Digital Eye Strain + Blue Light 2018

DIGITAL EYE STRAIN + BLUE LIGHT

A Research Approach to

BLUE LIGHT + THE EYE Prescribing for SCREEN

Views on

THE BLUES

Helping Eyewear Patients

ADDICTION

ATTAIN VISUAL COMFORT

A Continuing Education Supplement to VCPN, September 2018. Approved for one ABO credit hour of continuing education, Technical Level II. vision care

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Image courtesy of ClearVision Optical

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DIGITAL EYE STRAIN + BLUE LIGHT: SCREEN ADDICTION

Prescribing FOR SCREEN ADDICTION This case study illustrates the need for ECPs to take the lead with their patients on digital eye strain, diagnosing the problem and easing discomfort.

By Thomas Gosling, OD

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he accommodative demands of screen addiction are becoming a major problem, especially with Millennials and younger generations (those who are 10 to 38 years old).

Most of this age group is spending a significant amount of time viewing smartphones, tablets and laptop computers throughout the day, and their visual systems have never been under such stress. Nearly 70% of this group admits to suffering from digital eye strain. Eyecare professionals need to be more aware if their patients are suffering from symptoms of digital eye strain and offer solutions. The discussion begins best in the exam room.

According to The Vision Council, 90% of patients do not talk to their eyecare provider about digital device usage. On my intake questionnaire, I ask every patient to estimate the time they spend looking at their smartphone, tablet, computer and printed material.

Next, I ask if they are experiencing any symptoms of digital eye strain, including fluctuating vision, tired eyes, headaches, body fatigue, dry eyes, sight sensitivity, eye rubbing, poor night vision or reduced concentration.

Recently, I had a young patient getting his driver’s license who failed the DMV vision screening test. He came in complaining he needed eyeglasses for driving. When I reviewed his intake questionnaire, he had checked every key symptom of digital eye strain and indicated using his smartphone “24/7.” His autorefractor results of -1.25D sphere OU indicated he needed eyeglasses for distance. His entering visual acuities were 20/40 OU. During the refraction, I used a technique that I use to assure I do not push too much minus, especially with patients exhibiting symptoms of digital eye strain and heavy screen use. I fog them with +2.50D over what I feel their Rx is. I slowly take away this plus until they begin reading the 20/40 line. Once they get to 20/40, I drop in the retinoscopy lens (+1.50D) for about five seconds to relax the accommodation.

After giving another -0.25D, I remove the retinoscopy lens.

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Eyecare professionals need to be more aware if their patients are suffering from symptoms of digital eye strain and offer solutions.

In this case, the patient jumped from 20/40 to 20/25. Repeating this pattern, he was seeing 20/20 with +0.50D OU. When I relaxed his focus and brought him to plano he was seeing 20/15 OU. I pulled back the phoropter and stuck my finger through the eye holes. He was confused as to why he was just seeing so well with nothing.

I explained that his internal focus was getting locked up from all his smartphone screen time. I then had him look back at the chart, which was blurred from me getting close to him and locking up his focus again.

His problem was not that he needed eyeglasses for distance but that he needed help relaxing his eyes at near. I like to use a +1.00D flipper in the exam lane to explain this to patients. In this case, I had him look at his phone as I placed the flipper in front of him. Holding it there, I explained that these lenses were relaxing his eyes at near and that when I removed them I wanted him to “feel” what his eyes are going through all day. Upon removal, he immediately pulled back and began blinking heavily. He understood quickly that his screen time was the problem and wanted to know how it could be fixed.

For patients with digital eye strain, I use lenses that give a “boost” to the accommodative system, which helps relieve their symptoms. I use these “anti-fatigue” lenses every day, and the ones I use have a +0.57D, +0.95D or +1.32D in the near zone. In this case, I used a plano with +0.95D support, and the patient reported a significant improvement in his vision and accommodative stress.

We are living in a new time with new visual demands, and we need to be aware of how they affect younger populations. n Thomas Gosling, OD is owner of Optical Matters in Littleton, CO. SEPTEMBER 2018 | DIGITAL EYE STRAIN + BLUE LIGHT | VCPN

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DIGITAL EYE STRAIN + BLUE LIGHT: VIEWS ON THE BLUES

Views on THE BLUES Blue light blocking lenses are doing things for my patients that eyeglasses don’t normally do.

By Gilan L Cockrell, OD, FAAO

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any of us are aware of the potential dangers of blue light and its various impacts regarding our well being. These concerns are justified and, with consumer awareness at an all-time high, it is essential that we properly identify patient needs and address their concerns.

