Against the backdrop of virtual learning, lockdowns, and dramatically increased screen use, Children and Screens held its #AskTheExperts webinar “Eyes on Screens: Maintaining Your Kids’ Ocular Health in a Digital World” on Wednesday, February 10th 2021 at 12:00pm ET via Zoom.  An interdisciplinary panel of experts discussed the latest research on the relationship between increased screen use, vision, headaches, eye strain, dry eyes and other issues as well as what is known about time spent outdoors and blue light glasses.  Through an engaging conversation and live question-and-answer session, ophthalmologists, optometrists, and screen time  experts offered practical, concrete advice for parents, caregivers, researchers,  clinicians, and others.


  • David B. Granet, MD, MHCM, FACS, FAAO, FAAP

    Director; Professor of Ophthalmology & Pediatrics Anne F. and Abraham Ratner Children's Eye Center; University of California, San Diego
  • Kenneth Sorkin, OD, FAAO

    Optometrist Long Island Pediatric Ophthalmology and Strabismus
  • Saoirse McCrann, PhD

    Doctor of Optometry; Senior Science Writer Novartis
  • Mark Rosenfield, MCOptom, PhD

    Professor; Editor-in-Chief State University of New York (SUNY), College of Optometry; Ophthalmic and Physiological Optics
  • Lauren Hale, PhD

    Professor of Family, Population and Preventative Medicine Stony Brook University
  • Ken Nischal, MD, FRCOphth

    Chief; Director; Professor of Ophthalmology Division of Pediatric Ophthalmology, Strabismus; Pediatric Program Development, UMPC Eye Center; University of Pittsburgh School of Medicine

[Dr. Pam Hurst-Della Pietra]: Welcome, we are so glad that you have all joined us for today’s webinar to learn more about pediatric ocular health and digital media. You and more than 800 others have registered for today’s workshop. I am Dr. Pam Hurst-Della Pietra, president and founder of Children and Screens Institute of Digital Media and Child Development and host of this popular series. Over the next 90 minutes, our eminent group of experts will discuss the current research share insights from clinical experience and provide practical tips for your children, your patients, and your students. Stay tuned to learn more about how close is too close to the screen, how young is too young to be on screens, how effective are those blue light blocking glasses, and are there differences between using cell phones compared to laptops or between playing video games versus other uses of screens. Our panelists have reviewed the questions you submitted and will answer as many as possible during and after their presentations. If you have additional questions during the workshop please type them into the Q&A box at the bottom of your screen. When you do, please indicate whether or not you’d like to ask your question live on camera if time permits, or if you would prefer that the moderator read your question. We’re recording today’s workshop and we’ll upload a video onto youtube in the coming days. All registrants will receive a link to our YouTube channel where you can find this video as well as videos from our past 26 webinars. It is now my great pleasure to introduce our moderator. Dr. David Granet is a professor of ophthalmology and pediatrics, the Anne and Ratner chair of pediatric ophthalmology, the director of the Anne F. and Abraham Ratner Children’s Eye Center, and the director of the division of pediatric ophthalmology and eye alignment disorders at the University of California San Diego. We are delighted that Dr. Granet the host of “Health Matters with Dr. Granet” and an all-around expert is here with us today. So without further ado, I will hand you over to David.


[Dr. David B. Granet] Pam, thank you so much for that very kind introduction. I hope that everyone listening realizes that this entire panel is extraordinary that you put together and right off the bat I think that we owe a thank you to Children and Screens the Institute of Digital Media and Child Development for putting this together because these are the questions that everyone asks. I know that we have parents on, I know that we have public health officials on, I know that we have health professionals on, I know that we have educators on, and this crosses all those boundaries because our children looking at screens in some ways is the largest public health health experiment ever created by mankind for our children if you think about it this is something that we’ve just started doing and using across the board in schools, and parents are using with their children even young children as you’ll see in just a few minutes. The impact that these screens can have may be affecting behavior, it may be affecting learning, but we’re going to be talking about ocular health today and what that means is the anatomy of the eye, what does it do to your tear film, what does it do to your ability to keep your eyes healthy, what does it do to your cornea, does it affect your retina and your retinal development your optic nerve all the parts of the eye but also what does it do to your concentration, what does it do to impact all the ways a child interacts with the world, and we may even have a few words for parents as well. Your questions including things like do blue light glasses work or should we be using eye drops all the time or as Pam noted, how close is too close and all those other questions are going to be addressed by all of our speakers and not only in their presentations in our interactive discussio. So enough for me, I think we all want to get started and dive right in and our first speaker it’s my pleasure to introduce Dr. Ken Sorkin. Dr. Sorkin is a pediatric optometrist at ProHEALTH Care Long Island Pediatric Ophthalmology and Strabismus, as well as past president of the Nassau County Optometric Society. It really gives me great pleasure as someone who grew up in Nassau County to introduce Dr. Sorkin for his discussion today on really what are the issues that we’re dealing with Ken, what are the kinds of things that we have to worry about, what should be be worried about, what should parents be worried about. It’s all yours Ken, thank you.


