Treatment of ADHD insomnia with blue wavelength blocking glasses

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ChronoPhysiology and Therapy 2013:3 1–8
ChronoPhysiology and erapy
Treatment of attention decit hyperactivity
disorder insomnia with blue wavelength
light-blocking glasses
Rachel E Fargason
Taylor Preston
Emily Hammond
Roberta May
Karen L Gamble
Department of Psychiatry and
Behavioral Neurobiology, University
of Alabama at Birmingham School
of Medicine, Birmingham, AL, USA
Correspondence: Rachel Fargason
3rd Floor Callahan Eye Foundation
Hospital, 1720 University Boulevard,
Birmingham, AL 35294, USA
Tel +1 205 934 4301
Fax +1 205 975 9600
Email Rfargason@uab.edu
Background: The aim of this study was to examine a nonmedical treatment alternative to
medication in attention deficit hyperactivity disorder (ADHD) insomnia, in which blue wavelength
light-blocking glasses are worn during the evening hours to counteract the phase-delaying effect
of light. Outcome measures included sleep quality and midsleep time. The capacity of ADHD
subjects to comply with treatment using the glasses was assessed.
Methods: Daily bedtime, wake-up time, and compliance diaries were used to assess sleep
quality and timing during a baseline observation week and a 2-week intervention period. The
Pittsburgh Sleep Quality Index (PSQI) was administered following baseline and intervention.
The intervention protocol consisted of use of blue wavelength-blocking glasses and a moderate
lighting environment during evening hours.
Results: Partial and variable compliance were noted, with only 14 of 22 subjects completing
the study due to nonadherence with wearing the glasses and diary completion. Despite the
minimum 3-hour recommendation, glasses were worn, on average, for 2.4 hours daily. Lighting
was reduced for only 58.7% of the evening. Compared with baseline, the intervention resulted
in significant improvement in global PSQI scores, PSQI subcomponent scores, and sleep diary
measures of morning refreshment after sleep (P = 0.037) and night-time awakenings (P = 0.015).
Global PSQI scores fell from 11.15 to 4.54, dropping below the cut-off score of 5 for clinical
insomnia. The more phase-delayed subjects, ie, those with an initial midsleep time after 4:15 am,
trended towards an earlier midsleep time by 43.2 minutes following the intervention (P = 0.073).
Participants reported less anxiety following the intervention (P = 0.048).
Conclusions: Despite only partial compliance with intervention instructions, subjects com-
pleting the study showed subjectively reduced anxiety and improved sleep quality on multiple
measures. The more sleep-delayed subjects trended toward an earlier sleep period following
use of the glasses. Blue-blocking glasses are a potential insomnia treatment for more compliant
subjects with ADHD insomnia, especially those with prominent sleep delay. Larger studies of
blue light-blocking glasses in more phase-delayed groups could reveal significant advances in
chronotherapeutics.
Keywords: insomnia, attention deficit hyperactivity disorder, circadian rhythm disorders,
chronobiological treatment
Introduction
Attention deficit hyperactivity disorder (ADHD) insomnia is a prevalent problem. An
estimated 4.4% of the adult population suffers from ADHD, with over 70% of these
individuals experiencing insomnia.
1,2
Dim-light melatonin onset studies and clinical
studies using DSM-IV-TR (Diagnostic and Statistical Manual of Mental Disorders,
Fourth Edition, Text Revision) criteria have demonstrated that two-thirds of subjects
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with ADHD insomnia have circadian rhythm sleep disorder,
delayed sleep phase type,
3,4
and one-third have primary
insomnia without evidence of circadian delay.
4
Even groups
of ADHD subjects who do not report sleep problems often
manifest clinically significant insomnia.
3,5
Recent studies
show a link between ADHD and genes involved in the
circadian timekeeping system.
6,7
A polymorphism at the
3′-untranslated region of the circadian locomotor output
cycles kaput (CLOCK) gene is associated with adult ADHD.
6
It is unknown whether a common genetic link underlies
both the ADHD and the circadian disorder, or if the sleep
disorder is simply a modifier of ADHD symptomatology.
Intrinsically photoreceptive melanopsin-containing retinal
ganglion cells are primarily responsible for transmitting the
presence of short-wavelength light to the primary circadian
pacemaker in the suprachiasmatic nucleus, which in turn
suppresses the hormone melatonin.
