“Using language children can understand is essential”
Three researchers from the Centre for Eye Research Ireland discuss their involvement in turning research on smartphone use and myopia into an article for children
24 September 2021
What were the key takeaways from the research: Smartphone use as a possible risk factor for myopia for optometrists delivering myopia management in practice?
Professor James Loughman (JL), professor of optometry and vision science, and head of the Centre for Eye Research Ireland (CERI): As clinicians our role is to provide evidence-based guidance to our patients. Some questions are difficult to answer definitively and quickly. Do we know for certain that smartphones cause myopia? Absolutely not. Most things we interpret in clinical practice, however, are not definitively proven. But, when there is a clear convergence of evidence towards a common conclusion, that is the time to begin to allow that evidence to influence our clinical practice.
Our paper makes an important contribution to the question as to whether smartphone usage is associated with myopia. Coupled with other available evidence, there seems to be a clear convergence on three things:
- More outdoors time is protective
- Although there are unanswered questions, near work does appear to be associated with myopia – a recent and comprehensive meta-analysis which assesses the weight of all the available evidence suggests so. Optimising near work habits also seems to be protective, such as in a prospective study in the British Journal of Ophthalmology – again not definitive, but all leading the same general direction that near work is important
- We also know for certain that smartphone use is on the rise, both in terms of the number of children exposed and length of time being used. Our study shows this, and if you look beyond the ophthalmic literature you will see additional evidence that they are being used ubiquitously and at length by children and for a dramatically increased length of time.
All of this information, when combined, leads us to conclude that (on the basis of the best available evidence) it would seem sensible to urge children to find the right balance between phone use and time outdoors. We feel this suggestion presents the evidence in a way that is valid, evidence-based and a common-sense approach.
Encouraging children to spend more time outdoors instead of glued to their screen can do no harm. Failing to use all of the available evidence to take an on-the-fence position that we don't yet know enough, can do some harm, based on what we do know. As clinicians, therefore, I think we have a responsibility to educate parents and patients as to the possible risks of smartphone usage and to encourage better habits to minimise the potential risk.
Do you think the way optometry professionals communicate with children and families about myopia and myopia management could change?
JL: I think it needs to change. For centuries, the management of myopia, and refractive error more generally, has focused almost exclusively on the alleviation of symptoms rather than targeting root causes as a means to halting progression. Parents and children need to be educated on the risks of myopia and the possible benefits of a more targeted treatment regimen designed to prevent further progression and thereby mitigate risk of disease or vision loss. Our communication strategies need to evolve in order to encourage less myopigenic lifestyles or behaviours and to promote uptake of new treatments and continuation with treatment until clinically necessary (even in the case where progression continues).
The best advice for now might just be to encourage parents and children to find the right balance between outdoors exposure and near work, including phone use
How could the findings of this research help to inform discussions in practice?
JL: This paper provides some evidence to support the concept that they may be involved in myopia. However, the evidence is not yet definitive, and smartphones are certainly not the only factor involved. We do not yet know the exact nature of the long-term effects of excessive phone use, nor do we know the benefits of exerting stricter control over their use.
We do know, however, that smartphone usage is likely to continue to increase. The best advice for now might just be to encourage parents and children to find the right balance between outdoors exposure and near work, including phone use.
What are the key considerations to keep in mind when talking to children about the potential risks and causes of myopia?Professor James Loughman: We should learn the lessons of obesity management. We cannot successfully engage children to make better lifestyle choices without engaging the entire family. The home environment is important in the aetiology of childhood conditions which are linked to behaviour, such as obesity and myopia. Parents regulate choices and influence involvement in physical activity for their children.
Family-based interventions combining physical activity, outdoors exposure and behavioural components are therefore considered the current best practice in younger children, so we need to encourage behaviour change within the family.
As far as the risks are concerned, we need to communicate these in ways that make sense to children. There is no point talking about disease and vision loss in older age – the message has to be nuanced to illustrate the importance of minimising these risks in the context of their current life.
