Available online at www.sciencedirect.

com

Computers in
Human Behavior
Computers in Human Behavior 24 (2008) 2026–2042
www.elsevier.com/locate/comphumbeh

Computer Vision Syndrome: A widely spreading

but largely unknown epidemic among
computer users
a,b
Zheng Yan , Liang Hu b, Hao Chen b, Fan Lu b,*

a
University at Albany, Department of Educational and Counselling Psychology,
School of Education, Edu 227, Albany, NY 12222, United States
b
School of Optometry and Ophthalmology and Eye Hospital, Wenzhou Medical College,
270 Xueyuan Road, Wenzhou, Zhejiang 325003, China

Available online 19 November 2007

Abstract

The present paper is intended to introduce behavioral researchers to Computer Vision Syndrome
(CVS), a widely spreading but largely unknown epidemic among professional and ordinary com-
puter users, and to call for behavioral research programs to help computer users address this visual
epidemic. Beginning with three clinical cases, the paper analyzes the classic definition of CVS, dis-
cusses the prevalence of CVS, reviews five major symptoms of CVS (i.e. eyestrain, headache, blurred
vision, dry eyes, and neck/back pain), summarizes five types of contributing factors of CVS (i.e. com-
puter screens, computer environments, human eyes, computer users, and computer tasks), and pre-
sents basic preventive and treatment strategies. Finally, three future research directions for
behavioral science research are briefly discussed.
 2007 Elsevier Ltd. All rights reserved.

Computers have significantly impacted cognitive, social, physical, and various other
aspects of the modern daily lives of computer users. Extensive literature in ergonomics
and optometry has indicated that computer use is closely associated with various visual
problems, which are referred to as Computer Vision Syndrome (CVS) in medical science.
The following three clinical cases demonstrate CVS.

*
Corresponding author.
E-mail address: lufan@wzmc.net (F. Lu).

0747-5632/$ - see front matter  2007 Elsevier Ltd. All rights reserved.
doi:10.1016/j.chb.2007.09.004
 Z. Yan et al. / Computers in Human Behavior 24 (2008) 2026–2042 2027

Case 1. A 34-year-old female project manager visited an optometric clinic for both eye
fatigue during near work and frequent frontal headaches in the early evening. She had
treated her symptoms with Tylenol in the past but found no relief. Based on her eye exam-
ination, she was diagnosed with Computer Vision Syndrome. Her eye fatigue and head-
aches were due to (a) five hours of work per day at the computer over the last 12
months, (b) a viewing distance of only 12 in. from the computer monitor, and (c) her com-
puter monitor being positioned on top of the CPU creating a viewing angle that was above
eye level. The treatment was to wear a pair of glasses for near work, increase viewing dis-
tance from the computer, and lower the computer monitor (Glasser & Anshel, 2003).
Case 2. A 28-year-old female information technology manager came to an optometric
clinic and reported increased eye fatigue and dry eyes. She had previously consulted her
physician but was found to be in good health. The eye examination suggested that she
had normal eye and vision conditions, but she was diagnosed with Computer Vision Syn-
drome with transient nearsightedness. Her eye fatigue and dry eyes were associated with
two factors: (a) working for 8 h or more a day at the computer during the past 12 months,
though at a normal viewing distance of 22 in. and (b) the existence of various visual ergo-
nomic problems – namely, her computer screen was higher than eye level and produced
glare and reflection. The treatment was to adjust her computer workstation. She received
significant improvement of her symptoms (Glasser & Anshel, 2003).
Case 3. A 32-year-old male attorney visited an eye clinic with complaints of distance
blur following long hours of computer use, and headaches about three times a week.
He had taken Tylenol in the past with no relief of his symptoms. The eye examination indi-
cated that he had normal eye conditions, but suffered from Computer Vision Syndrome.
His symptoms were mainly due to 5 h of intense work at the computer daily. The treat-
ment was to wear computer glasses for near work (Glasser, 2000).
The three clinical cases presented above are based on the actual records of two nation-
ally-known optometrists who specialize in computer-related vision problems. From these
three cases, one can observe several basic aspects of CVS. First, the three adult profession-
als (project manager, IT supervisor, and attorney) all used computers at work for 5–8 h
every day for a period of months. Based on standards set by the National Institute of
Occupational Safety and Health, they would all be classified as occupational computer
users rather than occasional computer users. Second, they were all diagnosed as typical
CVS patients who suffered from a variety of typical symptoms of CVS on a daily basis,
ranging from eye fatigue, frequent headaches, dry eyes, to blurred vision. Although these
symptoms are not life-threatening as diseases such as cancer or AIDS, they can be as trou-
bling as a nagging tooth problem or chronic back pain. Third, although these three indi-
viduals had used computers extensively, none of them had basic knowledge of CVS. While
suffering from CVS, they show very limited knowledge of CVS, either wrongly taking
Tylenol or being puzzled when seeing a physician. Fourth, all three CVS patients eventu-
ally received proper diagnoses and effective treatment, and all experienced substantial
improvement in their visual symptoms, showing that CVS is diagnosable and treatable.
These three cases represent only the tip of the iceberg of the widely spreading epidemic
of CVS among computer-users worldwide and demonstrate the extent to which CVS is lar-
gely unknown by computer users (Blehm, Vishnu, Khattak, Mitra, & Yee, 2005; Mutti &
Zadnik, 1996; Sheedy, 2000; Sheedy & Parsons, 1990). CVS has been extensively studied –
first in the field of visual and computer ergonomics in the 1980s, and more recently in the
field of environmental and occupational optometry in the 1990s. However, few behavioral
2028 Z. Yan et al. / Computers in Human Behavior 24 (2008) 2026–2042

