Ophthalmic & Physiological Optics ISSN 0275-5408

Computer-related visual symptoms in office workers

Joan K Portello1, Mark Rosenfield1, Yuliya Bababekova1, Jorge M Estrada2 and Alejandro Leon2
1

SUNY College of Optometry, New York, USA, and 2Fundacion Universitaria del Area Andina Pereira, Pereira, Colombia

Citation information: Portello JK, Rosenfield M, Bababekova Y, Estrada JM & Leon A. Computer-related visual symptoms in office workers.
Ophthalmic Physiol Opt 2012, 32, 375382. doi: 10.1111/j.1475-1313.2012.00925.x

Keywords: computer vision syndrome, dry

eye, ethnicity, gender, nearwork, reading
Correspondence: Mark Rosenfield
E-mail address: mrosenfield@sunyopt.edu
Received: 19 January 2012; Accepted: 31
May 2012

Abstract
Purpose: Many individuals report visual symptoms during office work and specifically computer use. This study determined the prevalence of symptoms in a
population of office workers, and examined the association between these
symptoms and both dry eye disease and other demographic factors.
Method: A written questionnaire was used to quantify the prevalence of symptoms in 520 New York City office workers, and to determine the effect of risk
factors including gender, ethnicity, age, smoking, type of refractive correction
and hours spent doing computer work. The questionnaire also examined the
prevalence of ocular surface disease.
Results: A significant positive correlation was observed between the symptom
score and the number of hours spent working on a computer in a typical day.
The most prevalent symptom was tired eyes, which was reported by approximately 40% of subjects as occurring at least half the time. 32% and 31% of
subjects reported symptoms of dry eye and eye discomfort, respectively. Symptoms varied significantly with gender (being greater in females), ethnicity
(being greater in Hispanics) and the use of rewetting drops. A significant positive correlation was observed between computer-related visual symptoms and
the Ocular Surface Disease Index (OSDI), a measure of dry eye.
Conclusions: Visual symptoms associated with computer use occur frequently in
the general population producing discomfort for extended periods of time.
They are strongly associated with ocular surface disease. Therapeutic regimens
need to be developed for this widespread condition.

In 2003, it was estimated that 55% of jobs involved

computer use (http://www.bls.gov/news.release/ciuaw.nr0.
htm). It seems likely that this number has now increased,
and when combined with non-vocational computer use
(including the use of desktop and laptop computers, tablets and other hand-held devices such as smartphones)
for activities such as e-mail and text messaging, internet
access and entertainment, one might suggest that the
viewing of personal electronic screens is now almost
universal.1
Thomson2 presented the findings of nine investigations
which estimated the prevalence of visual symptoms in
computer users. The studies were published between
1974 and 1993, and the prevalence ranged from 25% to
93% of users (mean prevalence = 56%). Symptoms
reported included eyestrain, headaches, ocular discomfort,

dry eye, diplopia and blurred vision either at near or

when looking into the distance after prolonged computer
use. Given the improvement in the quality of electronic
monitors, one might conjecture that the prevalence of
computer-related visual symptoms should have declined
over time. However, more recent investigations have also
noted a very wide range of prevalence rates ranging from
19.6%3 to 72%.4 In each of these latter studies, prevalence rates refer specifically to the symptom of eyestrain
or asthenopia.
However, there is limited published data regarding
factors which might be associated with these visual
symptoms in computer users. For example, while the
prevalence does seem to be higher in females,48 as well
as individuals who spend more than 45 h daily working on computers.9,10 the role of other factors such as

Ophthalmic & Physiological Optics 32 (2012) 375382 2012 The College of Optometrists

375

Visual symptoms in office workers

JK Portello et al.

