An Investigation of the Psychosocial Outcomes of Dry Eye Disease Treatment in Children with Computer Vision Syndrome

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Methods In this study, a total of 38 children (6 boys, 32 girls) with CVS-related dry eye symptoms were evaluated with the Schirmer test, tear break-up time (TBUT), and ocular surface disease index (OSDI) at the time of diagnosis and after artificial tear drops treatment. Additionally, the quality of life (QoL) levels and the anxiety and depression symptoms were assessed using self- report scales for children. Results The mean age and mean total screen exposure of patients were 13.95 ± 2.42 years and 5.65 ± 2.31 hours, respectively. After treatment, TBUT and Schirmer test values of the patients increased significantly, while OSDI values decreased ( p < 0.001 for all). The total anxiety and the depression scores of the patients decreased ( p = 0.001, and p = 0.003, respectively); whilst the physical, emotional, social and school functionality scores increased ( p < 0.05 for all) with treatment. There was a significant correlation between the improvements in Schirmer test values and anxiety scores (r = -0.32, p = 0.045) and QoL total scores (r = 0.38, p = 0.016). Conclusions Enhanced QoL and decreased anxiety and depression scores, correlated with the amelioration of dry eye symptoms indicate that the CVS related DED has psychosocial effects, which may decrease after appropriate treatment, in pediatric patients. Future research endeavors that integrate comprehensive evaluations of dry eye and psychiatric symptoms can yield more comprehensive and precise insights into the interplay between psychiatric disorders and DED in children with CVS, as well as the outcomes of different treatment approaches. dry eye disease computer vision syndrome children quality of life anxiety depression Introduction Computer Vision Syndrome (CVS) is defined as a collection of eye-related issues and visual disturbances that occur due to prolonged use of digital screens [ 1 ]. CVS is commonly associated with prolonged computer usage exceeding 3 hours per day or 30 hours per week, and it is often characterized by visual, ocular and musculoskeletal symptoms [ 2 ]. The exponential proliferation of digital devices has become an integral part of daily life, putting millions of individuals across all age groups at risk of developing CVS. Individuals spend more time on computers, laptops, smartphones, tablets, and e-readers, which contribute to CVS. Children, also spend extensive hours using digital screens for schoolwork, playing video games, and sending and receiving text messages [ 3 ]. The prevalence of CVS in children and adolescent is estimated to range from 50–70%, as reported in previous studies [ 4 , 5 ]. The primary manifestation observed in CVS is the emergence of dry eye disease (DED), which exhibits a prevalence rate of approximately 60% [ 6 ]. DED is characterized by persistent symptoms such as tearing, burning or stinging sensation, ocular discomfort, blurred vision, and photophobia, which have been documented to have negative effects on the quality of life (QoL), encompassing not only vision related daily life, but also the broader aspects of general well-being [ 7 – 9 ]. Additionally, studies have revealed a higher prevalence of psychiatric disorders in patients with DED [ 10 – 12 ]. Among psychiatric diagnoses, anxiety and depressive disorders were the most frequently investigated, and findings consistently indicated that individuals with DED exhibited elevated levels of anxiety and depressive symptoms compared to those without DED [ 13 – 15 ]. Treatment options for DED often involve the use of artificial tear substitutes, which aim to replenish the natural tear film and provide lubrication to the eyes in order to alleviate symptoms [ 16 ]. Previous studies have reported that artificial tear treatments have been associated with improvements in overall enhancement of patients' QoL [ 17 ]. Additionally the potential of tear drops in patients with DED to mitigate symptoms of anxiety and depression has been announced [ 18 , 19 ]. Drawing from the aforementioned research studies, it can be inferred that DED treatment holds the potential to yield positive effects on the psychological well-being of children who were diagnosed with CVS. The primary objective of the present study was to assess the impact of DED treatment on health-related QoL, as well as levels of depression and anxiety levels, among pediatric patients with CVS. Hence, the research study posited the following hypothesis: After topical drop treatment, children with CVS would exhibit an enhanced overall QoL and a reduction anxiety and depression levels compared to their pretreatment assessments. Additionally, there would be positive correlations between improvements in psychosocial status and dry eye measurements. Finally, it was also aimed to the examine the effects of digital screen use on the relationship between the improvement of CVS-related DED and psychosocial outcomes. To the best of our knowledge, this study represents the first comprehensive evaluation of the impact of DED treatment on the QoL, along with anxiety and depression levels, in pediatric patients with CVS. Methods Study Design and Participants This prospective study was conducted at the ophthalmology department of a secondary-level hospital. The study protocol was approved by the local research ethics committee (Ethics approval number: 55-2022) and conducted in accordance with the ethical principles of the Declaration of Helsinki. Written informed consent was obtained from all children and their parents. Children with CVS between 9–18 years old who referred to the ophthalmology outpatient clinic were included. The study sample comprised 38 children with CVS. The condition known as CVS encompasses a range of ocular complaints experienced by digital screen users, including but not limited to eyestrain, eye fatigue, burning sensations, irritation, redness, blurred vision, and dry eyes, among other symptoms associated with prolonged computer use or viewing digital screens. Exclusion criteria were any other eye diseases (eg, retinal disease, uveitis, glaucoma, congenital cataract, pterygium, conjunctivitis, keratitis, blepharitis, history of ocular trauma or previous surgery, nystagmus, or orbital pathology), previous diagnosis of dry eye, use of artificial tears, any eye medication, contact lens wear, any neurological diseases (eg, cerebral palsy, epilepsy), any psychiatric diagnoses, and any other chronic illnesses (eg, type 1 diabetes). At initial assessment, 85 children with CVS were enrolled in the study. Moreover, potential factors contributing to DED symptoms, such as sun exposure, windy weather, or exposure to air conditioning, were scrutinized, and 15 patients presenting with these conditions were also excluded. Out of remaining 70 children, 50 of them had a complete ophthalmologic examination during the subsequent check-ups (20 participants did not attend the follow-up examinations), 12 of whom did not cooperate with psychiatric assessments were excluded. Finally, a total of 38 children were encompassed within the scope of this study. To assess computer exposure time, a questionnaire was employed to determine the duration of daily computer usage, measured in hours per day. Total screen exposure time was calculated for each child before and after DED treatment. Opthalmologic Evaluation Dry eye evaluation tests including tear break-up test (TBUT), Schirmer test and also Ocular Surface Disease Index (OSDI) were recorded before and one month after treatment. Treatment for dry eye was administered using artificial tear drops comprising dextran and hydroxypropyl methylcellulose, Symptomatic DED was diagnosed with the OSDI questionnaire, an OSDI value ≥ 13 was considered a diagnosis of DED. Ocular surface damage and signs of DED were assessed using TBUT and Schirmer tests. To evaluate TBUT, fluorescein was instilled into the bottom of the lower sac and the tear film was examined with a blue filter; the appearance of the first dry spots on the cornea is observed since the last blink, the average is taken in seconds of three consecutive measurements and a diagnostic value of ≤ 10 is considered. Schirmer’s test was evaluated with topical tetracaine to test basal tear secretion using a specialized Schirmer’s strip prepared from Whatman filter paper Grade 41. A value of Schirmer test ≤ 10 was considered DED. According to TBUT and Schirmer test with anterior segment evaluation, Dry Eye Workshop (DEWS) grades and Oxford scores were determined [ 20 ]. Psychiatric Measures Following the ophthalmologic examination, all participants were asked to complete the psychiatric scales in one session (approximately 30 minutes). After one month of follow-up, the same questionnaires were repeated. In the current study, Revised Children’s Anxiety and Depression Scale Child Version (RCADS-CV) and Pediatric Quality of Life Inventory (PedsQL) were used to assess children’s psychiatric symptoms and quality of life, respectively, based on children’s own reports. PedsQL was developed by Varni et al. to assess health-related quality of life in children [ 21 ]. The PedsQL TM 4.0 General Core Scales includes 23 items and four subscales: (1) physical functioning, (2) emotional functioning, (3) social functioning, and (4) school functioning. A 5-point response scale with scores ranging from 0 to 4 was used to assess child self-reports. Items were reverse scored and linearly transformed to a 0 to 100 scale (0 = 100%, 1 = 75%, 2 = 50%, 3 = 25%, 4 = 0%), so that higher scores indicated better quality of life. The range of measurement was based on the percentage of the total summary and subscale scores on the PedsQL [ 22 ]. The Turkish version of the PedsQL was found to be valid and reliable for the age group from 7 to 18 years [ 23 , 24 ]. RCADS-CV was developed to screen for anxiety, depressive, and obsessive-compulsive symptoms in children and adolescents. This self-report questionnaire consists of six subscales and 47 items: generalized anxiety disorder (GAD), separation anxiety disorder (SAD), panic disorder (PD), obsessive-compulsive disorder (OCD), social phobia (SP), and major depressive disorder (MDD). Additionally, there exist two comprehensive subscales referred to as "Total Internalizing" and "Total Anxiety. Each item is scored between 0 and 3 (0 = never, 1 = sometimes, 2 = often, 3 = always) [ 25 ]. The validity and reliability of the Turkish version were conducted by Görmez et al. [ 26 ]. Statistical Analysis A statistical power analysis was conducted to estimate the required sample size for sample size determination through the utilization of a paired sample t-test. In order to achieve an 80% power level (alpha = .05) [ 27 ] for the detection of a "medium" effect size, the anticipated sample size required, as determined by G*Power 3.1, was approximately 34 [ 28 , 29 ]. Statistical analyses were performed using SPSS 24.0. Comparisons of psychiatric scale measures and dry eye evaluation tests between pre- and post-treatment were reported using paired samples t test and Wilcoxon signed-ranked test according to the normality of the data. Pearson’s correlation analyses