studies (e.g. Dillon & Emurian, 1995) have been conducted to describe, analyze, and pose
solutions for CVS. For researchers in the behavioral science of computer use, it is useful to
learn from the current CVS research in ergonomics and optometry in order to help com-
puter users deal with CVS. With this consideration, this paper will review existing litera-
ture, focusing on five basic questions about CVS: What is CVS? How many computer
users suffer from CVS? What are the major symptoms of CVS? Why do computer users
develop CVS? What should computer users do to fight against CVS? The paper concludes
with suggestions for future directions for researchers in behavioral sciences with regard to
CVS. Instead of providing a comprehensive review of the existing literature in both ergo-
nomics (e.g. Dillon, 1992; Smith, 1987; Tattersall, 1992) and optometry (e.g. Blehm et al.,
2005; Cole, 2003; Mutti & Zadnik, 1996), the purposes of this paper are mainly to increase
public awareness about CVS among computer users, and to call for effective research pro-
grams among behavioral scientists. In addition, while there is a relatively large body of
human factors literature devoted to the study of visual fatigue (e.g. Fostervold, Aaras,
& Lie, 2006; Megaw, 1995; Miyao, Hacisalihzade, Allen, & Stark, 1989; Rechichi, Car-
melo, & Scullica, 1996), the present paper will focus more on the optometric literature
directly examining CVS in order to further familiarize readers with optometry as a disci-
pline of medical science.

1. What is CVS?

According to the American Optometry Association (American Optometric Association

(AOA)., 1995), CVS is defined as ‘‘the complex of eye and vision problems related to near
work which are experienced during or related to computer use.’’
This classic definition provides three key pieces of information about CVS: (a) CVS is a
formally accepted medical and clinical term, such as William syndrome, Down syndrome,
and Stockholm syndrome, rather than a folk science notion. (b) It has a wide variety of
associated symptoms related to both eyes and vision rather than just one or two symp-
toms. (c) The major cause of CVS is the near work of using computers rather than other
visual processes. As the most widely used definition of CVS, it has had deep and broad
impacts on CVS research.
This definition, however, was developed by the American Optometric Association more
than 10 years ago. We would like to challenge three aspects of this definition. First, the
phrase ‘‘eye and vision problems’’ might be too vague. Some commonly observed CVS
symptoms are vision-related (e.g. headache and neck pain) rather than vision-specific
(e.g. eyestrain and accommodation disorder). Second, the phrase ‘‘near work’’ at the com-
puter might be too simple. Near work at the computer is not the sole cause of CVS, and
two major interconnected factors should instead be considered together: near work at the
computer (a viewing distance of less than 20 in.) and long-hour work at the computer
(intense computing work for more than 3 h per day). These two factors combined cause
eye fatigue as well as other computer vision symptoms. In addition, the definition lacks
an explicit description of near work (e.g. viewing distance vs. viewing angle). Third, the
term ‘‘computer use’’ might be too general. There are various types of professional or daily
computer users (e.g. office workers, website designers, college students, telephone opera-
tors), various computer screen devices (e.g. desktops, laptops, palm handhelds,
cell phones), and various computer use tasks (e.g. emailing, browsing, gaming, chatting,
 Z. Yan et al. / Computers in Human Behavior 24 (2008) 2026–2042 2029

shopping). Consequently, the effects of differences in computer use on eyes and vision
might vary.