Recent examples of blue light in the news created a buzz on this topic. The cover story of the August 2018 issue of National Geographic, “Sleep: Inside the New Science of Slumber,” was read by millions and picked up immediately by major news networks. It begins, “Our floodlit society has made sleep deprivation a lifestyle. But we know more than ever about how we rest — and how it keeps us healthy.” 1 In addition, CNN headlined an article, “Blue light like that from smartphones linked to some cancers, study finds” 2 on April 27, 2018.

In our practice we regularly prescribe appropriate blue light lens options for dealing with our patient’s respective lifestyle needs.

IMPACTS OF EXPOSURE Blue light at night suppresses the secretion of melatonin that in turn inhibits our cognitive ability. All digital devices (smartphones, tablets, computers and TVs) as well as LED and most energy-efficient lights have peak emittance at about 455 nanometers (nm). Blue light, in the range of 450nm to 500nm, is responsible for triggering the receptors in our retina to suppress the release of melatonin. Conversely, as we dramatically reduce the intensity of blue light in this range from reaching our retina, the suprachiasmatic nucleus signals the pineal gland to release melatonin, thus promoting regular sleep patterns. Devices and energy-efficient lights are telling our bodies to stay awake. Only lenses that block a significant percentage of blue light at peak emittance (about 455nm) and above will help stimulate melatonin regulation.

Managing blue light exposure helps create the opportunity for maximal cognition during the day. (I don’t know about other people, but there haven’t been many days where I feel more intelligent than I need to be.)

ONE SUCCESSFUL CASE The first patient whom I prescribed blue light blocking lenses presented with what appeared to me to be signs of sleep deprivation. When I questioned his mother about his sleep patterns she responded by regaling me with tales of his very poor sleep, poor academic performance as well as acting out in self-defeating ways. Further questioning

revealed that he spent many hours on his digital devices, as well as using them right up to bedtime. With great trepidation I discussed the innovation of blue light blocking lenses and their purported positive effects on melatonin regulation (now supported by studies such as Ryab-Quang Van’s presented at the AAO in September of 2017). The study revealed almost double the melatonin levels in the participants when wearing blue light blocking lenses after 6pm.

I scheduled a six-week follow up. At the follow-up visit both the son and the mother had noticed a tremendous (her word) improvement in his sleep quality, interaction with others and academic performance. Although, his story is anecdotal, we continue to prescribe the same lenses to many more patients, both children and adults, with the same great results. The slight tint with these lenses is a product feature we promote to ensure that the full benefits of improved sleep and productivity are experienced.

IMPROVED SLEEP AND COMFORT Eye strain and visual blur are created by blue light scattering both in the atmosphere and inside our eyes. Whether from the sun, digital devices or energy-efficient lighting, blue light creates haze and visual discomfort.

THE GREAT OUTDOORS Outdoor blue light wavelengths are problematic across the entire blue light spectrum from 400nm to 500nm and are connected to potential macular cellular damage, eye strain and visual discomfort.

We can all appreciate the effectiveness of glare reduction by polarized lenses. The newest development is blue light blocking polarized lenses with proprietary modification that allows all of the benefits of a premium polarized lens with the ability for enhanced digital screen viewing. Not only do they provide the patient with a higher level of protection from the sun’s potentially harmful blue light rays, they also offer dramatically improved contrast sensitivity and visual clarity versus regular tinted or standard polarized lenses. Additionally, users will also find greater ease when viewing digital devices. The result is the most effective color enhancing sun lens available.

I encourage you to implement a blue light product strategy with your staff and offer your patients the best lenses to address their lifestyle needs, indoors and out. n Gilan L Cockrell, OD, FAAO, is CEO of Williams Group Consulting.

1. NationalGeographic.com/Magazine/2018/08/Science-of-Sleep/ 2. CNN.com/2018/04/27/Health/Artificial-Blue-Light-Prostate-Breast-Cancer-Study/index.html

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Americans check their phones 12 billion times a day.1 It’s no longer a question of who is using digital devices since 60% of Americans spend more than five hours a day on them.2 All this digital device use is affecting your patients’ eyes, and they may not know that new contact lens innovation can help their dry, tired eyes — two symptoms of digital eye fatigue. As eyecare professionals, it’s important to educate patients about the effects of digital device use and what they can do to help their discomfort.

Your patients rely on digital devices, and now there is a contact lens designed for their digital lifestyles. Biofinity Energys contact lenses are the breakthrough sphere innovation for monthly contact lens wearers to help with eye tiredness and dryness associated with digital eye fatigue.

With the increase in digital device use, eyes require more near viewing. Prolonged digital device use can overwork ciliary muscles and cause eye tiredness and dryness. Biofinity Energys with Digital Zone Optics lens design can help reduce ciliary muscle stress during digital device use. 3

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8 out of 10 device users5 agreed that Biofinity Energys made their eyes feel less tired.6

Biofinity Energys are the only contact lenses with Digital Zone Optics lens design to help with eye tiredness associated with digital eye fatigue and Aquaform Technology to help with eye dryness.

