- Susan Norton
Our collective fear about what smartphone and tablet screens might be doing to children is nothing new; it has increased with every dopamine hit from the latest addictive app. Obesity, poor sleep, behavioral problems, violence and loss of social skills are all on the Mayo Clinic's list of horrors linked to kids' excessive screen time.
Smartphones might be nuking kids' eyes, too — or at least drying them out. So says Burlington optometrist Dora Sudarsky, who is seeing signs of dry-eye syndrome in children as young as 12. In the past, the condition was more often associated with women over 40.
The Luddites reading this article in print may be feeling smug. But 4-year-olds playing on an iPhone X probably think that dry eyes are the least of their antisocial, rage-filled worries, if they think about their eyes at all. But game out the implications, and the dystopian future ahead looks dark indeed.
That's where my mind went, at least, after Sudarsky invited me to get screened for one of the leading causes for dry eye — something called meibomian gland dysfunction — using a new imaging machine at her Burlington clinic, Chroma Optics. I, a millennial, was terrified. I'd binged — like, really binged — on video games through middle school, gossiped away my high school years on AIM messenger and Netflixed the years since. Surely my eyes were burnt toast.
And come to think of it, they were actually hurting a bit. In the 24 hours before my screening, I imagined that the future for everyone my age and younger would feel like being trapped inside a Jose Saramago novel narrated by Ben Stein.
"You're not going to die from dry eye," Sudarsky assured me, before telling me about a Detroit meteorologist who died by suicide after complications from LASIK, a surgical procedure that can trigger dry eye. Most often, though, the condition is just uncomfortable.
It can also affect a patient's vision, which is why Sudarsky says she's begun using a dry-eye screening instrument called LipiScan in her standard eye exams.
Dry eye is either extremely common or relatively rare, depending on how you define it. "It's literally as common as having dry skin on your hands in the winter," University of Vermont Medical Center ophthalmologist David Diaz says, and can be triggered by climate, hormones and contact lenses. "For the vast majority of people, it's a nuisance issue about as worthy of medical attention and expense as dryness on your skin."
Around 7 percent of U.S. adults have what Diaz calls "clinically significant" dry eye, citing data from a 2013 survey of 75,000 adults. Its prevalence varies widely by gender and age: Women are twice as likely to be diagnosed as men, and individuals older than 75 are almost seven times as likely to have it as those between 18 and 34.
The survey found that just 2.7 percent of U.S. adults between ages 18 and 34 were diagnosed with dry eye, but Sudarsky believes that figure will increase as the smartphone generation grows up.
"It's way more common than it used to be," she says. "I think it's going to start getting even worse, because people are giving cellphones to their 2-year-olds to keep them busy."
A 2015 study published in the journal Pediatrics found that almost all children in a survey of low-income, minority families were using mobile devices before age 1. Most were using the devices daily by age 2, and three quarters had their own device by age 4. The study was patterned after a large-scale, nationally representative 2013 study that revealed a five-fold increase over two years in the number of children ages 8 and younger who owned iPads and similar devices: from 8 percent in 2011 to 40 percent in 2013.
Published research connecting pediatric dry eye and screen use is scant, but one peer-reviewed 2016 study in BMC Ophthalmology found a correlation among a sample of children in South Korea. Children in the "urban" group, who used smartphones more frequently, were diagnosed with dry eye at three times the rate of their "rural" peers, who used them less. The study also found that outdoor activity was "protective" against dry eye and that symptoms tended to subside after just four weeks without smartphone use.
The theory behind a link between screen time and dry eyes involves blinking. Humans tend to blink less while staring at screens, which in turn can disrupt the chemical conditions on the surface of the eye. The eye stays lubricated using a layer of tears, called a tear film. The tear film is supported by a series of 15 to 20 tiny meibomian glands on the edge of the eyelid, which secrete an oil that helps prevent the tear film from evaporating too quickly. Without consistent blinking, those glands are more likely to become clogged, producing dry-eye symptoms. And if the glands stay clogged for too long, they can start to degrade.