2. How many computer users suffer from CVS?

According to US Census Bureau’s latest data on computer use (Day et al., 2005, Table
C and Table D), the computer user population (3 years and older) in the United States in
2003 was estimated to be approximately 188 million, while the total national population (3
years and older) in 2003 was approximately 275 million. That is, approximately 68% of
Americans used computers in their daily lives. Among American computer users, how
many of them suffer from CVS? While no national census data is available, two methods
have been used in the CVS research literature to estimate the prevalence of CVS.
The first method is to estimate how many computer users have reported suffering from
CVS on the basis of various empirical studies. For instance, Mutti and Zadnik (1996)
reported that 75% of computer users who worked long hours at the computer had com-
plaints of visual symptoms. Various empirical studies reported diverse estimations, rang-
ing between 23% and 90% (e.g. Blehm et al., 2005; Mutti & Zadnik, 1996; Sheedy, 2000;
Yeow & Taylor, 1991), with a general estimation of about 70% of the computer user pop-
ulation (Sheedy & Parsons, 1990). Since (a) different research studies had different target
populations and sampling approaches, (b) most of them were based on self-report data
that normally would underestimate the prevalence of CVS, and (c) these studies were con-
ducted in different years between the 1980s and 1990s, it is understandable that these esti-
mations have been very diverse. Given that the current national population in 2007 is 302
million as reported at www.census.gov, if we choose 68% as the percentage of Americans
who use computers and 23% as the most conservative estimate of the percentage of Amer-
ican computer users who suffer from CVS, the total CVS population in the United States
in 2007 can be estimated to be at least 47 million (i.e. 309 · 68% · 23% = 47).
The second method is to calculate the percentage of eye patients visiting visual clinics
for CVS rather than for other visual diseases. According to Sheedy’s (2000) estimation,
14–17% of optometric patients had a chief complaint related to working at a computer,
and approximately 15 million eye examinations were given annually due to CVS. Since this
estimation was based on optometrists’ clinic reports rather than research subjects’ self-
reports, it can be considered more objective. However, on the other hand, the estimation
was limited only to those CVS patients who had substantial eye discomfort and actually
visited the clinic. Thus, this method of estimation might provide more accurate approxi-
mations of the CVS clinic population with rather severe CVS symptoms. As a result,
the true CVS population in the United States is likely much larger than 15 million.
Based on these two methods, it might be safe to estimate that the CVS population in the
United States is at least 15–47 million and at least 14–23% of computer users might have
different degrees and types of CVS symptoms.
In contrast to the pervasiveness of computer use and the prevalence of CVS among com-
puter users, CVS is largely unknown to professional computer users, ordinary computer
users, and even many optometrists (e.g. Anshel, 2005; Sheedy, 1992; Sheedy & Parsons,
1990). As shown in the three clinical cases presented, after suffering from CVS symptoms,
the three CVS patients either wrongly self-medicated with Tylenol, or initially considered
their symptoms to be unrelated to vision. Lack of knowledge and understanding, and even
misconceptions about CVS, can often be observed among computer users. Interestingly
2030 Z. Yan et al. / Computers in Human Behavior 24 (2008) 2026–2042

enough, all of the authors of this paper (some of whom are optometrists and/or ophthalmol-
ogists by training) have been suffering from CVS for years due to their long hours of com-
puter use. Nevertheless, ten years ago none of us were aware of CVS as an actual medical
condition. One of the initial motivations to study CVS was to address our own symptoms.
Why do many computer users who have long suffered from CVS nevertheless have lim-
ited knowledge of CVS? There are several potential explanations for this phenomenon.
First, CVS is essentially a visual problem. The adverse effects of CVS on computer users
are not serious or deadly. Thus, many computer users might not pay much attention to
their symptoms. Second, CVS requires interdisciplinary studies. There may be poor com-
munication across different fields and the scientific research community as a whole. Third,
CVS is a new and unique concept, and there may not be many educational programs to
effectively educate computer users about how to protect their eyes, despite the fact that
the American Optometric Association conducted a public awareness campaign in 1995.
Fourth, although many computer users may have had much experience with CVS, they
might not have the appropriate vocabulary to label and describe their symptoms. Finally,
public and professional attention is primarily drawn to the well-known musculoskeletal
disorders associated with computer use (e.g. Carpal Tunnel Syndrome) rather than to a
condition characterized primarily by visual problems.

3. What are the major symptoms of CVS?

CVS does not have only one or two symptoms, but rather, a wide variety of symptoms
(e.g. AOA, 1995; Sheedy, 2000). Different terms have been used to describe symptoms of
CVS, such as visual discomfort, ocular disorder, visual difficulty, visual impairment, visual
pain, visual problems, eye fatigue, eyestrain, visual stress, visual complaints, and visual
diseases. In general, CVS symptoms can be divided into three major categories (e.g. Blehm
et al., 2005; Sheedy, 1996; Sheedy, 2000): (a) eye-related symptoms (e.g. dry eyes, watery
eyes, irritated eyes, burning eyes), (b) vision-related symptoms (e.g. eyestrain, eye fatigue,
headache, blurred vision, double vision), and (c) posture-related symptoms (e.g. sore neck,
shoulder pain, sore back). These symptoms can also be considered as either subjective
symptoms (e.g. visual complaints reported by patients) or objective symptoms (visual
problems diagnosed by eye doctors).
The most comprehensive and widely cited research related to CVS symptoms was con-
ducted by Sheedy in the early 1990s (Sheedy, 1992; Sheedy & Parsons, 1990). One study was
based on a survey of over 1000 national optometrists, and another based on multiple years
of clinical work from one of the earliest computer vision syndrome clinics. Various symp-
toms were reported in these studies, including eyestrain, headaches, irritated eyes, sore eyes,
slowness of focus change, dry eyes, lighting and glare discomfort, blurred vision, double
vision, neck pain, shoulder pain, back pain, after-image distortion, and color distortion.
Among the various symptoms listed in these two reports, the top five CVS symptoms, eye-
strain, headache, blurred vision, dry eyes, and neck/back pain, are reviewed in this section.

3.1. Eyestrain

Eyestrain normally refers to computer users’ subjective complaints about uncomfort-

able, painful, and/or irritable visual experiences (Sheedy, 1992). It is the most widely
reported symptom of CVS among the top symptoms based on both clinic experiences of
 Z. Yan et al. / Computers in Human Behavior 24 (2008) 2026–2042 2031

optometrists nationwide and their own clinic records from the 1980s and 1990s (Sheedy,
1992; Sheedy & Parsons, 1990).
Eyestrain results from visual disorders when visual demands exceed visual capacity
(Anshel, 1997; Sheedy, 1996; Yeow & Taylor, 1989; Yeow & Taylor, 1991). Trusiewicz,
Niesluchowska, and Makszewska-Chetnik (1995) found long-hour work at the computer
reduced important visual functions such as accommodation and convergence and could be
the cause of eyestrain among computer users.