age,1114 ethnicity, cigarette smoking, type of refractive

correction or dry eye on the occurrence of these symptoms is unclear. Accordingly, the aim of the present
study was to determine the prevalence of visual symptoms associated with computer use in a population of
office workers in an urban setting and to examine the
association between these symptoms and the factors
listed above.
Methods
A written survey was administered to determine the prevalence of visual symptoms in 520 office workers in midtown Manhattan. Contacts were made with companies in
the area immediately adjacent to the SUNY College of
Optometry which is located in the Bryant Part district of
New York City. This area is densely populated with international businesses and has an extremely large number of
commercial offices. The study followed the tenets of the
Declaration of Helsinki, and informed consent was
obtained from all subjects after an explanation of the nature and possible consequences of the study. The protocol
was approved by the Institutional Review Board at the
SUNY State College of Optometry.
The written survey requested information on the following areas (a copy of the survey is shown in Appendix
1):
(1) Age
(2) Gender
(3) Ethnicity
(4) Number of hours spent working on a computer in a
typical day
(5) Type of refractive correction worn during computer
use
(6) Use of artificial tears or rewetting drops during computer use
(7) Cigarette smoking.
Additionally, a questionnaire developed by Hayes et al.15
comprising 10 questions concerning the degree of ocular
discomfort experienced was included. A total symptom
score was obtained from these data. This symptom questionnaire has been used in previous studies1,16,17 and
shown to be repeatable.16 The Ocular Surface Disease
Index (OSDI) survey18 which assesses dry eye symptoms
was also included in the questionnaire.
Results
The socio-demographic characteristics of the population
tested are shown in Table 1. Symptoms included in the
questionnaire were graded as 4 (occurring all of the
time), 3 (most of the time), 2 (half of the time), 1 (some
of the time) or 0 (none of the time). A grade was
376

obtained for each symptom and the total score (ranging

from 0 to 40) represented the sum of the individual
symptom scores. The median total symptom score was
8.0 [interquartile range (IQR) = 11; overall range 040].
The percentage of subjects reporting symptoms over
the past week is shown in Table 2. It may be observed
that 39.8% of the subjects reported experiencing tired
eyes at least half of the time during the past week, while
the percentage of subjects experiencing dry eyes, eyestrain
and/or eye discomfort and irritated or burning eyes at
least half of the time was 32%, 31% and 28%, respectively.
Examination of both the total symptom score and
OSDI data using the Kolmogorov-Smirnov test indicated
that neither were normally distributed (total symptom
score: D = 0.275, p < 0.0001; OSDI: D = 0.317, p <
0.0001). Accordingly, non-parametric statistical tests have
been employed throughout.
The median OSDI score was 12.5 (IQR = 20.8; range
093.8). Based on this index, patients can be categorized
as normal (012 points) or as having mild (1322
points), moderate (2332 points), or severe (33100
points) ocular surface disease.19 Using these criteria,
49.1% of subjects were classified as having a normal ocular surface, while 21.0%, 11.6% and 18.3% had mild,
moderate and severe ocular surface disease, respectively.
A significant positive correlation was observed between
the total symptom score and the OSDI findings (Spearman rs = 0.74; p < 0.0001). This is shown in Figure 1.

Table 1. Socio-demographic characteristics of the population tested

Mean age in years (1SD)
39.2 (14.2)
Gender (%)
Female
327 (63.5)
Male
188 (36.5)
Ethnicity (%)
African-American
91 (17.8)
Asian
60 (11.7)
Hispanic
81 (15.9)
White
257 (50.3)
Other
22 (4.3)
Mean number of hours working on a computer (1SD)
5.9 (3.1)
Type of refractive correction worn during computer operation (%)
None
184 (36.9)
Spectacles
238 (47.8)
Contact lenses
70 (14.1)
Spectacles over contact lenses
6 (1.2)
Use of rewetting drops/artificial tears (%)
91 (20.5)
Ocular surface disease index (OSDI) (%)
Normal
255 (49.1)
Mild
109 (21)
Moderate
60 (11.6)
Severe
95 (18.3)

Ophthalmic & Physiological Optics 32 (2012) 375382 2012 The College of Optometrists

JK Portello et al.

