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July - August 2007 289
Original Article

Computer vision syndrome: A study of the knowledge, attitudes and practices

in Indian Ophthalmologists

Jatinder Bali, MS; Neeraj Navin, MS; Bali Renu Thakur, MD

Purpose: To study the knowledge, attitude and practices (KAP) towards computer vision syndrome prevalent
in Indian ophthalmologists and to assess whether ‘computer use by practitioners’ had any bearing on the
knowledge and practices in computer vision syndrome (CVS).
Materials and Methods: A random KAP survey was carried out on 300 Indian ophthalmologists using a 34­
point spot-questionnaire in January 2005.

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Results: All the doctors who responded were aware of CVS. The chief presenting symptoms were eyestrain

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(97.8%), headache (82.1%), tiredness and burning sensation (79.1%), watering (66.4%) and redness (61.2%).
Ophthalmologists using computers reported that focusing from distance to near and vice versa (P=0.006, χ2

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test), blurred vision at a distance (P=0.016, χ2 test) and blepharospasm (P=0.026, χ2 test) formed part of the
syndrome. The main mode of treatment used was tear substitutes. Half of ophthalmologists (50.7%) were not

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prescribing any spectacles. They did not have any preference for any special type of glasses (68.7%) or spectral

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filters. Computer-users were more likely to prescribe sedatives/ anxiolytics (P= 0.04, χ2 test), spectacles (P=
0.02, χ2 test) and conscious frequent blinking (P= 0.003, χ2 test) than the non-computer-users.

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Conclusions: All respondents were aware of CVS. Confusion regarding treatment guidelines was observed
in both groups. Computer-using ophthalmologists were more informed of symptoms and diagnostic signs
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but were misinformed about treatment modalities.
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Key words: Computer vision syndrome, computer-users, Indian ophthalmologists

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Indian J Ophthalmol 2007;55:289-94

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Increased use of computers has led to an increase in the number Various studies have recommended different modalities to
of patients with ocular complaints which are being grouped overcome CVS. There is a significant difference in the spectacle
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together as computer vision syndrome (CVS). This newfound prescription required for focusing on a standard printed near
entity, frequently mentioned in the World Wide Web and the card and focusing on the image of a typical computer screen,
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lay press, is now being accepted in medical literature.1-3 The both at a viewing distance of 20 inches and people require
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Occupational safety and health administration department of special glasses.3,9 The presbyopes are prescribed different
the US Govt. [OSHA] has defined CVS as a “complex of eye types and designs of glasses in place of their usual bifocals
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and vision problems that are experienced during and related while working on a computer.10 Feigin et al. have reported
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to computer use; it is a repetitive strain disorder that appears beneficial effects of spectral filters.11 Comfort is more with
to be growing rapidly, with some studies estimating that 90% yoked base up and base in prisms with plus lenses than
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of the 70 million US workers using computers for more than with plus lenses alone.12 Some initial studies reported users’
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three hours per day experience CVS in some form.”2 preference for general wear progressive lenses over bifocals.13
A modification, occupational progressive lenses, is now
The visual display terminal (VDT) images are made of pixels or
available which incorporates a large area in the top half of the
dots, the resolution being measured in dots per inch. Ziefle reported
lens for mid-distance viewing of the VDT and a bottom half
that the search reaction time and fixation duration increased when
of the lens for near distance (for keyboard, desktop, mouse).14
the resolution decreased.4 Prolonged work on computers has been
Antireflective coating on these glasses helps in reducing glare
associated with diminished power of accommodation, removal of
and the computer workers using spectral-filter (SF) spectacles
near point of convergence and deviation of phoria for near.5 These
were more comfortable at their work than others who were
changes are most likely transient.6,7
not using such glasses.11 But larger multi-center trials are still
The computer-related vision symptoms have been divided required before any blanket recommendation in their favor
broadly into four main categories,viz asthenopic, ocular surface can be made. Long sessions without proper work breaks are
related, visual and extra-ocular, by Blehm et al.8 associated with increased incidence of asthenopia.15 Frequent
breaks are recommended from work. Looking away from the
TNC Hospital, Tilaknagar, Delhi - 110 085, India (BJ); Onkarnagar terminal at a distant object at least twice an hour was sufficient
Polyclinic, Onkarnagar, Delhi, (NN); Dept of Neurology, G. B. Pant to prevent the symptoms.16
Hospital, Delhi, India (BRT)
The aim of the study was to assess the knowledge, attitude
Correspondence to Dr. J Bali, D-10, MCD Medical Complex, Kalidas Road, and practices (KAP) prevalent in a group of the Indian
Gulabibagh, Delhi - 110007. India. E-mail: [email protected] ophthalmic community towards CVS. It intended to probe
Manuscript received: 08.01.06; Revision accepted: 21.01.07 whether ‘computer use by practitioners’ induced any difference

