Canadian Association of Radiologists Journal 70 (2019) 5e9

www.carjonline.org

Health Policy and Practice / Sant
e : politique et pratique m
edicale

Computer Vision Syndrome: Darkness Under the Shadow of Light

Ashish Chawla, DABRa,*, Tze Chwan Lim, FRCRa, Sumer N. Shikhare, FRCRa,
Peter L. Munk, FRCPCb, Wilfred C.G. Peh, FRCRa
a
Department of Diagnostic Radiology, Khoo Teck Puat Hospital, Yishun Central, Singapore
b
Department of Radiology, Vancouver General Hospital & University of British Columbia, Vancouver, British Columbia, Canada

Abstract
Radiologists typically spend long hours staring at the computer monitor. This unavoidable nature of our work can lead to detrimental
effects on the eyes. Moreover, there is little awareness among radiologists with regards to such potential harm. Ocular hazards, such as
computer vision syndrome, are increasingly becoming more relevant to the radiology community. In this article, we discuss the ocular
occupational hazards faced by radiologists and suggestions that may help in minimizing such hazards.

R
esum
e
Les radiologistes passent souvent de longues heures a fixer un
ecran d’ordinateur. Cet aspect in
evitable de notre travail peut avoir des
effets n
efastes sur les yeux. De plus, les radiologistes sont peu sensibilis
es a de tels risques. Les dangers pour les yeux, tel le syndrome de
vision informatique (ou fatigue oculaire num
erique), gagnent en importance dans la communaut
e de radiologistes. Dans cet article, nous
pr
esentons les risques professionnels oculaires auxquels les radiologistes sont confront
es et des suggestions qui pourraient contribuer a la
r
eduction de ces risques.
Ó 2018 Canadian Association of Radiologists. All rights reserved.

Key Words: Computer vision syndrome; Occupational hazards; Asthenopia; Eyestrain; Ocular hazards; Radiologist hazards

In the last century, occupational harm to radiologists was
mainly focused on the harmful effects of ionizing radiation
[1]. Various guidelines, regulatory frameworks, and pro-
gressive equipement improvement were developed in the
interest of the health of radiologists and other radiation
health care workers. As a result, the incidence of radiation
work-related injury among radiologists is at a very low level.
The daily work pattern of radiologists has evolved
dramatically in the last decade. The shift from hard copy
viewing to reading from a picture archiving and communi-
cation system (PACS), means that radiologists have to spend
long hours gazing at brightly lit monitors. Typically, a radi-
ologist spends an average of 8e9 hours per work day in front
of the PACS workstation in addition to using brightly lit
screens of other digital devices (eg, smartphones, tablets,
personal computers, laptops, television, etc).
* Address for correspondence: Ashish Chawla, DABR, Department of
Diagnostic Radiology, Khoo Teck Puat Hospital, 90 Yishun Central,
Singapore.
E-mail address: ashchawla@gmail.com (A. Chawla).
Computer Vision Syndrome
Many screen-related hazards have been studied among
computer professionals, which explains the use of the term
‘‘computer vision syndrome’’ (CVS). The American Opto-
metric Association defines CVS or digital eye strain as a
‘‘group of eye and vision-related problems that result from
prolonged computer, tablet, e-reader and cell phone use.’’
The term may not be completely accurate but highlights its
prevalence in the computer users including software pro-
fessionals, gamers, clerks, bankers, and physicians. Among
physicians, radiologists are the most susceptible group due to
the unique nature of our job.
The prevalence of CVS among computer users ranges
from 32%e90% [2e5]. The incidence is directly related
to the number of hours spent in front of the computer or
‘‘visual display terminal.’’ In a survey, optometrists reported
that 14.25% of their patients presented with symptoms pri-
marily associated with use of the bright screens [6]. Radi-
ologists stare at computer monitors that are larger in
dimensions than personal computers. Significantly higher