Last year, Sudarsky installed LipiScan in her clinic to help identify and treat unhealthy meibomian glands before they wither, and in some cases before patients even report symptoms. The screening tool quickly produces high-definition images of the meibomian glands. A technician uses a paddle to hold down the eyelid, while the instrument snaps an X-ray-like photo. The second instrument, called LipiFlow, uses eye pods dubbed "activators" to unclog the meibomian glands. Patients wear activators that heat and massage their eyes for about 12 minutes.
"It's changing the way I treat dry eye," Sudarsky says.
The manufacturer, TearScience, states that the system is available at more than 850 locations in the U.S. and Canada, though Sudarsky is the only Vermont optometrist or ophthalmologist listed on its "Find a Doctor" web page. (TearScience launched its dry eye technology in 2012, and Johnson & Johnson purchased the company in 2017.) But not everyone is sold on the high-tech solution. Diaz, a specialist in glaucoma, says dry eye has been a "poster child for pharmaceutical abuse" over the last couple of decades.
"It's the lower back pain of the eye," he says. "Everyone's got it sometimes, and of everyone who's got it, 10 percent of them are going to shell out money [to treat it]."
He rattles off examples of how dry eye has been exploited by what's become a billion-dollar industry. One study Diaz cites found that the frequency of a dry-eye treatment called "punctal plugs" decreased by almost half once the Medicare reimbursement rate to providers conducting the procedure was reduced. In an effort to shield its lucrative prescription eye drop Restasis from generic competitors, drug maker Allergan devised a dubious licensing arrangement with the Saint Regis Mohawk Tribe in upstate New York that promised millions in annual royalties to the tribe. The move was widely criticized and was defeated in federal court last year.
Diaz says the Restasis example is "illustrative of an entire mind-set" within the industry of dry-eye treatment, in which the condition is hyped and patients overmedicated for profit. He's equally dubious about the value of the TearScience devices. Marketing materials for LipiScan/LipiFlow call the system "revolutionary," but Diaz suggests that the imaging device doesn't provide more information than standard optometry equipment.
"There are people who refer to that as LipiScam for a reason," he says. Beyond "pretty pictures," Diaz says, "there are simply zero studies, science-based studies, that say this adds anything meaningful to the treatment of this disease. In my mind, it's an example of adding cost into the system without producing tangible benefit."
But those "pretty pictures" can motivate patients. A 2017 article in the Review of Optometry noted that meibomian gland imaging had helped one Beverly Hills clinician's patients understand and take control of the syndrome. "When patients recognize the difference between their glands and healthy ones, they tend to be genuinely concerned and open to a custom treatment plan," wrote author and doctor of optometry Kambiz Silani.
Sudarsky says some of her patients have sought out the LipiFlow treatment after seeing the condition of their meibomian glands during a LipiScan screening. "They may be happy [with how their eyes feel], but they'll say, 'I don't want to lose any more of my glands, so I want to do this,'" she says.
Sudarsky says that's a good thing. While she, too, is skeptical of expensive prescription eye drops, she also says patients often have trouble — or don't want to bother — with the home remedies traditionally used to relieve dry-eye symptoms. Those remedies can be as simple as holding a warm, moist compress on closed eyelids or conducting blinking exercises. Now patients who want to monitor the health of their meibomian glands have access to a new, if expensive, therapy.
LipiFlow treatments cost $950 (half the cost it was before Johnson & Johnson bought TearScience, says Sudarsky) and aren't covered by most insurance plans. (LipiScan screenings are included in Sudarsky's standard eye-exam fee.) Sudarsky is confident that the machine has been effective for the 25 or so patients who have used it so far. "I've seen them come back, and their glands are working again." She recommends treatments once every one to three years.
To my surprise and relief, I shouldn't need LipiFlow anytime soon. My meibomian glands are in good working order, said the technician who scanned them. But she added that, at 29, I'm a little too old for the screen-induced dry-eye spike in younger people that the clinic has seen.
Either way, I'm going to follow the bit of advice all eye professionals seem to agree on: Remember to blink. One easy rule of thumb? Every 20 minutes, look at something 20 feet away for at least 20 seconds.
And maybe make sure the kids do, too.