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290 INDIAN JOURNAL OF OPHTHALMOLOGY Vol. 55 No. 4

in the knowledge and practices of the ophthalmologists. The trend of spectacle prescription by the ophthalmologists
and their preference for special type of spectacle lenses has been
Materials and Methods depicted in Tables 3 and 4 [Fig. 3].
A spot survey was carried out on ophthalmologists attending In this study about half of the ophthalmologists (50.7%)
the annual conference of the All India Ophthalmological Society were not prescribing any spectacles to their patients and the
at Bhubaneshwar in January 2005 using a structured 34-point
questionnaire answered at-the-venue (Appendix 1).
Roughly 15% of the attending ophthalmologists (n=300) were
randomly given the questionnaire on the spot.
The results were evaluated using t-test and X2 tests.

Results

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Out of the 300 questionnaires distributed 134 (44.67%)
responded. Of these the majority (N=102) were male. The mean
age of the respondents was 43.74 ± 18.90 years with a range of

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26 years to 64 years.

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The responding ophthalmologists were divided into two

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groups:

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Group A: All the ophthalmologists who were using
computers at their hospitals/offices (n=32, 23.9%).

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Group B: All the ophthalmologists who were not using Figure 1: Symptoms ascribed to CVS
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computers at their hospitals/offices (n=102, 76.1%).
The respondents had been in practice from 0 to 35 years with
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a mean of 14.91 years (SD=7.84 years).

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Group A practitioners had started their ophthalmic careers

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more recently (mean=12.11years; SD= 7.86) compared to group

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B practitioners (t=-2.212; P=0.03).

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All respondents (N=134) claimed that they knew about

CVS as a definite clinical entity. The doctors believed that
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the symptoms occurred after one to 10 hours of exposure to

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computers (mean=3.59; SD=1.66 hours). According to them

almost four hours of continuous work on a computer was safe
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(mean=226.08 min; SD=116.174 min).

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The major symptoms reported by the ophthalmologists

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were: eye strain (97.8%), headache (82.1%), tiredness and

burning sensation (79.1%), watering (66.4%), redness (61.2%),
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shoulder pain (44.0%) and neck pain (35.8%). The responses to Figure 2: Treatment modalities of CVS. T - Topical, S - Systemic
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the symptoms ascribed to CVS are summarized in Fig. 1 .

Of the 104 responses available regarding the number of patients
being treated every month by these practitioners, the monthly
figure ranged from two to 60 with a mean of 15.93(SD=11.65).
The ophthalmologists in both Group A and Group B held
similar views on the symptoms of CVS but a significantly larger
proportion of ophthalmologists in Group A believed that slow
focusing from distance to near and vice versa (P=0.006, X2 test),
blurred vision at a distance (P=0.016, X2 test) and blepharospasm
(P=0.026, X2 test) formed part of the syndrome complex as
compared to their counterparts in Group B [Table 1].
The participants advised their patients to blink consciously
at a rate of about 14 times per minute (mean=13.81 times per
min; SD=6.90). Table 2 shows tabulated results of the different
modalities of treatment preferred by ophthalmologists in this
study [Fig. 2]. Figure 3: Special lenses prescribed

