Correspondence

Dry Eyes and Video Display Terminals

N Engl J Med 1993; 328:584February 25, 1993

Article

To the Editor:

Many persons report ocular fatigue after prolonged work at video display terminals, in part prompting legislation regulating the use of these terminals1. Since one of the main causes of ocular fatigue is dry eyes, we hypothesized that this type of work exacerbates drying of the ocular surface.

The ocular surface is normally covered with a tear film composed of lipid, aqueous, and mucin layers, spread by each blink of the eye. We studied several factors affecting tear dynamics in 104 healthy office workers (45 men and 59 women; age range, 20 to 69 years), about half of whom used computers for an average of three hours per day. None had ocular fatigue. The mean (±SD) rate of blinking, which was measured at 22.5 °C and 40 percent humidity, was 22 ±9 per minute under relaxed conditions, 10 ±6 per minute while the subjects were reading a book at table level, and 7 ±7 per minute while the subjects were viewing text on a video display terminal. Ocular surface, calculated by measuring the width of the palpebral fissure,2 was 2.2 ±0.4 cm² under relaxed conditions, 1.2 ±0.4 cm² while the subjects were reading, and 2.3 ±0.5 cm² while the subjects were working at the video display terminal. The subjects were able to look down while reading the book, partially negating the effects of a decreased frequency of blinking, but they had to keep their eyes wide open to see the video display terminal.

To evaluate the effect of exposed ocular surface area on tear dynamics, the rate of tear evaporation was measured with a recently developed instrument3. The rate of evaporation increased as the area of exposed ocular surface increased, and the rate of increase was greater with larger surface areas. In other words, the rate of tear evaporation per square centimeter also increased with the ocular surface area, suggesting that the increase in evaporation was due not only to an increase in the exposed ocular surface, but also to qualitative instability of the tear film over the larger surface, possibly as a result of thinning of the mucin and lipid layers.

These results indicate that the use of video display terminals is associated with a decreased frequency of blinking and an increased rate of tear evaporation, each of which can contribute to dry eyes. Artificial tears, and, in more severe cases, special spectacles4 provide relief from dry-eye symptoms. In addition, the width of the palpebral fissure, and hence the exposed ocular surface area, can be decreased by placing the terminal at a lower height, with the screen tilted upward. At a time when much research is focusing on the physiologic responses to the use of video display terminals, our findings should contribute to both the understanding and the correction of workers' discomfort resulting from the use of these omnipresent machines.

Kazuo Tsubota, M.D.
Tokyo Dental College, Chiba, 272, Japan

Katsu Nakamori, Ph.D.
Taisho Pharmaceutical Co., Ltd., Ohmiya City, 330, Japan

4 References

1. 1

   Foreman J. San Francisco passes ordinance regulating VDT use. Arch Ophthalmol 1991;109:477-477
   Web of Science | Medline

2. 2

   Rolando M, Refojo MF, Kenyon KR. Increased tear evaporation in eyes with keratoconjunctivitis sicca. Arch Ophthalmol 1983;101:557-558
   Web of Science | Medline

3. 3

   Tsubota K, Yamada M. Tear evaporation from the ocular surface. Invest Ophthalmol Vis Sci 1992;33:2942-2950
   Web of Science | Medline

4. 4

   Tsubota K. The effect of wearing spectacles on the humidity of the eye. Am J Ophthalmol 1989;108:92-93
   Web of Science | Medline

Citing Articles (69)

Citing Articles

1. 1

   Evangelos Anagnostou, Ioanna Kouzi, Sofia Vassilopoulou, Georgios P. Paraskevas, Konstantinos Spengos. (2012) Spontaneous Eyeblink Rate in Focal Cerebrovascular Lesions. European Neurology 67:1, 39-44
   CrossRef

2. 2

   Reiko Arita, Kouzo Itoh, Shuji Maeda, Koshi Maeda, Atsuo Tomidokoro, Shiro Amano. (2011) Association of contact lens-related allergic conjunctivitis with changes in the morphology of meibomian glands. Japanese Journal of Ophthalmology
   CrossRef

