Myopia in children is reaching epidemic proportions and the reason is obvious: too much time behind the screen

“Look closely, Ava, where are the forks pointing?” Doctor’s assistant Veronique van der Knaap points to a poster with E-shaped symbols that are tilted in different ways. Four-year-old Ava sits on her mother’s lap with her legs dangling and hesitantly turns her pointer to the left. Van der Knaap knows enough. ‘You’re doing very well, but your eyes are having a bit of trouble.’

Van der Knaap – an energetic woman who has been in the profession for almost 19 years – carries out eye screenings on children almost every day. Or ‘the eye game’, as she introduces it to the four-year-olds on Wednesday morning. She says she works in ‘the nicest Center for Youth and Family in the Netherlands’: this CJG (formerly the child health clinic) is a library in the heart of Rotterdam with a view of the Markthal.

Van der Knaap is increasingly forced to refer children to an ophthalmologist. Ophthalmologists are now talking about an epidemic: a growing number of Dutch people are becoming nearsighted at a young age. Caroline Klaver is the leader of Dutch ophthalmologists who are trying to create more awareness of this problem. “About eighty years ago, 1 in 5 young adults needed glasses,” says Klaver. “Now it’s already half.”

Smartphone and tablet

Nearsightedness (myopia in jargon) can have several causes, including genetic predisposition. ‘But the main culprits in these developments are the smartphone and the tablet,’ says Klaver. She explains that this is mainly about one thing: distance. When an eye needs to focus on a point close to the face, the lens becomes convex to bring the focal point into sharp focus. That takes energy, and if it happens more often, it can lead to the eye becoming longer. This may require glasses for distance vision.

“That can happen when reading books, but also by looking at a phone screen for a long time,” says Klaver. A lot of screen time in childhood can lead to myopia later in life. According to Klaver, part of the solution is simple and cheap: playing outside. Together with colleagues, she introduced the 20-20-2 rule: after looking at a screen for a maximum of twenty minutes, look outside for at least twenty seconds, and outside for at least two hours a day.

The problem is greatest in China, where 90 percent of young adults are nearsighted. The forecast for 2050 is that half of the world’s population will be nearsighted. Klaver: ‘In Taiwan, children are now required to play outside for two hours a day, and they are already seeing a decline in myopia among children.’

Arm’s length distance

During the consultations, Van der Knaap tells the parents about the 20-20-2 rule. “It’s important to keep the screen at least an adult arm’s length from the face,” she adds. When she asks parents about their children’s screen use, most say it is ‘an hour or half an hour a day, in front of the television.’ But when Van der Knaap asks about tablet and telephone use, it usually turns out more.

‘Here too, babies, toddlers and preschoolers are sometimes put behind a telephone in the waiting room,’ says Van der Knaap. ‘When we have to do something that children find exciting, such as weighing or vaccinating, parents sometimes have the tendency to pick up their phone to distract themselves. We discourage this. We advise: no screen use under the age of two.’

Ava’s mother, Laura van der Wal, is familiar with the 20-20-2 rule and is conscious about screen use. She says that her daughter sometimes plays games or watches videos on the iPad. ‘Sometimes you can’t avoid it. I’m also often on my phone and children want to imitate their parents.’ Van der Knaap explains that watching television occasionally is not a problem, as long as the distance to the eyes is large enough. “I’m also a mother, so I understand that a screen is sometimes nice to have your hands free,” she says.

Irreparable eye damage

According to Klaver, it is especially important to monitor screen use at a young age, when the eye is still developing. ‘The sooner someone needs glasses, the longer their eyes will continue to grow. Becoming nearsighted is like blowing up a balloon; the wall is getting thinner and thinner.’ This can lead to irreversible eye damage: the connective tissue can sag with age, the retina can detach, it can cause ‘bald spots’ at the back of the retina, or eye problems such as cataracts or glaucoma.

Jennifer Verhoekx, one of the mothers present, can easily list these risks. “My husband and I are both ophthalmologists,” she says. Still, she is curious how her daughter will fare with the eye test: eye complaints run in the family. Her children do not have a tablet or telephone of their own, but even she sometimes cannot avoid it. ‘In a restaurant it is sometimes very practical.’ Her daughter’s eyes seem to be doing well: on the poster she points out E’tje after E’tje.

It may also be a false alarm for Ava. A youth doctor briefly looks into her eyes with a light, but sees nothing remarkable. “It may be that the eye strength is not good, but also that Ava does not fully understand the test yet,” says Van der Knaap. She now has to practice at home and come back for a second check. Van der Wal’s mother would not mind it if her daughter had to wear glasses in the future. ‘But if it were because of the screens, so if I could really have done something about it, I would find it annoying.’