[Dr. Kenneth Sorkin] Great, thanks so much nice to see another Nassau County resident online with me. I’m just gonna get my screenshare up and we’ll get started. So a lot of information to go through today I will try my best to keep it brief. So if we take a look at this child we’re gonna get started here I want you to take a look at the screen here at this young lady and I want you to take some mental notes to see what you think about how she’s interacting with her screen. Just take some mental notes, we’re gonna come back to it a bit and to see, you know, what she’s doing right what she maybe is not doing so right. So with regard to histories over the years it’s changed dramatically, what I used to see in training and early in my career the questions from children and parents have changed dramatically. It used to be all about reading and holding books too closely, things like dyslexia would often come up, questions as to why children’s prescriptions are changing so quickly, you know of course sports, why is my child not the expert in hitting a baseball like they used to be. So what’s changed? Well, the things that kids look at has changed. Boards, blackboards, whiteboards, smart boards have changed dramatically. Why are they different? Well, the light that comes off a smart board versus a whiteboard or a blackboard is very different reflected light, versus a screen that’s self-illuminated is quite different as far as stimulating the eye. The early introduction of reading; kids are reading at a much earlier age than previously. Toddlers and preschoolers are reading sooner. The dvd player, the portable ones, the ones that are embedded in the back of the minivan seat, playing with handheld video games. Kids aren’t copying from the board nearly as much. I’ve heard from kids that in the classroom themselves they’re not looking at the board. They’re on their laptops almost exclusively. And of course, the social media boom and video games and the ever-present cell phone at the end of the hand. So with regard to today’s examinations what what has changed? Well, parents are more concerned about  how kids are spending too much time on their screens. There’s constant blinking parents are looking at me and he’s like he’s doing this and he’s blinking his eyes forcefully. What’s going on with, you know, with how much time they should be spending on their devices? Why is my child’s prescription changing so rapidly, t’s only been a few months? And these complaints are not unwarranted studies show that that infants through age five are spending over three hours a day on their screens, teenagers five to seven hours that’s beyond academics so talking about recreational time. I tell my parents that kids have a reserve tank, there’s only so much focusing power their child’s eyes have, if they use up all their fuel on these recreational tasks, then they’re not going to have as much for their academics. So developmentally, how young is too young for a child to be looking at a screen? Well we’ve all seen it, I’ve seen kids walk into my office with babies as young as six or seven months in strollers holding a bright cell phone in their hands. These things have become video pacifiers. If you watch this video clip I want you to pay attention to the baby’s reaction, and note not only hers but the parent as well. You can see immediately when the baby takes hold of the phone it’s not just a toy, it immediately quells her crying. So much like a pacifier, there is something taking place there that is beyond. I’m going to beat the drum here for annual eye examination. Eye examinations of course are beyond vision screenings. A child can pass a vision screening despite having significant refractive error. If a child is too nearsighted or too far-sighted, then the demand on their eyes is going to be quite different. Farsightedness in particular causes the eyes to focus too hard. If their eyes again are using up that reserve of focus without the need of without the aid of eyeglasses their child’s eyes are going to give out sooner. Their binocular function can also be affected. I’ve come up with basic four rules for managing visual hygiene. First thing is maintain a good screening distance. If you look at a child’s arms, they should be shaped like a letter “L” not a letter “V”. Keep a good distance away. Taking rest breaks. In my opinion, 25 minutes of near work should warrant at least two minutes off. Have the child close their eyes for 30 seconds and relax, and look far away for about two minutes. This is easy to do at home; in school it’s a lot more difficult. But my colleagues will be talking about something called the 20 20 20 rule a little bit later that helps. Proper lighting is crucial. Lower the screen intensity; there’s no specific degree which with it should be lowered, but the contrast with the ambient room light is important. Get outside whenever possible. Outdoor exposure has been associated with protection against myopia and my colleagues will be talking about that a little bit later. So what are the recommendations that parents look for? Well there aren’t a lot out there, believe it or not, but the American Academy of Pediatrics and the WHO the recommendation, this is kind of an amalgam of there too, if you’re a year or younger, there really should be no screen time and you have to think about what children should be doing  in that time period. A child at that age should be looking at 3D objects, making eye contact with their parents, holding toys that are tactile. While they’re on the screen none of that is taking place. From 12 to 24 months avoiding digital media other than closely monitored video chats in other words if their grandparents are far away and there’s no other way to see them that’s one of the things that might be appropriate. But beyond that it should be very limited. Ages two to five about an hour a day and again this is going to vary quite a bit with the child’s environment. Six plus, and this is a trickier group, academics kick in. Using a screen has become ubiquitous so knowing a child’s eyes and how much they can handle past the age of six is really our purview in eye care. So, the sources of discomfort are myriad. Visual demands change throughout life and of course throughout the day. Think about your child’s schedule during in whatever age they are. Your preschooler, your third grader, your middle school and high schooler very often they wake up in the morning, what’s the first thing they reach for? Their cell phone is right by their bedside. While we’re sleeping there’s very little tear film being produced so whatever you have during the day is all you have when you wake up in the morning. As soon as those eyes spring open and you’re on a screen staring, it’s going to set yourself up for a very uncomfortable day. Now as far as permanent vision damage or eye damage not taking place, but again dry eye is a significant eye disorder. Medically children are not small adults they can focus to a much greater degree than we can ask, any 45 year old who tries to look at their phone. Their eyes also have crystal clear lenses. A lot of light gets through their eye; our lenses become a bit yellowed as we age and as they do that screens out different types of light. So, how can we help? If we look at that young girl that we looked at before, think about what’s going on here. This is not a video, she has blinked, but clearly the screen is too close. The screen is very bright look at the reflection of her face. Her background is very dark. She’s in the covers. And of course it’s close to bedtime, she’s actually in the bed. She’s very young; a child should be with her parents so they can be supervised as far as how they’re using their screen. The posture is very poor; she’s holding up her head, it’s not going to be a comfortable position for the neck or the eyes. The color is very saturated. My colleagues are also going to talk about something called night mode, where screens can have their blue wavelength subdued. And of course look at the dark circles under eyes, clearly she’s tired. So again, screens are not evil. They’re great teaching tools; think of sesame street, think of all the programming kids have. It teaches critical thinking, it teaches basic social skills, math skills and literacy. The proper use of electronics has to be tailored for each stage of life. Do not just give your child a device and assume they know how to use it. Again, comprehensive eye exams; we don’t know how your child is focusing unless they have a dilated psychoplegic eye exam to know how their eyes are functioning, and of course if they’re healthy. The four rules: proper distance, good lighting, take rest breaks, get outside. Look for signs that your child is being adversely affected you must observe them. If they’re blinking too much, if they’re rubbing their eyes, if they’re getting headaches. Take an active role in monitoring your child; set a good example. At the very least, your eyes will feel better too. 


[Dr. David B. Granet] A couple of  just some quick thoughts, you know while you were talking it hit me about what we’re talking about behavioral changes in children when they look at screens. You saw a baby react like an addict would if you remove their drugs. And we know there’s there’s work that’s been done showing that that many of these screens what’s on the screen really connects to the limbic system in the brain and it the gamification of education does the same thing. It’s like kids are in Las Vegas all the time with lights going off. So one of the questions that came in is what can educators do if they’re putting children in front of screens especially elementary school kids for during Covid? We’re hoping kids get back to school but in the meantime we’re planting our kids in front of the screens for eight hours a day. 


[Dr. Kenneth Sorkin] Yeah, yeah it’s a really really good point and you know it’s changed so rapidly that it’s not taken generations for this to occur; this occurred very very quickly. You know, expressive language disorders have actually been diagnosed in 18 month olds because of increased screen time. When a child is learning these things these are crucial facial cues, watching the lips move as a child speaks, learning how to focus on 3D objects; this has all been removed with screens. So what educators really have to do is they have to take these into consideration. The amount of time they’re spent focusing on a 2D object as opposed to interacting with people. So you know getting back to books and looking up and down relaxing the focus, not simply locking in their focus at a set distance for too long a period of time. 


[Dr. David B. Granet] Great, we also have a live question for you from a member of our audience if I can ask our Gabrielle and Tara to bring up that live question please.


[Audience] Hello there, can you hear me okay?


[Dr. David B. Granet] Yep Elizabeth, we can. Go ahead.

[Audience] Great, so listen I am a California lawyer I’m based here in Paris where I’m a digital parenting consultant in Europe, and I speak with a lot of parents and listening to you I have to admit I did a couple of screen captures because it was just fabulous but I would love to know what are the three simple things that parents can do to help their child whatever they age whatever wherever they’re located, and I also have a second question that they didn’t know that I was going to ask and that is what’s a resource for me and what’s a resource for other child online protection experts that we can read to get caught up with this this aspect of screens and our children’s eyesight?


[Dr. Kenneth Sorkin] All right yeah as far as the the three things again iI’m going to just fall back on what you can do as far as getting a child examined by a professional who is experienced in examining children. We can assume that just because our eyes are focusing properly and our eyes feel good that our kids don’t, so getting a comprehensive eye exam is number one; you got to find out if their eyes are functioning properly and they’re healthy. The two other things again is really just you must must take an active role in what your kids are doing, specifically limiting time again make sure that they take rest breaks from the screen and make sure this personal interaction okay, people must communicate with people via screens it’s fine it’s kind of all we have at the moment, but you have to make sure that they have those outside exposures. Keeping their eyes comfortable; if the eyes hurt if they’re distracting, learning is not going to take place. We were chatting earlier that kids are going to react very differently when they’re doing something recreational on their screen, if they’re having fun they’re going to plow through those symptoms. If they’re doing something and it’s not so fun for them like academics those symptoms are going to go right to the top of the list and about “I can’t see, my eyes hurt, I’m not doing this anymore” so make sure that they’re under optimal conditions at all times. As far as resources go again nothing better than a one-on-one interaction with a good professional so make sure you you tap into your local pediatric eye doctor. Beyond that, the American Academy of pediatric Ophthalmology is an excellent source. The American Optometric Association, AOA, has a great resource page on their websites as well. 


[Audience] Thank you so much.


[Dr. David B. Granet] Elizabeth, thank you so much for your question. I’m going to add also that Children and Screens, our hosts for today, also have great resources on their website. The World Society for Pediatric Ophthalmology and Strabismus, WSPOS, has several consensus statements and great resources as well. So, there’s lots of places for parents to turn and there are now more and more books that are coming out. An ophthalmologist actually, Andrew Doan, wrote a book about the dangers of  screens and what they can do to the teenage mind, which is a very different situation so, just another resource for you.


[Audience] Excellent, I love it.