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July - August 2007 Bali et al. Computer vision syndrome: A study of KAP 291

Table 1: Symptoms associated with computer vision syndrome Group A v/s Group B
Yes No Do not know Total
Slow focusing from distance to near and vice versa Group A 23 4 5 32
Group B 41 24 37 102
Blurred vision at a distance Group A 15 11 6 32
Group B 41 24 37 102
Blepharospasm Group A 8 17 7 32
Group B 9 52 41 102

Table 2: Treatment modalities of computer vision syndrome Table 3: Spectacle prescription in computer vision syndrome
(all ophthalmologists)
Modality Yes No Total

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Spectacles being prescribed Frequency Percent
Artificial tears 131 3 134
Analgesics 17 117 134 None 68 50.7

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Topical NSAIDs 9 125 134 Yes correction as per refraction for distance 37 27.6

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Topical steroids 13 121 134 Bifocals 15 11.2

Topical cycloplegics 4 130 134 Trifocals 3 2.2

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Topical anesthetics 1 133 134 Progressive adds 11 8.2

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Topical antibiotics 0 134 134 Total 134 100.0

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Systemic antibiotics 0 134 134
Sedatives/ Anxiolytics 19 115 134 Table 4: Preference to any special type of spectacle lens (all
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Do you advise blinking more often or ophthalmologists):
consciously? 117 17 134
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Frequency Percent
Patient advised to look away from screen
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periodically 82 52 134 None 92 68.7

Yes but not sure which type is preferable 11 8.2
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Convergence exercises are prescribed 45 89 134

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Divergence exercises are prescribed 15 119 134 Glass without antireflective coating 2 1.5
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Hard progressive adds without antireflective

coating 1 0.7
majority (27.6%) among those prescribing were correcting it
Soft progressive adds without antireflective
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for distance only. The majority of doctors prescribing glasses

coating 1 0.7
either do not have any preference for any special type of glass
Glass with antireflective coating 17 12.7
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(68.7%) or they do not have any idea regarding what glass is

CR 39 with antireflective coating 4 3.0
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to be prescribed (8.2%).
Soft progressive adds with antireflective coating 6 4.4
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The treatment advice given by Group A and B ophthalmologists

Total 134 100.0
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differed significantly on the issues of artificial tears (P= 0.002,

X2 test), sedatives/ anxiolytics (P= 0.04, X2 test), use of bifocals,
trifocals or any spectacles (P= 0.02, X2 test), blinking more often
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In the present study a significantly larger proportion of

consciously (P= 0.003, X2 test) and use of divergence exercises
Group A (71.9%) associated slow focusing with CVS than
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(P= 0.02, X2 test) [Table 5].

Group B ophthalmologists (40.2%) [P=0.007]. Blurred vision
Discussion at a distance was reported by a significantly larger proportion
(P=0.03) of Group A (46.9%) as a symptom than Group B
In this questionnaire-based spot-survey, the ophthalmologists (8.8%) ophthalmologists. Pseudomyopia has been ascribed to
responded that the symptoms of CVS occurred after a mean visual display unit (VDU) use by investigators.17,18 Group A
of 3.59h (SD=1.66h) of exposure to computers. In their opinion ophthalmologists reported visual symptoms more frequently
almost four hours of continuous work on a computer was than Group B. This might be due to their personal experience
considered safe (mean=226.08 min; SD=116.174 min). This on computers. Blepharospasm was reported as a symptom
duration for onset of symptoms was more than the definition by Group B (25.0%) and Group A (8.8%) ophthalmologists
given by OSHA.2 It could signify the lack of awareness on part [P=0.03]. This could point to better level of awareness in Group
of the ophthalmologists. However, this could be an artifact A ophthalmologists compared to Group B. There may be some
induced by the small sample size. error due to recall bias also. Further studies with a larger sample
size are hence indicated.
The symptoms reported by ophthalmologists, in decreasing
order were asthenopic, ocular surface-related and extra-ocular. The majority of the ophthalmologists (97.8%) agreed that the
Eyestrain has been attributed to the changes in the following main mode of treatment of CVS is artificial tears (tear substitute).
visual functions after work on a computer monitor: diminished Elastoviscous eye drops were found to be more effective in
power of accommodation, removal of the near point of attenuating the sensation of discomfort than regular balanced
convergence and deviation of phoria for near vision.6 salt solution.19 Another study reported that herbal eye drop

