PERSPECTIVE

Digital Screen Time During the COVID-19

Pandemic: Risk for a Further Myopia Boom?

CHEE WAI WONG, ANDREW TSAI, JOST B. JONAS, KYOKO OHNO-MATSUI, JAMES CHEN, MARCUS ANG,
AND DANIEL SHU WEI TING

O

PURPOSE: To review the impact of increased digital de- N DECEMBER 30TH, 2019, DR WENLIANG LI ALERTED
vice usage arising from lockdown measures instituted the world about the possibility of a severe acute
during the COVID-19 pandemic on myopia and to respiratory syndrome–like virus outbreak in
make recommendations for mitigating potential detri- Wuhan, China.1 Several months later, the World Health
mental effects on myopia control. Organization (WHO) declared COVID-19 a ‘‘pandemic’’

DESIGN: Perspective. outbreak.2 As of November 13th, 2020, there were >53

METHODS: We reviewed studies focused on digital de- million infected patients worldwide, with >1.3 million
vice usage, near work, and outdoor time in relation to deaths.3 The exponential increase in infections has
myopia onset and progression. Public health policies on alarmed citizens across the globe, including heads of state
myopia control, recommendations on screen time, and in- and WHO leaders.4–6 Research has focused mainly on
formation pertaining to the impact of COVID-19 on the epidemiology, risk modelling, pathophysiology, and
increased digital device use were presented. Recommen- clinical features of severe acute respiratory syndrome-
dations to minimize the impact of the pandemic on myopia CoV-2,7,8 but the impact of increased digital screen time
onset and progression in children were made. caused by the lockdown and quarantine measures in

RESULTS: Increased digital screen time, near work, and many cities worldwide on myopia has largely been unno-
limited outdoor activities were found to be associated ticed. By 2050, it is estimated that 5 billion people world-
with the onset and progression of myopia, and could wide will be myopic,9–11 prompting many governments to
potentially be aggravated during and beyond the implement nationwide myopia control policies in the
COVID-19 pandemic outbreak period. While school clo- past decade. The rise in usage of digital technology and
sures may be short-lived, increased access to, adoption of, online e-learning during this pandemic outbreak may
and dependence on digital devices could have a long-term jeopardize the effectiveness of these policies.12 We discuss
negative impact on childhood development. Raising the disruption of the COVID-19 pandemic lockdown mea-
awareness among parents, children, and government sures on the learning environment of children and adoles-
agencies is key to mitigating myopigenic behaviors that cents, review the evidence on digital screen time and its
may become entrenched during this period. impact on myopia, and make recommendations to reduce

CONCLUSION: While it is important to adopt critical the detrimental effects on myopia during and beyond this
measures to slow or halt the spread of COVID-19, close outbreak.
collaboration between parents, schools, and ministries is
necessary to assess and mitigate the long-term collateral
impact of COVID-19 on myopia control policies. (Am
J Ophthalmol 2021;223:333–337. Ó 2020 Published by
GLOBAL TIGHTENING OF INFECTION
Elsevier Inc.)
CONTROL MEASURES
AT PRESENT, MANY GOVERNMENTS ARE IMPOSING STRICT
Accepted for publication Jul 21, 2020. quarantines and travel bans on an unprecedented scale,13
From the Singapore National Eye Center (C.W.W., A.T., M.A.,
D.S.W.T.) and the Singapore Eye Research Institute, Singapore Health based on a modelled study (N. M. Ferguson et al, unpub-
Service (SingHealth) (C.W.W., A.T., M.A., D.S.W.T.), Duke– lished data, March 2020). In this study, 2 fundamental stra-
National University of Singapore Medical School, Singapore; tegies were proposed to control the spread of COVID-19
Department of Ophthalmology (J.B.J.), Medical Faculty Mannheim,
Heidelberg University, Heidelberg, Germany; Department of among the community: mitigation and suppression. With
Ophthalmology and Visual Science (K.O-M.), Tokyo Medical and the mitigation approach, the study found that 8 of 10 peo-
Dental University, Tokyo, Japan; and Clearly (J.C.), London, United ple may still be affected, resulting in 510,000 deaths in the
Kingdom.
Inquiries to Daniel Shu Wei Ting, Singapore National Eye Center, 11 United Kingdom and 2.2 million deaths in the United
Third Hospital Ave, Singapore 168751; e-mail: [email protected] States by the end of the pandemic (N. M. Ferguson et al,