Globally, nearly four out of five contact lens wearers are interested in exploring ways to reduce their eye tiredness with an eyecare professional, yet only 14% of contact lens wearers report that they or their eyecare professionals bring up digital device use during appointments.4 Digital is the new norm, so why would you prescribe a contact lens that isn’t designed to meet your patients’ digital lifestyles? n

1. 2017 Deloitte Global Mobile Consumer Survey: The Dawn of the Next Era in Mobile 2. The Vision Council 2016 Digital Eye Strain Report: Eyes Overexposed, the Digital Device Dilemma 3. Prospective, multi-center (nine sites), subject-masked, bilateral wear, cross-over, non-dispensing study comparing the difference of the change in AMF frequency measured by the Accommodative Function Analyzer instrument (AFA). Based on a statistically significant difference of the mean change of Accommodative Microfluctuations and when compared to Biofinity sphere after reading on an iPhone for 20 minutes held at a distance of 25 cm. 4. CooperVision Digital Device Usage and Your Eyes Report, 2018 5. Among patients who use digital devices at least 4 hours per day at least 5 days per week and self-report symptoms of eye fatigue at least once per week. 6. After one week of wear; data on file.

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ABO TECHNICAL LEVEL II

Helping Eyewear Patients

ATTAIN VISUAL COMFORT COURTESY OF CLEARVISION OPTICAL

APPROVAL: ABO APPROVED FOR 1 HOUR, TECHNICAL, LEVEL II ONLINE COURSE: STWFV030-2 ISSUE DATE: SEPTEMBER 1, 2018 EXPIRATION DATE: JULY 1, 2023 APPROVAL: This course has been approved for one hour of Technical, Level II continuing education credit by the American Board of Opticianry. NOTE: This course is only available with online testing. Please see instructions at the end.

COURSE DESCRIPTION: Eyecare professionals strive every day to help their patients achieve visual comfort. That goal is praiseworthy, but its implementation can be challenging, especially in view of the living and working environments today’s patients experience and their extensive use of digital devices at work and at home. These factors can lead to visual discomfort. This course indicates the sources of visual discomfort for eyewear patients due to illumination and other environmental conditions, digital eye strain and blue light absorption, and offers helpful suggestions for providing comfortable solutions.

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By Ed De Gennaro, MEd, ABOM

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According to The Vision Council, slightly more that three-quarters of the adult population in the United States wears some form of vision correction (Rx eyeglasses, contact lenses or reading glasses). With over 75% of the population using corrective eyewear, the goal of helping achieve visual comfort reaches a huge majority of Americans. No matter how accurate the correcting lens power or powers or how attractive the eyewear may be, if the patient is uncomfortable with the correcting product, they’ll be miserable wearing it … or worse, stop wearing it.

The topic of visual comfort has several contributing factors. Fortunately, the human visual system is adaptive and tolerates optical and environmental factors that are not conducive to visual comfort. Even so, with continued exposure to these factors, the patient is likely to develop symptoms. If you’re sincere about providing your patients the best visual comfort, it’ll be helpful to understand the factors that affect it and what you can do to promote it for them.

LIGHTING A lot of research on visual comfort centers on lighting in the workplace. As an

ophthalmic practitioner, you didn’t have input into your patient’s workplace design, but you’re confronted by its consequences.

The best defense here is to understand the fundamental principles of workplace lighting so you can make recommendations for environmental and optical solutions.

Lighting and colors in our surroundings affect our mood and level of fatigue. That’s why workplace spaces should be carefully designed for ergonomic functionality and visual comfort. According to the ILO (The International Labour Organization, an agency of the United Nations), “Visual disorders associated with deficiencies in the illumination system are common in the workplace.”

The ILO suggests each workstation be designed properly for the intended purpose by professional lighting personnel. This implies that a “cookie cutter” approach often used in lighting systems in settings such as large office buildings be reconsidered for more individual systems.

The ILO lists the following factors as prerequisites for attaining visual comfort in the workplace: • uniform illumination • optimal luminance • no glare • adequate contrast conditions • correct colors • absence of stroboscopic effect or intermittent light

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ENVIRONMENTAL SOLUTIONS Some solutions will not require optical products. For example, some overhead fluorescent lights recessed into a white ceiling can be intense and overwhelm a person under them many hours a day. The fix might be moving the person to another location in the office or wearing a visor or hat with a brim in this environment.

