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To assess the magnitude and determinants of computer vision syndrome (CVS) among radiologists in Saudi Arabia using a reliable and validated survey instrument.
Materials and Methods
This nationwide cross-sectional web-based survey took place in April 2021 and included all radiologists and radiology residents residing practicing in Saudi Arabia. We used the reliable and validated CVS questionnaire. Univariate and multivariate analyses were carried out using nonparametric methods. The CVS score was correlated with different demographic- and health-related variables. The Mann-Whitney U test and Kruskal-Wallis test were used to determine if there was a statistically significant difference between subgroups.
Results
The survey was completed by 416 participants. The prevalence of CVS was 65.4% (95% CI: 60.8-70.0). The median CVS score was 7.5 (interquartile range: 4.0; 12.0). Mild CVS was observed in 188 participants (69.1%), moderate CVS was observed in 69 (25.4%), and severe CVS was observed in 15 (5.5%). The most common symptoms perceived by participants were headache (72.1%), dryness (70.7%), burning (63.7%), blurred vision (56.3%), and increased sensitivity to light (55.5%). Multinomial regression analysis suggested that female sex (p < 0.001), work as a general radiologist (p = 0.05), and the use of eyeglasses (p = 0.001) were significant predictors of CVS.
Conclusion
The prevalence of CVS among radiologists in our study was high. Local and international societies need to establish and implement legislative and preventive measures to ensure the safety and ocular and visual health of radiologists.
Radiologists are exposed to unique occupational health hazards, different from those faced by physicians working in other specialties. In the past century, hazards to radiologists caused by overexposure to ionizing radiation have received much attention. The development of new radiation protection guidelines and advances in machine development have resulted in a dramatic decrease in the incidence of exposure to radiation and its related injuries. Several changes in the role of radiologists as health care providers within the health care system have been observed over the last two decades. These changes became more conspicuous due to the greatly increasing impact of information technology on all aspects of the specialty (
). The field of diagnostic radiology has significantly evolved, with a dramatic shift from film-based to filmless images, creating more challenges and increasing the workload of radiologists (
). Currently, a major component of the daily work of a diagnostic radiologist involves sitting and staring at one or multiple high-resolution display monitors with high brightness for long hours to thoroughly examine the radiological images of patients and report the findings therein. These display monitors coupled with high-performance computers are known as picture archiving and communication systems (PACS). Nonradiation occupational hazards such as fatigue, chronic eye strain, and musculoskeletal and mental issues can negatively impact the health of radiologists and lead to an increase in the number of medical errors (
Computer vision syndrome (CVS) is defined by the American Optometric Association as a group of eye- and vision-related problems that result from prolonged exposure to digital display devices. The reported prevalence of CVS among computer users in the literature is variable and can reach up to 90%. Blehm et al. categorized CVS into four categories. The first category is asthenopic CVS, which includes symptoms of eyestrain, tired, sore, and dry eyes. The second category is ocular surface-related CVS, and it includes eye dryness, burning, grittiness, and heaviness related to differences in age, sex, environmental factors, rate of blinking, use of contact lenses and the length of exposure to monitors. The third category is visual CVS and includes symptoms such as blurred vision, double vision, slowness of focus change, and presbyopia. The fourth category is extraocular symptoms, mainly shoulder, neck, and back pain (
A recent editorial in Academic Radiology highlighted the importance of studying eye strain and developing strategies that mitigate its negative impact on radiologists (
). In addition, several studies have attempted to investigate and identify various factors related to CVS among radiologists and other professionals using different methods (
). Given the recent increased interest in this topic, we decided to conduct this national survey, aiming to assess the magnitude and determinants of CVS among radiologists in Saudi Arabia with the use of a reliable and validated survey instrument.
METHODS
This nationwide cross-sectional web-based survey took place in April 2021 and included all radiologists and radiology residents residing and practicing in the Kingdom of Saudi Arabia and registered with the Saudi Commission for Heath Specialties (SCFHS). The sample size was calculated using OpenEpi software (Version 3.0, Open Source Epidemiologic Statistics for Public Health, USA) and an estimated prevalence of CVS among radiologists of 50%. The calculation indicated that a sample size of 387 radiologists was needed, with a design effect of 1.2 for the cluster sample and a confidence level of 95% (
Dean AG SK, Soe MM. OpenEpi: Open Source Epidemiologic Statistics for Public Health, Version. Available at: www.OpenEpi.com, updated 2013/04/06. Accessed August 18, 2021.