were conducted to determine the associations between the improvements in ophthalmic measurements and in psychiatric scales. Results Of 38 children with CVS, 84.2% (n = 32) were female and 15.8% (n = 6) were male. The mean age was 13.95 ± 2.42 years. The mean duration between two consecutive assesments was 35.36 ± 8.62 days. Demographic and clinical characteristics of the patients are shown in Table 1 . Table 1 Sociodemographic and Clinical Characteristics of Patients Characteristic Value Age (years) 13.95 ± 2.42 Sex (male/female), n (%) 6 (15.8) / 32 (84.2) BCVA 0.97 ± 0.05 Spherical equivalent, D -0.09 ± 0.55 IOP, mmHg 15.7 ± 3.1 Screen time exposure (hour per day) 5.65 ± 2.31 SD: Standard Deviation; BCVA: Best corrected visual acuity; D: Diopter; IOP: Intraocular pressure Values are presented as mean ± SD, unless otherwise noted. Table 2 Comparison of dry eye evaluation tests and psychiatric scale scores before and after treatment Dry eye evaluation tests Pre-treatment Mean ± SD / Median (IQR) Post-treatment Mean ± SD / Median (IQR) p t / Z TBUT * 7.45 ± 3.43 9.92 ± 2.89 < .001 -6.04 Schirmer test * 11.84 ± 6.50 15.66 ± 6.40 < .001 -4.84 Oxford ** 0 (0) 0 (0) .014 -2.44 DEWS * 2 (1) 2 (1) < .001 -4.91 OSDI * 45.99 ± 15.47 25.46 (13.37) < .001 8.20 Scales PedsQL * Physical functioning 72.44 ± 19.28 82.15 ± 14.40 < .001 -3.98 Emotional functioning 64.86 ± 21.03 73.94 ± 18.16 .006 -2.89 Social functioning 84.86 ± 21.73 90.13 ± 13.87 .04 -2.07 School functioning 68.28 ± 18.82 75.65 ± 17.09 .003 -3.16 Total 72.76 ± 16.94 80.47 ± 12.61 < .001 -3.92 RCADS-CV * GAD 49.08 ± 10.97 43.07 ± 11.24 .002 3.30 SAD 53.29 ± 11.37 49.36 ± 10.35 .03 2.13 PD 57.24 ± 13.07 52.44 ± 10.91 .01 2.73 OCD 53.21 ± 11.52 47.78 ± 10.94 .004 3.08 SP 48.16 ± 13.10 40.39 ± 10.88 .001 3.80 MDD 49.55 ± 14.09 44.47 ± 12.25 .003 3.22 Total Anxiety 52.94 ± 13.22 45.05 ± 12.25 .001 3.76 Total Internalizing 52.36 ± 13.58 44.73 ± 12.40 .001 3.76 SD: Standard Deviation; IQR: Interquartile Range; TBUT: Tear Break-Up Time; DEWS: Dry Eye Workshop; OSDI: Ocular Surface Disease Index; PedsQL: Pediatric Quality of Life Inventory; RCADS-CV: Revised Child Anxiety Depression Scale; GAD: Generalized Anxiety Disorder; SAD: Social Anxiety Disorder; PD: Panic disorder; OCD: Obsessive-Compulsive Disorder; SP: Social Phobia; MDD: Major Depressive Disorder. The characteristics of normally distributed variables are represented by Mean ± SD, and for non-normally distributed variables, Median (IQR) serve as representative measures. * Paired samples t test ** Wilcoxon signed-ranked test Bold values indicate statistical significance. According to the analyses of the children’s dry eye evaluation tests, comprising TBUT, Schirmer test and OSDI values before and after the artificial tear drops treatment, statistically significant differences were identified. Additionally, significant improvements in the QoL and anxiety, depression and OCD symptoms were found among children with CVS following the treatment (Table 2 ). There was a significant difference between the pre- and post-treatment evaluations in terms of screen exposure time as hours per day ( M pre = 5.65 ± 2.31, M post = 4.88 ± 2.56; t(37) = 3.11, p = .004). Upon assessing the associations using Pearson’s correlation test, between reductions in screen time measures (hours per day) and the improvement in DED evaluation test results, no statistically significant correlations were identified ( p = 0.33, p = 0.16, p = 0.12 for TBUT, Schirmer and OSDI, respectively.). Additionally, no significant correlation was detected between the reductions in screen usage prior to and following treatment, and the subsequent decrease in scores on the RCADS-CV ( p = 0.76), and QoL total scales ( p = 0.61). While investigating the associations between the improvements in DED and psychosocial outcomes, the statistically significant differences were detected in only Schirmer test values. As the comparisons for TBUT ( p = 0.27 for RCADS-CV internalizing and p = 0.32 for QoL total) and for OSDI ( p = 0.59 and p = 0.64, respectively) were performed, yielding results did not demonstrate significant differences. Statistically significant correlations were found between the magnitude of increase in Schirmer test values and the increase in quality of life scores (total and emotional functioning domain), as well as the decrease in generalized anxiety, total anxiety and total internalizing scores. Additionally, QoL scores were negatively correlated with anxiety and internalizing scores (Table 3 ). Table 3 Correlations between improvement in psychiatric scale scores and Schirmer tests Schirmer RCADS-Anxiety RCADS- Internalizing RCADS-GAD PedsQL-Total RCADS-Anxiety -0.32* RCADS-Internalizing -0.30 0.99*** RCADS-GAD -0.32* 0.89*** 0.88*** PedsQL-Total 0.38* -0.48** -0.47** -0.39* PedsQL- Emotional Functioning 0.32* -0.29 -0.30 -0.27 0.79*** RCADS: Revised Child Anxiety Depression Scale; PedsQL: Pediatric Quality of Life Inventory; GAD:Generalized Anxiety Disorder Pearson’s correlation test Bold values indicate statistical significance. * p < .05 ** p < .01 *** p <. 001 Discussion In the present study, we aimed to examine the effects of DED treatment on the improvements of QoL as well as depression and anxiety symptoms. Each hypothesis is further elaborated and examined in the following, providing detailed discussion. It has been announced that the widespread use of digital screens such as computers, tablets and smartphones has significantly contributed to the spread of DED in children and adolescents [ 30 , 31 ]. A recent study explored the correlations between computer exposure time and DED Evaluation tests, including Schirmer, TBUT and OSDI, indicating that a longer exposure time results in greater visual symptoms [ 32 ]. In contrast, a literature review indicated that electronic devices do not cause organic damage to the visual system [ 33 ]. Additionally, children comprising our sample group may not have undergone sustained exposure to screens, nor have they been professionally exposed to screens or computers for a prolonged duration at a chronic level. This aligns with the findings of the present study, which revealed no correlations between screen exposure time measures and DED evaluation tests. The limited size of our sample may present a significant constraint or limitation. And also, it is important to note that our study lacked a control group (non-DED), limiting our ability to make comparisons. Therefore, we were only able to assess these factors within a single group consisting of pediatric patients with DED associated with CVS. It is well known that DED has a detrimental impact on the patient's daily life. The unpleasant symptoms of dry eye, such as burning or stinging, ocular grittiness, foreign body sensation, blurred vision, and photophobia could contribute to the impaired QoL [ 34 ]. In addition to the alterations in visual performance and ocular functioning, chronic pain may also play a role in the poor QoL of patients with DED [ 8 , 9 , 35 ]. Topical eye drop treatments were found to be associated with improved QoL compared to baseline, as a significant number of patients reported relief from symptoms [ 36 , 37 ]. Our study revealed that statistically significant improvements in QoL were observed across all domains during the post-treatment assesment. Furthermore, positive correlations between QoL scores, specifically emotional functioning and total summary, and the Schirmer test results. These findings provide further support for prior research. In terms of the depression and anxiety levels of children, we detected statistically significant reductions in depression, all subtypes of anxiety, and total internalized symptoms following the treatment. Additionally, there were significant associations between the increase in Schirmer test values and the decreases in generalized anxiety and total anxiety scores. This is consistent with previous studies which have revealed that the severity of DED symptoms impacted on the depressive symptoms in youthful [ 35 ] and elderly populations [ 38 ]. While the observational nature of the present study prevents drawing causal inferences, it is conceivable that the reported associations may stem from multiple factors [ 35 ]. Dry eye symptoms may trigger or intensify symptoms of anxiety and depression. For example, ocular pain and discomfort could result in psychosocial stress, depression and anxiety [ 39 , 40 ]. On the contrary, depression, stress, and anxiety, may influence subjective ocular symptoms and pain perception, contributing to the formation of a cyclic relationship [ 41 , 42 ]. Depressive individuals may have a lower threshold for perceiving physical discomfort and pain [ 38 ]. Likewise, anxiety can also arise from patients' concerns regarding their symptoms and the possibility of occurence of DED [ 15 ]. Additionally, it has been suggested that patients with depression exhibit an increased susceptibility to DED due to the elevation of proinflammatory cytokines [ 43 ], and alterataions of neurotransmitters and neuropeptides [ 44 ]. Finally, depressive disorder and DED may have a common pathophysiology. Shared risk factors and increased production of inflammatory cytokines may contribute to the pathogenesis of both diseases [ 13 , 38 ]. In summary, while our study aligns with previous research, it is important to acknowledge that our findings may be limited due to the exclusion of patients with psychiatric disorders such as anxiety and depression. Additionally, the psychiatric assessments in our study were solely based on self-report scales, focusing on symptom levels. Therefore, these findings may not provide a comprehensive understanding of the relationship between DED and depression and anxiety. A notable association has been indicated between the severity of DED and the presence of depression and anxiety symptoms, suggesting that the successful management of DED may have a beneficial effect on alleviating symptoms of depression and anxiety [ 18 ]. A recent study showed the association between the eye drop frequency and depression, anxiety scores, suggesting that topical eye drops potentially plays a significant role in psychosocial status of patients with DED [ 19 ]. Concurrently, in our study, we found statistically significant associations between the improvement of DED symptoms, as measured by the Schirmer test, and reduced levels of anxiety and depression when comparing pre- and post-treatment outcomes. These findings suggest a relationship between psychological symptoms and the burden of DED [ 18 ], indicating that anxiety and depression may improve with the relief of dryness. Moreover, the observed decrease in symptoms of anxiety and depression may be attributed to the improvement in sleep quality [ 45 ], which has been reported to be compromised in patients with DED [ 14 , 46 ]. Although we found statistically significant differences in DED screening tests, including Schirmer, TBUT and OSDI between pre- and post-treatment assesments, a significant correlation was observed between the improvement in psychological well-being, including QoL and symptoms of depression and anxiety, and the amelioration in the Schirmer test results exclusively. These outcomes may be due to the low levels of