Other simple fixes might be moving lights to different locations, changing bulb intensity or bulb temperature (which affects the color of the light, such as cool white, bright white, warm white, etc.). Dark walls or ceilings or starkly contrasting colors on these surfaces can be troublesome. While many environments use light, subtle colors, others do not, which may need to be addressed by the worker’s employer. Glare from equipment might also be managed with a simple, non-optical solution. Simply adding a shade or some other filtering device over the lamp may solve the problem.

Always search for the simplest solution first.

While obvious, providing the correct lens powers for the tasks your patient performs is the foundational element of visual comfort to which all other solutions are added.

Tinted lenses may soothe vision by managing light intensity, quality and contrast. Antireflective lenses are a good option because they eliminate the glare created on the lenses from bright digital screens.

DIGITAL EYE STRAIN In the last few years, The Vision Council has raised awareness about an enormous problem, digital eye strain. With the increased use of digital devices in the workplace and at home, people around the world are spending significant time staring at their digital device

screens. This often results in an array of visual and physical discomfort symptoms The Vision Council collectively labeled digital eye strain. According to The Vision Council’s data, “More than 83% of Americans report using digital devices for more than two hours per day, and 53.1% report using two digital devices simultaneously, with 60.5% reporting experiencing symptoms of digital eye strain.”

It’s common for young people to use digital devices for five hours or more each day,

and intermediate viewing places stress on the patient’s accommodation system. Remaining in a stationary posture for prolonged times can also create symptoms. When someone stares at a screen, their blink rate declines, which can cause dry eye symptoms. The glare from digital devices is also a contributing factor because it reduces clarity of the screen’s image, reduces contrast, and can cause visual confusion for the user. Another concern is the blue light that digital devices emit.

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according to some industry sources.

Digital device usage cuts across nearly all age groups. For example, 87.7% of those ages 18 to 39, 82.6% of those ages 40 to 59, and 76.3% of those ages 60 and up report using a digital device more than two hours a day.

Using a digital device this long is easy for many people, especially if they use a computer at home and/or at work, have a smartphone, and perhaps also have a tablet. Americans have come to rely on their digital devices for much of the information they gather and the work they wish to do. For example: • 75.6% use a computer to do research • 56.6% use a smartphone as an alarm clock • 54.2% use a computer to go shopping • 53.7% use a smartphone to check the weather • 48.7% use a computer to find a recipe Young children are often left with tablets or smartphones to occupy their time, with many spending countless hours each day with one.

Most digital devices require near and intermediate vision while using the device in a mostly stationary position. Over time, this often results in eye strain, dry eyes, headaches, neck and shoulder pain, and blurred vision, the symptoms of digital eye strain. Prolonged near

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ABO TECHNICAL LEVEL II

Factors other than lighting contribute to visual discomfort. Examples include the nature of the work being done, the visual distances of the work, what types of digital equipment the worker is using, the number of continuous working hours, and the physical and psychological stressors in the workplace.

What all this suggests is that when you’re interviewing a patient complaining of visual discomfort symptoms, include questions about their lighting and environment (both indoors and outdoors). Armed with this information (and other environmental, optical and medical information), you’ll be able to develop appropriate solutions.

ADDRESSING DIGITAL EYE STRAIN Thomas Gosling, OD, a private practice optometrist and owner of Optical Matters in Littleton, CO, shared that from his experience, “Digital eye strain is a huge problem because the use of smartphones, tablets and computers has become nearly universal, especially among young people.” He added, “I ask every patient nine questions related to digital eye strain. I’m seeing more young people with symptoms because of tasks like gaming, watching Netflix, texting, viewing social media, using apps, etc.

Many of them are using their devices for six or more hours a day.”

These are the symptoms Gosling screens for as indicators of digital eye strain (in the order he encounters them in his office): • fluctuating vision • tired eyes • headaches • body fatigue • dry eyes • light sensitivity • eye rubbing • poor night vision • reduced concentration 41

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ABO TECHNICAL LEVEL II

While young people have a great accommodative system, Gosling feels the accommodative system was not designed to look at near devices for long periods of time. “Many kids are holding their devices too close, somewhere between four inches and eight inches, and more are complaining of digital eye strain,” he recalled.

“Some of it is due to the screens being small, and some of it is because little children have shorter arms than adults, but some of it is caused by their accommodation locking up,” Gosling explained. “This happens when the ciliary body inside the eye locks in position and won’t relax. This causes them to hold their digital device even closer, which tightens the muscle further. This cycle continues until they are holding their device inches from their eyes.”

The problem spills over to distance vision.

Since their accommodative system is locked, these young patients experience pseudo myopia because their accommodation won’t relax. Gosling uses a refraction sequence that relaxes their accommodation, so they can discover why they’re having digital eye strain symptoms. It’s a clever technique. With older patients, Gosling usually gets complaints of having difficulty seeing at night.