0002-9394/$36.00 © 2020 PUBLISHED BY ELSEVIER INC. 333

https://doi.org/10.1016/j.ajo.2020.07.034
unpublished data, March 2020). Infected cases could be effect of more time spent indoors on recreational digital
significantly decreased with the suppression strategy, which screen time.
advocates closure of schools/universities, case isolation,
household quarantine, and social distancing. Before this
study, China locked down many cities; draconian restric-
tions were implemented nationwide in Italy, schools and
universities were closed in both the United Kingdom and
DIGITAL SCREEN TIME, NEAR WORK,
the United States, and many were subjected to legally
enforced quarantines or are in ‘‘self-quarantine.’’13 These AND OUTDOOR TIME
measures have kept children away from schools and led
IT MAY BE INTUITIVE TO LINK DIGITAL DEVICE USAGE TO
to extensive disruptions in elementary education. Many
increased time spent indoors and on near work, thus confer-
children are now compelled to learn via digital platforms.
ring an increased risk of myopia onset and progression in
According to the United Nations Educational, Scientific
children. However, the current evidence is inconclusive.
and Cultural Organization, approximately 1.37 billion stu-
A large cohort study of 5074 children in Rotterdam (the
dents (80% of the world’s student population) from >130
Generation R study), found an association between
countries globally are affected by these lockdown mea-
increased computer use and myopia at 9 years of age
sures,14 with digital or e-learning approaches replacing
(odds ratio ¼ 1.005 [95% confidence interval, 1.001-
face to face, classroom-based learning.
1.009]). The combined effect of near work, including com-
puter use, reading time, and reading distance, increased the
odds of myopia at 9 years of age (odds ratio ¼ 1.072 [95%
confidence interval, 1.047-1.098]).16 A study of 418 stu-
dents found that device-recorded smartphone data usage,
LOCKDOWN, DIGITAL LEARNING, AND an objective surrogate for time spent using the smartphone,
RISKS OF MYOPIA was independently associated with myopia in a study of 418
students (odds ratio ¼ 1.08 [95% confidence interval, 1.03-
THE WORLD HAS NEVER EXPERIENCED THE EXTENT AND IN- 1.14]).17
tensity of measures taken to curb the COVID-19 pandemic. In a meta-analysis involving 15 studies with a total of
Many digital technologies, including the Internet of 49,789 children 3-19 years of age, Lanca and Saw18 found
Things, are currently heavily used in various domains,12 that screen time was not associated with prevalent or inci-
including digital virtual learning for the children. There dent myopia, although there were several reasons for the
is a possibility that a prolonged battle against the lack of association in their report. First, these studies used
COVID-19 virus may lead to an increase in the incidence self-reported measurements of screen time. This is subject
of myopia by shaping long-term behavioral changes condu- to recall bias and more objective measures of time spent
cive for the onset and progression of myopia. on digital devices is needed. Second, the number of studies
First, widespread school closures, in-house quarantine, included in the meta-analysis was small (5 of 15 studies).
and the proliferation of online learning increases digital This may have affected the validity of the pooled estimates.
screen time and the overall time spent on near work while Third, there was no proven spike in near work, despite the
decreasing outdoor time among school-going children. increase in screen time,19 indicating a substitution effect
Although school closures may be short-lived, increased ac- with traditional reading/writing being replaced by educa-
cess and adoption of such platforms may accelerate the tional screen time, while recreational screen time might
widespread acceptance of digital tools in the longer term. already have been limited because of the widespread belief
Behavioral changes that arise from the growing depen- that near work causes myopia.
dence on digital devices may persist even after the How strong is the evidence that near work causes
COVID-19 pandemic, and this is a possibility that cannot myopia? A meta-analysis spanning 12 cohort studies, 15
be underestimated. cross-sectional studies, and including 25,025 children 6-
Second, public policies for the control of myopia in 18 years of age concluded that there was an evidence rating
countries of East Asia, such as Taiwan and Singapore, of II for recommending a reduction in time spent with
are closely integrated within the education systems, reading to reduce the risk of myopia.20 This suggests that
particularly with respect to the incorporation of outdoor there is substantial evidence supporting this recommenda-
activities into school time.15 The widespread closure of tion. The effect of near work on myopia development
schools jeopardizes the implementation and continuity appeared to be related only to reading but not watching
of these programs. Admittedly, children may have more television, playing computer games, or even studying.21
time and flexibility to engage in outdoor activities if The relationship between near work and myopia was
they choose. However, in most countries it is projected further elucidated in the Collaborative Longitudinal Eval-
that medium-to long-term social distancing measures uation of Ethnicity and Refractive Error Study.22 Interest-
may curtail outdoor activities, leading to the undesirable ingly, differences in time spent reading, watching