correlation among objective dry eye tests that might reflect the diverse aetiology and complex pathophysiology of DED [ 47 ]. Furthermore, it is important to note that artificial tears do not address the underlying causes of DED [ 48 ]. As a result, additional treatment strategies are necessary for certain patients. However, our study solely focused on conditions related to a specific type of treatment, without conducting comparisons with alternative treatment options. Since digital screens are widely used, the age to meet digital screens is gradually decreasing. Studies have reported digital screen usage rates of up to 92.7% in the pediatric population [ 49 ], and DED is among the prevalent eye disorders in CVS [ 6 ]. In this study, decreased anxiety and increased functionality scores, correlated with dry eye severity, were found after dry eye treatment. It is thought that dry eye disease has psychosocial effects, which may decrease after appropriate treatment, in pediatric patients. The consultation-liaison psychiatry service involves a collaborative effort between psychiatrists and other medical specialists. Traditionally, ophthalmology and psychiatry have not had a close interface. However, our findings suggest a new possibility that liaison psychiatry could offer benefits to certain patients with ocular diseases, particularly those with CVS-related DED. This study has several limitations that should be acknowledged. Firstly, the study sample was limited to children with CVS, which may not be representative of the broader population. The generalizability of the results to children without CVS or other age groups could be limited. Secondly, the study relied on self-report measures to assess quality of life, anxiety, and depression levels, which may be subject to recall bias or subjective interpretation. Additionally, it is plausible that a noteworthy placebo effect may be present, potentially contributing to the observed results. Future studies could benefit from incorporating objective measures or clinical assessments to enhance the validity of the findings. While our study established a relationship between the amelioration of dry eye symptoms, improvements of psychiatric symptoms and QoL using a moderator regression model, the absence of a control group without DED hinders our ability to compare relevant variables. Since hypotheses of causality would require evaluations at different time points, longitudinal studies with a control group could provide more robust evidence in this regard. Moreover, the study did not extensively investigate the specific effects of digital screen use on the relationship between DED improvement and psychosocial outcomes. Lastly, it is important to note that there was no control group without any treatment for DED due to ethical considerations, as it is not appropriate to withhold eyedrop prescriptions from DED patients. Further research with a more focused approach on this aspect is warranted to provide a comprehensive understanding of these associations. In the available literature, limited research has focused on the impact of topical treatment on quality of life and psychosocial well-being, including anxiety and depression symptoms, in children with CVS-related dry eye disease. The present study presented a significant reduction in anxiety levels and improvement in QoL functionality scores following treatment for DED. These findings suggest that pediatric patients with DED experience psychosocial effects that can potentially be mitigated through appropriate treatment. Additional research endeavors are warranted to elucidate the relationship between psychiatric disorders and DED symptoms among children and adolescents with CVS. Abbreviations CVS Computer vision syndrome DED Dry eye disease TBUT Tear break-up test OSDI Ocular surface disease index DEWS Dry Eye Workshop RCADS-CV Revised Children’s Anxiety and Depression Scale Child Version PedsQL Pediatric Quality of Life Inventory Declarations Availability of data and materials The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions. Funding The authors declare that no funds, grants, or other support were received during the preparation of this manuscript. Competing Interests The authors have no relevant financial or non-financial interests to disclose. Author Contributions All authors contributed to the study conception, design, material preparation, data collection and analysis. The first draft of the manuscript was written by Rahime Duygu Temeltürk and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript. Ethics Approval This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committee of Haseki Training and Research Hospital (23.03.2022 / 55-2022). Consent to Participate Written informed consent was obtained from the children and their parents. Consent To Publish All authors have given consent for the study to be published in European Journal of Pediatrics. References Blehm C, Vishnu S, Khattak A, et al (2005) Computer vision syndrome: a review. Surv Ophthalmol 50:253–262 Association AO (2020) Computer vision syndrome. Am Acad Ophthalmol https//www aoa org/patients-and-public/caring-for-your-vision/protecting-your-vision/computer-vision-syndrome(8 May 2019) Anbesu EW, Lema AK (2023) Prevalence of computer vision syndrome: a systematic review and meta-analysis. Sci Rep 13:1801 Mohan A, Sen P, Shah C, et al (2021) Prevalence and risk factor assessment of digital eye strain among children using online e-learning during the COVID-19 pandemic: Digital eye strain among kids (DESK study-1). Indian J Ophthalmol 69:140 Rafeeq U, Omear M, Chauhan L, et al (2020) Computer vision syndrome among individuals using visual display terminals for more than two hours. Delta J Ophthalmol 21:139 Uchino M, Yokoi N, Uchino Y, et al (2013) Prevalence of dry eye disease and its risk factors in visual display terminal users: the Osaka study. Am J Ophthalmol 156:759–766 Paulsen AJ, Cruickshanks KJ, Fischer ME, et al (2014) Dry eye in the beaver dam offspring study: prevalence, risk factors, and health-related quality of life. Am J Ophthalmol 157:799–806 Li M, Gong L, Chapin WJ, Zhu M (2012) Assessment of vision-related quality of life in dry eye patients. Invest Ophthalmol Vis Sci 53:5722–5727 Miljanović B, Dana R, Sullivan DA, Schaumberg DA (2007) Impact of dry eye syndrome on vision-related quality of life. Am J Ophthalmol 143:409–415 Han SB, Yang HK, Hyon JY, Wee WR (2017) Association of dry eye disease with psychiatric or neurological disorders in elderly patients. Clin Interv Aging 12:785 Liang C-Y, Cheang W-M, Wang C-Y, et al (2020) The association of dry eye syndrome and psychiatric disorders: a nationwide population-based cohort study. BMC Ophthalmol 20:1–6 Kaãtelan S, Bakija I, Bogadi M, et al (2021) Psychiatric Disorders and Dry Eye Disease-A Transdisciplinary Approach. Psychiatr Danub 33:580–587 Labbé A, Wang YX, Jie Y, et al (2013) Dry eye disease, dry eye symptoms and depression: the Beijing Eye Study. Br J Ophthalmol 97:1399–1403 Ayyıldız D, Ayyıldız T (2019) Kuru Göz Hastalığının Depresif Belirti Düzeyi ve Uykusuzluk ile İlişkisi. J Turkish Sleep Med 1:49–52 Szakáts I, Sebestyén M, Németh J, et al (2016) The role of health anxiety and depressive symptoms in dry eye disease. Curr Eye Res 41:1044–1049 Jones L, Downie LE, Korb D, et al (2017) TFOS DEWS II management and therapy report. Ocul Surf 15:575–628 Gomes JAP, Santo RM (2019) The impact of dry eye disease treatment on patient satisfaction and quality of life: A review. Ocul Surf 17:9–19 Bitar MS, Olson DJ, Li M, Davis RM (2019) The correlation between dry eyes, anxiety and depression: the sicca, anxiety and depression study. Cornea 38:684–689 Vakros G, Scollo P, Hodson J, et al (2021) Anxiety and depression in inflammatory eye disease: exploring the potential impact of topical treatment frequency as a putative psychometric item. BMJ open Ophthalmol 6:e000649 Bron AJ, Abelson MB, Ousler G, et al (2007) Methodologies to diagnose and monitor dry eye disease: report of the Diagnostic Methodology Subcommittee of the International Dry Eye WorkShop (2007). Ocul Surf 5:108–152 Varni JW, Seid M, Rode CA (1999) The PedsQL TM : measurement model for the pediatric quality of life inventory. Med Care 126–139 Varni JW, Burwinkle TM, Seid M (2005) The PedsQL TM as a pediatric patient-reported outcome: Reliability and validity of the PedsQL TM Measurement Model in 25,000 children. Expert Rev Pharmacoecon Outcomes Res 5:705–719 Memik NÇ, Ağaoğlu B, Coşkun A, Karakaya I (2008) The validity and reliability of pediatric quality of life inventory in 8-12 year old Turkish children. Turk J Child Adolesc Ment Heal 15:87–98 Memik NÇ, Ağaoğlu B, Coşkun A, et al (2007) Çocuklar için yaşam kalitesi ölçeğinin 13-18 yaş ergen formunun geçerlik ve güvenilirliği. Türk Psikiyatr Derg 18:353–363 Chorpita BF, Yim L, Moffitt C, et al (2000) Assessment of symptoms of DSM-IV anxiety and depression in children: A revised child anxiety and depression scale. Behav Res Ther 38:835–855 Gormez V, Kılınçaslan A, Orengul AC, et al (2017) Psychometric properties of the Turkish version of the Revised Child Anxiety and Depression Scale–Child Version in a clinical sample. Psychiatry Clin Psychopharmacol 27:84–92 Cohen J (1988) Statistical power analysis for the behavioral sciences New York. NY Acad Faul F, Erdfelder E, Buchner A, Lang A-G (2009) Statistical power analyses using G* Power 3.1: Tests for correlation and regression analyses. Behav Res Methods 41:1149–1160 Faul F, Erdfelder E, Lang A-G, Buchner A (2007) G* Power 3: A flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behav Res Methods 39:175–191 Marshall SJ, Gorely T, Biddle SJH (2006) A descriptive epidemiology of screen-based media use in youth: a review and critique. J Adolesc 29:333–349 Moon JH, Lee MY, Moon NJ (2014) Association between video display terminal use and dry eye disease in school children. J Pediatr Ophthalmol Strabismus 51:87–92 Sánchez-Valerio M del R, Mohamed-Noriega K, Zamora-Ginez I, et al (2020) Dry eye disease association with computer exposure time among subjects with computer vision syndrome. Clin Ophthalmol 4311–4317 Díaz AA, Reyes NB, Rangel LEC (2017) Efectos de los dispositivos electrónicos sobre el sistema visual. Rev Mex Oftalmol 91:103–106 Le Q, Zhou X, Ge L, et al (2012) Impact of dry eye syndrome on vision-related quality of life in a non-clinic-based general population. BMC Ophthalmol 12:1–8 Asiedu K, Dzasimatu SK, Kyei S (2018) Impact of dry eye on psychosomatic symptoms and quality of life in a healthy youthful clinical sample. Eye Contact Lens 44:S404–S409 Rolando M, Autori S, Badino F, Barabino S (2009) Protecting the ocular surface and improving the quality of life of dry eye patients: a study of the efficacy of an HP-guar containing ocular lubricant in a population of dry eye patients. J Ocul Pharmacol Ther 25:271–278 Friedman NJ (2010) Impact of dry eye disease and treatment on quality of life. Curr Opin Ophthalmol 21:310–316 Kim KW, Han SB, Han ER, et al (2011) Association between depression and dry eye disease in an elderly population. Invest Ophthalmol Vis Sci 52:7954–7958 Na K-S, Han K, Park Y-G, et al (2015) Depression, stress, quality of life, and dry eye disease in Korean women: a population-based study. Cornea 34:733–738 