Original Article

Association of screen time, quality of sleep and dry eye in college‑going

women of Northern India

Parul Chawla Gupta, Minakshi Rana1, Mamta Ratti2, Mona Duggal, Aniruddha Agarwal3, Surbhi Khurana,
Deepak Jugran, Nisha Bhargava4, Jagat Ram

Purpose: To evaluate the association of daily screen time and quality of sleep with the prevalence of dry eye Access this article online
among college‑going women. Methods: This study was a cross‑sectional, comparative questionnaire‑based Website:
study of 547 college‑going women in northern India. A 10‑item Mini Sleep Questionnaire was used to www.ijo.in
check the quality of sleep, and the Standard Patient Evaluation of Eye Dryness (SPEED) scale was used to DOI:
examine the prevalence of dry eye among college‑going women. Results: Multinomial logistic regression 10.4103/ijo.IJO_1691_21
showed a significant association between dry eye with daily screen time spent (P < 0.05) and the quality PMID:
*****
of sleep (P < 0.05) among college‑going girls. Using Latent Class Analysis, two latent classes were selected
based on the Bayesian Information Criteria. It was found that the majority population falls in class two and Quick Response Code:
was having Severe Sleep‑Wake difficulty. It was seen that the participants in class two belonged to the age
bracket of 18–21 years, were from stream Humanities, education of father and mother equal to graduation,
father working only, belonging to the nuclear family, having one sibling, hailing from the urban locality,
spending more than 6 h daily on‑screen, a majority of them using mobile phones, not using eye lubricants,
and reported an increase in screen time during COVID‑19. Conclusion: Dry eye and sleep quality are
essential global health issues, and coupled with increased screen time, may pose a challenge in the present
era. Preventive strategies need to be incorporated in school and college curriculums to promote physical,
social, and psychological well‑being and quality of life.

Key words: Computer vision syndrome, digital eye strain, Latent Class Analysis, Mini Sleep Questionnaire,
SPEED questionnaire

Computer vision syndrome has a prevalence of more than 50% is a facilitator of sleep.[3,4] Computer‑associated symptoms
among computer users.[1] An increase in websites and societal have been divided into two groups: those associated with the
groups has enticed the youth to devote additional time to digital accommodation (blurring of vision while refocusing, headache,
devices or computer monitor screens. Online education and eye strain) and those linked to dry eyes (burning, grittiness,
entertainment platforms for gaming and movies are prevalent tearing, and dryness).[5] Dry eye from digital media use is
since the last decade. Consequently, there has been a constant produced due to decreased and incomplete blinks leading to
upsurge in screen time for the youth in many countries.[1] an unstable tear film.[6]
Several studies in the past have found an association Digital device use has increased during the COVID‑19
between increased multimedia exposure and health issues. pandemic as people were compelled to stay homebound,
While there is substantial public understanding of the harmful especially during nationwide lockdowns, to safeguard themselves
effects of cellphone radiation, society is less aware of the from the deadly virus.[7] The main objective of this survey was
additional consequences of increased screen time on well‑being, to examine the association of daily screen time and the quality
leading to stress on the visual and musculoskeletal system, of sleep with the prevalence of dry eye among college‑going
besides leading to circadian rhythm disturbances. women. Women were chosen as respondents in our study due
to the higher prevalence of dry eye disease in females.[7–11]
Circadian rhythm disturbances are due to the blue light
emitted by these devices and the electromagnetic fields they Methods
produce.[2] Blue light leads to melatonin suppression which
The study was an exploratory and cross‑sectional, comparative
questionnaire‑based study. The study was approved by the
Advanced Eye Centre, Post Graduate Institute of Medical Education
and Research, 1Department of Sociology, Mehr Chand Mahajan
DAV College for Women, 2Department of Commerce, Mehr Chand This is an open access journal, and articles are distributed under the terms of
Mahajan DAV College for Women, Chandigarh, India, 3Department the Creative Commons Attribution‑NonCommercial‑ShareAlike 4.0 License,
of Ophthalmology, Eye Institute, Cleveland Clinic, Abu Dhabi, which allows others to remix, tweak, and build upon the work non‑commercially,
as long as appropriate credit is given and the new creations are licensed under
UAE, 4Principal, Mehr Chand Mahajan DAV College for Women,
the identical terms.
Chandigarh, India
Correspondence to: Prof. Jagat Ram, Advanced Eye Centre, Post For reprints contact: WKHLRPMedknow_reprints@wolterskluwer.com
Graduate Institute of Medical Education and Research, Chandigarh,
India. E‑mail: drjagatram@gmail.com Cite this article as: Gupta PC, Rana M, Ratti M, Duggal M, Agarwal A,
Received: 20-Jun-2021 Revision: 22-Aug-2021 Khurana S, et al. Association of screen time, quality of sleep and dry eye in
college‑going women of Northern India. Indian J Ophthalmol 2022;70:51-8.
Accepted: 26-Aug-2021 Published: 23-Dec-2021