[Dr. David B. Granet]  Thank you for your question. I know it sounded like a setup but you were just in the audience and thank you for all the work that you’re doing where you are; I love it. So Ken I wanna get back to you. One last question as in the short time we have before we have to wrap up this segment which is: can you demonstrate that what you meant about your arm and the “L” versus the “V” and what that means?


[Dr. Kenneth Sorkin] Yeah, so see if I can do it, you know when a child is or anybody’s holding a phone or holding a tablet when their arms are set at a right angle it maintains what’s called the “Harmon Working Distance”, which is the hypotenuse of a triangle if your arms are the adjacent and opposite so if your arms are like “V”’s okay, if your arm is up like this, the screen is way too close, causing the child’s eyes to focus harder and also for the eyes to converge inward. If it’s set back here, the accommodation or focusing demand is at a more appropriate point. Also the eyes are in a slightly downward looking position. If your eyes are up here looking straight ahead if your eyes are level your eyes are open much wider. That increases the um increases the surface area of the cornea, and that’s going to increase evaporation. Or your eyes are looking down you’re taking advantage of the tear film that pulls at the bottom of the eye. 


[Dr. David B. Granet] Oh terrific, I’m sure we’re gonna have more questions and I look forward to your input as we go into the discussion. Thank you so much for setting the stage for the rest of our whole conference today.


[Dr. Kenneth Sorkin] Sure.


[Dr. David B. Granet] Next up, it’s my pleasure to introduce Dr. Saoirse McCrann. Dr. McCrann is a renowned researcher whose research at the Center for Eye Research in TU Dublin, we went all over the world to get you the best experts, focused on finding new ways and means to limit the progression of short-sightedness, what we might call nearsightedness or myopia in children. She now works as a senior science writer at Novartis. Saoirse, we look forward to hearing what you have to say.


[Dr. Saoirse McCrann] Thank you so much for the the lovely introduction. Okay, here we go. Hi everyone, yes so as David said and my name is Saoirse and it’s actually now just after 5 P.M. in Ireland and I have already spent just over 7 hours at my screen today. So yes, my plugged-in lifestyle evolves around me working at a computer and shopping online and interacting with my friends and doing yoga via my smartphone apps or banking online or watching Netflix on my laptops or even even tracking my steps on my phone, on my small fitbit screen so it’s actually endless. So is it any wonder that a recent 2020 report found that we spent over 13 hours on screens per day? But, even before we were forced to work or school or stay connected online due to COVID-19, we already had high screen time hours. And what’s more worrying, is that it’s children under the age of 13 who are now the fastest growing internet audience in the world. Now why does this worry me? Well, because increased screen time has been linked to short-sightedness in children, with short-sighted children found to use almost double the amount of data on their smartphones daily compared to non-short-sighted children. Now by now you might know that short-sightedness is also known as myopia so I’ll use those two words interchangeably, and it’s when the eye grows too long and it causes blurred distance vision and it’s very very common. In fact, it’s the fastest spreading condition in the world and it’s predicted to affect 5 billion people by 2050. Now, that’s half of the world’s population and if we look at the profile of individuals who are short-sighted we will see that the prevalence is much higher in younger people. So looking at this figure you’ll see that the prevalence of myopia is over 90 percent among school-leavers in Southeast Asia, so basically almost all school-leavers are now short-sighted there and this is a starting statistic. What’s more, Europe and the USA are also on this pathway, and the prediction is that within another couple of generations we will also be at these rates if we don’t intervene and do something about nearsightedness. But why does it matter if our children are myopic, if they are short-sighted? why should we be concerned? Could they not just get glasses or contact lenses or maybe laser surgery when they’re a little older? Well, it may surprise you to know that glasses are not a cure for short-sightedness and even with glasses, our eyes can continue to grow longer becoming more and more short-sighted. So this does not only mean more frequent trips to the eye care practitioner to get a new glasses prescription, but short-sightedness can put our eyes in danger. As if our eyes have grown too long, they are now overstretched, and this is what’s happening in short-sightedness and this can cause eye disease and even blindness later in life. So, take a look at the images here on my right anyways and the eye in the middle image, image B, that’s the short-sighted eye, and you’ll see it’s longer than the normal eye on the top. But this short-sighted eye sees the distant images as blurry. So, if you consider blurry vision as the symptom of myopia and now take a look at the bottom image, image C, the short sided eye now has glasses and it can see clearly, but the glasses here are only dealing with the blurry vision symptom by helping the eye to see more clearly. But the eye is still too long and it’s once the eye grows too long this is what cannot be reversed and this is what causes the damage. So what can we do to protect your children against short-sightedness? Well, finding out what causes myopia in the first place is the first piece of the puzzle in order to see if we can implement some changes here. So scientists now know that we may be short-sighted because it’s been passed on to us genetically and unfortunately there’s nothing we can do to change the genes we’re born with. But apart from this and anyways it’s not genetics that has caused a huge recent increase in the number of people with short-sightedness, it’s our lifestyle and Ken has already touched on this. So you know as from what I’ve said already is that short-sightedness is linked to increased screen time, but it’s also linked to less time outside, more time doing closed tasks such as reading, more time in education and urbanization. But if we think about screens, and our smartphones in particular, they combine a number of these lifestyle risk factors thought to cause myopia. So smartphones are a close task for one and in fact we hold our earphones even closer to our faces than the typical book which can increase the amount of what’s known as peripheral defocus on the retina, and its peripheral defocus that is thought to contribute to causing short-sightedness. And as I said, there is an association between reading and myopia and often when we’re on our phones and we’re reading – be it an email or a Whatsapp message or an Instagram caption and thirdly, when we are engrossing our smartphones we’re usually not outdoors and time outside has been shown to prevent the onset of myopia. So, what can we do to protect against or slow down the progression of short slightness in children? Well, the first and simplest advice I would give is to make some lifestyle changes. So, encourage children to go outside, when and where possible because as I said outdoors has been shown to be protective against myopia and has the added advantage of reducing screen time. Secondly, make habits,  not choices. So this is an important one. They say it takes 21 days to form a habit or maybe I should say to break a habit, because breaking a habit really means establishing a new habit. And the habit loop shown here governs any habit. The habit loop consists of three elements, a cue, a routine and a reward. So for example, when the queue is going to bed,  you automatically and routinely and hopefully go to brush your teeth out of habit and in return you’re rewarded with nice clean teeth and fresh breath going to bed. And if we use this analogy we can also change bad habits or form better ones. So if your child is bored or or taking a break from their skill work or homework then start to break the cycle of your child automatically picking up their phone and rather give the eyes a real break from close work and get into the habit of doing 10 minutes of fun exercise or dancing on their lunch break so then they’re not just going from near task to near task and jumping from their skill book to a phone say. Or if your child is going to bed and no phones in the bedroom policy should be the routine and the habit and the rewards will then speak for themselves so you’ll have healthy habits and healthy smiles and healthy eyes. And while we’re on the topic of how we can possibly slow down short-sightedness, there are now myopia control options if your child is already short-sighted so this can involve slowing down the progression through special types of contact lenses or glasses or eye drops and these are offered by certain eye care practitioners and clinical trials globally. So, a question I often get asked is how much screen time is too much for my child? Now, this is a tricky question and it differs now by age and nowadays it’s even trickier because we’re at home so much more but in my opinion not all screen time is equal, especially nowadays, so it is up to parents to decide how and how often their their child should use their screen and whether the screen time is positive or negative. For instance, time spent on homework or other educational activities might not need to be as restricted as time spent and playing smartphone games or watching TikTok. And for kids of all ages though, and Ken did say this as well, screen time should not replace the time needed for socializing and sleeping, eating and playing and, as Ken said, for the first time ever in 2019 the World Health Organization offered its own advice on the subject and recommended that less are recommended less than one hour sedentary screen time per day for children under four years with no screen time advice for under twos. And, if you know where you feel that your child is using the screen too much, then how about just starting with a small change, because it’s the smallest changes that can make the biggest impact. So I’m going to leave you a few examples here. American Airlines for one cut one olive from each salad and it’s rumored, or said, that they save forty thousand dollars annually. And before NorthWest Airlines merged with Delta, they noticed that they cut their lines into 16 slices instead of 10 slices, which was saving a whopping 500,000 annually. And me, I also made a small change to my life in the past three months and i formed a habit of not looking at my screen after 9 pm. Guess what, my screen time average has reduced by 62 minutes per day so then last week when I was preparing this presentation I decided to have a look with what i could achieve with it with an extra 62 minutes per day if I lived until i was 81, now the results are shocking. So, with my extra time I could go to the moon and back 15 times or I could walk the Great Wall of China not once, but nearly twice or climb Mount Everest 15 times or even watch the whole Simpsons series 100 times, which I do not recommend for your eyes, but you do get my drift here. So, even though I plan not to do these things in my lifetime, I don’t plan on going to the moon and back 15 times,  what I’m really trying to say here is that it was really an only small change for me and it’s now a habit and I don’t even think about it. So I’m not asking that you or your children have to give up screens altogether but a small change like this could really make a difference in protecting the eyes of your children. Thank you.