3.2. Headache

Headaches often accompany other CVS symptoms, though many patients might not
consider them to be a vision-related problem (Sheedy, 2000; Travers & Stanton, 2002).
They are also difficult to diagnose correctly and treat effectively. Based on the clinical
experience of CVS experts (e.g. Anshel, 2005), vision-related headaches most often occur
toward the front of the head with a few exceptions, on one side of the head more than the
other, and typically occur toward the middle or end of the day.

3.3. Blurred vision

Eyestrain as an initial symptom can further develop into blurred vision or other tempo-
rary visual difficulties (Anshel, 2005; Sheedy, 1992; Sheedy & Parsons, 1990). Blurred
vision occurs when the eyes do not focus on an image accurately due to a lack of visual
acuity (the ability to distinguish between two distinctive points at near, intermediate, or
far distance) or visual accommodation (the ability to change the focal power of the eye).
Blurred vision can result from several vision processing problems, including refractive
error (e.g. hyperopia, myopia, astigmatism), an improper glasses prescription, or accom-
modative disorders. A poor computer working environment such as a dirty computer
screen, a higher viewing angle, reflected glare, or a poor quality or defective computer
screen, can lead to blurred images (Anshel, 1997).

3.4. Dry eyes

Dry eyes are among the most common eye problems that cause CVS patients to consult
their eye doctors (e.g. Hikichi et al., 1995; Miljanovic, Dana, Sullivan, & Schaumberg,
2007; Nakaishi & Yamada, 1999; Tsubota & Nakamori, 1993). They represent one of the typ-
ical symptoms of CVS. Dry eye syndrome refers to a breakdown in the quantity or quality of
tears that are used to moisten, cleanse and protect the eyes. With each blink, tears moisten the
surface of the eyes and wash away dust and microorganisms. When tears dry up, the eyes may
feel ‘‘gritty’’ as if there were sand in them. This can further cause burning or itchy eyes, dis-
comfort wearing contact lenses, increased sensitivity to light or excessive tearing, and in
extreme cases, blurred vision (Acosta, Gallar, & Belmonte, 1999; Tsubota, 1998; Tsubota
& Nakamori, 1993).

3.5. Neck and backaches

Many common symptoms of CVS are vision-related, such as eyestrain, blurred vision,
and dry eyes, but CVS also appears to be non-vision-related, causing symptoms such as
2032 Z. Yan et al. / Computers in Human Behavior 24 (2008) 2026–2042

headaches and neck and back aches (Anshel, 2005; Sheedy, 1992; Sheedy & Parsons,
1990). The major cause of neck and back pain related to CVS is an improper viewing posi-
tion when using the computer. For instance, if the computer screen is higher or lower than
eye level, it causes an awkward posture that contributes to sore neck, back, or shoulders
(Sheedy, 1995). In many office situations, workers’ vision is compromised, and they must
adapt their postures to ease the visual strain. For example, if an older worker uses single-
vision glasses which are designed for a 15 in. viewing distance, he or she must lean in
toward a computer screen, which may be 25 in. away, in order to see the image clearly
(Anshel, 1997).
It has been nearly 20 years since Sheedy’s seminal work was published. Today, the
landscape of computer use has been changed dramatically, and computer user popula-
tions have diversified significantly. There might be more newly emerging symptoms of
CVS due to online games, e-learning, e-business, and e-government and other new
types of computer use with diverse computer users. New symptomatology studies are
needed in the field of optometry with visual clinic populations, and in ergonomics with
industrial clients, but more importantly in other fields, such as psychology, education,
entertainment, and business, and with diverse populations such as addictive computer
users, college students, hard-core gamers, or online shoppers.

4. Why do computer users develop CVS?

It was generally believed that near work at the computer and long-hour work at the
computer are two general factors contributing to CVS. In addition to these two general
factors, the CVS research literature has suggested that a wide variety of specific factors
are associated with CVS. Fig. 1 provides a simple model of eye–computer interaction that
illustrates five major types of contributing factors of CVS.
As shown in Fig. 1, five types of vision-related components are involved when a com-
puter user uses his or her eyes to interact with a computer: (a) a computer screen as the
visual object, compared with paper for reading, (b) a computer room as the visual environ-
ment, compared with a kitchen for cooking, (c) human eyes as the visual organ, compared
with teeth for eating, (d) a computer user as the visual subject, compared with a driver in a
car, and (e) a computer task as the visual task, compared with other tasks such as reading
a newspaper or enjoying a painting. We use this classification to discuss major factors that
contribute to CVS.

4.1. Computer screen

The computer screen is a unique visual object. Since the 1970s, researchers in visual
ergonomics and other fields have conducted hundreds of studies to examine the effects
of computer screens on visual functioning (e.g. Anshel, 2005; Fostervold et al., 2006;
Megaw, 1995; Miyao et al., 1989; Rechichi et al., 1996).
As a visual object, a computer screen is substantially different from paper in
many ways. These differences, as described briefly below, show that viewing a com-
puter screen is much more visually demanding than viewing paper, thus contributing
to CVS.
 Z. Yan et al. / Computers in Human Behavior 24 (2008) 2026–2042 2033

3. Human Eye

1. Computer Screen

2. Computer Room

4. Computer User

5. Computer Task

Fig. 1. A model of computer use illustrating five major factors that are associated with CVS.