3. 3

   Syed Noorul Hasan, Mohammad Muzammil, Abid Ali Khan. (2011) Effect of illumination, noise and text/background colour on spontaneous eye blink rate. Theoretical Issues in Ergonomics Science 12:6, 514-532
   CrossRef

4. 4

   Sowjanya Gowrisankaran, Niru K. Nahar, John R. Hayes, James E. Sheedy. (2011) Asthenopia and Blink Rate Under Visual and Cognitive Loads. Optometry and Vision Science1
   CrossRef

5. 5

   Mark Rosenfield. (2011) Computer vision syndrome: a review of ocular causes and potential treatments. Ophthalmic and Physiological Optics 31:5, 502-515
   CrossRef

6. 6

   Takashi Kojima, Osama M.A. Ibrahim, Tais Wakamatsu, Atsushi Tsuyama, Junko Ogawa, Yukihiro Matsumoto, Murat Dogru, Kazuo Tsubota. (2011) The Impact of Contact Lens Wear and Visual Display Terminal Work on Ocular Surface and Tear Functions in Office Workers. American Journal of Ophthalmology
   CrossRef

7. 7

   Xiaobo Zhang, Qi Chen, Wei Chen, Lele Cui, Huixiang Ma, Fan Lu. (2011) Tear Dynamics and Corneal Confocal Microscopy of Subjects with Mild Self-Reported Office Dry Eye. Ophthalmology 118:5, 902-907
   CrossRef

8. 8

   Tatsuya Mimura, Mikiro Mori, Hiroto Obata, Tomohiko Usui, Satoru Yamagami, Hideharu Funatsu, Hidetaka Noma, Shiro Amano. (2011) Conjunctivochalasis: associations with pinguecula in a hospital-based study. Acta Ophthalmologicano-no
   CrossRef

9. 9

   James V Aquavella. (2011) Technology and demographics. Expert Review of Ophthalmology 6:1, 5-6
   CrossRef

10. 10

    Sang-Chul Kwon, Yun-Bae Kim. (2011) Antioxidative and aldose reductase-inhibitory effects of a fermentation filtrate of Rubus coreanus. Laboratory Animal Research 27:4, 365
    CrossRef

11. 11

    Tatsuya Mimura, Satoru Yamagami, Mikiro Mori, Hideharu Funatsu, Tomohiko Usui, Hidetaka Noma, Shiro Amano. (2010) Contact Lens–Induced Subconjunctival Hemorrhage. American Journal of Ophthalmology 150:5, 656-665.e1
    CrossRef

12. 12

    Reiko Arita, Kouzo Itoh, Shuji Maeda, Koshi Maeda, Ayumu Furuta, Atsuo Tomidokoro, Shiro Amano. (2010) Meibomian Gland Duct Distortion in Patients With Perennial Allergic Conjunctivitis. Cornea 29:8, 858-860
    CrossRef

13. 13

    E. Knop, N. Knop, H. Brewitt, U. Pleyer, P. Rieck, B. Seitz, F. Schirra. (2009) Meibom-Drüsen. Der Ophthalmologe 106:11, 966-979
    CrossRef

14. 14

    Maria Musumeci, Pasquale Aragona, Milena Bellin, Francesco Maugeri, Laura Rania, Claudio Bucolo, Salvatore Musumeci. (2009) Acidic Mammalian Chitinase in Dry Eye Conditions. Cornea 28:6, 667-672
    CrossRef

15. 15

    Maurizio Rolando, Silvia Autori, Francesco Badino, Stefano Barabino. (2009) Protecting the Ocular Surface and Improving the Quality of Life of Dry Eye Patients: A Study of the Efficacy of an HP-Guar Containing Ocular Lubricant in a Population of Dry Eye Patients. Journal of Ocular Pharmacology and Therapeutics 25:3, 271-278
    CrossRef