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6 A. Chawla et al. / Canadian Association of Radiologists Journal 70 (2019) 5e9

prevalence of eyestrain occurs among radiologists compared Table 1

to ophthalmologists and paediatricians [7]. Vertinsky et al Primary steps
have reported the prevalence of CVS among radiologists to Periodic eye examination Comprehensive eye examination
be as high as 36% [8]. including assessment of refractive
errors and eye movements
Appropriate and comfortable
Pathophysiology of CVS eyeglasses
Change work pattern Follow the ‘‘20-20-20’’ rule
Symptoms of CVS are categorized into 4 main groups: (a) Intersperse administrative or
asthenopia, (b) ocular surface-related, (c) visual, and (d) academic work between the reading
sessions scheduled for the day
extraocular [9]. Asthenopia is the term to describe eye strain Read a mix of studies or modalities
due to any cause, and is the major component of CVS. Ocular and avoid reading too many
surface related symptoms include dry eyes, red eyes, and screening CT studies
irritated eyes. Visual symptoms of CVS comprise blurring of Frequent breaks (avoid eye strain) Time spent during discussion of the
vision, double vision, difficulty in focus, and headache. images with colleagues is rest time
for the eyes, away from the PACS
Extraocular symptoms such as neck pain, shoulder pain, and workstation
backache are often due to poor ergonomic design and posture. Time spent interacting with patients
Symptomatology of CVS is related to exposure of the in the procedure room is rest time for
eyes to a brightly lit screen for prolonged periods, further the eyes, away from the PACS
complicated by poor posture and environmental factors workstation
Move away from the PACS
(particularly ambient light). Viewing a monitor screen at a workstation during meal break
close distance requires accommodation, convergence, and Ensure adequate hydration and
miosis. One must be aware that working on a computer frequent ‘restroom breaks’
differs vastly from reading a printed text. The text and im- Install software in phone or computer
ages on computer screens are composed of small pixels and for break reminders
Avoid dry eyes Wear eyeglasses instead of contact
when there are fewer pixels, the resultant decrease in reso- lenses for work
lution causes excessive demand on one’s visual system. Remember to take frequent full
Screen factors, such as brightness, contrast, screen glare, and blinksdwink eyewear may help
screen refresh rate, increase stress on the visual apparatus. Use artificial tears if there is
Low refresh rate causes flickering and is known to contribute sensation of dry eyes
Maintain optimal humidity at the
to symptoms of CVS [9]. Computer users with myopia and workplace
hypermetropia can develop blurring of vision, diplopia, and Exclude a systemic cause of dry eyes
transient myopia after a day’s work [9,10]. These impair- Adequate hydration Have easy access to water
ments are transient in most of the workers [11] but may Maintain a target for water
persist in some even after work [12]. Dry eyes are a common consumption
Personal eye care Use eyeglasses with blue light filter
symptom of CVS among computer users due to corneal Take dedicated breaks for eye
drying from reduced blink rate and incomplete blinking [13]. massage
The blink rate is significantly reduced while working on Closing the eyes for few minutes can
computers compared to resting time [14]. Small font size and be refreshing
low contrast of suboptimal quality monitors are other factors Consider applying self-warming eye
mask once a day
reducing the blink rate [15]. Compared to reading a textbook, Exposure to other screens Minimize use of other digital devices
one uses a horizontal gaze when reading a computer monitor, outside of work (such as smartphone
resulting in more evaporation of corneal tear film and and tablets)
consequent dryness. Symptoms of CVS Keep a record of eye symptoms and
whether they are related to work
Ophthalmology consult for
Predisposing and Preventive Strategies for CVS assessment of CVS
CVS ¼ computer vision syndrome; PACS ¼ picture archiving and
We have summarizied the helpful steps to minimize CVS communication system.
in Tables 1 and 2. Much of what we know about CVS has
been accrued from studies performed on computer users.
Duration of exposure to a computer screen is the strongest in those working longer than 6 hours per day [8]. Excessive
predictor for developing CVS [2,4,8,16]. Most studies have usage (more than 2 hours) of smartphones can independently
reported an increase in the prevalence of CVS in users who cause CVS and the duration of usage is the most significant
work for more than 6e7 hours [4,8,16]. However, a recent risk factor [17]. It is understandable that the risk of devel-
study on university students suggested that CVS can develop oping CVS increases when usage of smartphones is com-
after more than 2 hours of computer use [2]. A study on bined with continuous PACS work for long hours. In one
radiologists also concluded that the prevalence of CVS is study, the median duration spent at the PACS workstation
strongly related to numbers of working hours and is greater between ‘‘breaks’’ was 1.5 hours [18].