8
ADHD subjects have
suppressed, shortened, and delayed evening melatonin
secretion, which affects both melatonin-related hypnotic
and circadian phase resetting functions, as well as bodily
functions such as blood pressure, thermoregulation, and
glucose regulation.
3,9
Exogenous melatonin is commonly
used to treat insomnia in ADHD, but study results for
efficacy are conflicting,
10
as a result of the varying potency
of a substance not approved by the US Food and Drug
Administration and the individual variability in timing and
dosing needs of melatonergic agents.
11,12
Another study
of chronobiological treatments for ADHD demonstrated
that advancing the circadian phase in ADHD subjects by
use of morning bright light therapy is strongly correlated
with improvement in core ADHD symptoms.
13
Despite the
positive results of that study, it has not been replicated with
objective measures of circadian phase. Chronobiological
treatments, such as bright light therapy, have become the
standard of care for some psychiatric conditions, such as
seasonal affective disorder,
14
and are gaining momentum with
the use of total sleep deprivation to advance circadian phase
in manic bipolar subjects in order to stabilize mood.
15
Despite
recent advances, many potential uses of chronobiological
treatments for psychiatric disorders with circadian disruption,
including ADHD, are as yet unexplored.
Chronic exposure to electrical lighting in the evening
further disrupts melatonin signaling in both ADHD and control
subjects, suppressing and delaying the normal nocturnal
rise in melatonin to a profound degree, and shortening
melatonin duration and the body’s internal representation
of night.
16
Melatonin suppression, with associated insomnia,
is particularly sensitive to light in the blue wavelength
(about 460 nm) emitted from cell phones, computers, and
television.
17
Self-medication for insomnia is common,
and medications prescribed for insomnia carry the risk of
addiction, accidents, cognitive impairment, and medical
side effects.
18,19
Nonpharmacological chronobiological
treatments are low risk, and specifically address the circadian
deficit in ADHD insomnia. Because neural pathways
from the retina to the primary circadian pacemaker in the
suprachiasmatic nucleus respond only to shorter wavelength
light of ,550 nm, physiological darkness can be produced by
use of blue wavelength-blocking glasses with the advantage
of continued evening functioning. Blue light-blocking glasses
have been shown to preserve normal evening night-time
melatonin production in subjects exposed to light.
20,21
One
randomized study of subjects with insomnia demonstrated
improved sleep quality and mood in an intervention group
wearing blue wavelength-blocking glasses, compared with
a placebo group.
22
Daytime use of the glasses in permanent
night-shift workers resulted in longer sleep, better daytime
sleep efficiency, and less sleep fragmentation.
23
Analogously,
darkness treatment improved sleep and mood in subjects with
bipolar disorder.
24,25
This is the first study to examine the chronobiological
treatment of blue wavelength-blocking glasses in adults
with ADHD insomnia. It explores the primary hypothesis
that wearing glasses that filter blue wavelength light from
overhead lights and electronic appliances will counteract
the deleterious effects of evening light on sleep, thereby
advancing sleep phase. In addition, we hypothesize that use
of these glasses will improve sleep quality measures, such
as sleep efficiency, total sleep time, and sleep fragmentation
in subjects with ADHD insomnia, providing a potential
nonmedical treatment alternative to hypnotic medication.
Finally, we explore the feasibility of this regular and
sustained intervention for sleep behavior in the adult
ADHD population, which is a population at risk for poor
compliance.
Materials and methods
Subjects aged 19 years and older attending the Adult ADHD
Clinic, Department of Psychiatry, University of Alabama at
Birmingham School of Medicine (UAB) were recruited for
this 3-week study extending from fall 2011 to spring 2012.
The UAB institutional review board approved the study
and all participants signed an informed consent form prior
to participation. Participants were informed that the study
explored a treatment for delayed sleep rhythms; all subjects
agreed to treatment in anticipation of this specific benefit.
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Inclusion criteria included a DSM-IV-TR diagnosis of
both ADHD and circadian rhythm sleep disorder, delayed
sleep phase type, by physician-administered semistructured
interview and the ADHD-Rating Scale-IV validated
diagnostic scale. Exclusion criteria included shift-work, use
of sleep medication, active or severe psychiatric disorders,
substance abuse or dependence, sleep disorders other than
insomnia, chronic pain, and active or severe medical problems.