 The computer screen is self-illuminated, whereas reading paper relies on the reflection
of light from other lighting sources. Its brightness is one of the key features of a com-
puter screen, which is associated with visual fatigue (Anshel, 2005).
 The computer screen constantly refreshes at a certain rate, whereas paper is steady. A
minimal screen refresh rate of 75 Hz is needed, and much higher refresh rates (300 Hz
or higher) may decrease ocular symptoms and increase user functionality (Blehm et al.,
2005; Jaschinski, Bonacker, & Alshuth, 1996; Kennedy & Murray, 1991).
 Objects displayed on the screen consist of a series of pixel-based dots with decreasing
brightness on their outer edges, thus making it hard for eyes to focus, whereas objects
on the paper are printed with solid ink images (Anshel, 2005).
 The computer screen has different resolutions that affect visual fatigue and readability
(Miyao et al., 1989), whereas paper does not have this resolution issue.
 The computer screen consists of different combinations of background and foreground
and thus results in varied contrasting colors, whereas paper typically has a white back-
ground with black or color objects. A high degree of screen contrast makes the screen
much brighter and thus is associated with visual strain (Anshel, 2005).
 An ideal computer screen should be free of reflections and glare. Computer screens,
even anti-glare screens, are subject to interfering reflections from other lighting sources,
thus making eyes fatigue more easily. In contrast, paper does not have a serious glare
issue (Anshel, 2005).
 Viewing the computer screen requires a much higher viewing angle, thus making one
susceptible to dry eyes and neck pain, as compared with reading the paper at a much
lower viewing angle. It is recommended that the screen should be placed 10–20 degrees
below the eye level (Anshel, 2005).
 Besides the viewing angle, the viewing distance between the eyes and the computer
screen is important and often not easily adjusted, as compared with simply moving
books by hand to adjust the viewing distance. Recent empirical studies suggest that
viewing distances of 35–40 in. may actually reduce the incidence of visual strain (Jas-
chinski, 2002; Jaschinski, Heuer, & Kylian, 1999).
2034 Z. Yan et al. / Computers in Human Behavior 24 (2008) 2026–2042

4.2. Computer room

A typical computer room is an indoor office that provides a special visual environment
for eye–computer interactions. There is extensive literature suggesting that various compo-
nents of computer rooms are closely associated with computer users’ visual comfort and
visual functioning.
Lighting conditions are the most important component of computer rooms that affect
visual functioning. Proper lighting in the computer room will make viewing computer
screens easy and clear, and thus enable computer users to reduce visual fatigue and
improve work performance. Research has suggested that an ideal computer environment
should have the following visual features: (a) The level of the primary source of light in
a computer room should be half as bright as that normally found in a work place. Spe-
cifically, recommended lighting levels are 40–50 Fc for ambient light, compared to
100 Fc or more in previously non-computerized offices (Anshel, 2000b). A computer user
is at a greater risk of experiencing visual discomfort when the source of light is brighter
and closer to where the eyes are focusing. (b) The computer room should have equalized
brightness. (Abelson & Ouster, 1999). Constant and bright illumination from surround-
ing sources of light (overhead fluorescent lights, large open windows, desk lamps) can
potentially reduce the visibility of the screen, creating reflection and glare, leading to
sensations of discomfort, and resulting in transient adaptation effects from fixating back
and forth between the two luminance levels. In addition, other sources of extreme
brightness differences in the computer room include bright-white clothing, light-colored
desk surfaces, highly polished furniture and decorative accessories, large mirrors, desk
lamps directed toward the eyes, or desk lamps which illuminate the desk too brightly
(Anshel, 1997). (c) The room should have the proper type of lighting. Among natural
light, filament lamps, luminescent lamps, sodium lamps, and mercury-arc lamps, it
was found that sodium lamps were the most conducive to high visual capacity (Blehm
et al., 2005).
Besides room lighting, other factors affecting visual capacity include air flow, tempera-
ture, and humidity. Research has suggested that strong air flow, high temperature, and low
humidity increase dry eyes and other types of eye fatigue (Anshel, 2005; Sheedy, 1997).
With the increased use of laptop computers in diverse indoor and outdoor visual envi-
ronments, such as the airport, restaurant, playground, track field, bookstore, and cafe-
teria, more computer users work in challenging and unchangeable visual environments,
as compared with the environment of a typical computer room. Empirical research is
needed to assess these variations of computer environments on computer users’ eyes
and vision.