An academic radiologist and an academic ophthalmologist designed the survey based on a literature review and after discussion with a focus group of radiologists. Survey data were collected anonymously using the online survey tool JotForm (JotForm; San Francisco, CA). A pilot test was undertaken with 10 radiologists to detect flaws in the survey before more widely distributing the survey. The project and the survey instrument were reviewed and received approval from the Institutional Review Board at the institution of the first author. The SCFHS agreed to send the invitation to participate in our survey by email to all eligible radiologists and radiology residents. The Radiological Society of Saudi Arabia (RSSA) also agreed to send email invitations to its members practicing within the geographical limit of the Kingdome of Saudi Arabia. The invitation was sent on April 8, 2021, and the survey was open for a 5-week period. No personal identifying information was collected. During each stage of the study, the tenants of the Helsinki Declaration were strictly followed.
The demographic and work pattern information collected included age, gender, professional rank according to the SCFHS, number of years of work in the field, subspeciality, and type of institution of current affiliation. The visual aid-related information collected included questions regarding the use of eyeglasses, reading glasses, contact lenses, and history of refractive surgery, in addition to its type and time if present. Information related to work patterns, such as the number of days per week and hours per day spent reviewing cases in front of the monitor, was collected. We also asked participants about the presence of any systemic diseases, such as diabetes, hypertension, and any other chronic disease, and the use and duration of use of devices, such as mobile phones, laptops, tablets, televisions, and wall projectors.
In this survey, we used the reliable and validated CVS questionnaire (CVS-Q) described by Seguí et al. to measure CVS at the workplace (
). A total of 16 ocular- and visual-related symptoms from the CVS-Q were presented to the participants. These symptoms were burning, itching, feeling of a foreign body, tearing, excessive blinking, eye redness, eye pain, heavy eyelids, dryness, blurred vision, double vision, difficulty focusing on near objects, increased sensitivity to light, colored halos around objects, feeling that vision is worsening, and headache. Frequency was defined as how often the symptom occurs: never if the symptom never occurs, sometimes or occasionally if the symptom occurs sporadically or once per week, and always or often if the symptom occurs 2 to 3 times per week or every day.
To measure frequency, participants were asked to report their perception of the frequency of each of the 16 symptoms using the following options: always or often = 2, sometimes or occasionally = 1, and never = 0. To measure the intensity of the perceived symptom, participants were asked to grade the severity using either mild to moderate = 1 or severe = 2. Symptoms reported as never occurring were automatically scored as 0 (none) on the intensity scale. The following formula was used to calculate the total score:
To attain a good balance between sensitivity and specificity, a cutoff value of 6 for the total CVS score was used, as described by Seguí et al.; thus, participants with a total score of 6 or more were defined as having CVS (
). In the absence of a universal consensus on CVS severity grading and after discussion with a multidisciplinary group of experts and an academic optometrist, we decided to adopt the following criteria: participants with a total score of 6-12 were deemed to have mild CVS, those with a score of 13-19 were deemed to have moderate CVS, and those with a score of 20 or more were considered to have a severe CVS.
Statistical Analysis
Statistical analysis was performed using Statistical Package for Social Sciences version 25 (IBM SPSS Statistics for Windows, Armonk, NY). Descriptive statistics were calculated for all variables. Categorical variables are presented as counts and percentages. Numerical variables are presented as the mean and standard deviation if normally distributed. Univariate and multivariate analyses were carried out using nonparametric methods. The variables in the subgroups were not normally distributed. Hence, the CVS score is presented as the median and interquartile range (IQR). The CVS score was correlated with different independent demographic- and health-related variables using univariate analysis. Variables significantly correlated with the score were studied for interactions and predictors using regression analysis. The Mann-Whitney U test was used to determine if there was a statistically significant difference between two subgroups, and the Kruskal-Wallis test was used to determine if there was a statistically significant difference among more than two subgroups of independent variables. A p-value of ≤0.05 was considered statistically significant.