[Dr. David B. Granet] Saoirse, thank you that was awesome and huge amounts of information for everyone. While you were talking I pulled out my IPhone and checked my screen time data on it which is I’m embarrassed to even say the number, I’m more guilty than you are let me put it that way  of how much screen time we are. Parents can check their children’s phones similarly the way I just did to see how much screen time they’re spending as well. One of the things I wanted to make sure that we’re talking about is that we’re not telling people not to read and we’re not telling parents not to encourage their children to read. It’s sort of what they’re doing after they’re done reading that we’re talking about, right?


[Dr. Saoirse McCrann] Yes, yes so that’s what I was saying about positive and negative; kind of deciding how they should be spending their time during your time. so I would never say or discourage educational activities or reading those kind of things but jumping from one year task to another so if they’re taking a break from the reading try not to let a child automatically pick up their phone and start watching their videos or start making TikTok; try and get into the habit of like weather permitting and COVID permitting and everything maybe we can’t go outside now so maybe just putting on a YouTube dance video and just really um really just distracting yourself from your tasks for for a few minutes and just getting the eyes to relax totally looking in the distance. 


[Dr. David B. Granet] Yeah, my 13 year old son’s in eighth grade and his school when they go to PE at home he’s running up and down the stairs in the house and running around the house. I thought that was very clever to get them away from the screen doing other things so they do an internal scavenger hunt where they look for things. I think there are clever ways that parents can help move their children away from the screen.


[Dr. Saoirse McCrann] Absolutely, and fun ways as well, you know, so then it’s a nice kind of alternative screen work.


[Dr. David B. Granet] Yes, my mom is a professor of education we used to play board games scrabble those things like that to to get away from looking at a screen. So, thank you so much for what you brought to the table today that was just great information and we’re going to have a discussion at the end of this where we’ll look forward to getting more of your input. 


[Dr. Saoirse McCrann] Thank you.


[Dr. David B. Granet] So with that, I want to introduce our next speaker, Dr. Mark Rosenfield.  Dr. Rosenfield’s a professor at the New York State College of Optometry, where he conducts research into binocular vision, digital eye stream ,and the measurement and etiology of refractive error, that is whether or not we can determine people are nearsighted, far-sightedness, have astigmatism, etc. So, Mark the stage and the platform is all yours. I look forward to hearing your input.


[Dr. Mark Rosenfield] David, thank you and it’s an absolute pleasure to be here and hopefully this is working so you should all be able to see my screens. So, in case you’ve been living under a rock for the last 12 months or so you might have noticed that things have changed and this coronavirus has been responsible for it’s impacted every single person in the world, I think. Things are very different and we were very aware of screens but in some ways nothing’s changed because what we call digital eye strain, digital eye strain is the condition where people are complaining about symptoms when they’re looking at screens, that was very prevalent long before we’d ever heard of coronaviruses. For example, this study from the American Optometric Association back in 2014, long before COVID, showed that 80 percent of children between 10 and 17 years of age reported that their eyes burned, itched, were tired or blurry after they’ve been using a device. So in many ways this isn’t new, but what’s new is the amount of time that people are spending on screens. And this study again, well before COVID in South Korea, showed that children who had twice as many symptoms both ocular and visual symptoms if they use their phones for more than two hours a day. The thing that amazes me really in this study is that they were able to find a control group where they got kids who were using their phones for less than two hours a day that that’s almost the most surprising aspect of the study. So, what could we do about it? Well, we could ask children and teenagers to reduce their screen time and I wish you luck with that and let me know how that goes. Alternatively, a couple of things that I am going to talk about is try not to get try to make sure they’re not holding the device too close. And Ken has already mentioned this and I’ll give a couple of suggestions and then I’m going to talk about these blue blocking filters that a lot of people have raised questions about, and is there really any evidence that they work? So, let’s talk about viewing distances. Holding phones too close seems to cause eye strain. So we wanted to know we got the impression that people were holding these devices pretty close, so we figured let’s go out and measure it. And this was done in students so students tend to be older university students so around 19, 20, 21 years of age so we’re not talking about little kids here, we’re talking about pretty much fully grown adults. And, we found that when they were viewing either if for example, a text message on their screen, the average viewing distance was about 14 inches, but some students were holding the devices closest just under 7 inches. And similarly when they looked at a web page on their phone the average viewing distance was about 12 inches, but again some people were holding them as close to 7 inches. Now, why does it matter? So what? Is this a problem or is it not really relevant. Well, I think it’s very relevant for a couple of reasons. Firstly, the typical viewing distance when we’re looking at printed material, when we’re looking at paper, is around 16 inches or so but our studies showed that for students on a phone they’re holding it about 12 to 14 inches on average and some of them much closer than that. Why does that matter? Well,l because the closer you hold something, the harder it is for your eyes to focus on that target, something that we call accommodation. And also, as you know when you look at a near target your eyes have to turn inwards to look at the target and the closer the target is, the more your eyes have to turn in, so the harder they have to work or what we call the harder they have to converge. So the closer the viewing distance the greater the demands that you’re placing upon the eyes. So, I would recommend that the device should never be any closer than 16 inches. Well that’s fine for an adult, but if you have a small child I don’t have research on this but I suspect that little kids have little arms and tall bigger kids have bigger arms and adults have longer arms still; so, when they’re using a handheld device if it’s in the hands of a little kid they’re going to hold it close, because they have to hold it close, because they have short arms. So is there an option? Is there an alternative? Well yeah I think there is and especially with young kids. Maybe try having them use a desktop mounted device and you can see just with this setup you can see how the little boy is forced to be further away from it just by the way the furniture is set up. Somebody asked me the other day, do they still make desktop computers? Absolutely they do. You don’t see them advertised as much as tablets and and smartphones but absolutely, desktop computers are still out there. They have a bigger screen which also might be more comfortable. But the thing that they do is they force a longer viewing distance and that might be beneficial for the child. And then we have blue light. And this is kind of a hot topic at the moment and people are wondering whether symptoms of digital eye strain are associated with the fact that there’s a lot a lot of blue light emitted by the devices and there’s no question that there is a fair amount of blue light being coming from the devices. And so, there are all sorts of lenses and I just picked on a few; I should say i have no financial interest in any of the devices any of the lenses the ones you see here or any others, but there are all sorts of lenses being advertised out there quote “to prevent digital eye strain to relieve headaches to make you more comfortable”. So we wanted to see is it true? We know the digital screens when people are looking at screens for a long period of time that does produce symptoms, and we know that screens produce quite a high proportion of blue light. So does that mean that the  blue light is indeed responsible for the digital for the digital eye strain symptoms? So I’m going to show you the results from two studies that we have conducted and published in peer-reviewed literature.  The first one compared a blue blocking filter with a neutral density filter, which you can think of as just being like a regular sunglass type of lens, and we compared symptoms when people read either through the sunglass the tinted or the blue blocking filter and to make a long story short, this is the bar on the left is the symptoms for the blue blocking filter and the bar on the right is the symptoms for the neutral density or the sunglass lens if you like. And you can see that the results are absolutely identical, and there is no significant difference in terms of symptoms whether you’re using a blue blocking filter or whether you’re just using a tinted lens.  So we thought well we didn’t do it on a double blind basis. Double blind means the subjects knew which filter they were looking through and the the experimenter knew which which filter the the subject was looking through so there might have been an issue there. The other issue is this study that we did we blocked almost 100 percent of the blue light and that’s highly abnormal because if you look at blue blocking filters in spectacle lenses and here just a range of different lenses if you look at the amount of blue blocking light a blue light that they’re actually blocking the answer is not very much. The highest block filter is blocking only 25 percent of the blue, or in other words, 75 percent of the blue is getting through, whereas some of the filters are blocking less than 10 percent of the blue, or in other words,  90 percent of the blue is getting through to the eye. So we thought maybe blocking a hundred percent of the blue light was unrealistic. So we figured let’s do another study this time we made it double blind so we had three pairs of glasses that looked like this in identical frames with different types of lenses two of which contain blue blocking filters and this time the subjects didn’t know which pair of glasses they were looking through the experimenter didn’t know which pair of glasses the subject was wearing, we tested them three times, we compared the symptoms after a very demanding reading task, and again to cut a short story make make a short story, there is no difference no significance in difference in the symptoms whether they were wearing a blue blocking filter or they were wearing no blue blocking filter. In other words, we have no evidence whatsoever to support the proposal that blue blocking filters reduce symptoms of eye strain and perhaps making it worse, I can’t think of a single physiological mechanism to explain why blue light would lead to eye strain why is blue light necessarily causing more strain than say red light or green light so there’s no I can’t come up with any physiological basis for this. Now the one thing that may be helpful with blue blocking filters, is they do may be helping in terms of sleep patterns and I know that Lauren is going to mention this towards the end of the presentation, so that might be a positive factor for blue blocking filters. One other concern that people have is is the amount of blue light that’s being emitted from these devices dangerous? And hopefully I can put you at rest with regard to that. So the International Commission on Non-Ionizing Radiation Protection, that’s a mouthful, recommended that we didn’t need to worry if the amount of light coming from a device was less than 10 to the four candelas per meter squared. Now don’t worry if that sounds like Greek to you. This is what’s important, this slide shows what is the percentage of that limit that we need to worry about being emitted by different devices. And you can see for desktop laptop and tablet computers we’re talking about one to two percent at most of that dangerous limit in other words we really don’t need to worry about you know is the amount of light going to cause damage to the back of the eye? Is it at a dangerous level? The answer is, it isn’t. Smartphones just a little bit higher but we’re still two to four percent of that dangerous limit. So I don’t think we need to be getting too concerned about the amount of light that’s being emitted and is that causing danger to the back of the eye. I really don’t think it is. So some recommendations for you. Try, if possible, to keep a viewing distance of at least 16 inches from the screen you might find it easier to do that with a desk mounted device rather the handheld device. Spend the money you’re going to use on blue blocking filters on something much nicer. Treat yourself; once COVID is over treat yourself to a meal out in a restaurant or something like that; don’t waste the money on the blue blocking filters if you’re worried about eye strain. And then finally, just to reinforce what Ken said at the beginning: get a comprehensive eye exam to rule out things like nearsightedness, farsightedness, astigmatism. And also, a child even if they have good vision even if they can see clearly they may have focusing or eye turn problems and the comprehensive eye exam is going to detect those, so it’s not just a matter of well they can read the street sign across the street so they must be fine, they may not be fine, because they may still be having focusing or eye-turn problems that could be causing other symptoms. Okay, and that completes my presentation. Thank you very much. 