© 2021 Indian Journal of Ophthalmology | Published by Wolters Kluwer - Medknow

52 Indian Journal of Ophthalmology Volume 70 Issue 1

Institutional Ethics Committee and adhered to the tenets of more Sleep‑Wake problems and frequency and severity of dry
the Helsinki Declaration. A pre‑structured and pre‑validated symptoms.
questionnaire was used to collect information on the prevalence
For each respondent, the sum of the responses for each
of dry eye and quality of sleep. With the help of the snowball
domain was added and divided into categories. For the
technique, the primary respondents, i.e., college‑going girls in
Sleep‑Wake Domain, the respondents were divided into
northern India, were contacted. The questionnaire was transcribed
four categories[16]: 10–24 points for Good Sleep‑Wake quality;
into a Google Form and provided to the participants through
25–27 points for mild Sleep‑Wake difficulties; 28–30 points for
WhatsApp or Email. The survey was reported according to the
moderate Sleep‑Wake difficulties; and >30 points for Severe
Checklist for Reporting of Internet E‑surveys (CHERRIES).[12]
Sleep‑Wake difficulties. For the Dry Eye Domain, based on
Informed consent was obtained from the participants preceding
the score of the items on severity and frequency of the dry
the study. Anonymity and confidentiality were maintained
eye symptoms, the respondents were divided into three
throughout the study. A 10‑item Mini Sleep Questionnaire was
categories[14,17]: 0–5 (no symptoms), 6–14 (mild to moderate
used to check the quality of sleep,[13] and the Standard Patient
symptoms), and 15–28 (severe symptoms).
Evaluation of Eye Dryness (SPEED)[14] dry eye scale was used to
examine the prevalence of dry eye among college‑going women. Development of dry eye assessment model
A few general questions were asked to review the screen time of We established a multinomial logistic regression model for
the respondents. The reliability/consistency of the questionnaire the prediction of the association of dry eye with daily screen
was checked using Cronbach alpha. For the Mini Sleep Scale and time spent and the quality of sleep following the methodology
dry eye scale, the Cronbach alpha was found to be 0.780 and described in the statistical analysis of the study.
0.867, respectively, which indicates a good internal consistency
and reliability. Hair et al. 2006[15] proposed that Cronbach alpha Development of latent class models to identify the hidden
coefficient of 0.6 is acceptable, and it indicates internal reliability cohort
and consistency. We followed the methodology of the development of latent
class described by Kumar‑M et al. [18] It consisted of five
The questionnaire contains five domains
steps: (1) selection of questions based on univariate analysis; (2)
Demographic domain: This consisted of the demographic and removal of questions with overlapping context; (3) addition
socioeconomic details of the participants, namely age (18–21, of the selected questions to develop latent class model; (4)
22–26, and 27–30 years); stream (Humanities, Science, and back exploration of the established latent class model for
Commerce); education pursued to date (up to 12th, under understanding the demographic pattern of the developed latent
graduation, post‑graduation); education of the father (illiterate, class model; (5) repetition of the process till a distinctive pattern
up to 10th, up to 12th, graduate, post‑graduate, doctorate/any is obtained.[18] Further, the number of hidden classes was
other); education of the mother (illiterate, up to 10th, up to identified after assessing the model diagnostics of the different
12th, graduate, post‑graduate, doctorate/any other); working number of classes. The Bayesian Information Criteria (BIC)
status of parents (both working, only father working, only was utilized for appraisal. The smaller the BIC, the superior
mother working); type of family (joint, nuclear [only parents the model.
and child]); the number of sibling (s) in the family (1, 2, 3, and
more than 3); place of residence (urban, rural). Statistical analysis
A total of 547 respondents participated in the study. The
General question domain: This consisted of the following
data were recorded into an Excel sheet and analyzed using
questions: Your daily screen time in the number of hours (0–2 h,
SPSS Version 20 and R version 4.0.4. In addition to the base
2–4 h, 4–6 h, and more than 6 h); Device on which maximum
package, the additional package used was gtsummary,[19]
time spent (television, laptop/desktop, mobile phone and
plyr,[20] readxl,[21] and poLCA[22] for conducting the Latent
tablet/iPad); Mention the purpose of use of screen most of the
Class Analysis. The categorical variables were defined using
time (social media, studies, movies, and gaming); Has your
frequencies along with percentages. For the evaluation of
screen time increased during the COVID‑19 pandemic? (Yes
continuous variables between more than two groups, the
and No); If Yes, then by how much? (25, 25–50, 50–75, and
Analysis of Variance was used, and for the comparison of
75–100%); Do you use eye drops for lubrication? (Yes and No).
categorical variables, the Chi‑square test of association/Fisher’s
Sleep‑Wake Domain: The Mini Sleep Questionnaire consists of exact test was used. A P value of less than 0.05 was considered
10 items based on the 7‑Point Likert Scale: difficulty falling asleep, statistically significant for all the tests.
waking up too early, hypnotic medication use, falling asleep
during the day, feeling tired upon waking up in the morning, Results
snoring, mid‑sleep awakenings, headaches on awakening, In the present study, a total of 547 college‑going girls in
excessive daytime sleepiness, excessive movement during sleep. northern India agreed to participate. The overall demographic
Dry Eye Domain: This domain consisted of the following profile of the participants is shown in Table 1. The major
items based on the SPEED questionnaire: frequency and characteristics of the participants were ages between 18 and
severity of dryness, grittiness, or scratchiness, soreness or 21 years (81.4%), a majority of the participants were from the
irritation, burning or watering, and eye fatigue symptoms Humanities stream (63.4%), studied up to graduation (79.7%),
the education of father equal to graduation (36.9%), the
Creation of categories based on the grading of responses to education of mother equal to graduation (34.4%), having one
the Sleep‑Wake Domain and Dry Eye Domain sibling (57.4%), only father working (68.7%), hailing from the
The responses to the Sleep‑Wake Domain and Dry Eye Domain urban locality (79.7%), belonging to the nuclear family (60.3%),
were graded to give a higher score for the options indicating spending more than 6 h daily on‑screen (45.5%).
January 2022 Gupta, et al.: Screen time, sleep and dry eye in college-going women 53