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 Computer vision syndrome / Canadian Association of Radiologists Journal 70 (2019) 5e9
Table 2
Secondary steps
Monitor settings Adjustment of the following factors on
all monitors:
i) Brightness
ii) Contrast
Watch out for screen flicker
Apply antiglare screen
Install a software to reduce blue light and
glare
Apply blue light filter on screen
Regular cleaning of the screens
Ergonomic design of monitor Adjust the height of monitors or chairs
such that the top border of the monitor is
at the eye level
Maintain an optimum distance between
the monitor and chair while reporting
(30e40 inches or an arm’s length)
Maintain good posture
Reading room modification Adjustable ambient light
Avoid direct light from the back of the
monitor and light sources behind the
reader
Smartphone settings Apply blue light filter screen
Install blue light reducing application
Taking frequent short breaks is considered the most
effective preventive method to minimize CVS [2,4,19,20].
Logaraja et al found that students who took a break after
every 2 hours of continuous use of computer had a higher
risk of developing symptoms of CVS as compared to those
who took a break every hour [4]. Hence, it is a good practice
to take a short break every hour. Uncorrected or under-
corrected refractive error and binocular vision can predis-
pose to CVS, probably due to decompensation from
unwanted visual demand [21,22]. A study among radiolo-
gists has shown that there is a significant decrease in visual
acuity of radiologists after the morning reporting session,
which can potentially lead to more diagnostic errors [23].
Radiologists should undergo regular eye examinations and
be prescribed the appropriate corrective eyeglasses. The
correction of presbyopia for radiologists may be tricky, as the
bifocal lens are meant for reading at a shorter distance, such as
from a book. The solution to this is an additional set of eye-
glasses meant for viewing the computer monitor at an
approximate distance of 30e40 inches. There is concern about
increased prevalence of CVS in those using contact lenses
compared to conventional eyeglasses, particularly if the
contact lenses are worn for more than 6 hours of computer
work [4,24]. Computer users wearing contact lens report an
increased rate of ocular symptoms (such as dryness) compared
to those not using contact lenses. In general, contact lens
wearers report symptoms of dry eyes more commonly than
those wearing eyeglasses and those without refraction errors
[25]. Wink glasses were specially developed to stimulate more
frequent blinking at an interval of 5 seconds when they are
worn for tasks like reading using a computer. These ‘‘smart eye
glasses’’ have been shown to increase the blink rate and post-
task tear stability, thus reducing symptoms of CVS [26]. Per-
sonal eye care is also useful in preventing CVS. Focusing on
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7
far objects during breaks, eye massage, and eye drops signif-
icantly reduce the symptoms of CVS [2]. Anshel et al sug-
gested a rule of 20-20-20, which implies looking at object 20
feet away every 20 minutes for 20 seconds [27].
Vertinsky et al reported eyestrain in radiologists from
reading screening CT examinations such as lung nodule
detection in screening thorax CT and lesion detection in CT
colonoscopy [8]. The study highlights the pressure on radi-
ologists in the interpretation of screening studies. The vol-
ume of such screening studies is expected to trend upwards
in almost all radiology subspecialties.
The ergonomic design of the PACS workstation, monitor
settings and design of the reading room are important factors
affecting the development of CVS. Accommodation and
convergence improve when the eyes are looking down and
inward, while looking up places more strain on accommo-
dation mechanism of the visual apparatus [28]. It has been
found that there is a significant reduction in symptoms of
CVS in the group that viewed the computer screen placed
below the eye level compared to the group that viewed the
screen placed above the eye level [2,29]. It is recommended
for the height of the workstation to be adjusted such that
there is a downward gaze of 14 degrees [30]. This can be
achieved by maintaining the upper border of the computer
monitor at or below the eye level. It is also recommended to
keep the monitor at an arm’s distance or about 30 to 40
inches away. Near shift of the monitor may increase
eyestrain, especially so if the gaze is horizontal (versus
downward gaze) [29]. Bilton et al proposed the 1-2-10
methoddsmartphones to be viewed at 1 foot, desktop
monitors to be viewed at least 2 feet away, and the television
to be viewed at least 10 feet away [31]. An adjustable
ergonomically designed chair is helpful in maintaining the
proper posture while working. Overall, the work area should
be customized to the individual reader for optimal comfort.
Monitor settings are important factors determining CVS.
Screen flicker is a predictor of eyestrain among radiologists
[8]. However, screen flicker is no longer a problem with
modern liquid crystal display and light-emitting diode