Visual symptoms in office workers

Table 2. Percentage of subjects (N = 520) reporting symptoms during computer use over the past week

Blurred vision while viewing the computer

Blurred vision when looking into the distance
after computer work
Difficulty or slowness in refocusing my eyes
from one distance to another
Irritated or Burning eyes
Dry eyes
Eyestrain
Headache
Tired eyes
Sensitivity to bright lights
Eye discomfort

None of
the time

Some of
the time

Half of
the time

46.6
47.2

36.0
29.4

10.2
11.0

5.2
8.9

1.9
3.5

47.8

30.6

11.4

8.3

1.9

40.7
38.7
39.7
47.9
26.1
49.6
35.3

31.8
29.8
29.7
29.8
34.2
24.1
33.9

14.1
15.3
14.9
10.3
17.0
12.4
15.0

10.5
11.4
11.6
9.3
16.2
9.8
11.9

2.9
4.8
4.1
2.7
6.6
4.1
3.9

Symptom scores as a function of age, gender, ethnicity,

number of hours spent working on a computer in a typical
day, type of refractive correction worn during computer
use, use of artificial tears or rewetting drops during computer use and cigarette smoking are shown in Table 3.
Effect of age
The mean age of the subjects was 39.3 years (IQR =
22.75; range 1883 years). No significant change in symptom score with age was observed (H = 5.66; p = 0.22). A
weak, but statistically significant positive correlation was
observed between age and the OSDI (Spearman rs = 0.09;
p = 0.046).
Effect of gender
188 of the respondents were male and 327 female (no
response was recorded on five questionnaires). Median
symptom scores (IQR) for the male and female subjects

Total symptom score

40

All of
the time

were 7.0 (9) and 10.0 (12), respectively (U = 4.8;

p < 0.0001).
Ethnicity
The self-reported ethnicity of the subjects is shown in
Table 3. A significant difference in symptom score was
observed across ethnicity with the highest symptoms
being observed in Hispanics (H = 14.5; p = 0.005).
Number of hours working on a computer
The median number of hours spent working on a computer in a typical day was 6.0 (IQR = 4.5; range 0.516).
A significant correlation was observed between the total
symptom score and the number of hours spent working
on a computer in a typical day. (rs = 0.24; p < 0.001).
The correlation between the OSDI score and the number
of hours spent working on a computer in a typical day
was not significant (rs = 0.003; p = 0.95).
Type of refractive correction worn during computer
operation

30

The type of refractive correction worn during computer use

is shown in Table 3. No significant difference in symptom
score in these subgroups was observed (H = 0.62; p = 0.89).

20
10
0

Most of
the time

20

40

60

80

100

OSDI

Figure 1. A significant positive correlation was observed between

the total symptom score and the OSDI index (rs = 0.74; p < 0.0001).
The solid diagonal line indicates the linear regression line (y =
0.35x + 4.13).

Use of rewetting drops

Of 444 respondents, 91 (20.5%) reported using rewetting
drops or artificial tears while working at the computer.
Median (IQR) symptom scores for the groups who did
and did not use rewetting drops were 15.0 (12) and 7.0
(11), respectively (u = 7.28; p = 0.0001).

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Visual symptoms in office workers

JK Portello et al.

Cigarette Smoking
Of 515 respondents, 56 (10.9%) reported smoking cigarettes. Median symptom scores for the smokers and nonsmokers were 8.50 (12) and 8.0 (11), respectively
(U = 0.15; p = 0.87). Median OSDI scores for the smokers and non-smokers were 12.50 (26.38) and 12.50
(20.84), respectively. For the smoking group, the mean
number of cigarettes smoked per day was 8.65 (range =
140). No significant correlation was observed between
the number of cigarettes smoked per day and either the
symptom score (rs = 0.08; p = 0.57) or the OSDI (rs =
0.007; p = 0.96).
Factor analysis
A principal-component factor analysis was performed to
evaluate the internal structure and supporting evidence
regarding the construct validity of symptoms included in
the questionnaire.20,21 Both the Kaiser-Meier-Olkin index
(KMO = 0.914), and the Bartlett sphericity test (p <
0.0001) showed a significant correlation between the variables. These results indicate that the procedure is valid
and allows us to identify factors included in the questionnaire.
The significant correlation suggests an underlying latent
variable that could reduce the dimensionality of the
symptoms. Principal factor analysis with orthogonal varimax rotation was undertaken to take advantage of these
intercorrelations (see Figure 2). The number of underlying
latent variables was determined by selecting factors with
eigenvalues higher than 1. Two dimensions are clearly
identified, which account for 64.4% of the total variance.
Factor loadings (correlation item-factor) are listed in
Table 4. It may be observed that three items namely
blurred vision at near, blurred vision in the distance after
computer use and difficulty in refocusing had a high correlation (r > 0.70). These items are related to the factor 2
which appears to be associated with accommodation. The
remaining items showed a moderately high correlation
for the factor 1 (r > 0.60), and appear to be associated
with dry eye.
Discussion
The results of the present study indicate that a large
number of office workers experience symptoms which are
associated with computer use. For example, nearly 40%
of the individuals surveyed reported the symptom of
tired eyes occurring at least half of the time during the
past week, while other symptoms, such as dry eyes, eyestrain and/or eye discomfort and irritated or burning eyes
were experienced at least half of the time by around
378