RESULTS
A total of 416 radiologists and radiology residents completed the survey. Participants ranged in age from 22 to 65, with a mean age of 35.8 ± 8.4 years. As observed in Table 1, the majority were male (65.4%). Approximately two-thirds (65.9%) were general radiologists with no subspeciality. Approximately 40% of radiologists indicated their use of visual aids such as eyeglasses and contact lenses. There were 16 (3.8%) radiologists with diabetes, 30 (7.2%) radiologists with hypertension and 12 (2.9%) radiologists with autoimmune diseases. Sixteen percent of radiologists had a history of refractive surgery. The mean number of hours spent in front of PACS monitors per week was 34.3 ± 14.6 hours. Details regarding the personal and ocular health of the participants are shown in Table 2. In addition to their occupational use of PACS monitors, most of the participants (394, 94.7%) indicated their use of other digital devices such as smartphones, laptops, and tablets. The median duration of use was 4 hours per day (IQR: 3.0; 6.0). A total of 254 (61.1%) reported that they watched television for a median of 1 hour per day (IQR: 1.0-2.7). Wall projectors were used by 24 (5.8%) radiologists.
Table 1Demographic Characteristics of the Participants
The prevalence of CVS in our study population was 65.4% (95% CI: 60.8-70.0). The median CVS score was 7.5 (IQR: 4.0; 12.0). Only 12 (2.0%) participants had none of the 16 symptoms (total CVS-Q score = 0). Using our proposed criteria for CVS severity grading, mild CVS (total CVS-Q score ranging between 6 and 12) was observed in 188 (69.1%), moderate CVS (total CVS-Q score between 13 and 19) was observed in 69 (25.4%), and severe CVS was observed in 15 (5.5%) of those who fulfilled the criteria for CVS.
The most common ocular- and visual-related CVS symptoms perceived by participants were headache (72.1%), dryness (70.7%), burning (63.7%), blurred vision (56.3%), and increased sensitivity to light (55.5%) (Fig 1). The least commonly reported symptoms were double vision (11.3%), colored halos around objects (25.5%), heavy eyelids (31.3%), excessive blinking (32.9%), and foreign body sensation (36.1%). The severity of each ocular- and visual-related CVS symptoms perceived by the participants is shown in Figure 2.
Figure 1Frequency of ocular- and visual-related CVS symptoms perceived by the participants. CVS, computer vision syndrome.
Females had a significantly higher CVS score than males (p < 0.001). Additionally, participants using eyeglasses (p = 0.003) had significantly higher CVS scores, and radiologists spending 20 hours or less in front of the monitors per week had significantly lower CVS scores (p = 0.002). The correlation of the CVS score with different variables is shown in Table 3.
Table 3Correlation of CVS Score with Different Variables
The multinomial regression analysis suggested that female gender (p < 0.001), work as a general radiologist (p = 0.05), and the use of eyeglasses (p = 0.001) were significant predictors of CVS. A comparison of the results of our study with those of previously published studies on CVS among radiologists and other professionals is shown in Table 4.
Table 4Comparison of the Results of Our Study with Those of Previously Published Studies on Computer Vision Syndrome Among Radiologists and Other Professionals
Prevalence and associated risk factors of computer vision syndrome among the computer science students of an engineering college of Bengaluru-A cross-sectional study.
Galore International Journal of Health Sciences and Research.2019; 4: 10-15
Not taking breaks, not massaging eyes, unusual viewing distance, improper posture, computer usage for more than 10 hours per day and not being aware of CVS were significant predictors of CVS
Medical students in Egypt undergoing ophthalmologic exam
76.0%
733
Refractive errors, prolonged screen hours, screen distance close to the eyes, improper gaze angle, poor screen resolution, and screen glare were risk factors for developing CVS and influencing its severity
13
Present study
2021
Radiologists in Saudi Arabia
65.4% Severe (5.5%)
416
Female gender and use of visual aids were risk factors for CVS
). Our study is the first to use the reliable and validated CVS-Q survey instrument in radiologists. The CVS-Q has a reported sensitivity and specificity of 75.0% and 70.2%, respectively (
). In our study, a high prevalence of CVS among radiologists was observed. Two-thirds of participants experienced CVS, and nearly one-third of them had a score suggestive of moderate to severe CVS. A greater proportion of female radiologists than male radiologists suffered from CVS, and they were more likely to have severe grade CVS than male radiologists. This was also observed in several previous studies (
). A higher prevalence of myopia, better compliance with the use of visual aids and more time spent indoors than males could be responsible for the higher prevalence and worse severity of CVS among females (
The prevalence and severity of CVS among radiologists in the present study were greater than what was previously reported in the literature. In our study, the prevalence of CVS among radiologists in Saudi Arabia was 65.4%, compared to 36.0% among radiologists in North America (
). The occurrence of CVS was also higher than what was recently reported by Al Dandan et al., who reported prevalence of digital eye strain to be 50.5% among radiologists in the eastern province of Saudi Arabia (
). The difference could be attributed to the variation in the CVS measurement tools used. The prevalence of CVS in our population was in the range of what was previously reported among computer office workers, bank workers, and information technology professionals (
). Although the prevalence of CVS was high among radiologists, it is difficult to compare it with that among other professionals using computers in their daily work. The use of a uniform scoring system and perhaps an objective method of assessing CVS may be more appropriate for comparing differences in occupational hazards among different professionals (
). CVS is an occupational hazard among radiologists, and more detailed studies on risk factors using prospective study designs and objective measurement tools are recommended. This will also enable us to review the impact of remedial measures adopted to address the identified risk factors and to conduct interventional prospective research.