4.3. Human eyes

Human eyes are an extremely exquisite and complicated visual system. Beginning in the
1980s, researchers in optometry, vision science, and other fields have studied how eyes and
vision are related to CVS. Three major characteristics of human eyes associated with CVS
are discussed below.
First, evolutionally and anatomically, human eyes are relaxed and comfortable viewing
objects at a long distance (e.g. over 20 ft) in the daylight, but need to use significantly more
 Z. Yan et al. / Computers in Human Behavior 24 (2008) 2026–2042 2035

eye muscles to focus on objects at a near distance (e.g. nearly 10 in.). This is one major
reason why human eyes tire easily when using computers, especially after a few hours
of continual near work.
Second, the front surface of the human eye is covered with tears. Tears are used to pre-
serve moisture for normal eye functions, maintain the proper oxygen balance of the exter-
nal eye structure, and maintain the proper optical properties of the visual system. Like
lubrication for car wheels, tears make eye movement easy, smooth, effective, and comfort-
able. Staring at a computer screen leads to two major changes in the tear dynamics. First,
the spontaneous eye blink rate (SEBR) during computer use reduces significantly. Com-
pared with SEBR during conversation (mean = 15–16 blinks per minute), the SEBR sig-
nificantly decreases during initial computer use (mean = 5–6 blinks per minute) due to
the high visual demand and mental concentration while viewing computers (Freudenthal-
er, Neuf, Kadner, & Schlote, 2003; Schlote, Kadner, & Freudenthaler, 2004). Fewer blinks
means fewer tears to be cleaned off and refreshed. Second, the size of the eye opening
increases when staring at the computer screen, resulting in greater tear evaporation. As
we gaze higher, the eyes open wider, and the tears are lost faster, like a pond with a large
surface area as compared with a pond with a small one. This is one of the reasons why long
hours of computer use will lead to dry eyes.
Third, human eyes need to adjust themselves in order to see objects from different dis-
tances, such as by enlarging or minimizing the pupil to control the amount of light going
into the eyes, lengthening or shortening the lens to change eye focus, and making muscles
outside the eyes longer or shorter to coordinate the two eyes. If one needs to view a com-
puter screen while looking at paper on the table from time to time, the eyes have to adjust
constantly. In addition, the words and images on a computer screen are difficult for the
eyes to focus on due to their poor edge resolution. The eyes tend to change the focus to
a resting point and then refocus on the screen. For these two major reasons, constant
focusing and refocusing is required. These constant changes take place thousands of times
a day when a computer user stares at a computer screen for hours, which then stresses the
eye muscles leading to eye fatigue and discomfort (Hoenig, 2002). This is one of the major
reasons why computer users experience headaches (an indication of adjusting eyes too
much) or blurred vision (lack of accommodation and convergence).

4.4. Computer users

Computer users consist of very diverse groups of visual subjects. Compared with com-
puter screens, computer rooms, and human vision, the existing literature on the relation-
ship between computer users and CVS is limited. Thus, little is known about what types of
computer users (e.g. being different in age, gender, occupation, personality, habits of life,
social and economic status) will be more vulnerable to CVS. This is a field in which psy-
chology and behavioral science can and should make significant contributions. Below is a
discussion of two important groups of computer users – users with existing visual prob-
lems, and younger computer users.
One of the most important factors to consider in studying computer users and CVS is
whether computer users are visually normal or have existing visual disorders. For com-
puter users wearing corrective lenses (regular glasses or contact lenses), they may have
three types of existing vision problems, including accommodative disorders (eye focusing),
binocular vision disorders (eye coordination), or refractive error (hyperopia, presbyopia,
2036 Z. Yan et al. / Computers in Human Behavior 24 (2008) 2026–2042

and myopia). With these visual problems, these computer users suffer from more severe
symptoms of CVS or develop CVS more quickly. For instance, office workers wearing
contact lenses were found to be more likely to suffer a higher severity of ocular discomfort
(e.g. Anshel, 2005).
Older and younger computer users are also at high risk for suffering from CVS. For
example, millions of school children use computers for long hours at school and at home,
though their vision is still not fully developed. It has been estimated that the average
American child is now spending about 1–3 h per day on the computer, and that up to
30% of the approximately 37 million American children who use computers at home or
school may need special computer eyewear to reduce their risk of premature vision prob-
lems (Hoenig, 2002). Hoenig (2002) found a strong correlation between children who work
many hours at a computer and premature myopia (nearsightedness) among 253 children
aged 6–10 years.
Unique aspects of how children use computers may also make them more susceptible
than adults to the development of these problems (Anshel, 2000b; AOA, 2006). (a) Young
computer users often cannot control themselves when it comes to playing or studying on
the computer. Many children will continue performing an enjoyable task, such as playing
a video game, for hours without a break. (b) Young computer users often misinterpret var-
ious visual problems with their computer screens, computer rooms, or eyes as normal. A
child who is viewing a computer screen with a large amount of glare often will not consider
changing the computer surroundings. Due to a lack of knowledge and experience, children
often accept blurred vision caused by nearsightedness, farsightedness, or astigmatism
because they assume everyone sees the way they do. (d) Most computer workstations
are arranged for adults’ use and many school computers are often set up incorrectly for
children (Hedge, 2005). Children may have difficulties seeing the monitor, reaching the
keyboard, or placing their feet on the floor, causing them arm, neck or back discomfort.
(e) Viewing computers requires various visual skills, such as visual acuity, visual fixation,
accommodation, and binocular fusion; children have not fully developed these skills
(Anshel, 2000b).