16. 16

    Tatsuya Mimura, Satoru Yamagami, Tomohiko Usui, Hideharu Funatsu, Yoshiko Mimura, Hidetaka Noma, Norihiko Honda, Shiro Amano. (2009) Changes of Conjunctivochalasis with Age in a Hospital-based Study. American Journal of Ophthalmology 147:1, 171-177.e1
    CrossRef

17. 17

    Santos Shan-Yu Tseng, Winston Wen-Ching Yang, John Ching-Jen Hsiao. (2008) Bilateral Corneal Erosion Due To Retail Purchase of Unfitted Prescription Contact Lenses: A Case Report. Cornea 27:10, 1179-1181
    CrossRef

18. 18

    Miki Uchino, Debra A. Schaumberg, Murat Dogru, Yuichi Uchino, Kazumi Fukagawa, Shigeto Shimmura, Toshihiko Satoh, Toru Takebayashi, Kazuo Tsubota. (2008) Prevalence of Dry Eye Disease among Japanese Visual Display Terminal Users. Ophthalmology 115:11, 1982-1988
    CrossRef

19. 19

    Asako Mori, Fuminobu Egami, Katsu Nakamori, Tomohiro Ohtsuki, Katsuyoshi Aikawa, Masuro Shintani, Yukihiro Matsumoto, Eiki Goto, Kazuo Tsubota. (2008) Quantitative videographic analysis of blink patterns of newscasters. Graefe's Archive for Clinical and Experimental Ophthalmology 246:10, 1449-1453
    CrossRef

20. 20

    Yu Ota, Yukihiro Matsumoto, Murat Dogru, Eiki Goto, Yuichi Uchino, Koji Endo, Kazuo Tsubota. (2008) Management of Evaporative Dry Eye in Ectrodactyly-Ectodermal Dysplasia-Clefting Syndrome. Optometry and Vision Science 85:9, E795-E801
    CrossRef

21. 21

    Z YAN, L HU, H CHEN, F LU. (2008) Computer Vision Syndrome: A widely spreading but largely unknown epidemic among computer users. Computers in Human Behavior 24:5, 2026-2042
    CrossRef

22. 22

    Guzin Iskeleli, Yunus Karakoc, Arzu Abdula. (2008) Tear film osmolarity in patients with thyroid ophthalmopathy. Japanese Journal of Ophthalmology 52:4, 323-326
    CrossRef

23. 23

    Pernille Kofoed Nielsen, Karen Søgaard, Jørgen Skotte, Peder Wolkoff. (2008) Ocular surface area and human eye blink frequency during VDU work: the effect of monitor position and task. European Journal of Applied Physiology 103:1, 1-7
    CrossRef

24. 24

    Shizuka Koh, Naoyuki Maeda, Yuichi Hori, Tomoyuki Inoue, Hitoshi Watanabe, Yoko Hirohara, Toshifumi Mihashi, Takashi Fujikado, Yasuo Tano. (2008) Effects of Suppression of Blinking on Quality of Vision in Borderline Cases of Evaporative Dry Eye. Cornea 27:3, 275-278
    CrossRef

25. 25

    Shizuka Koh, Naoyuki Maeda, Takashi Hamano, Yoko Hirohara, Toshifumi Mihashi, Yuichi Hori, Jun Hosohata, Takashi Fujikado, Yasuo Tano. (2008) Effect of Internal Lubricating Agents of Disposable Soft Contact Lenses on Higher-Order Aberrations After Blinking. Eye & Contact Lens: Science & Clinical Practice 34:2, 100-105
    CrossRef

26. 26

    EMILY PIK YIN CHOY, PAULINE CHO, IRIS FRANCES FORSTER BENZIE, CAMUS KAR MAN CHOY. (2008) Dry Eye and Blink Rate Simulation with a Pig Eye Model. Optometry and Vision Science 85:2, 129-134
    CrossRef

27. 27

    C Fenga, P Aragona, A Cacciola, R Spinella, C Di Nola, F Ferreri, L Rania. (2008) Meibomian gland dysfunction and ocular discomfort in video display terminal workers. Eye 22:1, 91-95
    CrossRef