Gosling’s “go-to” optical solution for digital eye strain is anti-fatigue lenses that have a modest plus power boost in the lower portion of the lens that gains progressively from a stable distance power. Think of it as a weak progressive addition lens. They provide a small amount of plus power for intermediate and reading tasks so the user’s accommodation works less, thereby easing symptoms. These lenses are offered in a series. For example, one company offers three lenses with power boosts of +0.57D, +0.95D and +1.32D. Another offers power boosts of +0.40, +0.60D and +0.85D. These lenses can also have anti-reflective coating to eliminate glare on the surfaces of the lens and blue light absorbers. Some patients may also opt for lightly tinted lenses.

Incidentally, these lenses are fitted like progressive lenses, so you’ll provide monocular PDs and fitting heights for each eye. This is because the power boost zone must be positioned properly. Because the power boost is weak in these lenses, aberration and distortion are essentially unperceivable.

symptoms is for patients to give their eyes a rest from near and intermediate tasks. To give people something simple to remember, The Vision Council promotes the 20/20/20 rule — every 20 minutes, look away from your digital device at something 20 feet or further for at least 20 seconds. It’s simple; 20/20/20 mimics 20/20 vision (which nearly everyone recognizes as good vision), and it’s catchy, so they’ll remember it. While the technique has never been evaluated experimentally, it derives from research done by the rule’s creator, Jeffrey Anshel, OD, who uncovered that shorter, more frequent breaks benefited musculoskeletal disorders. With that understanding, he adapted the concept for the visual system. The important takeaway is digital device users need frequent breaks to rest their eyes and change their body position. That doesn’t mean getting up from the computer for a break at work and grabbing a smartphone to catch up on a Twitter account. It means doing something that relaxes your eyes from near and intermediate viewing while also relaxing your body.

BLUE LIGHT While it’s been known for decades that blue light (those wavelengths from 380nm to 500nm as defined by the American National Standards Institute) enters the eye and reaches the retina, recent literature has indicated harmful effects of blue light from different portions of the blue light spectrum, which can be divided like this: • scattered haze from 380nm to 420nm • retinal/macular effects from 430nm to 450nm • melatonin suppression from 460nm to 480nm

Blue light has the shortest wavelengths of all visible light and therefore delivers the most energy to whatever it encounters. Blue light scatters when it encounters minute particles, such as water vapor in the sky, which makes the sky appear blue.

Scattering blue light in the eye can cause a veiling glare that reduces contrast and clear vision. It’s particularly a concern for the elderly (whose ocular media has floaters and other particulates) and those with corneal opacities, developing cataracts, intraocular lens implants, and LASIK surgery.

A correctly powered lens for a patient will have its blue light component focus in front of the retina (while the green focuses on the retina and the red focuses behind it). A lens can have as much as 1.00D of myopic defocus, which Gosling believes, “… is causing the accommodation system to seek its focus.

Because of this, the blink rate diminishes, and the eyes become dry and stressed in general, leading to progressive myopia.”

INDOOR VS. OUTDOOR Experts on the blue light topic suggest that no one solution is perfect in all lighting situations and recommend that a separate indoor and outdoor solution be provided. According to Greg Naes, president of BluTech, Inc., “If you’re not filtering blue wavelengths from digital devices, you’re not impacting digital eye strain. If you’re not filtering 455nm, there’s not much point in wearing the solution.” This is because light from LED screens peaks at 455nm and drops off sharply on each side to 420nm and 480nm, so these screens give off energy that may impact both sleep cycles and the retina. “What they don’t give off is much in the 380nm to 420nm range

20/20/20 RULE One way to relieve digital eye strain COURTESY OF VSP

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SLEEP Chou detailed several studies that support blue light influences on circadian rhythms (the body’s 24-hour biological clock), melatonin suppression and the sleep/wake cycle. “The retina,” Chou said, “has intrinsically photosensitive retinal ganglion cells (ipRGCs). These are light receptors that don’t give sight but send signals to the pineal gland in the brain that regulates

ABO TECHNICAL LEVEL II

(the ‘scatter’ wavelengths),” Naes noted.

Gosling thinks photochromic blue light lenses offer the best protection overall because the sun provides 100 to 500 times more blue light intensity (according to Transitions Optical) than any common digital device and delivers the full blue light spectrum. He feels they deliver greater blue light protection outdoors at around 85% and about 20% indoors in their clear state.

Naes added, “Photochromic lenses offer about 11% blue light absorption indoors at 455nm, which is not enough for indoor protection against digital devices. AR-treated blue light treatments offer 2% to 8.7% absorption at 455nm. BluTech has four solutions that provide 42% to 60% blue light absorption, depending on the product.