In determining not to have an age cut-off for this pilot
study, we considered typical age-related alterations in sleep
patterns. However, all study subjects, including older ones,
reported delayed sleep patterns significant enough to cause
daytime dysfunction, and hence met DSM-IV-TR criteria for
circadian rhythm sleep disorder, delayed sleep phase type,
which is a diagnosis made by clinical history. These subjects
resembled younger ADHD subjects by history much more
than their same-age peers, who in the absence of ADHD,
typically have more advanced sleep cycles. Also, while
older subjects demonstrate diminished arousal responses to
bright light exposure compared with younger subjects,
phase-delaying responses to light are undiminished.
26,27
Because the primary outcome measure for this study was
phase change from baseline resulting from intervention
using the experimental glasses, absolute baselines were less
important. Medication risks make subjects of advanced age
most needful of nonpharmacological treatments for delayed
circadian rhythm sleep disorder.
Procedure
The first week was the baseline assessment period. Assessment
measures were collected while the subjects engaged in
their usual evening activities. Following a reminder call,
the 2-week intervention period began. Participants were
instructed to wear a set of amber glasses that blocked
wavelengths of light from 530 nm and below (blue and
violet wavelengths of light) from sundown until bedtime
every evening. Subjects wearing corrective lenses wore
amber glasses designed to fit over their own pair of glasses.
LowBlueLights.com (Photonic Developments LLC and the
Lighting Innovations Institute) manufactured the glasses and
generously provided them for this project. One recent study
demonstrated that ordinary yellow-tinted “placebo” glasses
had partial blue wavelength-blocking effects.
22
In the absence
of a viable placebo option, we elected for an open trial format
using the baseline period for comparison. Participants were
instructed to wear the glasses every evening (beginning at
sundown) for a minimum of 3 hours prior to bedtime until
turning the lights out to sleep. Subjects were instructed to
create a moderate light environment by using only floor and
table lamps and avoiding overhead lights during the evening.
Reduction of the typical evening bright light environment
to a moderate light environment was incorporated into the
intervention protocol to reduce unfiltered light entering
the retina from the periphery of the glasses, which might
otherwise have confounded our study results. Reducing
bright light to moderate levels alone could not significantly
alter the study results, because even moderate indoor
lighting environments with the 200 lux intensity required to
concentrate on detail inhibit nocturnal melatonin onset and
delay sleep phase.
28
True dim-light conditions of ,60 lux do
not suppress melatonin onset but are impractical, and a single
candle is 20–30 lux.
28
If participants awoke during the night,
they were instructed to put the glasses on before turning on
a lamp. Subjects otherwise engaged in their usual evening
activities and routine. All subjects but one took optimized
doses of ADHD medications and were instructed to continue
taking their regular regimen during the study. Subjects
were instructed to minimize caffeine, nicotine, and alcohol,
avoiding caffeine after lunch and alcohol and smoking after
dinner. Instructions were provided verbally and in writing.
Compliance with instructions was assessed daily.
Assessment measures
Standard bedtime and wake-up diaries were assessed
daily during the first baseline week to capture information
regarding the participant’s subjective emotional state,
bedtime, sleep latency, nocturnal wakening, time spent
awake in the night, wake time, and feelings of alertness and
refreshment upon waking. During weeks 2 and 3, ie, the
intervention period, participants completed sleep diaries with
additional questions designed to measure compliance with
protocol instructions.
Pittsburgh Sleep Quality Index
The Pittsburgh Sleep Quality Index (PSQI) was measured at
the end of the baseline assessment week and again after the
intervention. The PSQI is a validated self-rating instrument
assessing aspects of sleep quality.
29
Field-testing of the
PSQI shows high sensitivity and specificity in differentiating
persons with insomnia from unaffected controls when
the score is .5.
30
The PSQI is considered appropriate in
identifying “new-onset” insomnia in the clinical setting.
30,31
Compliance measures
During the intervention period, nightly diary questions
recorded the precise times the glasses were worn,
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Treatment of ADHD insomnia with blue wavelength light-blocking glasses

ChronoPhysiology and Therapy 2013:3
the relationship between removal of glasses to lights-out
time, and the percent of evening time the lights were kept
dimmed.
Statistical analysis
Advances in sleep rhythms were measured by midsleep time,
ie, the time point midway between sleep time and waking time.
