Need increases to educate patients, offer protection against blue light
Eye care providers have been helping patients protect their eyes from ultraviolet light for decades. More recently, blue light has also been proven to cause significant eye damage, opening up an opportunity for education and targeted treatment.
In a recent poll on Healio.com/Optometry, 96 participants weighed in on the types of recommendations they are giving to patients regarding protection against blue light. Half of respondents said that they are not familiar with the topic or need more information before discussing it with patients.
In January 2014, the Vision Council released a report that focused on the effects of digital media on the eye health of Americans. It found that “63% of adults do not know that electronics emit high-energy visible or blue light,” highlighting a need for education that optometry could fulfill.
UV and blue light: The basics
Image: Morgan GL
“As far as damage, UV light affects the anterior segment causing skin cancers of the eyelid, pinguecula, pterygium and photokeratitis, and it contributes to cataract formation,” Gary L. Morgan, OD, told Primary Care Optometry News. “However, in developed countries, these are treatable conditions that are rarely sight-threatening. Blue light penetrates to the retina, causing photo-oxidation of retinal pigment epithelium (RPE) cells that, over time, can result in age-related macular degeneration, the leading cause of blindness in those older than 55 years.”
The National Eye Institute reported that there were more than 2 million patients with AMD in the U.S. in 2010. The institute also projected nearly 5.5 million patients with AMD by 2050.
“The most prevalent source of UV and blue light is, of course, the sun. Even the brightest levels of indoor lighting do not approach a fraction of the sun’s luminosity,” Pete Hanlin, LDO, ABOM, said in an interview. “The most common indoor sources of blue light exposure are compact fluorescent lamps (CFLs) and light-emitting diodes (LEDs). CFLs are the ‘screw in’ fluorescent bulbs that are replacing incandescent light bulbs. LEDs are found in virtually every single electronic device that has a screen, such as smartphones and tablets. Although the intensity of light produced from these sources is only a fraction of the sun’s energy, approximately 33% of the light they produce is potentially harmful.”
“Sunlight is the highest for UV light, but high-energy visible (HEV) or blue light is probably highest from computers, tablets, smartphones and video games,” Paul M. Karpecki, OD, FAAO, told PCON. “Contrary to popular belief, the highest risk time of ocular UV and HEV light exposure is not when the sun is high in the sky, which is the highest risk time for dermatological exposure. The highest risk times are in the morning between 8 a.m. and 10 a.m. and then late afternoon between 3 p.m. and 6 p.m. Although there is less direct UV at those times, the angles are more likely to hit directly into the eyes.”
The Beaver Dam Eye Study found a possible association between the incidence of early age-related maculopathy (ARM) and extended exposure to sunlight.
“We found that participants exposed to the summer sun for more than 5 hours a day during their teens, in their 30s and at the baseline examination, were at a higher risk of developing increased retinal pigment and early ARM by 10 years than those exposed less than 2 hours per day during the same periods,” the researchers said. “If cumulative sun exposure is related to the incidence of increased retinal pigment or early ARM, it is hypothetically the effect of exposure to visible rather than UV light.”
Morgan noted that the increasing number of electronic devices and the transition to CFL light bulbs has contributed to the increased interest in blue light
“While exposure to blue light is not new, the amount of exposure time each day has dramatically increased,” he said.
A recent forecast from Cisco found that the number of mobile devices will surpass the Earth’s population by the end of 2014.
“By 2018 there will be nearly 1.4 mobile devices per capita,” Cisco stated. “There will be over 10 billion mobile-connected devices by 2018, including machine-to-machine modules – exceeding the world’s population at that time (7.6 billion).”
“Today, due to the proliferation of electronic devices, kids 8 to 18 years old are spending 7.5 hours per day viewing LED backlit screens,” Morgan said. “Depending on age, these kids have short arms and are holding smartphones and tablets close to their eyes. They have large pupils, allowing more of the blue light emitted to enter their eyes, and they have not developed any significant ocular lens pigment (OLP), allowing blue light to enter at full strength. Will this lead to an earlier incidence of AMD in the future? The answer is unknown.”