28. 28

    Minako Kaido, Murat Dogru, Reiko Ishida, Kazuo Tsubota. (2007) Concept of Functional Visual Acuity and its Applications. Cornea 26:Supplement 1, S29-S35
    CrossRef

29. 29

    Shizuka Koh, Naoyuki Maeda. (2007) Wavefront Sensing and the Dynamics of Tear Film. Cornea 26:Supplement 1, S41-S45
    CrossRef

30. 30

    NIRU K. NAHAR, JAMES E. SHEEDY, JOHN HAYES, YU-CHI TAI. (2007) Objective Measurements of Lower-Level Visual Stress. Optometry and Vision Science 84:7, 620-629
    CrossRef

31. 31

    SOWJANYA GOWRISANKARAN, JAMES E. SHEEDY, JOHN R. HAYES. (2007) Eyelid Squint Response to Asthenopia-Inducing Conditions. Optometry and Vision Science 84:7, 611-619
    CrossRef

32. 32

    Biljana Miljanović, Reza Dana, David A. Sullivan, Debra A. Schaumberg. (2007) Impact of Dry Eye Syndrome on Vision-Related Quality of Life. American Journal of Ophthalmology 143:3, 409-415.e2
    CrossRef

33. 33

    Eiki Goto, Murat Dogru, Kazumi Fukagawa, Miki Uchino, Yukihiro Matsumoto, Megumi Saiki, Kazuo Tsubota. (2006) Successful Tear Lipid Layer Treatment for Refractory Dry Eye in Office Workers by Low-Dose Lipid Application on the Full-Length Eyelid Margin. American Journal of Ophthalmology 142:2, 264-270.e1
    CrossRef

34. 34

    O. Schmut, J. Horwath-Winter, G. Rieger, R. Winkler, M. Klieber, W. Loos, S. Griebenow. (2006) Jodsole-Therapie aus ophthalmologischer und internistischer Sicht. 150 Jahre Landeskuranstalten, 55 Jahre Paracelsus-Institut, 50 Jahre Augenabteilung Bad Hall. Spektrum der Augenheilkunde 20:3, 150-157
    CrossRef

35. 35

    Daniel M. Stein, Gadi Wollstein, Hiroshi Ishikawa, Ellen Hertzmark, Robert J. Noecker, Joel S. Schuman. (2006) Effect of Corneal Drying on Optical Coherence Tomography. Ophthalmology 113:6, 985-991
    CrossRef

36. 36

    JAMES E. SHEEDY, SOWJANYA GOWRISANKARAN, JOHN R. HAYES. (2005) Blink Rate Decreases With Eyelid Squint. Optometry and Vision Science 82:10, 905-911
    CrossRef

37. 37

    F. Ziemssen, N. Freudenthaler, K. Regnery, T. Schlote. (2005) Lidschlagaktivität während der Bildschirmarbeit. Der Ophthalmologe 102:9, 895-901
    CrossRef

38. 38

    F. Ziemssen, N. Freudenthaler, K. Regnery, T. Schlote. (2005) Lidschlagaktivität während der Bildschirmarbeit. Der Ophthalmologe 102:8, 805-811
    CrossRef

39. 39

    James E. Sheedy, Rob Smith, John Hayes. (2005) Visual effects of the luminance surrounding a computer display. Ergonomics 48:9, 1114-1128
    CrossRef

40. 40

    Minori Miyake-Kashima, Murat Dogru, Takayuki Nojima, Masayuki Murase, Yukihiro Matsumoto, Kazuo Tsubota. (2005) The Effect of Antireflection Film Use on Blink Rate and Asthenopic Symptoms during Visual Display Terminal Work. Cornea 24:5, 567-570
    CrossRef