Table 1: Description of demographics for overall and comparison of demographics between Sleep‑Wake Domain and Dry
Eyes domain
Characteristics Overall* Sleep‑Wake Dry Eyes domain
Domain P P
Count=547 Percent
Age 18‑21 years 445 81.40% 0.240*** 0.925***
22‑26 years 99 18.10%
27‑30 years 3 0.50%
Stream Humanities 347 63.40% 0.3002** 0.409**
Sciences 109 19.90%
Commerce 91 16.60%
Class Up to 12th 5 0.90% 0.1028** Fisher’s 0.8409** Fisher’s
Graduate 436 79.70% exact test exact test
Post‑graduate 106 19.40%
Education of Illiterate 11 2.00% 0.00278** Fisher’s 0.047**
father Up to 10th 37 6.80% exact test
Up to 12th 96 17.60%
Graduate 202 36.90%
Post‑graduate 154 28.20%
Doctorate/any other 47 8.60%
Education of Illiterate 17 3.10% 0.09916** Fisher’s 0.144**
mother Up to 10th 56 10.20% exact test
Up to 12th 103 18.80%
Graduate 188 34.40%
Post‑graduate 157 28.70%
Doctorate/any other 26 4.80%
Working status Both working 160 29.30% 0.08885** Fisher’s 0.8768** Fisher’s
of parents Only father working 376 68.70% exact test exact test
Only mother working 11 2.00%
Type of family Joint 217 39.70% 0.486** 0.611**
Nuclear (only parents and child) 330 60.30%
No. of siblings 1 314 57.40% 0.169** 0.623**
2 152 27.80%
3 60 11.00%
More than 3 21 3.80%
Place of Urban 436 79.70% 0.033** 0.366**
residence Rural 111 20.30%
No. of hours 0 to 2 h 21 3.80% 0.000*** 0.000***
daily time 2 to 4 h 95 17.40%
4 to 6 h 182 33.30%
More than 6 h 249 45.50%
*Statistics presented: n (%). **Statistical tests performed: Chi‑square test of independence; Fisher’s exact test. ***Statistical tests performed: Analysis of Variance

Among the demographic factors for the Sleep‑Wake Sleep‑Wake difficulty, Moderate Sleep‑Wake difficulty, Severe
Domain, education of father, place of residence, and the number Sleep‑Wake difficulty in the Sleep‑Wake Domain and no
of hours daily spent on‑screen came as significant predictors symptoms, mild to moderate symptoms, severe symptoms in
in the univariate analysis. Similarly, among the demographic the dry eyes domain are shown in Table 2.
factors for the dry eye domain, the education of the father and
Multinomial logistic regression was applied for the
the number of hours daily spent on‑screen came as significant
prediction of the association of the dry eye with the daily screen
predictors in the univariate analysis.
time spent and the quality of sleep among the respondents.
The questionnaire provided to the girls is given in As per the results, there was a significant association between
Supplementary Table 1, and the summary of the responses for dry eye with the daily screen time spent (P value = 0.00 <0.05)
individual questions for Sleep‑Wake and dry eye domain are and the quality of sleep/Sleep‑Wake (P value = 0.00 <0.05)
presented in Supplementary Table 2. The univariate analysis among college‑going women. Further, the power of the logistic
of the responses based on the Good Sleep‑wake quality, Mild multinomial model developed in the study was 58.86% of the
54 Indian Journal of Ophthalmology Volume 70 Issue 1

known observations and can be likely to design forthcoming Domain (having Good Sleep‑wake quality, Mild Sleep‑Wake
estimations [Table 3]. difficulty, Moderate Sleep‑Wake difficulty, Severe Sleep‑Wake
difficulty) [Table 4]. Further, it was found that the majority of the
With the help of the Latent Class Analysis, two latent classes population falls in class two and was having Severe Sleep‑Wake
were selected based on the BIC, where there was a significant difficulty. On further exploring the characteristics between
difference between the two classes based on the Sleep‑Wake the two classes, it was found that the participants in class two

Table 2: Description of responses for General Domain and comparison of responses between Sleep‑Wake Domain and
Dry Eyes Domain
Statements Responses Overall* Sleep‑Wake Dry Eyes
Domain P Domain P
Count=547 Percent
Device on which Television 17 3.10% 0.7844** Fisher’s 0.01053**
maximum time Laptop/Desktop 97 17.70% exact test Fisher’s exact test
spent
Mobile Phone 425 77.70%
Tablet/iPad 8 1.50%
Purpose Social media 160 29.30% 0.02427** 0.021**
Studies 333 60.90% Fisher’s exact test
Movies 38 6.90%
Gaming 16 2.90%
Increase in No 30 5.50% 0.000** Fisher’s 0.001**
screen time Yes 517 94.50% exact test
How much 25% 58 11.20% 0.000** 0.001**
increase 25‑50% 153 29.70%
50‑75% 222 43.00%
75‑100% 83 16.10%
Use of eye drops No 449 82.10% 0.853** 0.000**
Yes 98 17.90%
Dry eyes system No symptom reported 70 12.80% 0.000** 0.000**
reported Symptoms reported 477 87.20%
Sleep‑wake Good Sleep‑Wake quality 110 20.1% 0.00**
Mild Sleep‑Wake difficulty 48 8.8%
Moderate Sleep‑Wake difficulty 55 10.1%
Severe Sleep‑Wake difficulty 334 61.1%
Dry eye Mild dry eye 130 23.8% 0.00**
Moderate dry eye 94 17.2%
Severe dry eye 323 59.0%
*Statistics presented: n (%). **Statistical tests performed: Chi‑square test of independence; Fisher’s exact test

Table 3a: Association of dry eye with number of hours spent on screen and quality of sleep (sleep-wake)
Effect Model Fitting Criteria Likelihood Ratio Tests

‑2 Log Likelihood of Reduced Model Chi‑square df Sig.