What ODs need to know
Hanlin stressed the importance of treating and educating patients regarding the present, noting that patients “do not often appreciate the long-term ramifications of things like UV exposure.”
“Regarding UV light, optometrists need to understand that even though a patient may never present with full-blown photokeratitis, they may routinely experience the discomfort of mild photokeratitis,” Hanlin said. “This is the case even when wearing sun wear because many popular sun lenses reflect large amounts of UV from their back surfaces into the eyes. The antireflective (AR) coating on the back of many popular sun lenses reduces visible reflections to almost 0% but actually intensifies UV reflections from the back surface. Some popular lenses reflect as much as 30% to 50% of UV energy back into the eye.
“Even today, in a time when we are relatively well-informed regarding the risk factors for melanoma, a long-term effect of UV exposure, many people don’t bother with protection from the sun unless they are worried about sunburn, a short-term effect,” he continued. “By educating patients regarding the short-term benefits of protecting the eyes (no scratchy, dry feeling after a day in the sun), optometrists can help their patients look after the long-term health of the eye.”
“Just like there will always been sunburn despite widespread availability of sunscreen, there will always be eye damage due to UV exposure despite widespread availability of UV protective eye wear,” Brian Chou, OD, FAAO, added.
To better serve their patients, all doctors interviewed for this article recommended that their peers educate themselves on blue light in particular, highlighting various resources for education such as online courses, workshops, conference courses and peer-reviewed scientific journals.
“While UV protection is important, as it causes anterior segment injury and disease, these conditions are generally not sight-threatening,” Morgan explained.
“Blue light is an even trickier proposition,” Hanlin said. “The fact is, even when blue light is eventually definitively linked as a contributor to retinal disease, it will remain one among many risk factors, and the damage caused will remain far in the patient’s future. Optometrists need to recognize that today’s patients are being exposed to dramatically increased levels of blue light.”
Discussing light damage with patients
Karpecki said he focuses on specific groups of patients who would most benefit from protection when discussing potential light damage.
“Although patients with AMD, a family history of AMD or those who genetically test as high risk for AMD progression are important to recommend HEV light-blocking lenses to, they are not the only or even largest category that would benefit from them,” he said. “Any patient who uses a computer for more than 2 to 3 hours a day should consider this technology even if they have a plano prescription. Not only does it block the potentially harmful high-energy rays coming from a computer screen, tablet or other PDA, it helps with contrast on the screen and seems to relieve the strain of spending numerous hours on the computer.”
Karpecki also recommends light-blocking lenses for patients who spend extended periods of time playing video games.
“Another group that could benefit greatly are patients who have had cataracts removed,” he continued. “The cataractous crystalline lens served as a blue-blocking lens until it was removed. There are some HEV light-blocking IOLs on the market, but not all IOLs are and, therefore, HEV light-blocking technologies in a prescription lens should be considered.”
While some doctors stress discussions with at-risk patients, many of the doctors who spoke with PCON felt that it is appropriate to discuss the dangers of UV and blue light with all patients.
“For children, I engage parents in the discussion on their child’s electronic device usage,” Morgan said. “In our area, many schools are using textbooks on tablet computers, and many kids are now carrying smartphones. This constant blue light exposure, while inflicting long-term damage to the retina, can also affect our ability to fall asleep. Exposure to these wavelengths after dark will affect our internal clock, causing the pineal gland to suppress the excretion of melatonin, our sleep hormone.
“Electronic device usage along with CFL lighting is affecting our circadian rhythm, giving the sense of constant daylight,” he continued. “In kids, this can lead to loss of focus and concentration, irritability and hyperactivity, sometimes being mistaken for symptoms of attention deficit-hyperactivity disorder. It has also been shown that sleep disturbance in adults can lead to chronic conditions such as diabetes, obesity, heart disease, depression, stroke and cancer.
“As a profession, we need to take the time to educate patients on the dangers of blue light and offer effective solutions for protection,” Morgan added.