Table 3. Median total symptom score as a function of age, gender,

ethnicity, number of hours spent working on the computer in a typical day, type of refractive correction worn, use of rewetting drops/
artificial tears, cigarette smoking. p-values reflect findings from the
KruskalWallis or MannWhitney tests
Median total symptom
score (IQR)

p-value

Age (years)
0.22
1825
8 (11)
2633
9 (13)
3443
10 (11)
4452
8 (12)
5383
7 (12)
Gender
Female
7 (9)
<0.0001
Male
10 (12)
Ethnicity
African
9 (14)
0.0048
Asian
7.5 (10.5)
Hispanic
12 (10)
White
8 (10)
Other
9 (14)
Number of hours working on a computer
0.53
5.5 (9)
0.0001
3.55
8 (11)
5.57
8 (12)
7.59
10 (10)
9.516
12 (13)
Use of rewetting drops
Yes
15 (12)
0.0001
No
7 (11)
Type of spectacle correction worn during computer operation
Single-vision
8 (12)
0.89
Progressive-addition
9 (11)
Bifocals
12 (11)
Trifocals
14 (19)
Cigarette smoking
Yes
8.5 (12)
0.87
No
8 (11)

30% of the subjects. One may conclude that many millions of individuals are experiencing significant ocular
and visual symptoms when viewing personal electronic
screens both in the contemporary workplace and elsewhere.
A significant correlation was observed between the total
symptom score and the number of hours spent working
on a computer in a typical day. However, this finding
should be interpreted with caution, since the degree of
accuracy of these reports is unknown, and subjects may
have significantly over- or under-estimated the number of
hours. Additionally, the degree of variability between one
day and another is unclear. Further, this question failed
to consider other associated factors, such as the number
of breaks taken, viewing distance(s), whether the task
involved electronic screens exclusively, or a combination

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JK Portello et al.

Visual symptoms in office workers

Figure 2. Loading factors for the factor analysis. Two dimensions are
clearly identified, namely factor 1 (related to dry eye) and factor 2
(associated with ocular accommodation). SBL, sensitivity to bright
light; HA, headache; ES, eyestrain; Discomfort, eye discomfort; TE;
tired eyes; Burning, burning eyes; DE, dry eyes; BVD, blurred vision
looking into the distance; BVvC, blurred vision while viewing the computer; Refocus: slowness in refocusing.

Table 4. Correlation matrix from factorial analysis with orthogonal

varimax rotation

Item
Blurred vision while viewing the computer
Blurred vision when looking into the
distance after computer work
Difficulty or slowness in refocusing my
eyes from one distance to another
Irritated or Burning eyes
Dry eyes
Eyestrain
Headache
Tired eyes
Sensitivity to bright lights
Eye discomfort

Factors
1

0.38
0.21

0.72
0.84

0.29

0.83

0.72
0.72
0.74
0.65
0.81
0.62
0.83

0.29
0.23
0.33
0.30
0.19
0.32
0.23

of computer and hard-copy assignments. Nevertheless,

the general trend of greater symptoms with prolonged
working time is an expected finding, and is consistent
with previous reports.9,10 Use of other methodologies,
such as hourly diaries, monitoring work output or direct
recording of subjects during computer operation could be
adopted to give greater accuracy to the assessment of
actual working conditions.
Attempting to compare these findings with previous
reports is difficult, since many studies have presented the
prevalence of one or more symptoms, with no indication
of their frequency. Accordingly, an individual who briefly
experiences eyestrain on a single occasion may be counted
in the same way as someone dealing with a symptom for
many hours every working day. Current work in our lab-