4.5. Computer tasks

Computer tasks refer to the varied activities for which computers are used. A computer
is an artificial intelligence tool that can be used for performing various kinds of tasks (e.g.
studying, browsing, shopping). Different computer tasks have different visual demands for
different computer users, and thus should be an important consideration in studying CVS.
For example, data entry workers need to look at a hard copy document and occasionally
glance at the screen, while a graphic artist looks primarily at the screen (Anshel, 2000a).
This is probably the most uncharted area of research in the CVS literature.
First, computer use has shifted from primarily office-based work to different major
types of tasks, including study, communication, entertainment, business, and various
other computer tasks. Thus, research is needed to examine the differences and similarities
among different tasks.
Second, there are different media and materials used in different computer tasks, from
numbers, to text, graphics, audio, and video. These media and materials have different fea-
tures (e.g. static vs. dynamic, single vs. multiple, simple vs. complex) and will have different
impacts on human vision.
 Z. Yan et al. / Computers in Human Behavior 24 (2008) 2026–2042 2037

Third, different activity tasks will impact human eyes differently, such as reading (Chi &
Lin, 1998; Cushman, 1986; Garcia & Wierwille, 1985), gaming (Tsubota, Miyake, Mat-
sumoto, & Shintani, 2002; Yamada, 1998), and editing (Sheedy, Bailey, & Fong, 1987).
Research into new activity tasks such as browsing, emailing, chatting, instant-messaging,
blogging, and shopping are needed.

5. What should computer users do to fight against CVS?

5.1. Prevention

Although currently there are more computer users who work with computers for longer
hours than ever before, CVS is preventable, and developing good habits for using comput-
ers is important. Researchers have suggested several preventative strategies.
First, computer users should place the computer screen a distance of at least 20 in.
away, as suggested by clinical optometrists. Several studies have suggested that distances
of 35–40 in. may actually produce fewer complaints of visual strain (Jaschinski, 2002; Jas-
chinski, Heuer, & Kylian, 1998; Jaschinski et al., 1999). Such a relatively long viewing dis-
tance will allow the computer users’ eyes to relax.
Second, computer users should adjust their computer monitors to a viewing angle of
around 15 lower than the horizontal level (Burgess-Limerick, Plooy, & Ankrum, 1998;
Jaschinski et al., 1998; Mon-Williams, Plooy, Burgess-Limerick, & Wann, 1998; Psiho-
gios, Sommerich, Mirka, & Moon, 2001). This viewing angle will likely reduce both
visual discomfort (e.g. dry eyes) and musculoskeletal discomfort (e.g. neck pain and
back pain).
Third, computer users should follow the 20/20/20 rule as suggested by clinical optom-
etrists (e.g. Anshel, 2005). That is, after 20 min of computer use, one should look at some-
thing 20 ft away for at least 20 s. Several computer programs have been developed to help
computer users follow the 20/20/20 rule (e.g. displaying a small pop-up for 20 s every
20 min). Research has shown (Fenety & Walker, 2002; McLean, Tingley, Scott, & Ric-
kards, 2001) that regular small breaks improved work efficiency and compensated for time
lost on breaks. Frequent breaks are recommended to restore and relax the accommodative
system, thereby preventing eyestrain.
Fourth, computer users should carefully check the screen lighting and room lighting,
including glare, contrast, brightness, reflection, and dust (Novik, Soldatova, Martirosova,
& Semenets, 1991; Sheedy, Smith, & Hayes, 2005). For instance, research suggests that any
luminous source within the computer user’s field of view should not exceed three times the
mean screen luminance (Sheedy et al., 2005).
Fifth, computer users should have a good sitting position to avoid neck ache, back
ache, and headache (Ketola et al., 2002; Liao & Drury, 2000; Lie & Watten, 1994). Com-
puter users should pay attention to room conditions (e.g. humidity and dust) that can con-
tribute to the occurrence of CVS. Simple changes at the home or office, such as using a
humidifier, turning down the thermostat, and avoiding smoke, may reduce or eliminate
dry eyes.
Sixth, for those who need corrective lenses, it is important to have regular eye exams
and have good eyeglasses or contact lenses to correct visual problems (Anshel, 2005; She-
edy, 2000). Research indicates that sometimes even very small uncorrected eye problems
will cause substantial eyestrain due to the nature of long and intensive computer work.
2038 Z. Yan et al. / Computers in Human Behavior 24 (2008) 2026–2042

Those who wear contact lenses should follow all care instructions closely, as contact lenses
may contribute to dry eyes.
Seventh, for occupational computer users who need to use computers for more than 3
hours per day, warm eyelid massage every day is important (Schirra & Ruprecht, 2004;
Takahashi et al., 2005). Computer users might place a warm towel over closed eyes,
and at first gently massage the upper eyelid against the brow bone for 10 s and then gently
massage the lower eyelid against the lower bone for 10 s. Such a simple eyelid massage will
stimulate the tear glands, increase the blood circulation within the eyes, and reduce the
chance of developing dry eyes.