Intercept 119.719 a
0.000 0
No. of hours daily time 136.908 17.189 2 0.000
Sleep‑wake 188.741 69.021 6 0.000

Table 3b: Classification of dry eye based on the developed regression model
Observed Predicted

No Symptoms Mild to Moderate Symptoms Severe Symptoms Percent Correct

No symptoms 127 91 0 58.3%
Mild to moderate symptoms 63 195 0 75.6%
Severe symptoms 6 65 0 0.0%
Overall percentage 35.8% 64.2% 0.0% 58.9%
January 2022 Gupta, et al.: Screen time, sleep and dry eye in college-going women 55

Table 4: Descriptive characteristics of the selected model

Characteristics Class 1* Class 2* P**

Count=267 Percent Count=280 Percent

Age 18‑21 years 206 77.15 239 85.36 0.02536 Fisher’s
22‑26 years 59 22.1 40 14.29 exact test
27‑30 years 2 0.749 1 0.357
Stream Humanities 164 61.42 183 65.36 0.01005
Sciences 46 17.23 63 22.5
Commerce 57 21.35 34 12.14
Class Up to 12th 2 0.749 3 1.071 0.697
Graduate 210 78.65 226 80.71
Post‑graduate 55 20.6 51 18.21
Education of father Illiterate 10 3.745 1 0.357 0.00
Up to 10th 37 13.86 0 0
Up to 12th 94 35.21 2 0.714
Graduate 113 42.32 89 31.79
Post‑graduate 12 4.494 142 50.71
Doctorate/any other 1 0.375 46 16.43
Education of mother Illiterate 17 6.367 0 0 0.00
Up to 10th 56 20.97 0 0
Up to 12th 98 36.7 5 1.786
Graduate 90 33.71 98 35
Post‑graduate 6 2.247 151 53.93
Doctorate/any other 0 0 26 9.286
Working status of Both working 28 10.49 132 47.14 0.00
parents Only father working 233 87.27 143 51.07
Only mother working 6 2.247 5 1.786
Type of family Joint 129 48.31 88 31.43 0.00
Nuclear (only parents and child) 138 51.69 192 68.57
No of siblings 1 119 44.57 195 69.64 0.00
2 88 32.96 64 22.86
3 42 15.73 18 6.429
More 18 6.742 3 1.071
Place of residence Urban 178 66.67 258 92.14 0.00
Rural 89 33.33 22 7.857
No of hours daily time 0‑2 h 15 5.618 6 2.143 0.001841
2‑4 h 58 21.72 37 13.21
4‑6 h 90 33.71 92 32.86
More than 6 h 104 38.95 145 51.79
Device on which Television 13 4.869 4 1.429 0.00
maximum time spent Laptop/Desktop 30 11.24 67 23.93
Mobile Phone 224 83.9 201 71.79
Tablet/iPad 0 0 8 2.857
Purpose Social media 82 30.71 78 27.86 0.07754
Studies 161 60.3 172 61.43
Movies 21 7.865 17 6.071
Gaming 3 1.124 13 4.643
Increase in screen No 22 8.24 8 2.857 0.009996
time Yes 245 91.76 272 97.14
Use of eye drops No 230 86.14 219 78.21 0.02115
Yes 37 13.86 61 21.79

Contd...
56 Indian Journal of Ophthalmology Volume 70 Issue 1

Table 4: Contd...
Characteristics Class 1* Class 2* P**

Count=267 Percent Count=280 Percent

Sleep‑wake Good Sleep‑wake quality 57 21.35 53 18.93 0.005743
Mild Sleep‑Wake difficulty 28 10.49 20 7.143
Moderate Sleep‑Wake difficulty 15 5.618 40 14.29
Severe Sleep‑Wake difficulty 167 62.55 167 59.64
Dry Eye Mild dry eye 103 38.58 115 41.07 0.6818
Moderate dry eye 131 49.06 127 45.36
Severe dry eye 33 12.36 38 13.57