Hyon JY, Yang HK, Han SB (2019) Dry eye symptoms may have association with psychological stress in medical students. Eye Contact Lens 45:310–314 Kotte A, Joshi G, Fried R, et al (2013) Autistic traits in children with and without ADHD. Pediatrics 132:e612–e622 Vriezekolk JE, Geenen R, Hartkamp A, et al (2005) Psychological and somatic predictors of perceived and measured ocular dryness of patients with primary Sjögren’s syndrome. J Rheumatol 32:2351–2355 Mrugacz M, Ostrowska L, Bryl A, et al (2017) Pro-inflammatory cytokines associated with clinical severity of dry eye disease of patients with depression. Adv Med Sci 62:338–344 Galor A, Feuer W, Lee DJ, et al (2012) Depression, post-traumatic stress disorder, and dry eye syndrome: a study utilizing the national United States Veterans Affairs administrative database. Am J Ophthalmol 154:340–346 Ayaki M, Toda I, Tachi N, et al (2016) Preliminary report of improved sleep quality in patients with dry eye disease after initiation of topical therapy. Neuropsychiatr Dis Treat 329–337 Ayaki M, Kawashima M, Negishi K, et al (2016) Sleep and mood disorders in women with dry eye disease. Sci Rep 6:1–8 Németh J, Fodor E, Lang Z, et al (2012) Lid-parallel conjunctival folds (LIPCOF) and dry eye: a multicentre study. Br J Ophthalmol 96:1380–1385 Matossian C, Crowley M, Periman L, Sorkin S (2022) Personalized Management of Dry Eye Disease: Beyond Artificial Tears. Clin Ophthalmol 3911–3918 Coutinho F, Saxena G, Shah A, et al (2022) Mobile media exposure and use in children aged zero to five years with diagnosed neurodevelopmental disability. Disabil Rehabil Assist Technol 17:645–651 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3250007","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":225427497,"identity":"932038ca-7107-4b8a-acd0-75704119fd10","order_by":0,"name":"Rahime Duygu Temeltürk","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA7ElEQVRIiWNgGAWjYFCCBBiRwMzwAUixsZOihXEGSAszKVqYeUBsQlrM23PMJL+2pckbHE8+bGzza5s8HzMD44ePObi1yJx5YyYt25ZjuOHMs+Tk3L7bhm3MDMySM7fh1iIhkWMmLdlWwbjhRo7x4dye24xALWzMvERosQdrsey5bU+UFsmPbTmJIC3JDD9uJxLWwvOs2JrhXFryTKBfDHsbbie3MTM24/cLe/LGmz/Kkm37gCEm8ePPbdv57c0HP3zEowUIWKRB0aFwAEgwtoEEGBvwqgcC5o8/gKQ8WN0fQopHwSgYBaNgJAIAK0xS1DAw2jsAAAAASUVORK5CYII=","orcid":"","institution":"Ankara University","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Rahime","middleName":"Duygu","lastName":"Temeltürk","suffix":""},{"id":225427498,"identity":"1d5a6e5f-f8e9-4b03-a4e7-c5a18815967f","order_by":1,"name":"Ali Mert Koçer","email":"","orcid":"","institution":"University of Health Sciences, Ulucanlar Eye Education and Research Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Ali","middleName":"Mert","lastName":"Koçer","suffix":""},{"id":225427499,"identity":"11684c1a-7aca-4cb2-986e-1708f1a1c705","order_by":2,"name":"Ece Özal","email":"","orcid":"","institution":"University of Health Sciences, Başakşehir Çam and Sakura City Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Ece","middleName":"","lastName":"Özal","suffix":""}],"badges":[],"createdAt":"2023-08-09 20:44:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3250007/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3250007/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":43764830,"identity":"9620589d-edfc-4148-a397-9742c87fdfbe","added_by":"auto","created_at":"2023-09-27 12:59:39","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":347054,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3250007/v1/00b183c2-6f5c-4e11-8163-75e4bbb49b9a.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"An Investigation of the Psychosocial Outcomes of Dry Eye Disease Treatment in Children with Computer Vision Syndrome","fulltext":[{"header":"Introduction","content":"\u003cp\u003eComputer Vision Syndrome (CVS) is defined as a collection of eye-related issues and visual disturbances that occur due to prolonged use of digital screens [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. CVS is commonly associated with prolonged computer usage exceeding 3 hours per day or 30 hours per week, and it is often characterized by visual, ocular and musculoskeletal symptoms [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe exponential proliferation of digital devices has become an integral part of daily life, putting millions of individuals across all age groups at risk of developing CVS. Individuals spend more time on computers, laptops, smartphones, tablets, and e-readers, which contribute to CVS. Children, also spend extensive hours using digital screens for schoolwork, playing video games, and sending and receiving text messages [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. The prevalence of CVS in children and adolescent is estimated to range from 50\u0026ndash;70%, as reported in previous studies [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe primary manifestation observed in CVS is the emergence of dry eye disease (DED), which exhibits a prevalence rate of approximately 60% [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. DED is characterized by persistent symptoms such as tearing, burning or stinging sensation, ocular discomfort, blurred vision, and photophobia, which have been documented to have negative effects on the quality of life (QoL), encompassing not only vision related daily life, but also the broader aspects of general well-being [\u003cspan additionalcitationids=\"CR8\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Additionally, studies have revealed a higher prevalence of psychiatric disorders in patients with DED [\u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Among psychiatric diagnoses, anxiety and depressive disorders were the most frequently investigated, and findings consistently indicated that individuals with DED exhibited elevated levels of anxiety and depressive symptoms compared to those without DED [\u003cspan additionalcitationids=\"CR14\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTreatment options for DED often involve the use of artificial tear substitutes, which aim to replenish the natural tear film and provide lubrication to the eyes in order to alleviate symptoms [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Previous studies have reported that artificial tear treatments have been associated with improvements in overall enhancement of patients' QoL [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Additionally the potential of tear drops in patients with DED to mitigate symptoms of anxiety and depression has been announced [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDrawing from the aforementioned research studies, it can be inferred that DED treatment holds the potential to yield positive effects on the psychological well-being of children who were diagnosed with CVS. The primary objective of the present study was to assess the impact of DED treatment on health-related QoL, as well as levels of depression and anxiety levels, among pediatric patients with CVS. Hence, the research study posited the following hypothesis: After topical drop treatment, children with CVS would exhibit an enhanced overall QoL and a reduction anxiety and depression levels compared to their pretreatment assessments. Additionally, there would be positive correlations between improvements in psychosocial status and dry eye measurements. Finally, it was also aimed to the examine the effects of digital screen use on the relationship between the improvement of CVS-related DED and psychosocial outcomes. To the best of our knowledge, this study represents the first comprehensive evaluation of the impact of DED treatment on the QoL, along with anxiety and depression levels, in pediatric patients with CVS.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design and Participants\u003c/h2\u003e \u003cp\u003eThis prospective study was conducted at the ophthalmology department of a secondary-level hospital. The study protocol was approved by the local research ethics committee (Ethics approval number: 55-2022) and conducted in accordance with the ethical principles of the Declaration of Helsinki. Written informed consent was obtained from all children and their parents. Children with CVS between 9\u0026ndash;18 years old who referred to the ophthalmology outpatient clinic were included. The study sample comprised 38 children with CVS. The condition known as CVS encompasses a range of ocular complaints experienced by digital screen users, including but not limited to eyestrain, eye fatigue, burning sensations, irritation, redness, blurred vision, and dry eyes, among other symptoms associated with prolonged computer use or viewing digital screens. Exclusion criteria were any other eye diseases (eg, retinal disease, uveitis, glaucoma, congenital cataract, pterygium, conjunctivitis, keratitis, blepharitis, history of ocular trauma or previous surgery, nystagmus, or orbital pathology), previous diagnosis of dry eye, use of artificial tears, any eye medication, contact lens wear, any neurological diseases (eg, cerebral palsy, epilepsy), any psychiatric diagnoses, and any other chronic illnesses (eg, type 1 diabetes). At initial assessment, 85 children with CVS were enrolled in the study. Moreover, potential factors contributing to DED symptoms, such as sun exposure, windy weather, or exposure to air conditioning, were scrutinized, and 15 patients presenting with these conditions were also excluded. Out of remaining 70 children, 50 of them had a complete ophthalmologic examination during the subsequent check-ups (20 participants did not attend the follow-up examinations), 12 of whom did not cooperate with psychiatric assessments were excluded. Finally, a total of 38 children were encompassed within the scope of this study.\u003c/p\u003e \u003cp\u003eTo assess computer exposure time, a questionnaire was employed to determine the duration of daily computer usage, measured in hours per day. Total screen exposure time was calculated for each child before and after DED treatment.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eOpthalmologic Evaluation\u003c/h2\u003e \u003cp\u003eDry eye evaluation tests including tear break-up test (TBUT), Schirmer test and also Ocular Surface Disease Index (OSDI) were recorded before and one month after treatment. Treatment for dry eye was administered using artificial tear drops comprising dextran and hydroxypropyl methylcellulose,\u003c/p\u003e \u003cp\u003eSymptomatic DED was diagnosed with the OSDI questionnaire, an OSDI value\u0026thinsp;\u0026ge;\u0026thinsp;13 was considered a diagnosis of DED. Ocular surface damage and signs of DED were assessed using TBUT and Schirmer tests. To evaluate TBUT, fluorescein was instilled into the bottom of the lower sac and the tear film was examined with a blue filter; the appearance of the first dry spots on the cornea is observed since the last blink, the average is taken in seconds of three consecutive measurements and a diagnostic value of \u0026le;\u0026thinsp;10 is considered. Schirmer\u0026rsquo;s test was evaluated with topical tetracaine to test basal tear secretion using a specialized Schirmer\u0026rsquo;s strip prepared from Whatman filter paper Grade 41. A value of Schirmer test\u0026thinsp;\u0026le;\u0026thinsp;10 was considered DED. According to TBUT and Schirmer test with anterior segment evaluation, Dry Eye Workshop (DEWS) grades and Oxford scores were determined [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003ePsychiatric Measures\u003c/h2\u003e \u003cp\u003e Following the ophthalmologic examination, all participants were asked to complete the psychiatric scales in one session (approximately 30 minutes). After one month of follow-up, the same questionnaires were repeated.