With advances in technology and the digitization of daily life, it is no surprise that children are using digital devices at increasingly younger ages. The last three decades have brought a digital revolution, with the rise of smartphones, tablets, streaming platforms, and virtual learning dramatically changing how children learn and spend their free time.
Children often first encounter screens through their parents' cellphones or tablets, and many are introduced to digital devices before they can read and while they are still reaching other developmental milestones.
At the same time, pediatric myopia is increasing globally. A large systematic review and meta-analysis published in the British Journal of Ophthalmology analyzed 276 studies with more than 5.4 million participants from 50 countries.1 Myopia prevalence increased from 24.32% in 1990 to 35.81% in 2023. By 2050, prevalence is projected to reach 39.80%, affecting more than 740 million children and adolescents worldwide.1
Parallel trends do not establish causation, but they raise an important question for optometrists: what role does screen time play in the increasing risk and progression of pediatric myopia?
Digital devices may not independently cause myopia, but their use combines several factors associated with myopia, including prolonged near work, short working distances, sustained accommodation and convergence, and displacement of time that could otherwise be spent outdoors.
Data on pediatric screen use
Screen time begins very early for children today and increases substantially with age. According to the 2025 Common Sense Census data summarized by the American Academy of Pediatrics, children under two already average approximately 1 hour and 3 minutes of screen media per day. By ages two to four, this increases to 2 hours and 8 minutes, while children aged five to eight average 3 hours and 38 minutes per day.2-3
Screen exposure continues to rise among older children and adolescents. Common Sense Media reported that in 2021, children aged 8 to 12 averaged 5 hours and 33 minutes of entertainment screen media per day, while adolescents aged 13 to 18 averaged 8 hours and 39 minutes.4 Importantly, these figures do not include screen use for school or homework, meaning total daily screen exposure may be considerably higher.
Reasons for the rise in screen usage
Screen habits have also changed rapidly. Between 2019 and 2021, entertainment screen use increased by 17% among both age groups.4 These trends highlight not only how much screen exposure increases with age, but also how quickly screens have become a larger part of children's daily lives.
Several factors explain this rise. Parents themselves are increasingly engaged with screens, and children model the behavior they see around them. Parents also interact with their children through screens, whether taking photos, FaceTiming family members, using educational apps, or watching videos together.
With parents busy, screens provide convenient entertainment during times when children might otherwise have been playing with physical toys, playing outside, or simply being allowed to be “bored.”
In addition, books are increasingly digital, educational apps are introduced at young ages, and screens have become a routine part of the school day, with laptops and tablets used for reading, assignments, classroom activities, and homework. Television programs once watched from across the room are now streamed on tablets and smartphones.
Although screens have existed for decades, a television viewed across the living room creates a very different visual demand from a smartphone held 20cm from the eyes. Increasing use of handheld devices, both at school and at home, has therefore blurred the distinction between screen time and traditional near work.
Mechanisms linking screen time to myopia
Near work has long been considered a potential risk factor for myopia, well before handheld digital devices became part of daily life. Reading, studying, writing, and other prolonged near activities have repeatedly been associated with myopia, making sustained near work one possible mechanism linking increasing screen use with myopia development.
A 2015 systematic review and meta-analysis of 27 studies involving 25,025 children aged 6 to 18 found that greater near-work exposure was associated with higher odds of myopia. Children performing more near work had 14% greater odds of myopia, and for every additional diopter-hour of near work per week, the odds increased by approximately 2%.5
Calculating cumulative near work
A diopter-hour measures cumulative near work by combining the time spent on an activity with its near visual demand. It is calculated by assigning three diopter-hours for each hour spent reading, two for each hour of computer or video game use, and one for each hour of television viewing. In this way, activities performed at closer distances are weighted more heavily than those viewed from farther away.5
Handheld devices may further increase near visual demand because they are typically viewed at closer distances. Smartphones are typically held 20 to 50cm from the eyes, tablets 30 to 60cm, and computer monitors 45 to 80cm, while televisions are viewed from approximately 150 to 600cm.6
Children may also gradually bring a smartphone or tablet closer as they become engrossed in a game or video. The closer the viewing distance, the greater the accommodative and convergence demand required to maintain clear, single vision.