belonged to the age bracket of 18–21 years, a majority of them eye disease or ocular surface pathology were included.
were from the Humanities stream, education of father and A statistically significant escalation in the dry eye disease
mother equal to graduation, only father working, belonging to symptom score and the prevalence of computer vision
the nuclear family, having one sibling, hailing from the urban syndrome symptoms with increasing duration of use and daily
locality, spending more than 6 h daily on‑screen, a majority exposure to smartphones was found.[32]
of them using mobile phones, not using eye lubricants, and
reported an increase in screen time during COVID‑19. Most importantly, 65.61% of the women who reported dry
eye symptoms had Severe Sleep‑Wake difficulties. In some
Discussion studies, it is anticipated that more than 40% of people with dry
eye have sleep disorders.[33,34] In a questionnaire‑based study
Increased digital device use for professional and social of 3,070 participants, the subjects with sleep anomalies had
causes is considered a new normal these days. Studies have an augmented probability of dry eye severity.[35] Lee et al.[36]
documented that odds of an unhealthy lifestyle and subjective demonstrated that lack of sleep increased the tear osmolarity,
complaints increase with the use of electronic media beyond reduced the tear film break‑up time, and lessened the tear
1 h.[23] These ill effects on the health/lifestyle include depression secretions, each one of which independently triggered or
and anxiety,[24] sedentary behavior and obesity,[25] headache, exacerbated the ocular surface disease. Sleep ailments have a
neck/shoulder pain, backache,[1,26,27] shorter sleep duration,[28] propensity to be linked with autonomic dysfunction that affects
and dry eye.[27] the parasympathetic fibers in the lacrimal glands, resulting in
In our study, out of the 547 total respondents, 425 decreased tear secretions. Sleep loss generates a buildup of lipids
respondents (77.7%) were spending maximum time on mobile and lacrimal gland dysfunction. It decreases endogenous lipid
phones, and out of these, 47.06% of the respondents were facing palmitoylethanolamide (PEA) expression in the lacrimal glands
mild‑moderate dry eyes symptoms. The purpose of screen use which are responsible for the homeostasis of lipid metabolism.[37]
for 60.9% of the total respondents was studying. However, Sleep helps in memory consolidation.[38] Sleep deprivation
66.37% of these respondents were facing Severe Sleep‑Wake and poor sleep quality can pose a challenge to college students
difficulties. Moreover, 94.5% of the participants mentioned and can lead to lesser academic scores, impaired learning, and
that their screen time had increased during the COVID‑19 an augmented menace of vehicular accidents.[39] According to
pandemic, and out of these, 63.24% reported Severe Sleep‑Wake a study in Korea, individuals having a sleeping length lesser
difficulties, and 48.16% were having mild‑moderate dry eyes than 5 h were found to have 20% increased chances of suffering
symptoms. In a recent review, 90% of the studies found an from dry eye in comparison to those people with more than
association between screen use and late bedtime and/or 6 h of sleep duration.[40]
diminished total sleep time.[28] The prevalence of poor sleep
quality was 37.94% among 5,233 Chinese college students in We need to focus on sleep‑friendly screen‑behavior
another study. High screen time and less physical activity recommendations for the youths worldwide. These include
were significantly associated with suboptimal physiological, limiting screen time to 30–60 min before bedtime, restricting
psychological/mental, social health, and poor sleep quality.[29,30] all digital devices from the bedrooms, and avoiding snacking
A greater screen time has been significantly associated with on fast foods and sugars.[28,31] Dry eyes associated with digital
an increased dietary intake of sugary drinks, fast foods, and device use need to be addressed by promoting complete,
bakery items.[31] frequent, and forceful blinks, which can help release lipids
from the meibomian gland leading to amelioration of the
In our study, for 43% of the participants, the screen time
evaporative dry eye. Preservative‑free lubricant eye drops
had reportedly increased during COVID‑19 by 50–75%. Bahkir
and proper screen positioning of 4–5 inches below eye level to
et al.[7] reported an average increase of screen time by 5 h during
decrease ocular surface evaporation can be employed. Frequent
the pandemic in 51.1% of their study respondents.
pauses during screen use using customized Apps[41] or the
Further, in our analysis, 87.2% of the participants mentioned 20‑20‑20 rule (to focus on a distance of 20 feet every 20 min for
dry eye symptoms, and out of these, 53.24 and 14.46% were 20 s), utilizing small plus powered computer glasses to relax
facing mild/moderate dry eyes and severe dry symptoms, accommodation are other modalities to lessen eye strain. To
respectively. In another study, 94 medical students using minimize the circadian rhythm disturbances affecting sleep,
smartphones for over a year and without pre‑existing dry blue light filtering (yellow tinted) glasses can be worn.[1,42]
January 2022 Gupta, et al.: Screen time, sleep and dry eye in college-going women 57

The strength of our study lies in the fact that this is the first Gupta PK. Dry eye disease: Consideration for women’s health.
largest single‑gender community‑based study evaluating the J Womens Health 2019;28:502–14.
connection between screen time, sleep quality, and dry eye, as 11. Shah S, Jani H. Prevalence and associated factors of dry eye: Our
well as multiple elements of sleep quality with a high response experience in patients above 40 years of age at a Tertiary Care
rate. The self‑reported assessment of symptoms and quality Center. Oman J Ophthalmol 2015;8:151-6.
through questionnaires may be considered complementary 12. Eysenbach G. Improving the quality of web surveys: The Checklist
to objective examination findings documented in other for Reporting Results of Internet E‑Surveys (CHERRIES). J Med
studies. Moreover, we focused on the life quality and the Internet Res 2004;6:e34.
self‑assessment of the disease variables themselves, which 13. V, I., J, S., & O, C. (2018). A survey on sleep assessment methods.
might have more weightage than clinical evaluations. PeerJ, 6(5). https://doi.org/10.7717/PEERJ.4849.
14. Ngo W, Situ P, Keir N, Korb D, Blackie C, Simpson T. Psychometric
The limitations of our study include the following: first, the
properties and validation of the standard patient evaluation of eye
cross‑sectional nature of our study limits the establishment dryness questionnaire. Cornea 2013;32:1204–10.
of a temporal relation between screen time, sleep, and dry
15. Hair JF, Black WC, Babin BJ, Anderson RE, Tatham RL.Multivariate
eye. Second, recall and misclassification bias is possible
data analysis (Vol. 6). Upper Saddle River, NJ: Pearson Prentice
in questionnaire‑based studies. Third, snowballing being Hall 2006.
a non‑random sampling technique of data collection, can
16. Natale V, Fabbri M, Tonetti L, Martoni M. Psychometric goodness
contribute to selection/sampling bias as new participants may of the Mini Sleep Questionnaire. Psychiatry and Clinical
be recruited from their circle of acquaintances.[43] Neurosciences 2014;68:568-73.