[Dr. David B. Granet] Mark, that was awesome and I have a whole host of questions that came in from the wilds. All of them said our blue or blue glass is important, so blue blue locking glass is important, so you just answered all the questions.


[Dr. Mark Rosenfield] Okay, wonderful. 


[Dr. David B. Granet] So, you know,  for clarity you know we’ve heard about blue light and I want to say it directly: macular degeneration, cataracts, what you’re describing is that even though children’s eyes have more transmission than adult eyes do, that the levels that they’re looking at from the screen are not concerning, as far as we know. 


[Dr. Mark Rosenfield] That’s correct, I mean basically we’re talking about one to two percent of what has been shown to be the levels of which we need to worry about. So that it’s just not nearly enough. Far more dangerous in terms of need for eye protection is the radiation coming from the sun, so we need to be more concerned about sunlight protection than we need to about protection from the blue light coming from electronic devices. 


[Dr. David B. Granet] Especially we’re putting people and perhaps in sunglasses that dilate the people they better be blocking…


[Dr. Mark Rosenfield] Exactly, and you’ve got a young guy that is very clear and transmits a lot of light and so you know there’s more trend more of that light reaching the retina in a young eye than in an older eye.


[Dr. David B. Granet] Terrific, and I want to bring in Dr. Lauren Hale who’s one of our other experts that we have here. Dr. Hale is a Professor of Family, Population, and Preventative Medicine Stony Brook on Long Island, where she focuses on sleep including screen use and sleep. So we just heard Mark Rosenfeld talk about blue light, and specifically damage to the eye. And I’m curious about what blue light does in terms of its impact on sleep.


[Dr. Lauren Hale] Hi, yes, this is the big question and I want to thank Dr. Rosenfield for not only presenting his great studies but identifying that there is a disconnect; there is no physiological explanation as to why blue light may affect eye strain. But, there is a physiological reason why blue light may affect sleep, specifically blue light has an alerting effect on the brain and reduces or suppresses melatonin, which we all need at night, to help us with sleep onset. So, that’s why some have recommended that we wear the blue blue light blocking glasses in the evening, not all day, we don’t need them all day to help mitigate that suppression of melatonin and there is some evidence suggesting that it does or demonstrating that it does do this. So, it might be easier to fall asleep. However.. yeah don’t worry it’s nuanced, I’m not gonna uh stop there. It’s really important especially as a parent, to keep in mind that blue light is not the only reason why screens might make it hard for kids to fall asleep or adults. And those reasons have nothing to do with blue light blocking glasses so you need to consider that screens are stimulating, screens are a time sink, screens make a lot of noises while you’re falling asleep and after you fall asleep. So the recommendation from the sleep research community is put your screens away 30 to 60 minutes before bed, have your kids do it, have you do it, role model that for your parents, I love that Saoirse told us her personal story, and put your screens away. If you really need to be working late at night, you might try the benefits of uh the orange or amber tinted glasses to mitigate the melatonin suppression but it should not be your primary strategy.


[Dr. David B. Granet] And Lauren, there are different programs that will actually turn the blue light off on your screen without putting on glasses, that that can be used as well for evenings when you’re trying to make sure you get into sleep. If I understand sleep correctly, getting into a good habit  with the routine for how you go to sleep is important, and also making sure that your bed is used for sleep and not for work looking at a computer screen or a TV screen, do I have that right?


[Dr. Lauren Hale] You’re absolutely right. You want to have a nice clean differentiation between where you sleep and where you work or do other activities and that’s hard to do during COVID. I’m it’s it’s a challenge but putting away those screens is definitely advised. About the dimming, there’s not much evidence, that I’m aware of that, those are very successful that the dimming of your screens will reduce the melatonin, will successfully help with the melatonin issue, so I would follow the first rule of avoid screens in the 30 to 60 minutes before bed. it’s not easy…


[Dr. David B. Granet] Just turn it off; just jump in there.


