As we remain focused in our personal and professional ecosystems, many of us may be unaware of an industry that has a strong overlap with what we do best: esports. It’s understandable to struggle seeing how this could fit into practice, let alone consider it as a potential practice builder. It’s even understandable to initially be dismissive of “kids playing video games” being considered athletes. However, esports is an awakened giant that represents a great deal more opportunity for optometry practices than O.D.s may realize.

Consider this: A total of 204 million unique viewers tuned in to the 2016 NFL regular season in the U.S.¹ Comparatively, competitive video gaming drew 281 million viewers globally in 2016.² Surprised? This article will highlight why I believe we need to make the business of esports a part of practice.

WHAT IS ESPORTS? HOW BIG/COMMON IS IT REALLY?

Esports stands for “electronic sports” (the games do not need to be sports games, although several are). To add additional clarity, here is a great explanation from CNN:

“Esports describes the world of competitive, organized video gaming. Competitors from different leagues or teams face off in the same games that are popular with at-home gamers: ‘Fortnite,’ ‘League of Legends,’ ‘Counter-Strike,’ ‘Call of Duty,’ ‘Overwatch’ and ‘Madden NFL,’ to name a few. These gamers are watched and followed by millions of fans all over the world, who attend live events or tune in on TV or online. Streaming services like Twitch allow viewers to watch as their favorite gamers play in real time, and this is typically where popular gamers build up their fandoms.”

“Gamers,” as a general term, accounted for 66% of the United States population in 2018.³ The differentiators among casual players and athletes are the focus/training level, the competition, the audience and the equipment. Gamers typically spend several hours per day practicing (see more on the types of games below). Once they are ready, they compete in tournaments, either individually or with a team, that take place in multiplayer formats, typically rewarding players with a (substantial) cash prize pool. As an example, the prize pool for The International Dota 2 esports tournament in 2017 was $24.7 million.⁴ In that same year, the prize pool for the Masters was $11 million.⁵

Beyond the casual gamer, I think esports athletes can roughly be summarized into three main categories: the streamer, the aspiring player and the professional. The streamer is typically not as skilled as the professional player and, instead, builds a successful/profitable following with their personality. Aspiring players, however, are working toward becoming professional players. These players are training as much as they can, attending camps and intensive workshops that focus on perfecting their strategy and skill. Finally, there is the professional. They are often part of a team and heavily specialize in a single game. They are typically sponsored, often have legions of online followers and earn an average salary of $60,000 (with the top prize winners earning in the seven figures).⁶

Players can compete in several game formats:

• First-person shooter (FPS): This is your typical military-based shooter game, either solo or squad based.
• Fighting games: Games in which two players face off against one another in a one-on-one combat format.
• Multiplayer online battle arena (MOBA): Teams compete in visually intensive battle arenas, often in the realm of science fiction or fantasy.
• Sports games: This is competition in sports, such as football (“Madden”), basketball (“NBA2Kxx”) and soccer (“FIFA”).

HOW DO YOU IDENTIFY AN ESPORTS ATHLETE?

While not defining, here are a few key demographic elements:

• About 46% of gamers are women.⁷
• The average age of a North American esports professional player is between 24 and 27. Most aspiring gamers start to pursue their professional interests in their mid-teens and retire from esports in their mid 20s.⁸

Optometrists should consider asking all their teen and 20-something patients whether they are into esports (inquiring even for just a week), as a litmus test. O.D.s may be surprised with what they learn. Alternative ways to ask this question include: whether these patients are on Twitch (https://www.twitch.tv ), whether they play “Fortnite” and/or any of the other games mentioned above, or how many hours these patients typically play video games?

Utilizing a dry eye questionnaire could also prove beneficial to uncover frequent complaints from a demographic that would otherwise not typically complain about dry eye. (For a full list of questionnaires, see bit.ly/dryeyeqs.) Additionally, optometrists could create a brochure or post about how they can help gamers to draw attention to this service.

Beyond current patients, O.D.s can research their local community for esports clubs or official teams that could use their guidance in assuring these gamers’ vision is up to par for playing. For my part, I was surprised to learn that two of the universities with which I work — University of Central Florida and Barry University — have esports teams. Barry’s esports program is part of the school’s athletics department. Speaking to the athletic director, he explained that it is a fast-growing field of interest, in which Barry plans on staying at the forefront.

Terminology
“VISION TRAINING” VS. “VISION THERAPY“ IN ATHLETIC POPULATIONS

When speaking with athletes, I suggest using the phrase “vision training” vs. “vision therapy.” We can do therapy on a child, and we can do therapy on an athlete recovering from a concussion, but it is, at least in my opinion, a faux pas, to recommend an athlete do “therapy.” To an athlete, therapy means something is injured. We are doing “training” to enhance what the athletes already have. We need to be comfortable using the same lingo as athletes to live in their eco-system and, yes, these are esports athletes.

WHAT ARE THE VISUAL REQUIREMENTS OF THE ESPORTS ATHLETES?

I have found that a large majority of esports patients have multiple intermediate distance screens, spending hours looking at them while making “searching” eye movements, in all directions, for extended periods of time. Think of gamers like your patients who search and stare at spread sheets all day — but with much more intensity. Also, these patients have a high-level demand for eye-hand coordination and reaction time. As gamers become more advanced, they will develop the automaticity that will reduce the cognitive load of figuring out which buttons to smash and when. While some of the games, such as soccer and football, are on gaming consoles (e.g. XBOX, Nintendo Switch, etc.), the vast majority of competitive gamers sit at some form of a desk chair working from PCs.