oratory is examining the association between symptom

score and physical signs and/or changes in clinical parameters. Interestingly, a recent paper has shown significant
changes in both blood flow and muscle load in the orbicularis oculi muscle following demanding computer work.
This may provide an objective method of quantifying
computer related visual symptoms.22
In the present study, 29.9% of the subjects were classified as having either moderate or severe dry eye based on
their OSDI score. This is a higher prevalence than many
previous reports. For example, Moss et al.23 reported a
prevalence of dry eye of 14.4% in the Beaver Dam Eye
Study while Uchino et al.24 noted dry eye disease in
10.1% and 21.5% of male and female Japanese office
workers, respectively. Hikichi et al.25 observed that the
prevalence of dry eye was highest in computer operators
who wore contact lenses. In these subjects, 25% were
diagnosed with dry eye. Further, the prevalence varied
with the Japanese region being tested, and was highest in
Tokyo, with a reported prevalence of 28%. This is similar
to the value found from New York City office workers in
the current investigation. The high prevalence of ocular
surface disease observed both in Tokyo and New York
may have been related to the specific urban environment
(and possibly the air quality) found in these cities. However, Uchino et al.26 observed that the prevalence of dry
eye disease in a rural area of Japan was 12.5% in males
and 21.6% in females. These authors suggested that racial
differences may play a major role in the prevalence of this
condition. Differences in the prevalence of dry eye must
be interpreted with caution, since different methodologies
have been used to identify individuals with this condition.
For example, Moss et al.23 defined dry eye as a positive
response to the question, For the past 3 months or
longer, have you had dry eyes? No attempt was made to
quantify the severity of the condition. In contrast, Hikichi
et al.25 diagnosed dry eye if the patient had any symptoms, was positive for at least one staining test and positive for at least one tear dynamic test. Here, the degree of
severity was graded as moderate or severe if it exceeded a
given threshold.
The observation of greater computer-related visual
symptoms in females is also consistent with previous
reports.48 This may be related to the higher prevalence
of dry eye.2730 The results of the present study demonstrated significantly increased OSDI scores in females
compared with the male subjects. Further, we observed
that both the total symptom score and the OSDI were
highest in the Hispanic group and lowest in the Asian
group. In an investigation of 39 876 American women,
Schaumberg et al.29 also reported that the prevalence of
dry eye was greater in Hispanics (9.61%), when compared
with Asian (7.39%), White (6.70%) and African-American

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Visual symptoms in office workers

JK Portello et al.

women (6.38%). However, after controlling for age and

other variables, the authors noted no significant difference
in the prevalence of dry eye by race.
The factor analysis shown in Figure 2 indicated that
visual symptoms may be divided into two groups, being
either associated with accommodation or dry eye. This differentiation is almost identical to a division of asthenopia
proposed earlier by Sheedy et al.31 These authors noted
that symptoms commonly associated with this diagnostic
term included eyestrain, eye fatigue, discomfort, burning,
irritation, pain, ache, sore eyes, diplopia, photophobia,
blur, itching, tearing, dryness and foreign-body sensation.
While investigating the effect of several symptom-inducing
conditions on asthenopia, the authors determined that two
broad categories of symptoms existed. The first group,
termed external symptoms, included burning, irritation,
ocular dryness and tearing, and was related to dry eye. The
second group, termed internal symptoms, included eyestrain, headache, eye ache, diplopia and blur, and is generally caused by refractive, accommodative or vergence
anomalies. Accordingly, the authors proposed that the
underlying problem could be identified by the location
and/or description of symptoms.
In addition to the discomfort experienced during computer operation, the visual symptoms may also have a significant economic impact. For example, symptoms can
increase the number of errors made during a computer
task3235 as well as necessitating more frequent breaks.
Musculoskeletal injuries associated with computer use
may account for at least half of all reported work-related
injuries in the USA.36 Indeed, Spekle et al.37 noted that
conservative estimates of the cost of musculoskeletal disorders to the United States economy as reported in 2001,
when measured by compensation costs, lost wages and
reduced productivity were between 45 and 54 billion dollars annually or 0.8% of gross domestic product. Further,
the prevalence of neck, shoulder and arm symptoms in
computer workers may be as high as 62%.38 In addition
to productivity costs, it was estimated in 2002 that
employers in the USA paid approximately $20 billion
annually in workers compensation resulting from workrelated musculoskeletal disorders.39 Indeed, Bhanderi et
al.11 suggested that as many as 1015% of routine eye
examinations are related to computer-related visual symptoms. Additionally, Daum et al.40 estimated that provision
of an appropriate refractive correction alone could produce at least a 2.5% increase in productivity. This would
result in a highly favourable cost-benefit ratio to an
employer who provided computer-specific eyewear to
their employees. Accordingly, it is clear that the economic
impact of these symptoms is extremely high, and minimizing
symptoms that reduce occupational efficiency will result
in substantial financial benefit.
380