41. 41

    Srihari Narayanan, William L. Miller, Thomas C. Prager, Julie A. Jackson, Norman E. Leach, Alison M. McDermott, Mike T. Christensen, Jan P.G. Bergmanson. (2005) The Diagnosis and Characteristics of Moderate Dry Eye in Non-Contact Lens Wearers. Eye & Contact Lens: Science & Clinical Practice 31:3, 96-104
    CrossRef

42. 42

    Reiko Ishida, Takashi Kojima, Murat Dogru, Minako Kaido, Yukihiro Matsumoto, Mari Tanaka, Eiki Goto, Kazuo Tsubota. (2005) The application of a new continuous functional visual acuity measurement system in dry eye syndromes. American Journal of Ophthalmology 139:2, 253-258
    CrossRef

43. 43

    Eiki Goto. (2004) Quantification of Tear Interference Image. Cornea 23:Supplement 1, S20-S24
    CrossRef

44. 44

    Mari Tanaka, Yoji Takano, Murat Dogru, Ikuko Toda, Naoko Asano-Kato, Yoshiko Komai-Hori, Kazuo Tsubota. (2004) Effect of preoperative tear function on early functional visual acuity after laser in situ keratomileusis. Journal of Cataract & Refractive Surgery 30:11, 2311-2315
    CrossRef

45. 45

    Kyoko Nomura, Mutsuhiro Nakao, Kaoruko Matsubara. (2004) Subjective Symptom of Eye Dryness and Lifestyle Factors With Corneal Neovascularization in Contact Lens Wearers. Eye & Contact Lens: Science & Clinical Practice 30:2, 95-98
    CrossRef

46. 46

    Michel Guillon, Cecile Maissa, Pascale Pouliquen, Laurent Delval. (2004) Effect of Povidone 2% Preservative-free Eyedrops on Contact Lens Wearers With Computer Visual Syndrome:. Eye & Contact Lens: Science & Clinical Practice 30:1, 34-39
    CrossRef

47. 47

    JAMES E. SHEEDY, JOHN HAYES, and JON ENGLE. (2003) Is all Asthenopia the Same?. Optometry and Vision Science 80:11, 732-739
    CrossRef

48. 48

    Barry L. Cole. (2003) Do video display units cause visual problems?-a bedside story about the processes of public health decision-making. Clinical and Experimental Optometry 86:4, 205-220
    CrossRef

49. 49

    Kazuo Tsubota, Minori Miyake, Yukihiro Matsumoto, Masuro Shintani. (2002) Visual protective sheet can increase blink rate while playing a hand-held video game1 1A percentage from the sale of the protective sheets goes to the Cornea Center & Eye Bank, Tokyo Dental College, Ichikawa, Chiba, Japan.. American Journal of Ophthalmology 133:5, 704-705
    CrossRef

50. 50

    Eiki Goto, Yukiko Yagi, Yukihiro Matsumoto, Kazuo Tsubota. (2002) Impaired functional visual acuity of dry eye patients. American Journal of Ophthalmology 133:2, 181-186
    CrossRef

51. 51

    MICHAEL J. DOUGHTY. (2001) Consideration of Three Types of Spontaneous Eyeblink Activity in Normal Humans: during Reading and Video Display Terminal Use, in Primary Gaze, and while in Conversation. Optometry and Vision Science 78:10, 712-725
    CrossRef

52. 52

    Julie M Albietz. (2001) Dry eye: an update on clinical diagnosis, management and promising new treatments. Clinical and Experimental Optometry 84:1, 4-18
    CrossRef

53. 53

    Erin Kurusz Walline, J. Steven Moore. (2000) P-11: A Comparison of Workstation Dimensions and Body Postures Between 17 in. CRT, 21 in. CRT, and 19 in. Flat-Panel Monitors. SID Symposium Digest of Technical Papers 31:1, 567
    CrossRef

54. 54

    Carolyn G. Begley, Barbara Caffery, Kelly Kinney Nichols, Robin Chalmers. (2000) Responses of Contact Lens Wearers to a Dry Eye Survey. Optometry and Vision Science 77:1, 40-46
    CrossRef