Conclusion 17. Asiedu K. Rasch Analysis of the standard patient evaluation of eye
dryness questionnaire. Eye Contact Lens 2017;43:394–8.
To conclude, dry eye and sleep quality are essential global 18. Kumar MP, Mahajan R, Kathirvel S, Hegde N, Kakkar AK, Patil AN.
health issues, and coupled with increased screen time, may Developing a Latent Class Analysis model to identify at‑risk
pose a challenge in the present era. Preventive strategies populations among people using medicine without prescription.
need to be incorporated in school and college curriculums to Expert Rev Clin Pharmacol 2020;13:1411–22.
promote physical, social, and psychological well‑being and 19. Sjoberg DD, Curry M, Hannum M, Larmarange J, Whiting K,
quality of life. Zabor EC, et al. gtsummary: Presentation‑ready data summary and
analytic result tables. 2021. Available from: https://CRAN.R‑project.
Financial support and sponsorship org/package=gtsummary. [Last accessed on 2021 Apr 18].
Nil. 20. Wickham H. The split‑apply‑combine strategy for data analysis.
J Stat Softw 2011;40:1–29.
Conflicts of interest
21. Wickham HBJ (n.d.). Copyright holder of all R code and all C
There are no conflicts of interest.
code without explicit copyright, et al. Readxl: Read Excel Files.
2019. Retrieved November 28, 2020, from https://cran.r-project.
References org/package=readxl.
1. Sheppard AL, Wolffsohn JS. Digital eye strain: Prevalence, 22. Beath KJ. randomLCA: An R package for latent class with random
measurement and amelioration. BMJ Open Ophthalmol effects analysis. J Stat Softw 2017;81:1–25.
2018;3:e000146.
23. Mundy LK, Canterford L, Hoq M, Olds T, Moreno‑Betancur M,
2. Patil A, Bhavya, Chaudhury S, Srivastava S. Eyeing computer vision Sawyer S, et al. Electronic media use and academic performance in
syndrome: Awareness, knowledge, and its impact on sleep quality late childhood: A longitudinal study. PLoS One 2020;15:e0237908.
among medical students. Ind Psychiatry J 2019;28:68–74.
24. Zink J, Belcher BR, Imm K, Leventhal AM. The relationship between
3. Cajochen C, Kräuchi K, Wirz‑Justice A. Role of melatonin screen‑based sedentary behaviors and symptoms of depression
in the regulation of human circadian rhythms and sleep. and anxiety in youth: A systematic review of moderating variables.
J Neuroendocrinol 2003;15:432–7. BMC Public Health 2020;20:472.
4. Figueiro MG, Wood B, Plitnick B, Rea MS. The impact of light from 25. Mitchell JA, Rodriguez D, Schmitz KH, Audrain‑McGovern J.
computer monitors on melatonin levels in college students. Neuro Greater screen time is associated with adolescent obesity:
Endocrinol Lett 2011;32:158–63. A longitudinal study of the BMI distribution from ages 14 to 18.
5. Sheedy JE, Hayes JN, Engle J. Is all asthenopia the same? Optom Obes Silver Spring Md 2013;21:572–5.
Vis Sci Off Publ Am Acad Optom 2003;80:732–9. 26. Wong CW, Tsai A, Jonas JB, Ohno‑Matsui K, Chen J, Ang M, et al.
6. Hirota M, Uozato H, Kawamorita T, Shibata Y, Yamamoto S. Digital screen time during the COVID‑19 pandemic: Risk for a
Effect of incomplete blinking on tear film stability. Optom Vis Sci further myopia boom? Am J Ophthalmol 2021;223:333–7.
2013;90:650–7.
27. Portello JK, Rosenfield M, Bababekova Y, Estrada JM, Leon A.
7. Bahkir F, Grandee S. Impact of the COVID‑19 lockdown on Computer‑related visual symptoms in office workers. Ophthalmic
digital device‑related ocular health. Indian J Ophthalmol Physiol Opt J Br Coll Ophthalmic Opt Optom 2012;32:375–82.
2020;68:2378‑83.
28. Hale L, Kirschen GW, LeBourgeois MK, Gradisar M, Garrison MM,
8. Guillon M, Maïssa C. Tear film evaporation‑‑effect of age and Montgomery‑Downs H, et al. Youth screen media habits and sleep:
gender. Contact Lens Anterior Eye J Br Contact Lens Assoc Sleep‑friendly screen behavior recommendations for clinicians,
2010;33:171–5. educators, and parents. Child Adolesc Psychiatr Clin N Am
9. Courtin R, Pereira B, Naughton G, Chamoux A, Chiambaretta F, 2018;27:229–45.
Lanhers C, et al. Prevalence of dry eye disease in visual display 29. Ma C, Zhou L, Xu W, Ma S, Wang Y. Associations of physical
terminal workers: A systematic review and meta‑analysis. BMJ activity and screen time with suboptimal health status and sleep
Open 2016;6:e009675. quality among Chinese college freshmen: A cross‑sectional study.
10. Matossian C, McDonald M, Donaldson KE, Nichols KK, MacIver S, PLoS One 2020;15:e0239429.
58 Indian Journal of Ophthalmology Volume 70 Issue 1