Brian Chou, OD, FAAO, in private practice in San Diego, CA, at ReVision Optometry, feels, “Adjusting a digital device’s blue light screen filter can effectively reduce blue light emissions from digital devices, but photochromic lenses offer a more systemic protection for both indoors and outdoors.” Naes suggests that eyewear lenses also do a much better and more reliable job than device screen filters.

All three professionals agree that the biggest contributor to blue light exposure is outdoors, not indoors, and they all recommend sunglasses to mitigate the dangers of UV and blue light outdoors.

“Outdoors, the sun doesn’t discriminate,” Naes noted. “You’re getting the full blue light range of 400nm to 500nm.”

“Like indoors, there are two challenges, glare from the sun and blue light. Polarized lenses are great, but they make viewing some objects like smartphone screens difficult because of the polarizing filter, but they increase contrast, color saturation and reduce bright light. Ideally, if we could handle blue light and provide glare reduction while being able to use digital devices outside, that would be ideal,” Naes recommended.

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melatonin production. Blue light in the 460nm to 480nm range suppresses melatonin production, which inhibits you from getting sleepy.”

Some people in places such as Seattle, WA, and Anchorage, AK, suffer from seasonal affective disorder, a form of depression caused by a lack of sunlight.

Naes warns of a massive sleep epidemic and indicates the science of blue light and sleep cycles has a long history. According The Centers for Disease Control and Prevention, a third of U.S. adults report that they usually get less than the recommended amount of sleep.

He said, “You don’t want to be exposed to 459nm to 484nm wavelengths (associated with the sleep/wake cycle) at night, especially before bedtime. It’s not just about melatonin suppression; humans need some blue light to get them going throughout the day. We’re still cavemen/women by DNA, so at night we’re supposed to go back to our dark caves and secrete melatonin, which facilitates a deep restful night’s sleep.

Instead, we come home, break out our tablets and smartphones for hours, and get exposed to blue light, which confuses our body and interrupts the sleep/ wake cycle. Even if you fall asleep, you

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don’t get deep REM sleep; you get duration sleep.” For potential relief of eye strain from blue light, Naes suggests the lens needs to absorb at least 30% of the wavelengths at around 455nm.

RETINAL CELL DEATH “There are a number of studies that implicate short wavelength visible light causing damage to the retinal pigment epithelium cells, the photo receptors and ganglion cells,” Chou explained. These lab studies were done with rodents, primates and human cell cultures. He said, “While these studies showed retinal cell damage under specific parameters, there is no definitive proof yet that blue light causes macular degeneration or other retinal conditions in humans. At the moment, the level of evidence is that blue light may be a contributing factor to retinal disease, but it doesn’t have the high level of evidence-based support like UV does.” Based on studies Gosling mentioned, he feels that 430nm poses the greatest potential for retinal disturbance.

There are lots of blue light products in the marketplace, and they provide varying levels of blue light absorption. If you’re concerned about retinal harm, adding sun protection makes lots of sense because sunlight is 100 to 500 times stronger than 43

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interior light and delivers the full spectrum of blue light.

BOOTS LAWSUIT ECPs are putting themselves at risk of lawsuit by claiming blue light prevents retinal diseases such as age-related macular degeneration or other retinal damage. Boots Opticians in England was fined £40,000 by the General Optical Council (a British regulatory agency).

The Council ruled that Boots had overstated the claims that blue light from smartphones, LED TVs, and energy-saving light bulbs caused damage to the retina and that their blue-blocking lenses protected against this.

The Council found no compelling evidence of this claim and fined Boots.

Gosling, Chou and Naes all echoed the same caution about claims of blue light lenses protecting the eye from retinal cell death and pointed to the lack of human-based research with emphatic evidence of this potential connection.

Chou and others cited a study on retinal cell death in animals that indicated intense blue light at 435nm creating a disturbance in retinal cells. This is the study often cited when claims of a connection between blue light and potential retinal harm.

In view of the Boots sanctioning, practitioners should take a cautious approach to claims of retinal harm due to blue light. The most you might claim is there may be a connection to retinal diseases. Naes, Gosling and Chou all recommend focusing on benefits to the sleep cycle and blue light scatter.

Naes suggests that ECPs have a “duty to inform” (like they do with impact-resistant lenses) with blue light protection so 44

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every patient should be told about the effects of blue light on digital eye strain, sleep deprivation and perhaps the potential that blue light may pose for the retina.

FURTHER THOUGHTS Some doctors caution that some young myopic children shouldn’t get blue light protecting lenses because research has shown that spending two hours a day outdoors is associated with less myopic progression and that the blue light within sunlight may be what is inhibiting childhood myopic progression. The fear is that suppressing sunlight with photochromics or blue light outdoor lenses will negate that sunlight benefit and encourage myopic progression. Chou mentioned that it is premature at this stage for practitioners to make such recommendations ahead of the evidence, and that instead, there is still good rationale for children to wear

photochromic lenses for the UV protection and light adaptive comfort.