\u003c/p\u003e \u003cp\u003eIn the current study, Revised Children\u0026rsquo;s Anxiety and Depression Scale Child Version (RCADS-CV) and Pediatric Quality of Life Inventory (PedsQL) were used to assess children\u0026rsquo;s psychiatric symptoms and quality of life, respectively, based on children\u0026rsquo;s own reports.\u003c/p\u003e \u003cp\u003ePedsQL was developed by Varni et al. to assess health-related quality of life in children [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. The PedsQL TM 4.0 General Core Scales includes 23 items and four subscales: (1) physical functioning, (2) emotional functioning, (3) social functioning, and (4) school functioning. A 5-point response scale with scores ranging from 0 to 4 was used to assess child self-reports. Items were reverse scored and linearly transformed to a 0 to 100 scale (0\u0026thinsp;=\u0026thinsp;100%, 1\u0026thinsp;=\u0026thinsp;75%, 2\u0026thinsp;=\u0026thinsp;50%, 3\u0026thinsp;=\u0026thinsp;25%, 4\u0026thinsp;=\u0026thinsp;0%), so that higher scores indicated better quality of life. The range of measurement was based on the percentage of the total summary and subscale scores on the PedsQL [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. The Turkish version of the PedsQL was found to be valid and reliable for the age group from 7 to 18 years [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cem\u003eRCADS-CV\u003c/em\u003e was developed to screen for anxiety, depressive, and obsessive-compulsive symptoms in children and adolescents. This self-report questionnaire consists of six subscales and 47 items: generalized anxiety disorder (GAD), separation anxiety disorder (SAD), panic disorder (PD), obsessive-compulsive disorder (OCD), social phobia (SP), and major depressive disorder (MDD). Additionally, there exist two comprehensive subscales referred to as \"Total Internalizing\" and \"Total Anxiety. Each item is scored between 0 and 3 (0\u0026thinsp;=\u0026thinsp;never, 1\u0026thinsp;=\u0026thinsp;sometimes, 2\u0026thinsp;=\u0026thinsp;often, 3\u0026thinsp;=\u0026thinsp;always) [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. The validity and reliability of the Turkish version were conducted by G\u0026ouml;rmez et al. [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eA statistical power analysis was conducted to estimate the required sample size for sample size determination through the utilization of a paired sample t-test. In order to achieve an 80% power level (alpha\u0026thinsp;=\u0026thinsp;.05) [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] for the detection of a \"medium\" effect size, the anticipated sample size required, as determined by G*Power 3.1, was approximately 34 [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Statistical analyses were performed using SPSS 24.0. Comparisons of psychiatric scale measures and dry eye evaluation tests between pre- and post-treatment were reported using paired samples \u003cem\u003et\u003c/em\u003e test and Wilcoxon signed-ranked test according to the normality of the data. Pearson\u0026rsquo;s correlation analyses were conducted to determine the associations between the improvements in ophthalmic measurements and in psychiatric scales.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eOf 38 children with CVS, 84.2% (n\u0026thinsp;=\u0026thinsp;32) were female and 15.8% (n\u0026thinsp;=\u0026thinsp;6) were male. The mean age was 13.95\u0026thinsp;\u0026plusmn;\u0026thinsp;2.42 years. The mean duration between two consecutive assesments was 35.36\u0026thinsp;\u0026plusmn;\u0026thinsp;8.62 days. Demographic and clinical characteristics of the patients are shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSociodemographic and Clinical Characteristics of Patients\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eValue\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13.95\u0026thinsp;\u0026plusmn;\u0026thinsp;2.42\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex (male/female), n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (15.8) / 32 (84.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBCVA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.97\u0026thinsp;\u0026plusmn;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSpherical equivalent, D\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.09\u0026thinsp;\u0026plusmn;\u0026thinsp;0.55\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIOP, mmHg\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15.7\u0026thinsp;\u0026plusmn;\u0026thinsp;3.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eScreen time exposure (hour per day)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.65\u0026thinsp;\u0026plusmn;\u0026thinsp;2.31\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003eSD: Standard Deviation; BCVA: Best corrected visual acuity; D: Diopter; IOP: Intraocular pressure\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eValues are presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD, unless otherwise noted.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of dry eye evaluation tests and psychiatric scale scores before and after treatment\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDry eye evaluation\u003c/p\u003e \u003cp\u003etests\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePre-treatment\u003c/p\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD /\u003c/p\u003e \u003cp\u003eMedian (IQR)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePost-treatment\u003c/p\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD /\u003c/p\u003e \u003cp\u003eMedian (IQR)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003et / Z\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTBUT *\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.45\u0026thinsp;\u0026plusmn;\u0026thinsp;3.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.92\u0026thinsp;\u0026plusmn;\u0026thinsp;2.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-6.04\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSchirmer test *\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11.84\u0026thinsp;\u0026plusmn;\u0026thinsp;6.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15.66\u0026thinsp;\u0026plusmn;\u0026thinsp;6.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-4.84\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOxford **\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e.014\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-2.44\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDEWS *\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-4.91\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOSDI *\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e45.99\u0026thinsp;\u0026plusmn;\u0026thinsp;15.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25.46 (13.37)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e8.20\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eScales\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePedsQL *\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePhysical functioning\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e72.44\u0026thinsp;\u0026plusmn;\u0026thinsp;19.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e82.15\u0026thinsp;\u0026plusmn;\u0026thinsp;14.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-3.98\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmotional functioning\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e64.86\u0026thinsp;\u0026plusmn;\u0026thinsp;21.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e73.94\u0026thinsp;\u0026plusmn;\u0026thinsp;18.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e.006\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-2.89\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSocial functioning\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e84.86\u0026thinsp;\u0026plusmn;\u0026thinsp;21.73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e90.13\u0026thinsp;\u0026plusmn;\u0026thinsp;13.87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e.04\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-2.07\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSchool functioning\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e68.28\u0026thinsp;\u0026plusmn;\u0026thinsp;18.82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e75.65\u0026thinsp;\u0026plusmn;\u0026thinsp;17.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e.003\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-3.16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e72.76\u0026thinsp;\u0026plusmn;\u0026thinsp;16.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e80.47\u0026thinsp;\u0026plusmn;\u0026thinsp;12.61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-3.92\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRCADS-CV *\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGAD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e49.08\u0026thinsp;\u0026plusmn;\u0026thinsp;10.97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43.07\u0026thinsp;\u0026plusmn;\u0026thinsp;11.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e.002\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3.30\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSAD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e53.29\u0026thinsp;\u0026plusmn;\u0026thinsp;11.37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e49.36\u0026thinsp;\u0026plusmn;\u0026thinsp;10.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e.03\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e57.24\u0026thinsp;\u0026plusmn;\u0026thinsp;13.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e52.44\u0026thinsp;\u0026plusmn;\u0026thinsp;10.91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.73\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOCD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e53.21\u0026thinsp;\u0026plusmn;\u0026thinsp;11.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e47.78\u0026thinsp;\u0026plusmn;\u0026thinsp;10.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e.004\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3.08\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e48.16\u0026thinsp;\u0026plusmn;\u0026thinsp;13.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40.39\u0026thinsp;\u0026plusmn;\u0026thinsp;10.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3.80\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMDD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e49.55\u0026thinsp;\u0026plusmn;\u0026thinsp;14.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e44.47\u0026thinsp;\u0026plusmn;\u0026thinsp;12.