[Dr. Mark Rosenfield] There is also some evidence that if you can get your kids to read that it might be better late at night if they read using what we use what we call books made out of dead trees versus reading off a Kindle or a tablet device, and that has actually been shown to have a positive effect on sleep patterns. So if they want to read read out of an old-fashioned book instead of of a Kndle or an e-reader or something like that. 


[Dr. David B. Granet] Absolutely, terrific, thank  you both for that that input we’ll have some more time at the end for discussion but I wanted to make sure we we hit the blue light hard right then and there. Our next speaker, it’s my pleasure to introduce Dr. Ken Nischal. Dr. Nischal is a professor at the University of Pittsburgh School of Medicine, who’s also a Vice Chair and Chief of the Division of Pediatric Ophthalmology and Strabismus. He is one of the co-founders of the World Society of Pediatric Ophthalmology and Strabismus, for which he was awarded the Innovation Award by the Swiss Academy of Ophthalmology. He is one of the innovators and pioneers of cornea transplants in children, and is an acknowledged world expert in the surface of the eye for children especially. And he’s going to continue our tour around the world of various different accents that sound British; we have Australian, Irish, and now a British accent, even though you live in Pittsburgh. Ken, it’s my pleasure to introduce Ken. Ken, it’s all yours.


[Dr. Ken Nischal] David, thank you very much. I never quite know what to say when you  introduce me like that,  but thank you, I think, will suffice. I appreciate the invitation and I appreciate very much the the introduction, thank you so much. There’s a lot to talk about them in a short time so if I say anything that you’re not clear about, put it in the chat box and I will clarify it in our discussion. These are my disclosures none of them relevant to the talk today. So increase digital screen time what it does is, and my colleagues have made this very easy for me. We’ve talked about increased accommodation, that’s focusing, increased convergence, increase visual attention, you know the fact that you’re concentrating on a screen is important because that reduces your blinking, and when that reduces then your cornea, which is the window of the eye, it’s exposed to greater evaporation forces and so the tear film evaporates and when you have a pronounced or maintained effort, this results in the failure of adaptation mechanisms and you get exhaustion of the ocular muscles. As Mark was saying, you know, you’re converging, and you then get this visual fatigue or otherwise known as asthenopia. So let’s think about digital eye strain as I see it in my practice. There’s the issues of glare, dry eye sensation, fatigue, esotropia. Esotropia is when the eyes when they converge instead of converging appropriately converge too much. One eye turns in, and I will show you why that’s relevant. Headaches, and what patients and children complain about is like defocus blur so let’s talk about glare. It’s a reflection of light onto the screen making the screen viewing uncomfortable and if you look at this picture, which is a stock image, you can see that what’s going on is that the screen light is hitting this viewer’s eyes and it’s a little dark around her. So that might cause glare. But also if you sit directly under a bright light the reflection of your screen towards your face will also cause glare. So you’ve got to be mindful of that to make sure that  your ambient light is appropriate. Dry eye symptoms, now I want you to look at this image, it’s not perfect but it does show something. What it shows is this: when you blink that’s the look at to the the left of the of the schematic, you get a nice tear film, which has three layers. As your eyes stay open, after about 12 seconds in adults, the tear evaporation causes the tear film to break up. And if you still don’t blink that’s when you will start to get discomfort. Interestingly enough, the only paper that’s looked at the non-invasive, that’s what NI tier breakup time TBUT stands for, in children under 12 years was done by my group about 10 years ago and in children it’s 28 seconds so actually, the tear film breakup time is better in children but if you see a child whose tear break up time is only 12 seconds that may be normal in adults but in a child that’s abnormal. They’ve got evaporative dry eye disease and that leads to problems. And the other, the thing that i’m seeing more of, not only am I seeing dry eyes, I’m seeing inflammation of the lid margins I’m going to talk about that. So what about solutions for dry eye? Look at your air conditioning, make sure it’s not on full blast. Get a humidifier, and if you can’t afford a humidifier just a bowl of water warm water near where the child is working. Make sure your central heating isn’t full on because that has an effect on the evaporation. Artificial tears work you can get them over the counter. Remind children to blink, talk to them and say remember to blink. And if it’s really desperate, and you have terrible problems and I had a child this morning in my clinic you can put pencil plugs in this is a child who’s nine years old and you can put a plug in one of the drainage holes in the lid on the on the lower lids and that acts like a dam it acts like a reservoir.  Now we don’t do that as a first line, but if you have children in whom the artificial tears are not working, and they’re symptomatic especially if they’re staining on their cornea then this is something that you would do. Again, like my colleagues have said you need an eye exam. Now I don’t know about the rest of my colleagues but I am seeing more and more children with these little lumps in their lids uh coming up and the the incidence has definitely gone up since the COVID pandemic started and there was a lock down. And what you’re seeing is with the evaporation there are glands in the lid margins that produce oil and that dryness is causing the mouths of the glands to become inspirated, dried, and this is a problem. So warm compresses help, artificial tears help, but again it’s there’s an increased incidence of this at this moment in time. So what about fatigue? Constant accommodation and near-target work results in fatigue. And what that means is you’ve got to find a solution. Work breaks are important. The 20-20-20 rule was first brought to the attention of the public by the vision council about, I’d say, six years ago, so before the COVID pandemic. And what it states is that you should pause every 20 minutes while you’re doing screen work for at least 20 seconds it’s not exactly 20 seconds at least 20 seconds and look at a distance of about 20 feet or 6 meters. What that does is it allows you to blink it allows you take a break and it breaks that fatigue cycle. Esotropia is when the eye turns in and there has been there have been several reports of sudden onset esotropia from excessive smartphone use in teenagers. Now, what happens is that they’re holding the phone so close that one eye will turn in. They’ll get double vision, they get blurry vision, they get headaches so it’s important that if your child says that they’re seeing double that you get them to see a eye health professional emergently to make sure that there’s nothing else going on. But in these cases that were reported, by drastically reducing smartphone and digital time, they were able to settle down back to normality. Headaches, asthanopia is headaches due to visual fatigue visual straining. Convergence insufficiency is when you’re supposed to be able to look close you can’t quite do it and the effort the extra effort to do that causes headaches. And of course we’ve mentioned esotropia. Blurred vision can be seen by dry eye. The inability to focus normally, some children can’t focus normally they have a lag and again that can only be picked up once you have an eye examination and some children will have convergence insufficiency which i’ve talked about. So in conclusion, take a break, the 20-20-20 rule, lubricate. Think about putting lubrication in and teaching your child to help themselves do that whenever they feel that the aisles a little uncomfortable. Distance: I love the idea about the “L” rather than the “V”  but try and see if you can hold get the child to hold things away 25 inches away, that’s a desktop which we all remember and which you all should try and use. Keep a distance, adjust the height so that you’re at that you’re at eye level, in terms of the distance. But if you’re looking at something close in your hand as Ken said earlier, try and make sure that they’re looking down and adjust. Reduce glare and brightness by adjusting the settings on your device. Make sure your ambient light is good to help you be comfortable when you’re reading. Thank you so much.