Midsleep time is a reliable clinical measure of circadian phase
in the absence of other physiological measures.
32
Sleep diaries
and the PSQI were compared for baseline versus intervention
conditions by two-tailed paired t-tests. A two-way analysis
of variance was used to compare midsleep times following
intervention in phase subgroups of subjects.
Results
Participant demographics
Twenty-two subjects entered the study, with 14 subjects
completing it. Six subjects never began the study due
to illness, sudden travel, or irregular schedules, and two
motivated subjects were (with some embarrassment)
unable to complete it. All early terminations involved poor
motivation to complete the diaries or forgetting to wear
the glasses. Subjects were aged 21–76 years, with a mean
age of 43.9 years. The study population was 43% male and
57% female, 64.2% were married or cohabitating, 43% had
post-graduate degrees, and all subjects had some post high
school training. Only 7.1% of subjects were unemployed.
Participant compliance
During the intervention period, the glasses were worn for,
on average, 2.4 hours daily (instructions were for 3 hours
minimum). Glasses were put on at a mean decimal time of
20.7 (about 8:45 pm) and taken off at 23.20 (about 11:10 pm).
A high variability in compliance was noted between subjects,
with some starting as early as 18.95 (before 7:00 pm) and
others as late as 23.23 (about 11.15 pm). Subjects had been
instructed to wear the glasses until the lights were turned off
at bedtime. Glasses were removed on average 0.52 hours
(slightly over 30 minutes) before bed, but this time interval
varied from 0.47 hours after turning off lights to 3.15 hours
before bedtime. The average percentage of evening time
subjects kept overhead lights off after sundown, as instructed,
was 58.7%, but ranged from 7% to 91% of evening hours.
Outside light exposure varied from 11 minutes to 3.83 hours
and averaged 1.51 hours. One subject reported a mild
intermittent headache, possibly related to wearing the glasses
and another subject reported pain on the bridge of the nose
from the glasses.
PSQI sleep quality
We next examined whether sleep quality improved with the
intervention (Table 1). Significant improvement was noted
on global PSQI scores as well as nearly every subcomponent
following the intervention, with the exception of “sleep
medications,” which were not permitted during the study.
Global PSQI scores fell from a mean of 11.15 ± 3.50
to 4.54 ± 3.15 following the intervention. Scores below
the cut-off of 5 are considered to be within the normal
range. Figure 1 depicts the individual global PSQI scores
both before and after intervention using the experimental
glasses.
Sleep diary variables
In order to determine the effect of intervention on daily
self-reported sleep measures, paired-samples t-tests were
run for each subject before and after intervention using the
experimental glasses. Statistically significant differences
were noted on sleep diary items for the number of night-
time awakenings and “feeling refreshed on awakening”.
Feeling refreshed after sleep was significantly improved
after the intervention compared with baseline [t(13) = 2.329,
P = 0.037]. Night-time awakenings were significantly
reduced following the intervention compared with baseline
[t(13) = 2.805, P = 0.015]. To compare the consistency of
the sleep diary with the PSQI parameters, we compared
the reported sleep latency values. These two measures
were significantly correlated with each other [Pearson’s
correlation, R(14) = 0.585, P = 0.028].
Midsleep time
We hypothesized that blocking evening blue light exposure
may not advance circadian phase but may prevent further
phase delay. Therefore, we sought to examine whether
Table 1 Pittsburgh Sleep Quality Index results
Pair differences t df Signicance
(two-tailed)
Mean SD SEM
Sleep quality 0.62 0.65 0.18 3.4 12 0.005
Sleep latency 0.69 0.75 0.21 3.3 12 0.006
Total sleep time 1.46 1.13 0.31 4.7 12 0.001
Sleep efciency 1.23 1.01 0.28 4.4 12 0.001
Sleep disturbance 1.46 0.52 0.14 10.2 12 0.000
Sleep medications 0.39 0.77 0.21 1.8 12 0.096
Daytime dysfunction 0.77 0.73 0.20 2.8 12 0.002
Global PSQI 6.62 2.4 0.68 9.8 12 0.00
Notes: Table depicts mean decrease in scores (lower score means less impaired)
on each component of the PSQI and the Global PSQI. Statistical signicance was
noted on each measurable component.
Abbreviations: SD, standard deviation; SEM, standard error of the mean;
PSQI, Pittsburgh Sleep Quality Index.