334 AMERICAN JOURNAL OF OPHTHALMOLOGY MARCH 2021

television, playing computer games, and studying only vices, and a lack of outdoor activities. With regard to dig-
became apparent after the onset of myopia and not before. ital devices, the Ministry of Education restricted the use of
Increased outdoor activities in children have been electronics as a teaching tool to no more than 30% of over-
shown to protect against myopia onset, with a meta- all teaching time, <20 minutes per day spent on electronic
analysis reporting a reduction in both incident myopia homework (no more than 20 minutes), and prohibition of
and prevalent myopia. In addition, pooled results from clin- phones and tablets in classrooms.18 Students are also
ical trials found a reduced myopic shift of 0.30 diopters (D) encouraged to rest their eyes for 10 minutes after 30-40 mi-
after 3 years in both myopes and nonmyopes compared with nutes of educational screen time. The continuous use of
control subjects. The protective effect on myopia progres- digital devices for noneducational purposes should be
sion is less clear, with the same study finding no relation- limited to <15 minutes per day and a cumulative duration
ship between time outdoors and myopic progression.23 He of <1 hour a day. In addition, regulations have been put in
and associates24 showed that an additional 40 minutes of place to curb excessive online video gaming including
outdoor time per day achieved a 23% reduction in the inci- restricting playing time and developing an age-based re-
dence of myopia. Wu and associates25 showed a 54% lower striction system. In Taiwan, as part of their efforts to con-
risk of myopia progression among both myopic and trol myopia, lawmakers expanded legal regulations that
nonmyopic children who spent > _11 hours outdoors per ban children <18 years of age from smoking, drinking,
week. Reduced myopic shift (0.23 D) was further observed and using drugs to include the use of digital devices for
within the myopic subgroup of children randomized to the an unreasonable period of time.30 The regulation, however,
outdoor time intervention compared with myopic control did not define what would be considered ‘‘unreasonable,’’
subjects.25 Importantly, activities with exposure to moder- reflecting the lack of evidence and official guidelines for
ate light intensities such as in hallways or under a tree were both the duration and type of digital device usage that
sufficient to achieve this reduction in myopia progres- would have an impact on myopia. The American Academy
sion.25 The effectiveness of a public policy intervention of Pediatrics recommends restricting screen time to 1 hour
to promote increased outdoor time for Taiwanese school per day of high-quality content for children 2-5 years of age
children was further demonstrated in a recently published and suggests consistent limits for children >_6 years of age,
study by Wu and associates.26 After the implementation but stops short of prescribing specific limits for this age
of a myopia prevention program (Tian-Tian 120 outdoor group.31
program) in which schools were encouraged to take their In the United States, a national random sample of
students outdoors for 120 minutes per day, the long-term 40,337 children 2-17 years of age was assessed for the asso-
trend of increasing prevalence of reduced visual acuity ciations between screen time and psychological well-being.
(defined as uncorrected visual acuity <_20/25) in schoolchil- The study found moderate use of screens (4 hours/day) to be
dren from 2001 to 2011 (34.8%-50%) was reversed from associated with lower psychological well-being, including
2012-2015 (49.4% to 46.1%). However, the optimal out- less curiosity, lower self-control, more distractibility,
doors time and actual clinical impact on myopia progres- more difficulties in making friends, less emotional stability,
sion requires further study. Nonetheless, from a public being more difficult to care for, and inability to finish
health perspective, encouraging outdoor time of 2 hours tasks.32 Once home-based digital learning is no longer a
per day for school children has been deemed as a practical supplementary activity but instead a necessity in everyday
intervention that may reduce myopia progression with learning, the number of hours of indoor time and screen
additional health benefits,27 although this has been met time that school children will be exposed to may insidiously
with parental resistance in countries with high educational increase even after the COVID-19 pandemic. Moreover,
pressure. many schools may also request that parents increase their
children’s access to screen-based devices to perform
home-based learning programs.
What can be done to mitigate myopigenic behaviors that
emerge during the COVID-19 pandemic and may subse-
RECOMMENDATIONS FOR MYOPIA
quently be entrenched? First, public education to increase
PREVENTION parent awareness about the effects of indoor near work
and reduced outdoor time on the incidence and progression
THE WORLD HEALTH ORGANIZATION’S GUIDELINES ON
of myopia is important over the long term. Parents need to
physical activity, sedentary behavior, and sleep recom-
understand the importance of maintaining good eye habits
mends <1 hour of sedentary screen time for children 1-5
during the pandemic lockdown and beyond, including
years of age.28 Governments have also imposed limits on
frequent breaks from near work and limiting recreational
digital device usage in order to prevent myopia.29 In China,
screen time. Second, the government agencies for health
where nearly half the population has myopia, aggressive
and eye care professionals should continue to engage with
government policies have been implemented to combat
schools to shape a holistic home-based learning curriculum
the myopia epidemic. The culprits identified and targeted
that encourages creative learning not just from reading and
in these policies include heavy study load, use of digital de-

