoria with inadequate BO fusional reserves are closely correlated with
eye strain. These can be treated with vision therapy designed to build
convergence.

An uncompensated near esophoria is usually best treated by prescribing plus

lenses.

A vertical phoria will probably require vertical prism or vision therapy.

You should check the binocular balance during your refraction and correct accordingly.
Significant anisometropia is best corrected using contact lenses. If you suspect significant
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aniseikonia, you can correct this by contact lenses or by designed the appropriate spectacle
lenses according to the principles you learning in Vision Science III and Ophthalmic Optics.
Read Sheedy for more details on binocular vision anomalies. You can obtain additional
information from the AOA clinical practice guidelines for care of the patient with accommodative
and vergence dysfunction by downloading it from the AOA web site or the Environmental Vision
web site.