[Dr. David B. Granet] Thank you, Ken. You know I’m wondering about the reaction to dry eye. So you talked about very clearly the difficulties with convergence and staring at a screen and the eye drying out, but parents don’t know that’s happening. What they see is the reaction of their child, the behaviors of their child, the move the eye movements that they make. Can you comment on that


[Dr. Ken Nischal Yeah you know David it’s really interesting. Inthe last seven or eight months I’ve had an increasing number of children referred to me for abnormal eye movements. And it’s usually boys they’re, normally between the ages of about seven and twelve, and I don’t know why they do it but instead of blinking they decide that they’re going to make these odd eye movements they do that, they do this, and what they’re doing is they’re trying to roll their eyes to get them wet. And I’ve had children who’ve been investigated for all sort of neurological problems and they come to see me they’ve got dry eyes we put lubricating drops in or even plugs and before you know it they’re back to normal. So children react differently boys, you know, they’re a little bit more lazy than girls and rather than doing the straightforward blinking they find another way of lubricating their eyes. So it’s important to understand that that this behavior is happening because of increased evaporation of the tear film. And once you understand that, and you can you know if you if you can’t get a humidifier just a bowl of water near where they’re working that helps. Take breaks, teaching the child to take breaks, s really useful. One of the things that um one of my my daughters at university but she does some teaching for young children and she makes them play I spy by sitting outside by sitting by the window and looking at something outside their their house. And everybody has to guess what it might be, even though you can’t see it. Though just getting to look out and playing the good old-fashioned I spy game is a is another way that parents can can can interact with their kids and take them away from the screens. 


[Dr. David B. Granet] That’s a terrific point. You brought up and we’ve been talking about just here at the end the behaviors that can occur. I mentioned his name earlier and somehow he’s appearing Dr. Andy Doan has joined us. Dr. Doan is an MD- Ph.D, with his Ph.D. in neurosciences from Johns Hopkins, he is an ophthalmologist and octopathologist, he is a world-renowned expert in digital media and the impact as well as being an ophthalmologist with two books one “Hooked on Games” and the other “Digital Vortex Survival Guide”. Andy is an old friend I know you’re in the military so I assume the usual caveats go that these are your personal opinions and not those in the military but I don’t know how they got you here and where you showed up from but life should always be this way. Andy, you know, you can talk about behaviors from the eyes being dry, but what about the behaviors from the images and the and that the kids are seeing on screen and what I mentioned earlier the gamification of what they’re seeing on screen. What’s that doing to kids? 


[ Dr. Andrew Doan] Hi thanks for inviting me you know, Pam, it’s a small small world so you mentioned me so Pam and I are our friends so she texted me and that’s how I jumped on here.  So as an ophthalmologist you know we’re getting screenings from children from schools for development delay. So reading problems, emotional problems, school behaviors they want to make sure that the vision’s okay and what we’re finding in and you know myself and other clinicians are children who are developing behavior problems because of too much screen time and the way I describe it is that basically you know the games are neither good nor bad depends it depends on the content, and the content will teach them certain behaviors and so the brain is kind of like a muscle so if you are practicing a certain behavior your areas in that brain that represents that behavior. So for example, you know, we know research shows that surgeons that play video games have better hand-eye coordination and are better surgeons than those who don’t play a lot of video games and what I mean by a lot of video games is probably about one to two hours per day however, when you start getting into the six, eight hour range, your brain will over develop those skill sets and so if they’re playing a game where there’s encouraging bullying or encouraging anti-social behaviors, you’re going to have manifestations that will be emphasized or exaggerated in those children, especially younger children because their brains are more plastic and they’re more impressionable at that age.


[Dr. David B. Granet] Wow what an important concept to think about and if we can have all the our speakers turn on their videos andto join in on this conversation. We heard Dr. Hale and Andy talk about lack of sleep and what this can do activating before you sleep how about that affecting behaviors as well so it’s a secondary impact of the uh of screens and screen time.  Lauren or Andy if you want to jump in on that. 


[Dr. Lauren Hale] Absolutely, uh there is an enormous link between sleep and cognitive performance, behavioral performance,  psychological well-being, physical well-being so if your exposure to screens throughout the day or especially at night is interfering with your sleep, that’s a pathway through which we see behavioral outcomes and changes and it’s a big concern for those in the screen research community.


[Dr. David B. Granet] Okay so we’ve heard all about what the impact of screens are on ocular health, which is the real topic of our talk, but we’re really talking about people not just eyes and so you know I’m like to get everybody to jump in on this because we’ve gotten questions from several educators who are listening online with their about their online classrooms you know they’re hearing us talk about too much screen time, we have kids that may be leaning into the screen,they may be too close, they’re sitting all day, “I have a bad back” you know that’s not good, we’ve talked about repetitive behaviors sitting on a keyboard perhaps. What should they do? What’s our suggestions for these teachers? Anyone would like to jump in first. 


[Dr. Ken Nischal] Yeah I think it’s important you know we’re talking about the the issues that are are extremely important for parents to know about and to be concerned about. However, children have to be educated, education is really important, and we have to sort of find a balance. I think the strategies that all of us have talked about about taking breaks lubricating these all help, but I think the one of the things that was said right at the beginning of the the whole seminar or webinar I should say, was the fact that interaction with other people, siblings and parents it actually doesn’t actually break things up so you if you leave a child just to their own devices, pardon the pun, then there are they are they are going to run into potential problems. But of course the other side of the story is that parents are busy parents are trying to do their work from home as well but there has to be some interaction to help that break to help that the human interaction rather than just the digital one. So Mark my eighth grader and when he’s done with his day at online school comes down and turns the TV on to relax, does it matter what kind of screen they’re looking at, does it matter if it’s television or if it’s online school or if it’s their IPad to play a game?


[Dr. Mark Rosenfield] In some ways, no, but in some ways, yes. I think the the thing about the television is that it’s usually across the room especially with big you know we know how everybody has big screen tvs and so you you’re not going to sit on top of those you’re going to sit further back from them so it’s less strain on the eyes. I’m old enough to remember my grandparents yelling at me saying if I sat too close to the TV I would ruin my eyes and you know we went through that and that was in the days before anybody even thought about having computers at home, nevermind tablets and smartphones. So you know, looking at a TV screen well at least it’s  across the room, at least it’s at a further distance so in terms of the focusing effort and the converging effort that’s necessary there it’s pretty small. But, the best thing really is for the kids to be outside and one of the things and Saoirse mentioned this and others mentioned this in terms of myopia development, is we’ve shown that sunlight is important. Sunlight exposure exposing the retina to sunlight is important to try and prevent myopia development so watching TV is better than looking at a phone but being outside and looking at real distant targets and getting exposure to sunlight is probably even more important, as well as physical exercises. 


[Dr. David B. Granet] So Saoirse, the explosion of myopia around the world which in some Asian countries now approaches 80 percent of children and the United States is heading in that direction, we talked about some of the preventive measures. Can you just comment or, if you don’t feel comfortable someone else can, on some of the treatments? We mentioned lenses  and now we know that there are some drops that are available out there and different approaches and Ken you might want to, Ken Sorkin, you might want to jump in on this as well, on what’s available so so parents have heard this discussed at least?


[Dr. Saoirse McCrann] Yes, so there are different types of myopic control options in development and in clinical trials at the moment and there are some that are on the market as well. And so in terms of contact lenses there are  they’re quite like a multi-focal contact lens that you can wear, that people over the age of 40 wear as well, it’s the same type of design. What I talked about in my presentation was the term peripheral defocus and this counteracts that peripheral defocus on the retina by wearing that type of contact lens and slows down the progression of myopia. And the eye drops that I mentioned when I was doing my Postdoc Ph.D. research it was working on clinical trials using atropine and there are atropine, there are atropine trials taking place across the world now and the mechanism of actions how atropine works is not fully known yet but it is really successful in slowing down the progression of short slightness as well and it’s used routinely in Asia now actually as a method to to slow down the progression, and as we know in Asia they their prevalence is quite high. And then there are other types of glasses that are currently under investigation and possibly on the market at the moment and once again they’re looking at their peripheral defocus. I don’t know if anyone else wants to add anything to that.


[Dr. David B. Granet] Ken Sorkin, did you want to add?