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e.003\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3.22\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal Anxiety\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e52.94\u0026thinsp;\u0026plusmn;\u0026thinsp;13.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45.05\u0026thinsp;\u0026plusmn;\u0026thinsp;12.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3.76\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal Internalizing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e52.36\u0026thinsp;\u0026plusmn;\u0026thinsp;13.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e44.73\u0026thinsp;\u0026plusmn;\u0026thinsp;12.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3.76\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eSD: Standard Deviation; IQR: Interquartile Range; TBUT: Tear Break-Up Time; DEWS: Dry Eye Workshop; OSDI: Ocular Surface Disease Index; PedsQL: Pediatric Quality of Life Inventory; RCADS-CV: Revised Child Anxiety Depression Scale; GAD: Generalized Anxiety Disorder; SAD: Social Anxiety Disorder; PD: Panic disorder; OCD: Obsessive-Compulsive Disorder; SP: Social Phobia; MDD: Major Depressive Disorder.\u003c/p\u003e \u003cp\u003eThe characteristics of normally distributed variables are represented by Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD, and for non-normally distributed variables, Median (IQR) serve as representative measures.\u003c/p\u003e \u003cp\u003e \u003csup\u003e \u003cem\u003e*\u003c/em\u003e \u003c/sup\u003e \u003cem\u003ePaired samples t test\u003c/em\u003e\u003c/p\u003e \u003cp\u003e \u003csup\u003e \u003cem\u003e**\u003c/em\u003e \u003c/sup\u003e \u003cem\u003eWilcoxon signed-ranked test\u003c/em\u003e\u003c/p\u003e \u003cp\u003eBold values indicate statistical significance.\u003c/p\u003e \u003cp\u003eAccording to the analyses of the children\u0026rsquo;s dry eye evaluation tests, comprising TBUT, Schirmer test and OSDI values before and after the artificial tear drops treatment, statistically significant differences were identified. Additionally, significant improvements in the QoL and anxiety, depression and OCD symptoms were found among children with CVS following the treatment (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). There was a significant difference between the pre- and post-treatment evaluations in terms of screen exposure time as hours per day (\u003cem\u003eM\u003c/em\u003e\u003csub\u003epre\u003c/sub\u003e= 5.65\u0026thinsp;\u0026plusmn;\u0026thinsp;2.31, \u003cem\u003eM\u003c/em\u003e\u003csub\u003epost\u003c/sub\u003e= 4.88\u0026thinsp;\u0026plusmn;\u0026thinsp;2.56; t(37)\u0026thinsp;=\u0026thinsp;3.11, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.004).\u003c/p\u003e \u003cp\u003eUpon assessing the associations using Pearson\u0026rsquo;s correlation test, between reductions in screen time measures (hours per day) and the improvement in DED evaluation test results, no statistically significant correlations were identified (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.33, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.16, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.12 for TBUT, Schirmer and OSDI, respectively.). Additionally, no significant correlation was detected between the reductions in screen usage prior to and following treatment, and the subsequent decrease in scores on the RCADS-CV (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.76), and QoL total scales (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.61).\u003c/p\u003e \u003cp\u003eWhile investigating the associations between the improvements in DED and psychosocial outcomes, the statistically significant differences were detected in only Schirmer test values. As the comparisons for TBUT (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.27 for RCADS-CV internalizing and \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.32 for QoL total) and for OSDI (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.59 and \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.64, respectively) were performed, yielding results did not demonstrate significant differences. Statistically significant correlations were found between the magnitude of increase in Schirmer test values and the increase in quality of life scores (total and emotional functioning domain), as well as the decrease in generalized anxiety, total anxiety and total internalizing scores. Additionally, QoL scores were negatively correlated with anxiety and internalizing scores (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCorrelations between improvement in psychiatric scale scores and Schirmer tests\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSchirmer\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRCADS-Anxiety\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRCADS-\u003c/p\u003e \u003cp\u003eInternalizing\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRCADS-GAD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePedsQL-Total\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRCADS-Anxiety\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.32*\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRCADS-Internalizing\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-0.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.99***\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRCADS-GAD\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e-0.32*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.89***\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.88***\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePedsQL-Total\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e0.38*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e-0.48**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e-0.47**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e-0.39*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePedsQL- Emotional\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eFunctioning\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e0.32*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e-0.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-0.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-0.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.79***\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eRCADS: Revised Child Anxiety Depression Scale; PedsQL: Pediatric Quality of Life Inventory; GAD:Generalized Anxiety Disorder\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003cp\u003ePearson\u0026rsquo;s correlation test\u003c/p\u003e \u003cp\u003eBold values indicate statistical significance.\u003c/p\u003e \u003cp\u003e*\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.05\u003c/p\u003e \u003cp\u003e**\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.01\u003c/p\u003e \u003cp\u003e***\u003cem\u003ep\u003c/em\u003e\u0026lt;. 001\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn the present study, we aimed to examine the effects of DED treatment on the improvements of QoL as well as depression and anxiety symptoms. Each hypothesis is further elaborated and examined in the following, providing detailed discussion.\u003c/p\u003e \u003cp\u003eIt has been announced that the widespread use of digital screens such as computers, tablets and smartphones has significantly contributed to the spread of DED in children and adolescents [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. A recent study explored the correlations between computer exposure time and DED Evaluation tests, including Schirmer, TBUT and OSDI, indicating that a longer exposure time results in greater visual symptoms [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. In contrast, a literature review indicated that electronic devices do not cause organic damage to the visual system [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Additionally, children comprising our sample group may not have undergone sustained exposure to screens, nor have they been professionally exposed to screens or computers for a prolonged duration at a chronic level. This aligns with the findings of the present study, which revealed no correlations between screen exposure time measures and DED evaluation tests. The limited size of our sample may present a significant constraint or limitation. And also, it is important to note that our study lacked a control group (non-DED), limiting our ability to make comparisons. Therefore, we were only able to assess these factors within a single group consisting of pediatric patients with DED associated with CVS.\u003c/p\u003e \u003cp\u003eIt is well known that DED has a detrimental impact on the patient's daily life. The unpleasant symptoms of dry eye, such as burning or stinging, ocular grittiness, foreign body sensation, blurred vision, and photophobia could contribute to the impaired QoL [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. In addition to the alterations in visual performance and ocular functioning, chronic pain may also play a role in the poor QoL of patients with DED [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Topical eye drop treatments were found to be associated with improved QoL compared to baseline, as a significant number of patients reported relief from symptoms [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. Our study revealed that statistically significant improvements in QoL were observed across all domains during the post-treatment assesment. Furthermore, positive correlations between QoL scores, specifically emotional functioning and total summary, and the Schirmer test results. These findings provide further support for prior research.\u003c/p\u003e \u003cp\u003eIn terms of the depression and anxiety levels of children, we detected statistically significant reductions in depression, all subtypes of anxiety, and total internalized symptoms following the treatment. Additionally, there were significant associations between the increase in Schirmer test values and the decreases in generalized anxiety and total anxiety scores. This is consistent with previous studies which have revealed that the severity of DED symptoms impacted on the depressive symptoms in youthful [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e] and elderly populations [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. While the observational nature of the present study prevents drawing causal inferences, it is conceivable that the reported associations may stem from multiple factors [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Dry eye symptoms may trigger or intensify symptoms of anxiety and depression. For example, ocular pain and discomfort could result in psychosocial stress, depression and anxiety [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. On the contrary, depression, stress, and anxiety, may influence subjective ocular symptoms and pain perception, contributing to the formation of a cyclic relationship [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. Depressive individuals may have a lower threshold for perceiving physical discomfort and pain [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. Likewise, anxiety can also arise from patients' concerns regarding their symptoms and the possibility of occurence of DED [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Additionally, it has been suggested that patients with depression exhibit an increased susceptibility to DED due to the elevation of proinflammatory cytokines [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e], and alterataions of neurotransmitters and neuropeptides [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. Finally, depressive disorder and DED may have a common pathophysiology. Shared risk factors and increased production of inflammatory cytokines may contribute to the pathogenesis of both diseases [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. In summary, while our study aligns with previous research, it is important to acknowledge that our findings may be limited due to the exclusion of patients with psychiatric disorders such as anxiety and depression. Additionally, the psychiatric assessments in our study were solely based on self-report scales, focusing on symptom levels. Therefore, these findings may not provide a comprehensive understanding of the relationship between DED and depression and anxiety.