Long hours facing PACS monitors was a predictor of CVS and its severity in our study. Excessive exposure to computer monitors and daily usage of digital devices were among the risk factors for CVS in medical students in western Saudi Arabia (
). Radiologists should be advised to take frequent short breaks to enhance their productivity and visual well-being.
CVS encompasses a large array of symptoms. In our study, we evaluated 16 visual- and ocular-related CVS symptoms. The most commonly reported symptoms were headache, eye dryness, burning, blurred vision, and increased sensitivity to light. These symptoms were also reported as the most common symptoms in other studies on CVS in the general population during the coronavirus disease 2019 (COVID-19) lockdown, IT professionals and computer users (
). Health education and increasing awareness with regard to CVS symptoms and risk factors could be helpful in improving the visual and ocular well-being of radiologists. Ergonomic features are important in the radiology reading room. Viewing distance, height and inclination of the monitor and proper ambient light in the reading room are known factors associated with CVS (
Radiologists spend long hours in front of PACS monitors reviewing and reporting images from different imaging modalities, and thus, they share the same unavoidable occupational hazards as computer workers. Excessive exposure to monitors is an important factor that may predispose and lead radiologists to develop CVS. Policies and guidelines to minimize its occurrence were suggested by the European Agency for Safety and Health at Work (
Ocular health among radiologists in the age of PACS: Is it time for our profession to open its eyes to this issue in light of existing European legislation?.
). In Europe, radiologists are protected under legislation enacted by the European Union amended by The European Parliament (Directive 90/270/EEC), which requires employers to provide regular eye examinations and breaks during work (
We encounter several limitations in our study including reporting the perception of each symptom to determine the magnitude and severity of CVS instead of an objective measurement. A combination of subjective and objective measurements of CVS may have been more useful. Other limitations include the cross-sectional design and possible self-reporting inaccuracies. In addition, the survey took place 9 months after the end of the COVID-19 pandemic lockdown. During this period, health services were negatively affected, and the workload of radiologists was relatively less than usual compared to the period before COVID-19. Subsequently, CVS might be underestimated in our study. Also, we did not collect information regarding viewing distance, height and inclination of the monitor and ambient light in the reading room, and future studies could consider including them in the questionnaire.
In conclusion, eye care is an important occupational issue. In our survey, we observed a high prevalence of CVS among radiologists. Radiologists must be educated and made aware of preventive measures and strategies that allow them to avoid developing CVS. These may include, and are not limited to, taking frequent breaks, avoiding dry eyes, maintaining adequate hydration, practicing good personal care, minimizing the use of digital devices outside of work, keeping a record of eye symptoms related to work, and undergoing a periodic eye examination. Local and international societies need to establish and implement legislative measures to ensure the safety of radiologists, minimize the effect of CVS on their performance, and maintain their eye health.
Disclosure
Authors have no conflict of interests, and the work was not supported or funded by any drug company. This study was approved by the Institutional Review Board (IRB), Taibah University (IRB number TU-20-018).
Acknowledgments
The authors gratefully acknowledge the Saudi Commission for Health Sciences for sending the survey email to all practicing radiology residents and radiologists. Additionally, the authors would like to thank American Journal Experts for English language editing.
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Dean AG SK, Soe MM. OpenEpi: Open Source Epidemiologic Statistics for Public Health, Version. Available at: www.OpenEpi.com, updated 2013/04/06. Accessed August 18, 2021.
Ocular health among radiologists in the age of PACS: Is it time for our profession to open its eyes to this issue in light of existing European legislation?.
Prevalence and associated risk factors of computer vision syndrome among the computer science students of an engineering college of Bengaluru-A cross-sectional study.
Galore International Journal of Health Sciences and Research.2019; 4: 10-15
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