55. 55

    Kazuo Tsubota, Fuminobu Egami, Tomohiro Ohtsuki, Masuro Shintani. (1999) Abnormal blinking of newscasters. The Lancet 354:9175, 308
    CrossRef

56. 56

    KAZUO TSUBOTA, KENNETH K KWONG, TSUNG-YI LEE, JIRO NAKAMURA, HONG-MING CHENG. (1999) Functional MRI of Brain Activation by Eye Blinking. Experimental Eye Research 69:1, 1-7
    CrossRef

57. 57

    M.CARMEN ACOSTA, JUANA GALLAR, CARLOS BELMONTE. (1999) The Influence of Eye Solutions on Blinking and Ocular Comfort at Rest and During Work at Video Display Terminals. Experimental Eye Research 68:6, 663-669
    CrossRef

58. 58

    Kazuo Tsubota. (1998) Tear dynamics and dry eye. Progress in Retinal and Eye Research 17:4, 565-596
    CrossRef

59. 59

    Peder Wolkoff, Thomas Schneider, Jan Kildesø, Ritva Degerth, Margarethe Jaroszewski, Hannelore Schunk. (1998) Risk in cleaning: chemical and physical exposure. Science of The Total Environment 215:1-2, 135-156
    CrossRef

60. 60

    TSUTOMU FUJIHARA, TAKASHI NAGANO, MASATSUGU NAKAMURA, EIICHI SHIRASAWA. (1998) Lactoferrin Suppresses Loss of Corneal Epithelial Integrity in a Rabbit Short-Term Dry Eye Model. Journal of Ocular Pharmacology and Therapeutics 14:2, 99-107
    CrossRef

61. 61

    Carlos Belmonte, Julia Garcia-Hirschfeld, Juana Gallar. (1997) Neurobiology of ocular pain. Progress in Retinal and Eye Research 16:1, 117-156
    CrossRef

62. 62

    MARIA BEATRIZ G. VILLANUEVA, MIDORI SOTOYAMA, HIROSHI JONAI, YASUHIRO TAKEUCHI, SUSUMU SAITO. (1996) Adjustments of posture and viewing parameters of the eye to changes in the screen height of the visual display terminal. Ergonomics 39:7, 933-945
    CrossRef

63. 63

    MIDORI SOTOYAMA, HIROSHI JONAI, SUSUMU SAITO, MARIA BEATRIZ G. VILLANUEVA. (1996) Analysis of ocular surface area for comfortable VDT workstation layout. Ergonomics 39:6, 877-884
    CrossRef

64. 64

    Kazuo Tsubota, Ikuko Toda, Katsu Nakamori. (1996) Poor illumination, VDTs, and desiccated eyes. The Lancet 347:9003, 768-769
    CrossRef

65. 65

    Peder Wolkoff. (1995) Volatile Organic Compounds Sources, Measurements, Emissions, and the Impact on Indoor Air Quality. Indoor Air 5:S3, 5-73
    CrossRef

66. 66

    T. Hikichi, A. Yoshida, Y. Fukui, T. Hamano, M. Ri, K. Araki, K. Horimoto, E. Takamura, K. Kitagawa, M. Oyama, Y. Danjo, S. Kondo, H. Fujishima, I. Toda, K. Tsubota. (1995) Prevalence of dry eye in Japanese eye centers. Graefe's Archive for Clinical and Experimental Ophthalmology 233:9, 555-558
    CrossRef

67. 67

    Julie M. Albietz, Timothy R. Golding. (1994) Differential diagnosis and management of common dry eye subtypes. Clinical and Experimental Optometry 77:6, 244-260
    CrossRef

68. 68

    Ikuko Toda, Masafumi Ono, Hiroshi Fujishima, Kazuo Tsubota. (1994) Sjögren's syndrome (SS) and Epstein-Barr virus (EBV) reactivation. Ocular Immunology and Inflammation 2:2, 101-109
    CrossRef

69. 69

    Johnmarshall Reeve. (1993) The face of interest. Motivation and Emotion 17:4, 353-375
    CrossRef