Editor’s Perspective

Reexamining the ‘20-20-20’ Rule: Is It What You Think It is?

June 2, 2025

By Kevin Chan, OD, MS, FAAO, IACMM

Let’s admit it: We have all become more and more digitally consumed.  

Nearly half (41%) of teenagers aged 13 to 18 in the US engage in screen time of more than eight hours per day. Merely less than 5% of children aged 8 to 12 reported having ‘no screen time.’1 More concerningly, one in four teenagers with four hours or more of daily screen have reported experiencing anxiety (27.1%) or depression-related symptoms (25.9%), particularly in urban areas.2 

If these trends aren’t enough to catch your attention, studies have also found that digital media use for children aged 3 to 5 can inherently alter brain structure and impair the development of higher-order functional areas that are responsible for language development, reading and social skills associated with memory encoding and empathy.3 These astounding findings should be a wake-up call for all parents and practitioners. However, we have become more inadvertently desensitized as if it is just another statistic. 

Decoding the ’20-20-20’ Vision Rule

Since the COVID-19 pandemic, virtual environments have become a ‘new norm’ for many individuals, including children. While the ’20-20-20 rule’ is seemingly an ‘easy fix’ that helps parents and their kids recall the catchphrase easily, in reality, it isn’t what was intended.  

In essence, the phrase suggests individuals take breaks from digital screens every 20 minutes and gaze at an object positioned 20 feet away for 20 seconds. It was originally coined by Jeffrey Anshel, OD, FAAO, FOWNS, in the late 1990s.4 Prior to its genesis, it was rooted from the so-called ‘3B’ approach – ‘blink, breathe, and break,’ by which the 20-20-20 rule was extended from the ‘break’ recommendation. The original intent was to guide computer users on how to alleviate eye strain in a simple mnemonic. 

Nuances of the ‘20-20-20 Rule’

As the phrase becomes more prevalent, it has inevitably been amplified as clickbait, and it is used in a myriad of subject areas – notably in the arena of preventing or mitigating myopia progression. Despite the glorification of the 20-20-20 rule in the myopia management space, little relevant data is available to substantiate or support its role in slowing myopia progression.5,6 It inherently oversimplifies the complexity of our visual system. Here are some overlooked insights and guidance for practitioners and parents to reconsider and apply the 20-20-20 rule appropriately and judiciously.

Oversimplification of Visual Rest

While the 20-20-20 rule can be encouraging as an outlet to mitigate digital strain, it fails to address the multifaceted nature of visual fatigue. In essence, screen time and near work are often used interchangeably, yet they are not entirely synonymous. The term ‘screen time’ encompasses more than a function of time spent on screens; it also depends on factors such as screen brightness, viewing distance and individual susceptibility. Near work, as a more technical term in the microcosm, has been associated with the development of myopia.7,8 Simply looking away every 20 minutes does not necessarily offset the cumulative effects of prolonged exposure.6 Further research is warranted to support any plausible link to whether implementing the 20-20-20 rule would have any impact on myopia development and progression. 

‘Holy grail’ for myopia?

Digital eye strain has been associated with dry eye syndrome (DES).9,10 Nevertheless, several prospective studies showed little or no statistical significance in improving dry eye symptoms and binocular vision functionality despite implementing the 20-20-20 rule in the studies’ cohort groups.11,12 

As eye care practitioners, it is prudent to educate our patients that visual fatigue typically manifests not in episodes only, but also cumulatively over time. Despite the common belief that the 20-20-20 rule was intended to mitigate myopia progression, simply pausing for 20 seconds for every 20 minutes of near work is yet to be scientifically supported in this regard. Specifically, choroidal responses and retinal perfusion rates in individuals with myopia respond variably to different levels of near work.13,14 Thus, we should be vigilant with critical thinking when it comes to interpreting the 20-20-20 rule. A better alternative is to advise patients to engage in more frequent and extended rest for the eyes, combined with other ergonomic adjustments, to achieve a clinically meaningful ‘reset’ or relief.

Refined strategies beyond the 20-20-20 

Make no mistake — The 20-20-20 rule has shown its merit as an uplifting message for us all, and it is here to stay. That said, the realm of myopia management indeed encompasses a wider and more holistic approach to prioritize visual hygiene that promotes extended breaks, proper lighting and screen positioning, outdoor time and healthier near work habits at large. It is time to move beyond the catchphrase and pitfalls of the 20-20-20 rule and embrace more nuanced and effective strategies to optimize patients’ eye health. 

 

References: 

  1. https://backlinko.com/screen-time-statistics
  2. CDC NCHS Data Brief No. 513, October 2024
  3. https://scienceblog.cincinnatichildrens.org/screen-usage-linked-to-differences-in-brain-structure-in-young-children/
  4. Anshel J. Letter to the editor: 20-20-20 rule: are these numbers justified? Optom Vis Sci. 2023;100(4):296. doi:10.1097/OPX.0000000000002006
  5. Johnson S, Rosenfield M. 20-20-20 rule: are these numbers justified? Optom Vis Sci. 2023;100(1):52-56. doi:10.1097/OPX.0000000000001971
  6. Pucker AD, Gawne TJ. Fighting myopia with intermittent nearwork breaks: 20 seconds every 20 minutes might not be enough time. Optom Vis Sci. 2023;100(1):31-32. doi:10.1097/OPX.0000000000001965
  7. Gajjar S, Ostrin LA. A systematic review of near work and myopia: measurement, relationships, mechanisms and clinical corollaries. Acta Ophthalmol. 2022;100:376-387
  8. Li DL, Lanca C, Saw SM, Grzybowski A, Pan CW. Visual environmental risk factors in outdoor activities and near work and potential mechanisms. Ophthalmic Physiol Opt. 2025 May 5.
  9. Wolffsohn JS, Lingham G, Downie LE, et al. TFOS lifestyle: impact of the digital environment on the ocular surface. Ocul Surf. 2023;28:213-252. doi:10.1016/j.jtos.2023.04.004
  10. Salinas-Toro D, Cartes C, Segovia C, Alonso MJ, Soberon B, Sepulveda M, Zapata C, Yañez P, Traipe L, Goya C, Flores P, Lopez D, Lopez R. High frequency of digital eye strain and dry eye disease in teleworkers during the coronavirus disease (2019) pandemic. Int J Occup Saf Ergon. 2022 Sep;28(3):1787-1792. doi: 10.1080/10803548.2021.1936912.
  11. Rosenfield M, Johnson S. Effect of scheduled breaks on digital eye strain. Paper presented at: Association for Research in Vision and Ophthalmology Annual Meeting; May 1-4, 2022
  12. Talens-Estarelles C, Cervino A, García-Lázaro S, Fogelton A, Sheppard A, Wolffsohn JS. The effects of breaks on digital eye strain, dry eye and binocular vision: testing the 20-20-20 rule. Cont Lens Anterior Eye. 2023;46(2):101744). 
  13. Liu M, Wang Y, Li H, Zhao Y, Ma M, Xu S, Wei X, Xu R, Tian R, Zhou X, Wu H. Differences in choroidal responses to near work between myopic children and young adults. Eye Vis (Lond). 2024 Apr 2;11(1):12
  14. Liang X, Wei S, Zhao S, Li SM, An W, Sun Y, Bai W, Cai Z, Wang N. Investigation of Choroidal Blood Flow and Thickness Changes Induced by Near Work in Young Adults. Curr Eye Res. 2023 Oct;48(10):939-948)
Related Items:, , , , , , , , , , , , , , , , , , , , , , , , , , ,

Recommended for you

To Top