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wearing the glasses was more effective for subjects who
were more delayed to start with. Midsleep time for the
baseline circadian phase was used to divide the cohort into
two groups using the 50th percentile, with 4.25 decimal
time (4:15 am) the resulting cut-off, leaving an earlier group
with midsleep time before 4.25 and a more delayed group
with midsleep time 4.25 and later. A two-way repeated-
measures analysis of variance revealed no main effect of
the intervention [F(1,12) = 2.77, P = 0.122], although there
was a strong trend toward a phase type X intervention
interaction [F(1,12) = 3.85, P = 0.073], such that the glasses
condition tended to shift midsleep time earlier in the more
delayed group (Figure 2). The more delayed group shifted
to a mean of 0.72 hours (43.2 minutes) earlier following
the intervention. No change in circadian phase was seen in
the earlier group following intervention.
Sleep diary mood scores
Although clinical levels of anxiety and depression were
exclusion criteria for the study, we compared the mood
ratings for the sleep diary before and after the intervention
using paired t-tests. Participants indicated being significantly
less worried (the cognitive component of anxiety), following
the intervention [mean ± standard error of the mean: baseline
3.27 ± 0.17; intervention 3.48 ± 0.15, t(13) = −2.178,
P = 0.048]. Other measures, such as jitteriness, moodiness,
sadness, tension, irritability, and poor concentration, were
unchanged (P . 0.05).
Discussion
Use of the blue wavelength light-blocking glasses did not
significantly advance the circadian phase outcome measure of
midsleep time as expected. However, the seven subjects who
had more delayed sleep times advanced their sleep time by an
average of 43 minutes following the intervention, a positive
trend that with a larger sample size could reach significance.
In large pharmaceutical trials, improvements in sleep latency
of 15–29 minutes were clinically significant.
33,34
By contrast,
robust improvements occurred in sleep quality as measured
by global PSQI scores, despite the small sample size, attesting
to the size of the measured effect. Post-intervention scores
decreased to less than half of the baseline scores. Moreover,
the notable improvement in the PSQI subcomponents
confirmed the significant sleep diary findings of increased
morning refreshment and decreased night-time awakenings.
The correlation between PSQI and sleep diary findings
strengthens the consistency of these findings. Of interest,
while all sleep quality subcomponents measured were
significantly improved, the subjects’ chief complaints were
not of sleep quality problems, but circadian phase delays.
Several subjects verbally reported “no improvement” from
wearing the glasses in spite of positive improvement on the
research measures.
A recent study showed that abnormal sleep quality,
and in particular daytime sleepiness, was present even in
ADHD subjects who did not report insomnia or a circadian
delay complaint (as measured by the detailed PSQI scale).
5
Likewise, subjects in this study were not aware of all
aspects of their insomnia until specifically questioned by the
detailed PSQI. The robust improvement in these relatively
unrecognized symptoms with the glasses intervention
suggests that interventions that address circadian components
Baseline Intervention
Global PSQI score
20
18
16
14
12
10
8
6
4
2
0
Figure 1 Individual PSQI global scores. Global PSQI scores are shown for each
subject before and after the glasses intervention.
Note: Subjects’ mean scores dropped from 11.15 to 4.54, below the clinically
impaired score of 5 and into the normal range.
Abbreviation: PSQI, Pittsburgh Sleep Quality Index.
Mean midsleep time
(decimal hours)
6
5
4
3
2
1
0
Baseline
Following
intervention
Earlier
More delayed
Figure 2 Midsleep time.
Notes: Mean midsleep time is compared before and after intervention with glasses
for the earlier, #4.25 decimal time, and more delayed groups, 4.25+ decimal time.
n = 7 for each group. The earlier group shows little change following intervention but
the more delayed group demonstrates a positive trend, with an average 43 minutes
advance in midsleep time following the intervention (P = 0.073).
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Treatment of ADHD insomnia with blue wavelength light-blocking glasses

ChronoPhysiology and Therapy 2013:3
of insomnia may also improve sleep quality issues assessed
by the PSQI, such as sleep latency, sleep efficiency, total
sleep time, daytime sleepiness, and night-time arousals.