In conclusion, the findings of the present investigation

verify the high prevalence of both visual symptoms and
ocular surface disease in a population of office workers in
an urban environment. Symptoms correlated with the
number of hours spent using a computer and were highest in females, Hispanics and patients with dry eye. They
did not vary significantly with age, cigarette smoking or
the type of refractive correction worn. These associated
conditions are likely to have a significant detrimental
impact on both productivity and the quality of life41 of
the individual. Accordingly, it is important that clinicians
question their patients regarding their use of electronic
devices at work and elsewhere, and provide guidance
regarding good working practices to minimize the severity
of these symptoms.
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Appendix 1
Questionnaire administered to the subjects.
1. Age in years..
2. Gender:
a. Male
b. Female
3. Ethnicity:
a. African-American
b. Asian
c. Hispanic
d. White (non-Hispanic)
e. Other (please specify).

Ophthalmic & Physiological Optics 32 (2012) 375382 2012 The College of Optometrists

381

Visual symptoms in office workers

JK Portello et al.

4. Number of hours spent working on computer in a

typical day..
5. When working on the computer do you wear?
a. Neither glasses nor contact lenses.
b. Just glasses.
c. Just contact lenses.
d. Glasses over your contact lenses.

6. Do you ever put artificial tears or rewetting drops into

your eyes when you are working at the computer?
a. Yes
b. No
7. Do you smoke cigarettes?
a. No
b. Yes. About how many cigarettes do you smoke per
day

When working on a computer over the past week, have you experienced any of the following symptoms?
All of the time Most of the time Half of the time Some of the time None of the time
Blurred vision while viewing the computer
Blurred vision when looking into the distance
after computer work
Difficulty or slowness in refocusing my eyes
from one distance to another
Irritated or burning eyes
Dry eyes
Eyestrain
Headache
Tired eyes
Sensitivity to bright lights
Discomfort in eyes

4
4

3
3

2
2

1
1

0
0

4
4
4
4
4
4
4

3
3
3
3
3
3
3

2
2
2
2
2
2
2

1
1
1
1
1
1
1

0
0
0
0
0
0
0

Have you experienced any of the following during the last week?

Eyes that are sensitive to light

Eyes that feel gritty
Painful or sore eyes?
Blurred vision?
Poor vision?

All of the time

Most of the time

Half of the time

Some of the time

None of the time

4
4
4
4
4

3
3
3
3
3

2
2
2
2
2

1
1
1
1
1

0
0
0
0
0

Have problems with your eyes limited you in performing any of the following during the last week?
All of the time Most of the time Half of the time Some of the time None of the time
Reading
4
Driving at night
4
Working with a computer or bank machine (ATM) 4
Watching TV
4

3
3
3
3

2
2
2
2

1
1
1
1

0
0
0
0

Have your eyes felt uncomfortable in any of the following situations during the last week?

Windy conditions
Places or areas with low humidity (very dry)
Areas that are air conditioned

382

All of the time

Most of the time

Half of the time

Some of the time

None of the time

4
4
4

3
3
3

2
2
2

1
1
1

0
0
0

Ophthalmic & Physiological Optics 32 (2012) 375382 2012 The College of Optometrists