This might involve talking about their hobbies, likes and dislikes. If they like sports, for example, wouldn't it be nice not to have to wear glasses or goggles to play with their friends? If they hate wearing glasses, wouldn't it be nice to make sure that they can have a treatment when they get older which means they no longer have to wear glasses? To do this they have to take measures which stop them having to get stronger glasses every year. Different reasons to change can resonate with different children; it’s up to us to spend a little time to make sure our advice makes sense to the individual seated in the refraction chair in front of us.
Parents and children need to be educated on the risks of myopia and the possible benefits of a more targeted treatment regimen designed to prevent further progression and thereby mitigate risk of disease or vision loss
How did the opportunity to prepare the article Do smartphones hurt our eyes by causing short-sightedness? for Frontiers for Young Minds come about?
Dr John Butler (JB), mathematics and statistics lecturer at TU Dublin and a principal investigator at CERI: Having conducted research on sensory processing in children, it became part of my working day to explain the research concepts to participants to ensure that they felt that they had ownership of the process. When I came across Frontiers for Young Minds, I was delighted because this seemed like a very positive way to communicate research not just to the researchers, but the stakeholders and the wider community as well.
I mentioned it to Dr Saoirse McCrann, who is first author on this paper, as she had shown an interest in science communication. From this conversation, we decided to write our article based upon some of her PhD work on the impact of smartphones on myopia.
What was involved in the process of preparing and submitting the journal entry?
JB: The initial process of writing the paper for the journal was not dissimilar to writing a paper for another academic journal. We had a concept, we had an experiment, and we had results that we wanted to explain. The differences arose in how we communicated our findings, such as ensuring the language used wasn't too jargon-y and the lexicon was similar to what children would normally read. The huge benefit of writing it for Frontiers for Young Minds is the review process where children, with the support of academic mentors, read and review the paper. They gave honest feedback on parts they couldn't understand which we addressed to make it more readable and child-friendly.
For a good deal of research, it is not the concepts that are complicated, it is the language that we use to describe them. But if we use more appropriate language then anyone can understand
What do you hope this journal article will mean for readers and their families?
JB: I hope the article will explain some of our research about myopia and people will maybe think more about using their phones all the time. I also hope that the article will make people think differently about myopia and how environmental factors can impact it.
More specifically for the continued work in CERI, I think it will have a very positive impact as the young research participants can read about some of the ongoing work, which should engender confidence in the research and further cement them and their family as stakeholders in the process.
On a personal note, by coincidence, the week the paper was published my seven-year-old daughter’s class were role-playing being an optometrist, so I gave the teacher a copy of the paper, which she read some of in the class. This was nice as my daughter was excited about it and got to hear about some of my work.
Is there anything you have taken away in terms of explaining the concepts around myopia and its causes to children and families?
JB: For a good deal of research, it is not the concepts that are complicated, it is the language that we use to describe them. But if we use more appropriate language then anyone can understand the concepts and why they are important. I think this is particularly important for myopia research as early intervention is vital, so using language children can understand is essential.
What implications might the research have for myopia research?Ian Flitcroft, consultant ophthalmologist, adjunct professor of vision science at TU Dublin, and principal investigator at CERI: Our study provides the most reliable evidence to date that a relationship exists between phone usage and myopia. We found that short-sighted students used almost double the amount of mobile phone data daily compared to students who were not short-sighted. This provides the first objective indicator that smartphone use is higher among students who have already become myopic.
While these findings are important and add to the evidence base available, we have yet to provide definitive evidence that smartphone use causes myopia to develop or to progress at a faster rate. Our study certainly indicates that the possible relationship between smartphone use and myopia is an important research priority.
New studies are urgently required to track real-time use to provide a qualitative assessment of the nature of smartphone use. This needs to include what the phone is used for, such as reading, watching videos or movies, as well as the duration of use, proximity of device from the face – an important concern – settings in which it is used (indoor/outdoor) and other variables to better understand the mechanisms through which smart device use might influence myopia development.
Intervention studies should also be prioritised which limit smartphone use in some children, to assess the possible benefits of such a management strategy. Additional high-quality data such as this can more definitively establish any causal influence of smartphone use on myopia and the possible benefit of controlling access for future generations of children at risk of developing myopia or any of the complications associated with excessive eye growth. Such evidence could be particularly useful in relation to the design and implementation of future public health strategies for myopia control and prevention.