Chou cautioned, “Not all blue light is harmful. It can help regulate circadian rhythms, it can help elevate mood, and there is evidence that it may regulate myopia progression. If someone blocks all blue light indiscriminately, in the worst-case scenario, they might cause depression, sleeping troubles and myopic progression.

Blue light penlights have become a common demonstration aid in helping patients understand that lenses can absorb blue light. But Naes pointed out that these penlights emit 405nm +/- 10nm, which is not the wavelength range you want to reduce from digital device screens. Because of this, he recommends not using them.

LED street lights and indoor compact fluorescent light (CFL) bulbs also give off high levels of blue light. CFL bulbs have spikes of blue at 435nm, and LEDs peak at 450nm. As these products become widely used indoors and outdoors, concern for blue light protection from them has grown.

Essentially, these products are surrounding us with blue light emissions where older technology didn’t.

Helping patients attain visual comfort indoors and outdoors is a multifaceted task, but with good questioning, an understanding of digital eye strain and the optics of lenses and treatments, you’ll be able to make the right recommendations, some of which have no optical component at all. n Ed De Gennaro, MEd, ABOM, is editor emeritus of First Vision Media Group.

This course is ONLY available for online testing.

TO TAKE THE TEST ONLINE: Go to VisionCareProducts.com/Education 1. Under the black Log-In Bar, – log in (Note: If you have not registered on our new sites since September 2017 use the “register” link to register for online education, and record your user name and password for future access.)

2. Click on the course you would like to complete.

3. Review the course materials.

4. T ake the test, and at the end of the course, after you submit your answers, your results will automatically appear on your screen!

5. All passing tests will automatically be submitted to ABO at the beginning of each month. You may print a copy of your certificate for your records.

SEPTEMBER 2018 | DIGITAL EYE STRAIN + BLUE LIGHT | VCPN

8/27/18 10:14 AM

DIGITAL EYE STRAIN + BLUE LIGHT: A RESEARCH APPROACH TO BLUE LIGHT AND THE EYE

A Research Approach to

BLUE LIGHT + THE EYE COURTESY OF PPG

By Brian Chou, OD, FAAO, FSLS

W

ith all the confusion surrounding this topic it’s helpful to understand some of the studies that indicate how blue light may be affecting the eyes.

The light spectrum contains many more wavelengths than humans can see. Frequencies of light include microwaves, radio waves and x-rays, to name a few. The visible spectrum is only a very thin portion of wavelengths between 380nm and 780nm. The highest energy of the visible spectrum is immediately adjacent to the UV spectrum and is just above 380nm (typically noted as 380nm to 460nm). This high energy blue light scatters in the atmosphere and is the reason why the sky appears blue. Blue light makes up 25-30% of daylight. 1 Blue light is also produced by light-emitting diodes (LEDs). LED lighting is widely found in digital technologies such as televisions, smartphones and tablets. A 2016 report from The Vision Council found that 60% of Americans use digital devices for more than five hours each day, and 70% use at least two or more devices at one time. 2 From an ocular health perspective, it has been long known that blue light is toxic to certain ocular structures. The longer the wavelength, the higher the proportion that passes through the cornea and reaches the lens and retina. On average, the human cornea absorbs wavelengths below 300nm, and the lens absorbs those below 400nm. Upon closer analysis, though, this changes throughout life as a clear crystalline lens at birth and in childhood years transmits light at 300nm+, whereas an adult (and a more yellow crystalline lens) transmits at 400nm+.

Protection of children’s eyes is especially important since transmittance is greatest at a younger age, allowing higher levels of UV and blue light to reach the lens and retina. 3 The retina is posed a risk as it absorbs light over 400nm. 4 Given that the spectrum of high-energy blue light is known to be 380nm to 460nm, there is a portion of blue light that is problematic. Ocular exposure to light around 435nm (+/- 20nm) can induce irreversible cell death in the retinal pigment epithelium (RPE). 5 Historically, there have been several large-scale population studies that have demonstrated the ocular risk from blue light. The

Multiple studies on the sources and effects of blue light have demonstrated ocular risk, but it may take more research over several more years to fully understand its impact.

Chesapeake Bay Waterman Study had several iterations of meta-analysis, and an association was identified between cumulative blue light exposure and age-related macular degeneration (AMD).

Similarly, the Beaver Dam Eye Study concluded that exposure to bright visible light might be associated with AMD. Finally, the Visual Impairment Project suggested that individuals with more sunlight exposure are at a significantly increased risk for AMD. 4 As such, sunlight (and more specifically, cumulative blue light) has been identified as a risk factor for AMD. There is a specific photosensitive visual pigment that appears to be involved in this retinal toxicity, and it is referred to as A2E (N-retinylidene-N-retinylethanolamine).