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292 INDIAN JOURNAL OF OPHTHALMOLOGY Vol. 55 No. 4

Table 5: Significant difference in treatment modalities between group A and group B

Group A Group B
Sedatives/ anxiolytics Yes 8 11
No 24 91
Total 32 102
Use of bifocals trifocals or any spectacles
None should be prescribed 12 56
Should be prescribed but I am not sure which ones 13 37
Bifocals prescribed 2 3
Trifocals prescribed 5 6
Total 32 102
Blinking more often consciously

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Yes 27 90
No 0 10

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Do not know 5 2

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Total 32 102

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Use of divergence exercises

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Yes 5 10
No 25 92

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Total
2
32
0
102
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(Itone eye drop) was significantly better than tear substitutes.20 of firmly crystallized treatment guidelines. This may reflect
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This depicts that the majority of the ophthalmologists were abundance of information on the net, but which requires to be
treating only ocular-surface-related components of CVS. They scientifically proved. Further studies with a larger sample size
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might be using it as a placebo.20 It may also indicate ignorance are hence indicated.
of other modalities of treatment of CVS.
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An examination tailored to meet the requirements of VDU

Spontaneous eye blink rate has been found to be significantly users needs to be designed. A high index of suspicion for the
decreased during VDT use;19,21 however, it does not affect the condition is warranted. However, the tendency to ascribe any
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quality (tear break-up time) or quantity (Schirmer I test, Jones vague symptom to CVS must be discouraged. Computer vision
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test) of the tear film, although it does exacerbate the dry eye syndrome is a diagnosis of exclusion today as almost everyone is
symptoms in predisposed humans.21-23 In this study the majority working on computers. An internationally acceptable diagnosis
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of doctors (87.3%) especially those using computer at office and grading system needs to be devised for CVS. It is concluded
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advised their patients to blink more often and consciously, about that ophthalmologists were aware of CVS, however, there was
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14 times per minute (mean=13.81 times per minute; SD=6.90). confusion regarding the diagnosis and treatment of CVS. Those
Group A doctors advised conscious voluntary blinking more ophthalmologists who were computer users were slightly
often than the Group B doctors. Only half of the participants better informed as compared to their counterparts who were
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prescribed glasses, most of which were corrected for distance not using computers.
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only. Only 2% of them prescribed intermediate correction [Table