[Dr. Kenneth Sorkin] Yeah well just, no, I think Saoirse presented that perfectly the advent of atropine eye drops and myopia control is really going to be and has been and going to be a game changer. Just back up so we don’t confuse parents too much out there, when it comes to sun exposure of course we’ve been taught to protect our eyes from the sun and protect our skin from the sun so of course everything like this talk, the overall arching uh theme has been moderation. And same thing goes for sun exposure of course too much sun is not good for the eye it can cause damage, but proper exposure and again I don’t think it’s been elucidated exactly how much is proper. There have been some studies that have come out of China that said uh two hours a day outdoors has had a protective quality to it. So again don’t send your kids out in the sun for full days without protection because we’re stopping them from becoming myopic. As far as developmentally goes,again at every age we’ve known that screens can affect kids when we talk about infants we’ve done this in growing up if you remember when you introduced your infant to solid food for the first time coming off a bottle, if you went straight to fruit pears and peaches you’re gonna wind up with a really really happy kid and just you know continually feeding them that. When you go to try to introduce vegetables you’re gonna have a really tough time you’re gonna get peas and squash spit back in your face and you’re gonna get a happy kid but they’re gonna have rotten teeth. So like screens should be like candy it’s okay to use them in moderation for very young children but if you feed them a steady diet of it it’s going to be bad for their eyes and the things they should be doing with their eyes developmentally 3D objects, making eye contact, having that personal connection is going to be lost so make sure it’s done at the proper time. Again impulsiveness and restlessness and an inability to concentrate has been linked to teenagers and college students who you know admit they spend too much time on their phone even anxiety and depression so it affects every age so moderation is certainly the key. 


[Dr. David B. Granet] Yeah and as always sunglasses are the sunblock for the eyes so we want to protect people. Interestingly when the World Society of Pediatric Ophthalmology and Strabismus was putting together a sun protection guideline for the world, people who lived in Nordic countries were concerned that we were telling everyone to be too careful about getting sunlight because they wouldn’t have Vitamin D production otherwise. And so around the world things are different. Australia is very different than Norway in terms of what you have to protect.  Ken Nischal you know parents want to put drops in their eyes if their kids eyes are dry. Is that the right thing to do? And do they work?


[Dr Ken Nischal] Yeah they do work, there’s a whole range of drops that you can get there’s a there are gels that turn into a sort of long-lasting drop if you like you only have to use them two or three times a day. Look, what you have to be careful about is sometimes drop preserve drops will have preservative in them and what you want to avoid is something called benzyl alkonium, I  think it’s BAK, and if that’s in the drop then if you use it too often that can cause an irritation so if you can get preservative free drops if your child has got particularly sensitive skin you know that they react to drops, try and get preservative free drops but they the drops definitely help if you’re going to get a child to put a drop in before they start let’s say an hour’s worth of screen time on a lesson, then you want something that is not viscous, it’s sort of like a true drop. But if you can put a gel in and let that sort of settle in over about half an hour that tends to last for a couple of hours. So, yeah, that they do work and they do help.


[Dr. David B. Granet] How do you get drops in a kid? How do parents do that? I mean, you know…


[Dr Ken Nischal] So you know there are different ways. Imean the younger the child, the harder it is to to to do, but I’m talking about children who are right around five and upwards who you can rationalize with, sometimes, as to putting the drops in. But the older they get because they they get the symptoms and they they feel uncomfortable, they’re rubbing their eyes, you can then say to them you know if we put the drops in you won’t have to rub your eyes and kids are smart they they understand that so I’m sure it’s not easy on every child but the older they get the easier it becomes.


[Dr. David B. Granet] Lauren, you know, when I was in medical school we never talked about the social determinants of health. Recently I went back got a master’s degree and suddenly it was it was highlighted. When we talk about social determinants of health, where would that fit into this? I mean you know there are people who are having difficulty going to online school because they don’t have a screen and we’re doing everything we can to get them a screen. Here this whole panel is talking about limiting screen time. Just wondering where that fits into this this whole discussion.


[Dr. Lauren Hale] Right, thank you for raising that question. Hope you went back to get your MPH. Wonderful– this is a big question as many of you know of course COVID has also disproportionately affected minority communities so we see a lot of social justice issues in that too. I can’t quite answer the question about ocular health and I don’t know the effect to which disparities in ocular health vary or exist across the population. But I can say that we see differences in sleep by socioeconomic status and race, ethnicity and it tends to be just getting to this topic of screen time that families with more privilege are more able to create structures and routines around screen behavior. And that can help mitigate some of the adverse effects of screens on health and also to your point about the importance of speaking to a professional.  More privileged families are more able to talk to pediatricians and optometrists as necessary and so this is this is a real concern and we are seeing higher rates of online schooling among minority communities as well. So it’s certainly of great importance but I unfortunately don’t have all the answers.


[Dr. David B. Granet] As we get ready to wrap up, Andy Doan you sit in a special spot here and I’m so glad you could join us as an ophthalmologist but also someone who has looked at the greater impact of screens. They say eyes are the window to the soul and we’ve been talking about the impact that screens can have on that window and I’m wondering if you can talk to us about the impact that screens have on soul.


[Dr. Andrew Doan] You know this is a important topic and so Dr. Harley out of france has been working with something called virtual autism. And so what he’s been seeing is that, the earlier the kids are exposed to screens excessively, they are coming with, or they’re developing a syndrome that mimics organic autism, meaning that they have with social withdrawal, they don’t have the eye contact, they don’t have the language development. And I’ve seen it too in my clinic. So when kids come in for a screening for vision and we’re checking for if they need glasses to help them with their reading and their development delay what we’re seeing is that sometimes there’s too much screen time and the parents that we can get them to listen and buy into that, when they take those screens away we see an amazing explosion in development especially in two to three year olds where, you know, eye-to-eye eye contact improves, language goes from 10 words to like over 100 words in a month, behavioral emotional, just across the board you know everything that we value in a society as a good person with a good soul is developing and so that’s something we need to consider and I’ve been trying to get people to do more research into this, you know, and then there’s just not research funds to look at a population level and see how much screens are impacting the community in that regard. But I think that’s an issue that, that’s the you know the big elephant in the room right now is the behavioral ramifications long term. But as ophthalmologists we all know about visual amblyopia where we don’t correct vision in a cross-eyed or esotropic or exotropic child with the eyes turning in or out, you can have permanent visual damage by the age of 10 or 11. So the question is how about the frontal lobe? Is there an amblyopic manifestation there that we’re not seeing or detecting or looking for, and when is the age cut off for that? Because the brain does develop until age 25 when it finishes its development. So is there a time point in the child’s life where that becomes permanent and then becomes a serious you know ramification of a a child with all these behavioral issues.


[Dr. David B. Granet] Yeah thank you Andy. I opened the show by saying that in some ways we’re running the largest experiment in human history by what we’re doing with screens and children and I think you make that point better than I did. I want to thank all of our speakers, you guys were fabulous and and of course women, I better work on my language skills there and not just say guys. But it was really a fabulous discussion I want to thank our host, Children and Screens Institute of Digital Media and Child Development and toss the program back to Pam. Thanks Pam so much for having us all.


[Dr. Pam Hurst-Della Pietra] Thank you, David, Mark, Ken, Saoirse, Ken, Lauren and David, for being here and sharing with us your extraordinary insights and experience. Thank you for joining us today to find out how to protect your children’s ocular health, particularly with regard to their screen use. To continue learning about this topic please be sure to visit our website at and read our tips for parents and other resources. Our conversation addressing children’s well-being and digital media continues in two weeks when we bring you “Oh the Places They’ll Go! Reading in a Digital World” on Wednesday, February 24th at noon.  We’ll also post a video of today’s webinar on our YouTube channel where we encourage which we encourage you to subscribe to and share with your fellow parents teachers clinicians researchers and friends For more from Children’s Screens please follow us on Instagram, Facebook, Twitter and Linkedin at the account shown on your screen. When you leave the workshop you’ll see a link to our short survey. Please click on the link and let us know what you thought of today’s webinar. Stay safe and well.