A 2013 study defined the most toxic wavelengths of light in an in-vitro model. Their conclusion was that the most loss of retinal cell viability occurred between 415nm and 455nm. 5 What is additionally worrisome is that retinal cell death occurs via apoptosis (a continual cascade of death of neighboring cells) and is likely what makes AMD visually destructive. 6 There does exist some confusion as to where the risk of ocular damage originates. It should be explained that the sun emits over 100 times the amount of blue light than digital devices or LEDs. Though we spend many hours per day on illuminated screens and computer technologies, it has been proposed that the blue light hazard from digital devices may not approach dangerous limits. 7 What is known, though, is that digital device usage can wreak havoc on our sleep patterns by interfering with human circadian rhythms.

In the absence of blue light, ganglion cells in the human retina stimulate the pineal gland of the brain to release melatonin, a hormone that lets our bodies know it is time for sleep. This is in stark contrast to the presence of blue light, which suppresses melatonin production so our bodies are alert, energized and ready for work and play. This is a problem as 76% of Americans look at their digital devices in the hour before attempting to go to sleep. 2, 8 n Brian Chou, OD, FAAO, FSLS, is in private practice in San Diego at ReVision Optometry.

1. Baillet G., Granger B., How Transitions Lenses Filter Harmful Blue Light, Points de Vue, International Review of Ophthalmic Optics, online publication, March 2016 PointsdeVue.com/article/ How-Transitions-Lenses-Filter-Harmful-Blue-Light. 2. The Vision Council. 2016 Digital Eye Strain Report TheVisionCouncil.org/Digital-Eye-Strain-Report-2016 3. Behar-Cohen F., Baillet G., De Ayguavives T., Ortega García P., Krutmann J., Peña-García P., Reme C., Wolffsohn J.S., Ultraviolet damage to the eye revisited: eye-sun protection factor (E-SPF), a new ultraviolet protection label for eyewear, Clin. Ophthalmol. 8 (2014) 87-104 NCBI.NLM.NIH.gov/pubmed/24379652 4. Yam J.C., Kwok A.K., Ultraviolet light and ocular diseases, Int. Ophthalmol. 34 (2014) 383-400 NCBI.NLM.NIH.gov/pubmed/23722672 5. Arnault E. Barrau C, Nanteau C. Gondouin P, Bigot K, et al. Phototoxic Action Spectrum on a Retinal Pigment Epithelium Model of Age-Related Macular Degeneration, PlosOne 8 (2013) http://DX.DOI.org/10.1371/journal.pone.0071398 6. Sparrow J.R., Nakanishi K., Parish C.A., The Lipofuscin Fluorophore A2E Mediates Blue Light-Induced Damage to Retinal Pigmented Epithelial Cells, Invest. Ophthalmol. Vis. Sci. 41 (2000) 1981-1989 NCBI.NLM.NIH.gov/pubmed/10845625 7. O’Hagan J.B., Khazova M., Price L.L.A., Low-energy light bulbs, computers, tablets and the blue light hazard, Eye (2016) Nature.com/eye/journal/v30/n2/full/eye2015261a.html 8. Gronfier, C., The Good Blue and Chronobiology: Light and Non-Visual Functions, Points de Vue, International Review of Ophthalmic Optics, N68, Spring, 2013 PointsdeVue.com/article/Good-Blue-and-Chronobiology-Light-and-Non-Visual-Functions

VCPN | DIGITAL EYE STRAIN + BLUE LIGHT | SEPTEMBER 2018

45

The Gold Standard for

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Blue light from 450 nm to 500 nm disrupts melatonin production, affecting your sleep cycle.

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VCPN | DIGITAL EYE STRAIN + BLUE LIGHT | SEPTEMBER 2018

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1 Arnault E, Barrau C, Nanteau C, Gondouin P, Bigot K, et al. (2013). Phototoxic Action Spectrum on a Retinal Pigment Epithelium Model of Age-Related Macular Degeneration Exposed to Sunlight Normalized Conditions. PLoS ONE 8(8): e71398. doi:10.1371/journal.pone.0071398 (August 23, 2013). Identified Harmful Blue Light through in vitro experiment on swine retinal cells, where the most toxic wavelengths are high energy visible light falling between 415-455nm on the light spectrum (blue-violet light).

©2018 Essilor of America, Inc. All rights reserved. Unless indicated otherwise, all registered trademarks and trademarks are the property of Essilor International and/or its subsidiaries in the United States and in other countries. These products may be protected by one or more patents listed at www.essilorusa.com/patents.

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