One polysomnography study demonstrated that evening
light exposure had a seeming alerting effect persisting into
the sleep episode, as evidenced by reduced slow wave sleep
and shortened rapid eye movement sleep duration during
the initial sleep cycle, with later rebound of slow wave sleep
during the third sleep cycle. Blocking this alerting, sleep-
lightening effect from light with the glasses may explain
the improved sleep quality.
35
Sumova et al demonstrated
dual night-time melatonin peaks in patients with ADHD,
which they hypothesized could mediate the sleep disruption
observed in ADHD/sleep studies.
36
Similarly, by reducing
exposure to blue wavelength light, the glasses may normalize
melatonin output and decrease sleep disruptions, thereby
improving sleep quality. The relationship between circadian
rhythms and sleep quality requires further study. Of interest,
even though depression, anxiety, and other psychiatric
comorbid conditions were exclusion criteria for this study, the
subjects showed a significant decrease in anxiety following
the intervention.
The results of this study confirm the findings of previous
intervention studies using glasses. One study of insomnia
subjects comparing the efficacy of blue wavelength light-
filtering glasses with yellow-tinted “control” glasses showed
significant improvement in sleep quality and mood (as measured
by sleep diary) and no change in sleep timing measures, such
as time to bed or wake-time following use.
22
Shift-work studies
with polarized lenses also showed improvement primarily in
quality rather than circadian measures.
23
In reference to the feasibility of the use of these glasses
in ADHD subjects, only two thirds of participating subjects
were able to complete the study. Prospective subjects were
invited to participate in the study and were not heavily
vetted for compliance capability. Completing sleep diaries
is known to be difficult for ADHD patients,
13
who have
trouble sustaining attention for repetitive tasks, particularly
paperwork. The subjects in this study were highly variable
in their degree of compliance and adhered to the protocol
only to a moderate degree, maintaining a moderate lighting
environment for a little more than half the time recommended
and wearing the glasses for, on average, 2.5 hours per
night, which was less than the recommended minimum of
3 hours. Supportive spouses who gave reminders improved
compliance. Despite only partial compliance with the
protocol instructions, improvement in insomnia/sleep quality
symptoms was noted, suggesting at least some therapeutic
benefit from the intervention. Regardless, instruction
must be carefully given and capacity for compliance assessed
before a patient is encouraged to buy the glasses. A spouse
should be involved in treatment if at all possible. Use of
validated scales before and after treatment would assist in
more objective determination of benefit. ADHD subjects
who are able to comply more fully with instructions would
be the best candidates for treatment with these glasses and
might be expected to have the most improvement in their
circadian delay. Future study designs for subjects with
ADHD insomnia should take compliance difficulties into
account, and the high prevalence and morbidity of the
condition warrants continued research, however arduous,
into efficacious treatments.
A potential limitation of this study is the wide age range
of the subjects, and further studies of younger versus older
subjects are needed. All data gathered in this study were
self-reported. To avoid the confounding effect of insufficient
dark-time to wear the glasses, we terminated the study
before the days became significantly longer, limiting the
sample size. Confirmation of these findings will require
larger groups, including the different insomnia subtypes
(delayed circadian rhythm sleep disorder versus nondelayed
ADHD insomnia) and objective assessments of sleep quality,
melatonin levels, and other circadian measures to determine
if this and other chronobiological interventions have utility.
Although a strong placebo effect is observed in insomnia
studies, a placebo effect was less likely in the present study
because the participants were expecting an alteration in
sleep timing, which was not improved by the intervention
overall. However, sleep quality was noted to improve in
all cases, even in subjects who reported lack of any type of
improvement in sleep.
Conclusion
Despite moderate compliance with intervention instructions,
subjects who completed the intervention using blue light-
blocking glasses showed subjectively improved sleep quality
on a number of measures and reduced anxiety. Subjects with
an initial delayed midsleep time after 4:15 am showed a trend
towards earlier sleep following treatment. Blue wavelength
light-blocking glasses are a viable treatment for subjects with
ADHD insomnia who can comply with their use, especially
those subjects with greater sleep delays. Larger more
objective studies of subjects who are mostly delayed might
reveal significant advances in circadian rhythm in addition to
furthering our understanding of how evening light exposure
affects sleep quality.
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Acknowledgment
The authors thank LowBlueLights.com of Photonic
Developments LLC and the Lighting Innovations Institute
for donating the glasses used in this study.
Disclosure
The authors report no conflicts of interest in this work.
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