\u003c/p\u003e \u003cp\u003eA notable association has been indicated between the severity of DED and the presence of depression and anxiety symptoms, suggesting that the successful management of DED may have a beneficial effect on alleviating symptoms of depression and anxiety [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. A recent study showed the association between the eye drop frequency and depression, anxiety scores, suggesting that topical eye drops potentially plays a significant role in psychosocial status of patients with DED [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Concurrently, in our study, we found statistically significant associations between the improvement of DED symptoms, as measured by the Schirmer test, and reduced levels of anxiety and depression when comparing pre- and post-treatment outcomes. These findings suggest a relationship between psychological symptoms and the burden of DED [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], indicating that anxiety and depression may improve with the relief of dryness. Moreover, the observed decrease in symptoms of anxiety and depression may be attributed to the improvement in sleep quality [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e], which has been reported to be compromised in patients with DED [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. Although we found statistically significant differences in DED screening tests, including Schirmer, TBUT and OSDI between pre- and post-treatment assesments, a significant correlation was observed between the improvement in psychological well-being, including QoL and symptoms of depression and anxiety, and the amelioration in the Schirmer test results exclusively. These outcomes may be due to the low levels of correlation among objective dry eye tests that might reflect the diverse aetiology and complex pathophysiology of DED [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. Furthermore, it is important to note that artificial tears do not address the underlying causes of DED [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e]. As a result, additional treatment strategies are necessary for certain patients. However, our study solely focused on conditions related to a specific type of treatment, without conducting comparisons with alternative treatment options.\u003c/p\u003e \u003cp\u003eSince digital screens are widely used, the age to meet digital screens is gradually decreasing. Studies have reported digital screen usage rates of up to 92.7% in the pediatric population [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e], and DED is among the prevalent eye disorders in CVS [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn this study, decreased anxiety and increased functionality scores, correlated with dry eye severity, were found after dry eye treatment. It is thought that dry eye disease has psychosocial effects, which may decrease after appropriate treatment, in pediatric patients.\u003c/p\u003e \u003cp\u003eThe consultation-liaison psychiatry service involves a collaborative effort between psychiatrists and other medical specialists. Traditionally, ophthalmology and psychiatry have not had a close interface. However, our findings suggest a new possibility that liaison psychiatry could offer benefits to certain patients with ocular diseases, particularly those with CVS-related DED.\u003c/p\u003e \u003cp\u003eThis study has several limitations that should be acknowledged. Firstly, the study sample was limited to children with CVS, which may not be representative of the broader population. The generalizability of the results to children without CVS or other age groups could be limited. Secondly, the study relied on self-report measures to assess quality of life, anxiety, and depression levels, which may be subject to recall bias or subjective interpretation. Additionally, it is plausible that a noteworthy placebo effect may be present, potentially contributing to the observed results. Future studies could benefit from incorporating objective measures or clinical assessments to enhance the validity of the findings. While our study established a relationship between the amelioration of dry eye symptoms, improvements of psychiatric symptoms and QoL using a moderator regression model, the absence of a control group without DED hinders our ability to compare relevant variables. Since hypotheses of causality would require evaluations at different time points, longitudinal studies with a control group could provide more robust evidence in this regard. Moreover, the study did not extensively investigate the specific effects of digital screen use on the relationship between DED improvement and psychosocial outcomes. Lastly, it is important to note that there was no control group without any treatment for DED due to ethical considerations, as it is not appropriate to withhold eyedrop prescriptions from DED patients. Further research with a more focused approach on this aspect is warranted to provide a comprehensive understanding of these associations.\u003c/p\u003e \u003cp\u003eIn the available literature, limited research has focused on the impact of topical treatment on quality of life and psychosocial well-being, including anxiety and depression symptoms, in children with CVS-related dry eye disease. The present study presented a significant reduction in anxiety levels and improvement in QoL functionality scores following treatment for DED. These findings suggest that pediatric patients with DED experience psychosocial effects that can potentially be mitigated through appropriate treatment. Additional research endeavors are warranted to elucidate the relationship between psychiatric disorders and DED symptoms among children and adolescents with CVS.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eCVS\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eComputer vision syndrome\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eDED\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eDry eye disease\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eTBUT\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eTear break-up test\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eOSDI\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eOcular surface disease index\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eDEWS\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eDry Eye Workshop\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eRCADS-CV\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eRevised Children\u0026rsquo;s Anxiety and Depression Scale Child Version\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003ePedsQL\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePediatric Quality of Life Inventory\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that no funds, grants, or other support were received during the preparation of this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no relevant financial or non-financial interests to disclose.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors contributed to the study conception, design, material preparation, data collection and analysis. The first draft of the manuscript was written by Rahime Duygu Temelt\u0026uuml;rk and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics Approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committee of\u0026nbsp;Haseki Training and Research Hospital\u0026nbsp;(23.03.2022 / 55-2022).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to Participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from the children and their parents.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent To Publish\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors have given consent for the study to be published in European Journal of Pediatrics.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eBlehm C, Vishnu S, Khattak A, et al (2005) Computer vision syndrome: a review. Surv Ophthalmol 50:253\u0026ndash;262\u003c/li\u003e\n\u003cli\u003eAssociation AO (2020) Computer vision syndrome. Am Acad Ophthalmol https//www aoa org/patients-and-public/caring-for-your-vision/protecting-your-vision/computer-vision-syndrome(8 May 2019)\u003c/li\u003e\n\u003cli\u003eAnbesu EW, Lema AK (2023) Prevalence of computer vision syndrome: a systematic review and meta-analysis. Sci Rep 13:1801\u003c/li\u003e\n\u003cli\u003eMohan A, Sen P, Shah C, et al (2021) Prevalence and risk factor assessment of digital eye strain among children using online e-learning during the COVID-19 pandemic: Digital eye strain among kids (DESK study-1). Indian J Ophthalmol 69:140\u003c/li\u003e\n\u003cli\u003eRafeeq U, Omear M, Chauhan L, et al (2020) Computer vision syndrome among individuals using visual display terminals for more than two hours. Delta J Ophthalmol 21:139\u003c/li\u003e\n\u003cli\u003eUchino M, Yokoi N, Uchino Y, et al (2013) Prevalence of dry eye disease and its risk factors in visual display terminal users: the Osaka study. Am J Ophthalmol 156:759\u0026ndash;766\u003c/li\u003e\n\u003cli\u003ePaulsen AJ, Cruickshanks KJ, Fischer ME, et al (2014) Dry eye in the beaver dam offspring study: prevalence, risk factors, and health-related quality of life. Am J Ophthalmol 157:799\u0026ndash;806\u003c/li\u003e\n\u003cli\u003eLi M, Gong L, Chapin WJ, Zhu M (2012) Assessment of vision-related quality of life in dry eye patients. Invest Ophthalmol Vis Sci 53:5722\u0026ndash;5727\u003c/li\u003e\n\u003cli\u003eMiljanović B, Dana R, Sullivan DA, Schaumberg DA (2007) Impact of dry eye syndrome on vision-related quality of life. Am J Ophthalmol 143:409\u0026ndash;415\u003c/li\u003e\n\u003cli\u003eHan SB, Yang HK, Hyon JY, Wee WR (2017) Association of dry eye disease with psychiatric or neurological disorders in elderly patients. Clin Interv Aging 12:785\u003c/li\u003e\n\u003cli\u003eLiang C-Y, Cheang W-M, Wang C-Y, et al (2020) The association of dry eye syndrome and psychiatric disorders: a nationwide population-based cohort study. BMC Ophthalmol 20:1\u0026ndash;6\u003c/li\u003e\n\u003cli\u003eKa\u0026atilde;telan S, Bakija I, Bogadi M, et al (2021) Psychiatric Disorders and Dry Eye Disease-A Transdisciplinary Approach. Psychiatr Danub 