5.2. Treatment

Most CVS symptoms are treatable after the correct eye/vision examination and diagno-
sis (Sheedy, 2000). Since CVS has a wide variety of symptoms due to various contributing
factors, researchers in optometry and ergonomics have developed various diagnostic pro-
cedures and treatment programs for those who have CVS.
First, in addressing any CVS symptoms, it is important to learn about CVS and have
regular eye/vision examinations. This is the starting point of any timely diagnosis and
effective treatment. The American Optometric Association recommends that professional
computer users should obtain a comprehensive eye/vision examination when beginning
computer work and periodically thereafter. Computer users can also use web-based diag-
nosis tools (e.g. www.cvsdoctors.com and www.Doctorergo.com) for an initial self-
examination.
Second, eyestrain, one of the most observed CVS symptoms, usually results from a
combination of poor ergonomics, improper work habits, or an undetected visual condition
(e.g. Anshel, 2005; Gomzi, 1994). Thus, a complete eye exam, an on-site ergonomic eval-
uation, and instruction on correct working habits should be considered in order to ensure
a correct diagnosis. Possible treatment includes having proper computer glasses, perform-
ing an ergonomic adjustment, and undergoing behavioral therapy. For those who spend
more than 3 h a day using computers, and especially for occupational computer users,
it is useful to wear computer glasses.
Third, headaches are one of the major symptoms of CVS, but can be caused by a vari-
ety of sources (Gomzi, 1994). Thus, a complete eye exam should be conducted first. If the
headaches do not seem to be eye-related, computer users should consider an internal med-
ical exam. If it is determined that the inappropriate use of computers is causing the head-
aches, then reducing the duration of daily computer use, ensuring a correct viewing angle,
and maintaining a proper viewing distance will reduce or eliminate the headaches.
Fourth, general and computer glasses are the most likely solution to a blurred vision
problem (Butzon & Eagels, 1997; Butzon, Sheedy, & Nilsen, 2002). Computer glasses,
according to the American Optometric Association, are specifically designed for the com-
puter workplace and have a different lens design or prescription than general-wear glasses.
Research has indicated that computer glasses have been shown to be effective in the reduc-
tion of vision-related symptoms of computer users (Butzon et al., 2002). Vision therapy
could also be considered based on the nature of the problem and the patient’s age, time,
and preference (Lazarus, 1996; Ohlson, 2004).
Fifth, since multiple factors cause dry eyes, it is important first to have a proper
diagnosis and ergonomic evaluation to consider various potential reasons for the
 Z. Yan et al. / Computers in Human Behavior 24 (2008) 2026–2042 2039

problem. Treatment suggestions include: Blink frequently when using the computer
(Tsubota, 1998); Replace natural tears with artificial tears. Artificial tears usually solve
the problem of mild to moderate dry eyes (Acosta et al., 1999; Biswas et al., 2003);
Plug the eye’s drain on the lower eyelids to block drainage, which is recommended
for moderate to severe dry eyes; and seal the eye’s drain to blocking tear drainage
permanently.
Sixth, for neck and back ache, it is important for computer users to maintain the correct
posture, especially those who wear glasses (e.g. Bernard, 1997; Straker, Pollock, Burgess-
Limerick, Skoss, & Coleman, 2007). It is important to get regular eye exams and to have a
proper chair, table, and environment.

6. Where should behavioral scientists begin in studying CVS?

As previously discussed, eye–computer interactions concern five major components: the

computer screen, computer environment, eyes, computer users, and computer tasks. There
is extensive literature in behavioral ergonomics devoted to the study of both computer
screens and computer environments. There is also extensive literature in visual and occu-
pational optometry related to the examination of eye problems. While research is needed
to continue the advancement of current knowledge regarding computer screens (e.g. lap-
top screens), computer environments (e.g. atypical environments such as airports or res-
taurants), and human eyes (e.g. new environmental impacts), research is urgently
needed to study the following three specific areas.
First, efforts should be made to expand research in diverse computer user populations,
especially younger computer users. Middle-age adult occupational computer users repre-
sent the typical population that has been extensively studied over the past 20 years. Behav-
ioral researchers should examine different CVS populations of computer users to examine
factors such as current prevalence, specific visual symptoms, unique causes, underlying
mechanisms, and risk and protective factors.
Second, efforts should be made to examine diverse computer tasks, especially in the
areas of learning and entertainment. Computer tasks conducted in the workplace have
been studied extensively. However, computer use has expanded greatly from the initial
area of professional work to other areas such as learning and entertainment. Behavioral
researchers should examine the effects of different computer tasks on CVS, including the
effects of: (a) text-based materials, graphics-based materials, multimedia-based materials;
(b) reading, writing, games, online classes, chat rooms, instant messaging, email, WWW;
and (c) comparative studies of paper-based reading and screen-based reading. Different
activities might entail different intensity and duration of visual demands, subsequently
impacting CVS.
Finally, behavioral researchers should examine an urgent and important issue: Why is
CVS, a widely spreading epidemic, largely unknown to professional and ordinary com-
puter users? This topic is particularly interesting considering that extensive research has
been done in ergonomics since the 1980s and in optometry since the 1990s, and that pro-
fessional organizations such as the American Optometric Association have been conduct-
ing public awareness campaigns about CVS as early as 1995. Answering this question will
help millions of computer users gain knowledge about CVS and develop healthy behaviors
for using computers.
2040 Z. Yan et al. / Computers in Human Behavior 24 (2008) 2026–2042

Acknowledgements

This work was supported by the Wenzhou Medical College Major Research Project
Grant and the University at Albany Faculty Research Award awarded to Zheng Yan.
The authors wish to thank Dr. Jia Qu for his support of the project and Carla Corina
for her assistance in preparing the manuscript.

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