30. Wu X, Tao S, Zhang Y, Zhang S, Tao F. Low physical activity and 37. C h e n Q , J i C , Z h e n g R , Ya n g L , R e n J , L i Y, e t a l .
high screen time can increase the risks of mental health problems N‑palmitoylethanolamine maintains local lipid homeostasis
and poor sleep quality among Chinese college students. PLoS One to relieve sleep deprivation‑induced dry eye syndrome. Front
2015;10:e0119607. Pharmacol 2019;10:1622.
31. Al‑Hazzaa HM, Al‑Sobayel HI, Abahussain NA, Qahwaji DM, 38. Hennies N, Lambon Ralph MA, Kempkes M, Cousins JN,
Alahmadi MA, Musaiger AO. Association of dietary habits with Lewis PA. Sleep spindle density predicts the effect of prior
levels of physical activity and screen time among adolescents living knowledge on memory consolidation. J Neurosci Off J Soc Neurosci
in Saudi Arabia. J Hum Nutr Diet 2014;27(Suppl 2):204–13. 2016;36:3799–810.
32. Faruqui S, Agarwal R, Kumar R. A study of the correlation between 39. Hershner SD, Chervin RD. Causes and consequences of sleepiness
smartphone usage and dry eye in medical students at a tertiary
among college students. Nat Sci Sleep 2014;6:73–84.
care center. Trop J Ophthalmol Otolaryngol 2020;5:174‑82.
40. Lee W, Lim S‑S, Won J‑U, Roh J, Lee J‑H, Seok H, et al. The
33. Kawashima M, Uchino M, Yokoi N, Uchino Y, Dogru M, Komuro A,
association between sleep duration and dry eye syndrome among
et al. The association of sleep quality with dry eye disease: The
Korean adults. Sleep Med 2015;16:1327–31.
Osaka study. Clin Ophthalmol Auckl NZ 2016;10:1015–21.
34. Ayaki M, Kawashima M, Negishi K, Tsubota K. High prevalence 41. Slijper HP, Richter JM, Smeets JBJ, Frens MA. The effects of
of sleep and mood disorders in dry eye patients: Survey of 1,000 pause software on the temporal characteristics of computer use.
eye clinic visitors. Neuropsychiatr Dis Treat 2015;11:889–94. Ergonomics 2007;50:178–91.
35. Yu X, Guo H, Liu X, Wang G, Min Y, Chen SS, et al. Dry eye and 42. Loh K, Redd S. Understanding and preventing computer vision
sleep quality: a large community-based study in Hangzhou. Sleep syndrome. Malays Fam Physician Off J Acad Fam Physicians
2019;42:zsz160. doi: 10.1093/sleep/zsz160. PMID: 31310315. Malays 2008;3:128–30.
36. Lee YB, Koh JW, Hyon JY, Wee WR, Kim JJ, Shin YJ. Sleep 43. Kirchherr J, Charles K. Enhancing the sample diversity of snowball
deprivation reduces tear secretion and impairs the tear film. Invest samples: Recommendations from a research project on anti‑dam
Ophthalmol Vis Sci 2014;55:3525–31. movements in Southeast Asia. PLoS One 2018;13:e0201710.
Supplementary Table 1: Association of Screen time, Sleep and Dry Eye in college‑going
girls in northern India
A. Basic Information
1. Age
a. 18–21 years
b. 22–26 years
c. 27–30 years
2. Stream
a. Humanities
b. Sciences
c. Commerce
3. Class
a. Up to 12th
b. Graduate
c. Post‑graduate
4. Education of father
a. Illiterate
b. Up to 10th
c. Up to 12th
d. Graduate
e. Post‑graduate
f. Doctorate/any other
5. Education of mother
a. Illiterate
b. Up to 10th
c. Up to 12th
d. Graduate
e. Post‑graduate
f. Doctorate/any other
6. Working status of parents
a. Both working
b. Only father working
c. Only mother working
7. Type of family
a. Joint
b. Nuclear (only parents and child)
8. No. of siblings
a. 1
b. 2
c. 3
d. More than 3
9. Place of residence
a. Urban
b. Rural
c. Inadvertently
B. Screen‑time Review
10. No. of hours daily time
a. 0–2 h
b. 2–4 h
c. 4–6 h
d. More than 6 h
11. Device on which maximum time spent
a. Television
b. Laptop/Desktop
c. Mobile Phone
d. Tablet/iPad
12. Purpose
a. Social media
b. Studies
c. Movies
d. Gaming
13. Increase in screen time
a. No
b. Yes
14. How much increase
a. 25%
b. 25–50%
c. 50–75%
d. 75–100%
C. Mini Sleep Questionnaire
15. Difficulty in falling asleep
a. Never
b. Very rarely
c. Rarely
d. Sometimes
e. Often
f. Very often
g. Always
16. Waking up too early
a. Never
b. Very rarely
c. Rarely
d. Sometimes
e. Often
f. Very often
g. Always
17. Hypnotic medication use
a) Never
b) Very rarely
c) Rarely
d) Sometimes
e) Often
f) Very often
g) Always
18. Falling asleep during the day
a) Never
b) Very rarely
c) Rarely
d) Sometimes
e) Often
f) Very often
g) Always
19. Feeling tired upon waking up in the morning
a) Never
b) Very rarely
c) Rarely
d) Sometimes
e) Often
f) Very often
g) Always
20. Snoring
a. Never
b. Very rarely
c. Rarely
d. Sometimes
e. Often
f. Very often
g. Always
21. Mid‑sleep awakenings
a. Never
b. Very rarely
c. Rarely
d. Sometimes
e. Often
f. Very often
g. Always
22. Headaches on awakening
a. Never
b. Very rarely
c. Rarely
d. Sometimes
e. Often
f. Very often
g. Always
23. Excessive daytime sleepiness
a. Never
b. Very rarely
c. Rarely
d. Sometimes
e. Often
f. Very often
g. Always
24. Excessive movement during the sleep
a. Never
b. Very rarely
c. Rarely
d. Sometimes
e. Often
f. Very often
g. Always
D. Eye Dryness
25. Report the type of symptoms you experience within the last 3 months
Yes No
Dryness, grittiness, or scratchiness
Soreness or irritation
Burning or watering
Eye fatigue