33:580\u0026ndash;587\u003c/li\u003e\n\u003cli\u003eLabb\u0026eacute; A, Wang YX, Jie Y, et al (2013) Dry eye disease, dry eye symptoms and depression: the Beijing Eye Study. Br J Ophthalmol 97:1399\u0026ndash;1403\u003c/li\u003e\n\u003cli\u003eAyyıldız D, Ayyıldız T (2019) Kuru G\u0026ouml;z Hastalığının Depresif Belirti D\u0026uuml;zeyi ve Uykusuzluk ile İlişkisi. J Turkish Sleep Med 1:49\u0026ndash;52\u003c/li\u003e\n\u003cli\u003eSzak\u0026aacute;ts I, Sebesty\u0026eacute;n M, N\u0026eacute;meth J, et al (2016) The role of health anxiety and depressive symptoms in dry eye disease. Curr Eye Res 41:1044\u0026ndash;1049\u003c/li\u003e\n\u003cli\u003eJones L, Downie LE, Korb D, et al (2017) TFOS DEWS II management and therapy report. Ocul Surf 15:575\u0026ndash;628\u003c/li\u003e\n\u003cli\u003eGomes JAP, Santo RM (2019) The impact of dry eye disease treatment on patient satisfaction and quality of life: A review. Ocul Surf 17:9\u0026ndash;19\u003c/li\u003e\n\u003cli\u003eBitar MS, Olson DJ, Li M, Davis RM (2019) The correlation between dry eyes, anxiety and depression: the sicca, anxiety and depression study. Cornea 38:684\u0026ndash;689\u003c/li\u003e\n\u003cli\u003eVakros G, Scollo P, Hodson J, et al (2021) Anxiety and depression in inflammatory eye disease: exploring the potential impact of topical treatment frequency as a putative psychometric item. BMJ open Ophthalmol 6:e000649\u003c/li\u003e\n\u003cli\u003eBron AJ, Abelson MB, Ousler G, et al (2007) Methodologies to diagnose and monitor dry eye disease: report of the Diagnostic Methodology Subcommittee of the International Dry Eye WorkShop (2007). Ocul Surf 5:108\u0026ndash;152\u003c/li\u003e\n\u003cli\u003eVarni JW, Seid M, Rode CA (1999) The PedsQL\u003csup\u003eTM\u003c/sup\u003e: measurement model for the pediatric quality of life inventory. Med Care 126\u0026ndash;139\u003c/li\u003e\n\u003cli\u003eVarni JW, Burwinkle TM, Seid M (2005) The PedsQL\u003csup\u003eTM\u003c/sup\u003e as a pediatric patient-reported outcome: Reliability and validity of the PedsQL\u003csup\u003eTM\u003c/sup\u003e Measurement Model in 25,000 children. Expert Rev Pharmacoecon Outcomes Res 5:705\u0026ndash;719\u003c/li\u003e\n\u003cli\u003eMemik N\u0026Ccedil;, Ağaoğlu B, Coşkun A, Karakaya I (2008) The validity and reliability of pediatric quality of life inventory in 8-12 year old Turkish children. Turk J Child Adolesc Ment Heal 15:87\u0026ndash;98\u003c/li\u003e\n\u003cli\u003eMemik N\u0026Ccedil;, Ağaoğlu B, Coşkun A, et al (2007) \u0026Ccedil;ocuklar i\u0026ccedil;in yaşam kalitesi \u0026ouml;l\u0026ccedil;eğinin 13-18 yaş ergen formunun ge\u0026ccedil;erlik ve g\u0026uuml;venilirliği. T\u0026uuml;rk Psikiyatr Derg 18:353\u0026ndash;363\u003c/li\u003e\n\u003cli\u003eChorpita BF, Yim L, Moffitt C, et al (2000) Assessment of symptoms of DSM-IV anxiety and depression in children: A revised child anxiety and depression scale. Behav Res Ther 38:835\u0026ndash;855\u003c/li\u003e\n\u003cli\u003eGormez V, Kılın\u0026ccedil;aslan A, Orengul AC, et al (2017) Psychometric properties of the Turkish version of the Revised Child Anxiety and Depression Scale\u0026ndash;Child Version in a clinical sample. Psychiatry Clin Psychopharmacol 27:84\u0026ndash;92\u003c/li\u003e\n\u003cli\u003eCohen J (1988) Statistical power analysis for the behavioral sciences New York. NY Acad\u003c/li\u003e\n\u003cli\u003eFaul F, Erdfelder E, Buchner A, Lang A-G (2009) Statistical power analyses using G* Power 3.1: Tests for correlation and regression analyses. Behav Res Methods 41:1149\u0026ndash;1160\u003c/li\u003e\n\u003cli\u003eFaul F, Erdfelder E, Lang A-G, Buchner A (2007) G* Power 3: A flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behav Res Methods 39:175\u0026ndash;191\u003c/li\u003e\n\u003cli\u003eMarshall SJ, Gorely T, Biddle SJH (2006) A descriptive epidemiology of screen-based media use in youth: a review and critique. J Adolesc 29:333\u0026ndash;349\u003c/li\u003e\n\u003cli\u003eMoon JH, Lee MY, Moon NJ (2014) Association between video display terminal use and dry eye disease in school children. J Pediatr Ophthalmol Strabismus 51:87\u0026ndash;92\u003c/li\u003e\n\u003cli\u003eS\u0026aacute;nchez-Valerio M del R, Mohamed-Noriega K, Zamora-Ginez I, et al (2020) Dry eye disease association with computer exposure time among subjects with computer vision syndrome. Clin Ophthalmol 4311\u0026ndash;4317\u003c/li\u003e\n\u003cli\u003eD\u0026iacute;az AA, Reyes NB, Rangel LEC (2017) Efectos de los dispositivos electr\u0026oacute;nicos sobre el sistema visual. Rev Mex Oftalmol 91:103\u0026ndash;106\u003c/li\u003e\n\u003cli\u003eLe Q, Zhou X, Ge L, et al (2012) Impact of dry eye syndrome on vision-related quality of life in a non-clinic-based general population. BMC Ophthalmol 12:1\u0026ndash;8\u003c/li\u003e\n\u003cli\u003eAsiedu K, Dzasimatu SK, Kyei S (2018) Impact of dry eye on psychosomatic symptoms and quality of life in a healthy youthful clinical sample. Eye Contact Lens 44:S404\u0026ndash;S409\u003c/li\u003e\n\u003cli\u003eRolando M, Autori S, Badino F, Barabino S (2009) Protecting the ocular surface and improving the quality of life of dry eye patients: a study of the efficacy of an HP-guar containing ocular lubricant in a population of dry eye patients. J Ocul Pharmacol Ther 25:271\u0026ndash;278\u003c/li\u003e\n\u003cli\u003eFriedman NJ (2010) Impact of dry eye disease and treatment on quality of life. Curr Opin Ophthalmol 21:310\u0026ndash;316\u003c/li\u003e\n\u003cli\u003eKim KW, Han SB, Han ER, et al (2011) Association between depression and dry eye disease in an elderly population. Invest Ophthalmol Vis Sci 52:7954\u0026ndash;7958\u003c/li\u003e\n\u003cli\u003eNa K-S, Han K, Park Y-G, et al (2015) Depression, stress, quality of life, and dry eye disease in Korean women: a population-based study. Cornea 34:733\u0026ndash;738\u003c/li\u003e\n\u003cli\u003eHyon JY, Yang HK, Han SB (2019) Dry eye symptoms may have association with psychological stress in medical students. Eye Contact Lens 45:310\u0026ndash;314\u003c/li\u003e\n\u003cli\u003eKotte A, Joshi G, Fried R, et al (2013) Autistic traits in children with and without ADHD. Pediatrics 132:e612\u0026ndash;e622\u003c/li\u003e\n\u003cli\u003eVriezekolk JE, Geenen R, Hartkamp A, et al (2005) Psychological and somatic predictors of perceived and measured ocular dryness of patients with primary Sj\u0026ouml;gren\u0026rsquo;s syndrome. J Rheumatol 32:2351\u0026ndash;2355\u003c/li\u003e\n\u003cli\u003eMrugacz M, Ostrowska L, Bryl A, et al (2017) Pro-inflammatory cytokines associated with clinical severity of dry eye disease of patients with depression. Adv Med Sci 62:338\u0026ndash;344\u003c/li\u003e\n\u003cli\u003eGalor A, Feuer W, Lee DJ, et al (2012) Depression, post-traumatic stress disorder, and dry eye syndrome: a study utilizing the national United States Veterans Affairs administrative database. Am J Ophthalmol 154:340\u0026ndash;346\u003c/li\u003e\n\u003cli\u003eAyaki M, Toda I, Tachi N, et al (2016) Preliminary report of improved sleep quality in patients with dry eye disease after initiation of topical therapy. Neuropsychiatr Dis Treat 329\u0026ndash;337\u003c/li\u003e\n\u003cli\u003eAyaki M, Kawashima M, Negishi K, et al (2016) Sleep and mood disorders in women with dry eye disease. Sci Rep 6:1\u0026ndash;8\u003c/li\u003e\n\u003cli\u003eN\u0026eacute;meth J, Fodor E, Lang Z, et al (2012) Lid-parallel conjunctival folds (LIPCOF) and dry eye: a multicentre study. Br J Ophthalmol 96:1380\u0026ndash;1385\u003c/li\u003e\n\u003cli\u003eMatossian C, Crowley M, Periman L, Sorkin S (2022) Personalized Management of Dry Eye Disease: Beyond Artificial Tears. Clin Ophthalmol 3911\u0026ndash;3918\u003c/li\u003e\n\u003cli\u003eCoutinho F, Saxena G, Shah A, et al (2022) Mobile media exposure and use in children aged zero to five years with diagnosed neurodevelopmental disability. Disabil Rehabil Assist Technol 17:645\u0026ndash;651\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"dry eye disease, computer vision syndrome, children, quality of life, anxiety, depression","lastPublishedDoi":"10.21203/rs.3.rs-3250007/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3250007/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eTo examine the effects of topical eye drops treatment on the psychosocial status of pediatric patients with computer vision syndrome (CVS)-related dry eye disease (DED).\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eIn this study, a total of 38 children (6 boys, 32 girls) with CVS-related dry eye symptoms were evaluated with the Schirmer test, tear break-up time (TBUT), and ocular surface disease index (OSDI) at the time of diagnosis and after artificial tear drops treatment. Additionally, the quality of life (QoL) levels and the anxiety and depression symptoms were assessed using self- report scales for children.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe mean age and mean total screen exposure of patients were 13.95\u0026thinsp;\u0026plusmn;\u0026thinsp;2.42 years and 5.65\u0026thinsp;\u0026plusmn;\u0026thinsp;2.31 hours, respectively. After treatment, TBUT and Schirmer test values of the patients increased significantly, while OSDI values decreased (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001 for all). The total anxiety and the depression scores of the patients decreased (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.001, and \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.003, respectively); whilst the physical, emotional, social and school functionality scores increased (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05 for all) with treatment. There was a significant correlation between the improvements in Schirmer test values and anxiety scores (r = -0.32, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.045) and QoL total scores (r\u0026thinsp;=\u0026thinsp;0.38, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.016).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eEnhanced QoL and decreased anxiety and depression scores, correlated with the amelioration of dry eye symptoms indicate that the CVS related DED has psychosocial effects, which may decrease after appropriate treatment, in pediatric patients. Future research endeavors that integrate comprehensive evaluations of dry eye and psychiatric symptoms can yield more comprehensive and precise insights into the interplay between psychiatric disorders and DED in children with CVS, as well as the outcomes of different treatment approaches.\u003c/p\u003e","manuscriptTitle":"An Investigation of the Psychosocial Outcomes of Dry Eye Disease Treatment in Children with Computer Vision Syndrome","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-08-16 09:15:55","doi":"10.21203/rs.3.rs-3250007/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"eebf540e-014b-4959-a56f-9c0b0388e3de","owner":[],"postedDate":"August 16th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2023-09-27T12:59:29+00:00","versionOfRecord":[],"versionCreatedAt":"2023-08-16 09:15:55","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3250007","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3250007","identity":"rs-3250007","version":["v1"]},"buildId":"rHA-KDH7Qsr4HCuvH75dn","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}