Here is a breakdown of performance vision considerations for the gamer:

• VA
• Accommodation
• Figure ground
• Anticipatory timing
• Perception span
• Spatial localization
• Visual memory
• Accuracy of fixation
• Binocular alignment/fixation disparity
• Accuracy and fluidity of pursuits and saccades
• Visual reaction speed
• Processing speed
• Motor response time
• Multiple object tracking

HOW CAN YOU HELP THESE PATIENTS?

Optometrists can help these patients in many ways:

• Dry eye therapies. With intensity and concentration comes less blinking and more chance of ocular surface disruption. A bit of routine dry eye care could go a long way to enhance performance. This could include anything from artificial tears and ocular nutritional supplements, to any advanced treatment options you have for dry eye or meibomian gland dysfunction.
• Computer lenses. Optometrists should think, “What will give the gamer the most comfortable vision at the screen distance?” I would recommend either a single vision lens for best overall response to stimuli or a design that contains a power boost at the bottom. Less experienced gamers may still occasionally look down, while the more experienced gamers won’t need to.
• Blue light protection. Blue light fatigues our visual system when we look at screens for hours on end. Gamers have been using eyewear to reduce digital eye strain and blue light for more than 10 years. Some sort of blue light filter should be something to consider as an add-on to every gaming lens, although many high-end monitors now offer blue light filters as well. At the bare minimum, O.D.s should have the conversation about blue light.
• Vision training (see sidebar, p.16). Yes, vision training. If I can train a faster reaction time to a ball or a puck, I can help these athletes in the same way. The process is:
  1. Intake of visual information
  2. Processing/decision making
  3. Motor response

The response is different, but the order of operations is the same for any performance vision skill, and, thus, can be enhanced through training. For a binocular vision dysfunction, training will require a solid knowledge of binocular vision conditions, as well as the time/staff/equipment to properly do what we would usually call vision therapy. Therefore, for anyone who is not already active in vision training, but feels that the esport athlete is suffering from a minor alignment issue, I might recommend consideration of a “crutch” (with prism) or a referral to someone who already does vision.

Prism. Your gamer may not have a strabismus, but he may have an excess exophoria while scanning the screen. Without strong reserves, this person can have extreme fatigue or trigeminal dysphoria by the end of the day. Symptoms can range from eyestrain to headache and neck pain. Perhaps, the smallest amount of relieving prism could be a game-changer. Optometrists can facilitate this themselves, via their standard optical labs, or via specialized manufacturers that now offer variable prism.

GET IN THE GAME

In this article, I have introduced optometrists to a captive audience that appreciates the importance vision plays on their sport. Like so many sports vision articles, we say there is no reason to re-invent the wheel. Now, that O.D.s understand what esports athletes do and who they are, consider using what you already know to give these athletes the care they need. OM

REFERENCES

1. NFL Kickoff 2017 Information Guide. https://operations.nfl.com/media/2700/nfl-2017-kickoff-guide.pdf . Published 2017. Accessed Feb. 11, 2020.
2. Free 2018 Global Esports Market Report. https://resources.newzoo.com/hubfs/Reports/Newzoo_2018_Global_Esports_Market_Report_Excerpt.pdf? Published 2018. Accessed Feb. 11, 2020.
3. Penetration rate of gamers among the general population of the United States from 2013 to 2018. Statista. https://www.statista.com/statistics/748835/us-gamers-penetration-rate/ Published May 2018. Accessed Feb. 11, 2020.
4. Soper T. The International in Vancouver? Valve may move huge ‘Dota 2’ esports event from Seattle to Canada. GeekWire. Published Dec. 28, 2017. Accessed Feb. 11, 2020. https://www.geekwire.com/2017/international-vancouver-valve-may-move-huge-dota-2-esports-event-seattle-canada/
5. 2017 Masters purse, winner’s share, prize money payout. Golf News Net website. https://thegolfnewsnet.com/golfnewsnetteam/2017/04/09/2017-masters-purse-winners-share-prize-money-payout-103782/ Published April 9, 2017. Accessed Feb. 11, 2020.
6. Lykova D. ESports Earnings [25 Engaging Statistics for 2020]. Leftronic. https://leftronic.com/esports-earnings/ Published Nov. 20, 2019. Accessed Feb. 11, 2020.
7. Distribution of computer and video gamers in the United States from 2006 to 2019, by gender. Statista. https://www.statista.com/statistics/232383/gender-split-of-us-computer-and-video-gamers/ . Published May 2019. Accessed Feb. 11, 2020.
8. Average age of selected eSports games players in North America in 2015. Statista. https://www.statista.com/statistics/579779/age-esports-games-players/ . Published November 2015. Accessed Feb. 11, 2020.

DR. NANASY specializes in performance vision and is the director of the Florida Institute of Sports Vision, in Pembroke Pines, Fla. She is chair of the AOA Sports and Performance Vision Committe, and serves as a team eye doctor for professional, collegiate and youth sports, including the Miami Dolphins, Inter-Miami CF and University of Central Florida athletics.