The effects of breaks on digital eye strain, dry eye and binocular vision: Testing the 20-20-20 rule

Cont Lens Anterior Eye. 2023 Apr;46(2):101744. doi: 10.1016/j.clae.2022.101744. Epub 2022 Aug 11.


Purpose: To evaluate the benefits on the eyes of taking breaks based on the 20-20-20 rule.

Methods: Bespoke computer software using the laptop webcam to assess user breaks, eye gaze and blinking, and emitting personalized reminders of breaks based on the 20-20-20 rule, was downloaded onto the laptops of 29 symptomatic computer users. Digital eye strain (DES), binocular vision and dry eye were assessed before and after two weeks of using the reminders and one week after the discontinuation of the strategy. Binocular measurements included visual acuity, accommodative posture, stereopsis, fixation disparity, ocular alignment, accommodative facility, positive/negative vergences and near point of convergence. Symptoms were evaluated using the computer vision syndrome questionnaire, ocular surface disease index (OSDI), and symptom assessment in dry eye questionnaire (SANDE) versions one and two. Dry eye signs were assessed by measuring tear meniscus height, conjunctival redness, blink rate and incomplete blinking, lipid layer thickness, non-invasive keratograph break-up time, corneal and conjunctival staining and lid wiper epitheliopathy.

Results: A decrease in the duration of computer work and the duration of breaks, along with an increase in the number of breaks taken per day was observed as a result of the 20-20-20 rule reminders (p ≤ 0.015). No changes on any binocular parameter were observed after the management period (p ≥ 0.051), except for an increase in accommodative facility (p = 0.010). Dry eye symptoms and DES decreased with the rule reminders (p ≤ 0.045), although this improvement was not maintained one week after discontinuation (p > 0.05). No changes on any ocular surface and tear film parameter were observed with the rule reminders (p ≥ 0.089).

Conclusions: The 20-20-20 rule is an effective strategy for reducing DES and dry eye symptoms, although 2 weeks was not enough to considerably improve binocular vision or dry eye signs.

Keywords: 20-20-20 rule; Binocular vision; Computer vision syndrome; Digital eye strain; Dry eye; Dry eye symptoms.

MeSH terms

  • Conjunctiva
  • Cornea
  • Dry Eye Syndromes* / diagnosis
  • Humans
  • Tears
  • Vision, Binocular*