Technologies for protection
Treatments that offer protection against UV and blue light have recently proliferated and include AR coatings, HEV coatings and color filters. Many doctors suggested utilizing Essilor’s Crizal Prevencia or Eye Solution Technologies’ BluTech lenses to protect eyes against light.
“Transitions 7 (Essilor) photochromic is an excellent everyday lens feature that offers full UV protection,” Chou told PCON. “For sunglasses, I recommend polycarbonate or high index with polarization and back-surface AR treatment. For patients that specifically want blue-blocking lenses in addition to full UV protection, BluTech Lenses are suitable. There are also several proprietary AR treatments that have blue-blocking properties, including Crizal Prevencia, SeeCoat Blue (Nikon) and Recharge (Hoya).”
Hanlin lauded the use of Crizal UV lenses, which help reduce reflection of UV from the ocular surface.
Morgan said: “For all patients I recommend the use of blue light-filtering lenses. In particular, I recommend BluTech Lenses, as they contain OLP, the eye’s natural protective mechanism. It is important to note that OLP does not start to form until about age 40, with full protection afforded from OLP at about age 70, after which it is known as a cataract and is removed. BluTech lenses filter the majority of blue light along the entire blue light spectrum, 400 nm to 500 nm, as well as 100% of UV. I especially recommend these for digital device usage.”
Morgan said that such lenses should be considered mandatory safety eye wear, just as factory workers are required to wear eye protection.
“We routinely dispense plano BluTech lenses for those not requiring an Rx (including children and post-cataract patients) as well as contact lens wearers,” he added.
Morgan noted that his patients have shared positive responses after wearing these lenses.
“They report having less eye strain and fatigue at the end of the day,” he said. “This is likely due to the fact that blue light is myopically defocused in front of the retina (chromatic aberration), and the macula only contains 2% of blue photoreceptors and the fovea has none. By filtering out blue light, the eyes feel more relaxed at the end of the day. I have also had patients tell me they feel they can fall asleep easier at night after wearing the lenses for evening computer and digital device use.”
What the future holds
With the forecast of increased exposure to blue light, the opportunity exists to protect patients, our sources said.
“The opportunity to make a difference in our patients’ lives comes in the form of blue light education,” Morgan said. “While this takes a bit of extra time simply due to lack of awareness, this is changing. Over the past year, there have been numerous media reports on the dangers that blue light emitted from electronic screens poses. Many patients are now coming in with a basic understanding of the dangers of blue light and have questions on this. Offering blue light protective solutions is certainly in our patients’ best interest, and doing so will be beneficial for our practices.”
Hanlin also observed that aging patients will affect how optometrists address light exposure in the future.
“The incidence of cataracts and AMD will only continue to rise – cataract-related procedures are currently the most common surgeries in the U.S.,” Hanlin explained. “As time goes on, clinical awareness will continue to rise concerning the long-term hazards of UV and, most likely, blue light. Eventually, like Australia, the U.S. will probably have some legislative mandate regarding UV protection, if only to control the cost to the health care system. With blue light, today’s research will provide more data, allowing practitioners to develop plans of care designed to protect the retina.”
“Today with BluTech Lenses you incorporate both blue light and UV protection into one eyeglass lens,” Jeff Morris, MD, MPH, told PCON. “Since we have now identified this natural light protection called OLP, I would suspect in the future there will be variations of this in different formats, which will make a huge impact. The data would support that the ratio used, when combined with other things, makes all of the difference when it comes to patient vision and light protection. Now that we know we can impregnate [the protection] into an eyeglass lens, this is a game changer for medical care through eyeglasses.”
Danny Clarke, OD, reiterated that optometry has a responsibility to educate and protect patients when it comes to blue light.
“In our industry we have done a great job of stressing the importance of UV,” Clarke told PCON. “To be fair, this has been overdone in that we have given patients a false sense of security now that we are in the digital age. Blue light is the main concern in this day and age.” – by Chelsea Frajerman