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

Cristian Talens-Estarelles, Alejandro Cerviño, Santiago García-Lázaro, Andrej Fogelton, Amy Sheppard, James S Wolffsohn

Research output: Contribution to journalArticlepeer-review


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.

Original languageEnglish
Article number101744
Number of pages9
JournalContact lens & anterior eye : the journal of the British Contact Lens Association
Early online date11 Aug 2022
Publication statusE-pub ahead of print - 11 Aug 2022

Bibliographical note

Copyright © 2022. Published by Elsevier Ltd n behalf of British Contact Lens Association. This is an open access article under the CC BY-NC-ND license (

Funding Information:
This work was supported by the Spanish Ministry of Education [grant number FPU17/03665]; and the “Conselleria d’Educació, Investigació, Cultura i Esport de la Generalitat Valenciana” [grant number GV/2018/059].


  • 20-20-20 rule
  • Binocular vision
  • Computer vision syndrome
  • Digital eye strain
  • Dry eye
  • Dry eye symptoms


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