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    Deconstructing the 20-20-20 Rule for digital eye strain

    Many ODs recommend it, but where did it come from?

    Figure 1.Most optometrists have heard of the 20-20-20 Rule for preventing and relieving digital eye strain. The catchphrase suggests taking a 20 second break every 20 minutes by looking 20 feet away.

    Numerous sources now refer to it, including the American Optometric Association (Figure 1) and the American Academy of Ophthalmology.1,2 Maybe you, like many other eyecare professionals, offer this guidance to your patients. But have you ever wondered where this came from?

    In the past year, I’ve observed The Rule mentioned enough times in consumer and trade media that I began questioning where it came from. Was this guidance based on evidence, or did its popularity snowball from nebulous origins?

    I suspected the latter, believing that The Rule became famous for being famous. This article tells how I tracked down its origin.

    Previously from Dr. Chou: 7 strategies for fitting keratoconus patients

    Started by an engineer?

    With some sleuthing on the Internet, I came across a 2014 blog by an engineer in India which mentioned that he learned of the 20-20-20 Rule from his eye doctor.3 I e-mailed him several times but got no response. I started wondering, was this engineer—without any background in eye care—the person that started The Rule?

    I remembered how Airborne, the dietary supplement marketed to prevent the common cold, was created by a school teacher. Could the 20-20-20 Rule be another example in which a layperson started something that became popular and resonated with the public without supportive evidence for efficacy? I had to dig deeper.

    Google trends

    From January 2004, up to today, the number online searches for “20 20 20 rule” on Google approximately doubled (Figure 2). The existence of users searching for this term in 2004 told me that it was unlikely that the 2014 blog article by the Indian engineer was responsible for popularizing the catchphrase.

    Yet the confounding factor is that there are also 20-20-20 rules pertaining outside of eye care.

    Figure 2.

    Other uses

    My research showed me that the 20-20-20 Rule is found in other disciplines, such as the military, bariatric surgery, and drug addiction.

    The 20-20-20 Rule for military divorce was enacted in 1982 under the provisions of the Uniformed Service Former Spouses’ Protection Act.5

    A military spouse qualifies for medical benefits and commissary and exchange privileges for the remainder of life if the spouse was married for at least 20 years, the service member performed at least 20 years of service creditable for retirement pay, and there is at least a 20-year overlap of marriage and military service.4

    Deepening the intrigue, a food writer in 2012 coined a 20-20-20 rule for eating after bariatric surgery, suggesting to chew a mouthful of food 20 times before swallowing, putting down utensils for 20 seconds before the next mouthful, and to eat this way for a period of 20 minutes.6

    Related: How digital devices are affecting vision

    There is also a 20-20-20 rule for a cognitive-behavioral approach to treating drug addiction, describing how the therapist should spend the first, second, and third 20-minute periods during an hour-long session with the patient.7

    The upward trend of web searches for “20 20 20 rule” could represent inherent growth of Internet use along with interest in how The Rule pertains not only to the eyes, but for other areas. My next step was to look as far back as Google indexed.

    Brian Chou, OD, FAAO
    Dr. Chou earned his doctorate of optometry at UC Berkeley in 1999 and completed fellowship training in refractive surgery management at ...


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