monitors. The brightness of the monitor must be sufficient
for the ambient light and yet not to glaring to the eye. If there
is a large difference between screen brightness and ambient
light, the demand on focusing mechanism is increased when
the reader changes focus from the monitor to other areas of
the room. A survey of radiologists showed that although
radiologists commonly adjust the room lighting and posi-
tioning of their reading chair, they rarely adjust the monitor
brightness [18]. Glare can originate from the monitor screen,
various light sources, and room windows. Glare from com-
puter monitors is a time-limiting factor when one reads a
difficult passage and high luminance may reduce perfor-
mance, adding to errors [32,33].
Radiology reading rooms frequently are larger than
normal office, with multiple PACS workstations, each made
up of 3e7 monitors, resulting in significant glare. However,
appropriate luminance of PACS monitor is essential for
distinguishing between 256 shades of gray in a radiological
8 A. Chawla et al. / Canadian Association of Radiologists Journal 70 (2019) 5e9
image. The standard maximum luminance for diagnostic
monitor should not be less than 420 cd/m2 for mammography
and 350 cd/m2 for other studies [34]. The luminance can be
checked and adjusted by changing the setting of the monitor.
Anti-glare filters on the computer monitors are helpful in
reducing eyestrain. Improper placement of bright light
sources can also contribute to eyestrain due to either shadows
or reflection on the computer monitors. Hence, proper
placement of room lights is important. Room clutter can add
to unwanted reflection on the computer screens. Dust and
fingerprints on the monitors can also generate glare. The
reading room should be kept clear of clutter, computer
monitors should be cleaned regularly with screen wipes
(according to the vendor’s instructions), and monitors should
be switched off when not in use.
There is concern about the effect of the blue light
component of natural and artificial light on the circadian
rhythm and sleep. Human circadian pacemaker is effected by
light exposure to ocular receptors that in turn regulate
melatonin secretion; melatonin levels start rising in the
evening, remain high in night, and then fall in early morning.
Brainard et al reported that monochromatic light around
460 nm (ie, blue light) is a potent suppressor of melatonin
production [35]. Figueiro et al showed that a group of people
working on screen exposed to blue light produce less mela-
tonin, compared to the group wearing orange-tinted glass for
filtering the blue light [36]. Liquid crystal display and light-
emitting diode screens of current computer monitors and
smartphones emit blue light. This blue light has a shorter
wavelength (380e500 nm) and belongs to the higher energy
region of the visible spectrum. Exposure to blue light at the
end of the day can disrupt the circadian pattern and delay
sleep by supressing melatonin level.
There are many ways to moderate the amount of exposure
to blue light, particularly towards the end of the working day.
However, to date, some of the options and the respective
efficacies are not evidence-based. Blue light emission can be
reduced by adjusting the color temperature of the monitor by
reducing the blue light component that adds a yellowish tint
to the screen. In our experience, this is a simple solution for
radiologists with a short break-in period of about a week.
The second option is to apply a filter on the computer
monitor, while the third option is to wear commercially
available yellow-tinted eyeglasses. The fourth option is to
install third-party software meant for reducing blue light.
There are software applications that regulate the amount of
blue light emission based on the time zone of the user. These
software programs are relatively affordable and reduces the
amount of blue light emitting from the surface of the screen,
thus helping to maintain the sleep cycle. There are yellow
intraocular lenses available to decrease blue light reaching
retinal receptors for implantation during cataract surgery.
Psychological factors have also been investigated for their
role in CVS among bankers [3]. Some symptoms of CVS
may be an expression of work-related stress and social
support has a positive effect. Therefore, maintaining a
cordial work environment is highly recommended [3].
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Conclusion
Long hours facing computer monitors make the work of
radiologists quite similar to that of computer professionals
and hence, we also share similar occupational hazards. The
ocular health of radiologists is crucial in ensuring a long and
fruitful career. Excessive exposure to computer monitors
during or outside the work can be harmful to radiologists. We
have suggested some primary steps to be undertaken by ra-
diologists and secondary steps that involve workplace mod-
ifications, with an aim of maintaining healthy eyes for
radiologists. Ongoing research, increasing awareness, and
education among the radiology community with regard to
CVS should bring about improvement in the general ocular
health of radiologists.
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