26. Report the frequency of your symptoms in the eye using the list mentioned. 0 = Never, 1 = Sometimes, 2 = often, 3 = Constant
0 1 2 3
Dryness, grittiness, or scratchiness
Soreness or irritation
Burning or watering
Eye fatigue

27. Report the severity of your symptoms using the list mentioned. 0 = no problem, 1 = tolerable–not perfect but not uncomfortable,
2 = uncomfortable–irritating but does not interfere with my day, 3 = bothersome–irritating, interferes with my day,
4 = intolerable–unable to perform my daily tasks
0 1 2 3 4
Dryness, grittiness, or scratchiness
Soreness or irritation
Burning or watering
Eye fatigue

28. Do you use eye drops for lubrication?

a.) Yes
b.) No
Supplementary Table 2

Item‑wise analysis of Sleep‑wake Domain and comparison of responses based on Dry eye Domain
Statements Responses Never Very Rarely Sometimes Often Very Often Always Dry Eyes
Rarely Domain P
Difficulty in falling Count 49 46 68 192 68 64 60 0.000**
asleep Table n % 9.00% 8.40% 12.40% 35.10% 12.40% 11.70% 11.00%
Waking up too early Count 64 49 92 166 68 39 69 0.004**
Table n % 11.70% 9.00% 16.80% 30.30% 12.40% 7.10% 12.60%
Hypnotic medication Count 380 30 49 55 17 6 10 0.1007**
use Table n % 69.50% 5.50% 9.00% 10.10% 3.10% 1.10% 1.80% Fisher’s
exact test
Falling asleep during Count 71 84 97 149 47 61 38 0.022**
the day Table n % 13.00% 15.40% 17.70% 27.20% 8.60% 11.20% 6.90%
Feeling tired upon Count 63 48 54 128 85 63 106 0.000**
waking up in the Table n % 11.50% 8.80% 9.90% 23.40% 15.50% 11.50% 19.40%
morning
Snoring Count 274 67 58 82 25 23 18 0.000**
Table n % 50.10% 12.20% 10.60% 15.00% 4.60% 4.20% 3.30%
Mid‑sleep Count 99 90 87 127 59 44 41 0.000**
awakenings Table N % 18.10% 16.50% 15.90% 23.20% 10.80% 8.00% 7.50%
Headaches on Count 146 95 54 117 58 43 34 0.000**
awakening Table n % 26.70% 17.40% 9.90% 21.40% 10.60% 7.90% 6.20%
Excessive daytime Count 123 83 90 131 54 45 21 0.000**
sleepiness Table n % 22.50% 15.20% 16.50% 23.90% 9.90% 8.20% 3.80%
Excessive movement Count 119 87 98 100 68 30 45 0.000**
during the sleep Table n % 21.80% 15.90% 17.90% 18.30% 12.40% 5.50% 8.20%
Item‑wise analysis of Dry eye Domain and comparison of responses based on Sleep‑wake Domain

Frequency of symptoms

Statements Responses Never Sometimes Often Constant Sleep‑wake Domain P

Dryness, grittiness, Count 224 203 94 26 0.000**
or scratchiness Table n % 41.00% 37.10% 17.20% 4.80%
Soreness or irritation Count 233 193 91 30 0.000**
Table n % 42.60% 35.30% 16.60% 5.50%
Burning or watering Count 202 168 129 48 0.000**
Table n % 36.90% 30.70% 23.60% 8.80%
Eye fatigue Count 165 164 147 71 0.000**
Table n % 30.20% 30.00% 26.90% 13.00%
Severity of symptoms

Statements Responses No Tolerable-not Uncomfortable- Bothersome- Intolerable- Sleep‑Wake

problem perfect but irritating but does not irritating, unable to Domain P
uncomfortable interfere with my day interferes perform my
with my day daily tasks
Dryness, grittiness, Count 259 183 67 28 10 0.002816**
or scratchiness Table n % 47.30% 33.50% 12.20% 5.10% 1.80% Fisher’s exact test
Soreness or irritation Count 246 173 89 31 8 0.000** Fisher’s
Table n % 45.00% 31.60% 16.30% 5.70% 1.50% exact test
Burning or watering Count 212 179 100 44 12 0.000** Fisher’s
Table n % 38.80% 32.70% 18.30% 8.00% 2.20% exact test
Eye fatigue Count 183 179 115 53 17 0.000** Fisher’s
Table n % 33.50% 32.70% 21.00% 9.70% 3.10% exact test
**Statistical tests performed: Chi‑square test of independence; Fisher’s exact test