VOL. 223 DIGITAL SCREEN TIME AND MYOPIA IN THE COVID-19 PANDEMIC 335
study at home, but also include frequent breaks and indoor CONCLUSION
physical or household activities—cooking, baking, and
cleaning, for example. Third, where it is safe and legal to THE UNPRECEDENTED SCALE OF THE COVID-19 PANDEMIC
do so, outdoor activities with adequate social distancing has disrupted our lives beyond recognition. While the
should continue and be encouraged in school-going chil- world reels from the global impact of COVID-19, govern-
dren. Outdoor time of 2-3 hours per day may be even ments are also adjusting to allow everyday life to continue,
more achievable now with the flexibility of home-based such as the closure of schools with the education of our
learning.16 The health benefits of outdoor activities and school children using online platforms. In this regard, dig-
an active lifestyle should not be stifled by COVID-19.33 ital technology has been immensely beneficial in cush-
Amidst the worst outbreak known to human history, the ioning the disruption to school education, but it is crucial
world has been pushed to embrace digital technology at an to be cognizant of the impact of increasing dependence
unprecedented scale and pace. There is no denying the on digital devices. While it is important to adopt strict
benefits of digital technology in a time like this. Notwith- measures (eg, lockdown and home quarantine) to slow or
standing the global pandemic, it is of paramount impor- halt the spread of COVID-19, multidisciplinary collabora-
tance that parents help their children develop a healthy tion and close partnerships between ministries, schools,
relationship with digital devices. First, digital detox is a and parents are necessary to minimize the long-term collat-
method to encourage healthy digital device habits, using eral impact of COVID-19–related policies on various
digital applications to consciously monitor device usage health outcomes, such as myopia, which was already a ma-
and reminding users to disconnect from the digital world. jor public health concern before the pandemic.
Parents can set limits using in-device applications to
restrict the total screen time spent per day or per session.
Second, supervising digital content is important to ensure
that time spent on digital devices is maximized for learning
experiences. Guiding the child through digital device usage
helps to improve their ability to process and interpret dig- CRediT AUTHORSHIP CONTRIBUTION
ital content and thereby decrease the overall time spent on- STATEMENT
line. Third, having a daily schedule to allocate time for
specific activities and setting boundaries on when and CHEE WAI WONG: WRITING - ORIGINAL DRAFT, CRITICAL
where digital devices can be used can be an effective appraisal of the scientific content and final approval. Andrew
approach, while simultaneously building routine and disci- Tsai: Writing - original draft, critical appraisal of the scien-
pline during the COVID-19 pandemic where days are tific content and final approval. Jost B. Jonas: critical
largely unstructured. Fourth, parents should act as role appraisal of the scientific content and final approval. Kyoko
models by reducing their own digital device usage, Ohno-Matsui: critical appraisal of the scientific content and
spending more time with their children outdoors, engaging final approval. James Chen: critical appraisal of the scientific
their children in offline playtime, and involving them in content and final approval. Marcus Ang: Writing - review
nondigital indoor activities, such as chores, arts and crafts, and editing. Daniel Shu Wei Ting: Writing - original draft,
and music.31,34 critical appraisal of the scientific content and final approval.

ALL AUTHORS HAVE COMPLETED AND SUBMITTED THE ICMJE FORM FOR DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST.
Funding/Support: The authors indicate no financial support. Financial Disclosures: Dr Ting holds several patents on deep learning systems for eye dis-
eases and is an executive editor of artificial intelligence and digital technology for Ophthalmology and the British Journal of Ophthalmology. He is the
2018 USA Fulbright Scholarship recipient to Johns Hopkins University on a project for artificial intelligence and digital technology in medicine. Dr
Wong has received honoraria from Novartis, Bayer, and Roche and has intellectual property rights and is a patent holder for liposomal prednisolone phos-
phate (PCT/NL2017/050273). Dr Chen is the Chief Executive Officer and founder of Clearly. Dr Jonas is on the advisory board of Novartis and is a patent
holder with Biocompatibles UK Ltd. (Farnham, Surrey, UK; Treatment of eye diseases using encapsulated cells encoding and secreting neuroprotective
factor and/or antiangiogenic factor; patent number: 20120263794) and Europäische Patentanmeldung 16720043.5 and patent application US 2019
0085065 A1 (Agents for use in the therapeutic or prophylactic treatment of myopia or hyperopia). Drs Tsai, Ang, and Ohno-Matsui indicate to financial
conflict of interest. Contributions of Authors: Writing of the first and final drafts (C.W.W., A.T., D.S.W.T); Critical appraisal of the scientific content and
final approval (C.W.W., A.T., D.S.W.T., J.C., J.J., K.O.). All authors attest that they meet the current ICMJE criteria for authorship.

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