3]. This may be due to lack of a standardized protocol regarding References
such correction in computer users.14 1. Grant AH. The computer user syndrome. J Am Optom Assoc
Other modalities of treatment reported to be used included 1987;58:892-901.
analgesics (12.7%), topical NSAIDs (6.7%), topical steroids 2. Nilsen R. Computer eye syndrome. [cited on 2005 May 26].
(9.7%), topical cycloplegics (3.0%), topical anesthetics (0.7%), Available from: http://www.naturaleyecare.com/diseases.
looking away from the computer screen periodically (61.2%), 3. att WS. Computer vision syndrome and computer glasses. [cited
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use of convergence exercises (33.6%), use of divergence on 2005 May 26]. Available from: http://www.mdsupport.org/.
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A ophthalmologists were more likely to prescribe sedatives/ 1998;40:554-68.
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0.02, X2 test), use of bifocals, trifocals or any spectacles (P= 0.02, strain symptoms after work with a computer screen. Klin Oczna
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support in the literature the latter two are well documented to be between individual differences in oculomotor resting states and
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A, the irrational use of anxiolytics and sedatives could point 7. Culhane HM, Winn B. Dynamic accommodation and myopia.
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8. Blehm C, Vishnu S, Khattak A, Mitra S, Yee RW. Computer vision I. Baseline associations between musculoskeletal discomfort
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computer terminals. Bull Soc Belge Ophtalmol 1997;264:107-11. healthy volunteers. Graefes Arch Clin Exp Ophthalmol 2003;241:914­
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11. Feigin AA. Role of spectral filters for refraction dynamics in
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PK, et al. Comparative randomized controlled clinical trial of a
12. Liao MH, Drury CG. Posture, discomfort and performance in a herbal eye drop with artificial tear and placebo in computer vision
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of presbyopic operators. J Occup Med 1992;34:1023-7. distinct patterns of eye blinking in patients with moderately dry
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Progressive and Datalite CRT Trifocal. J Am Optom Assoc 22. Acosta MC, Gallar J, Belmonte C. The influence of eye solutions
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15. Sanchez-Roman FR, Perez-Lucio C, Juarez-Ruiz C, Velez-Zamora display terminals. Exp Eye Res 1999;68:663-9.
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23. Nakaishi H, Yamada Y. Abnormal tear dynamics and symptoms
computer terminal operators. Salud Publica Mex 1996;38:189-96. of eyestrain in operators of visual display terminals. Occup Environ

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16. Cheu RA. Good vision at work. Occup Health Saf 1998;67:20-4. Med 1999;56:6-9.

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17. Futyma E, Prost ME. Evaluation of the visual function in employees
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18. Demure B, Luippold RS, Bigelow C, Ali D, Mundt KA, Liese Source of Support: Nil, Conflict of Interest: None declared.
B. Video display terminal workstation improvement program:
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294 INDIAN JOURNAL OF OPHTHALMOLOGY Vol. 55 No. 4

APPENDIX 1

Name: Dr.
Age Sex
Designation: Education: MBBS only/PG Diploma/ PG Degree/ Subspecialist Fellowship
Highest Qualification: Do you routinely work on computer at office: Yes/No
If yes then specify the nature of work: Software/accounting/data retrieval/data entry/ mail only/php
How many hours every day on an average? Last month
Last week
In general
Since when have you been exposed to computers regularly? For Years months
Since 199 /200
Do you know about computer vision syndrome? Yes/ No
If yes, it occurs after _____hours of computer work
1 =yes; 2=no; 3=do not know
Typical symptoms of computer vision syndrome include:

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• Eyestrain 123
Headaches 123

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• Slow focusing 123

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• Tired, burning eyes 123
• Neck and shoulder pain 123

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• Blurred vision at distance 123

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• Neck pains 123
• Colored haloes around light 123

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• Mobile floaters 123
• Flashes of light before eyes 123
• Redness 123
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• Watering 123
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• Photophobia 123
• Blepharospasm 123
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How many patients with such symptoms do you treat in a month?

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What treatment do you normally prescribe to such patients? Please encircle the appropriate responses.
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• Topical lubricant eye drops 123

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• Analgesics 123
• Oral NSAIDs 123
• Topical NSAIDs 123
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• Topical cycloplegics 123

• Topical anesthetics 123
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• Topical antibiotics 123

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• Spectacles: - bifocals/trifocals/progressive lenses 123

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• Any special lenses you prefer to use: glass without antireflective coating/CR 39 without antireflective coating/ hard
progressive adds without antireflective coating/soft progressive adds without antireflective coating/glass with antireflective
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coating/CR 39 with antireflective coating/ hard progressive adds with antireflective coating/soft progressive adds with antireflective
coating 123
• I usually ask the patient to blink more often. 123
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How often
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• I usually ask the patient to look away from computer screen. 1 2 3

Once in _____ hours ____ minutes
• Convergence exercises are useful Yes/ No

• Divergence exercises are useful Yes/ No

How many hours of continuous computer work is safe?

After how much time do you prescribe a break from continuous computer work? ______Hours ______minutes.

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