Prolonged near fixation and increased accommodative demand have been proposed as possible mechanisms linking near work with myopia, including accommodative lag and retinal defocus. However, the exact relationship between accommodation, near work and axial elongation is still being investigated.7
Regular breaks during prolonged near work allow the eyes to shift focus to farther distances and interrupt sustained accommodation and convergence. Current myopia-management guidance recommends regular breaks during prolonged reading and screen use, as well as avoiding very close working distances.7
This is particularly relevant with handheld devices, where prolonged near work and short viewing distances often occur together.
The role of outdoor time
One of the strongest environmental factors associated with myopia is time spent outdoors, particularly for preventing myopia onset. In the landmark Guangzhou Outdoor Activity Longitudinal Trial of more than 1,900 first-grade children, adding 40 minutes of outdoor activity to each school day reduced the three-year incidence of myopia from 39.5 to 30.4%.8
Let’s look at the latest evidence
More recent evidence continues to support this relationship. A 2024 meta-analysis of 12,922 children aged 6 to 16 found that children with the greatest outdoor exposure had approximately 47% lower odds of developing myopia compared with those with the least exposure. Increasing outdoor time from 3.5 to 7 hours per week was associated with a 20% reduction in myopia-onset risk.9
The protective effect of outdoor time is thought to be partly related to exposure to brighter natural light. Retinal dopamine has been proposed as a mechanism that regulates ocular growth. Experimental studies have shown that bright light can increase retinal dopamine signaling and reduce myopic shifts and ocular elongation, although much of this evidence is experimental and the exact mechanism in humans remains under investigation.10
Screen use may also indirectly affect myopia risk by taking away from time children might otherwise spend outdoors. Smartphones, tablets, gaming and streaming increasingly compete with outdoor play for children's free time, meaning more screen time may result in both more near work and less exposure to the potentially protective effects of being outdoors.
Outdoor time appears to be more effective at preventing the onset of myopia than slowing progression once myopia has developed. Current guidance recommends approximately 1 to 2 hours outdoors each day for school-aged children.7 For children with progressive myopia, outdoor time should complement rather than replace evidence-based myopia-control treatment.
Evidence connecting screen use and myopia progression
The association between digital screen use and myopia has gained traction as more studies have become available.
What the meta-analyses show
Epidemiological studies have increasingly examined the relationship between digital screen use and myopia. A 2021 review published in The Lancet Digital Health evaluated 33 studies examining smart-device exposure and myopia.11 Smart-device screen time alone was associated with myopia with an odds ratio of 1.26, while smart-device use combined with computer use was associated with an odds ratio of 1.77.11
More recently, a 2025 JAMA Network Open analysis included 45 studies involving 335,524 participants and found that each additional hour of daily digital screen time was associated with 21% higher odds of myopia.12
The relationship was not completely linear. Compared with no digital screen exposure, the odds ratio increased from 1.05 at 1 hour per day to 1.65 at 3 hours and 2.24 at 5 hours, with the greatest increase occurring between approximately 1 and 4 hours of daily screen use.12
Insights from longitudinal research
Longitudinal studies have also looked at this relationship over time. The Generation R study followed children in the Netherlands and found that greater computer use was associated with myopia at age nine.13
Reading time and shorter reading distances were also associated with myopia, while greater outdoor exposure appeared to reduce some of the risk associated with near-work behaviors.13 Unlike many studies looking at screen use and myopia at a single point in time, Generation R followed children's visual habits and refractive development over time.
Limitations in the research
While these findings are compelling, there are important limitations. Many of the available studies look at children at a single point in time, making it difficult to determine whether greater screen use came before the development of myopia. In the 2025 analysis, screen time was associated with existing myopia and myopia progression, but the findings for new-onset myopia were not statistically significant.12
Another limitation is that screen use represents only one part of a child's overall myopia risk. Important factors such as parental myopia and genetic susceptibility, time spent outdoors, total near work, near work habits, and working distance are not accounted for across studies. This makes it difficult to determine how much of the observed relationship is specific to digital devices rather than the holistic combination of environmental and genetic factors that influence myopia development.
Measuring screen exposure itself is also challenging and subjective. Many studies rely on children or parents estimating daily screen use, which may not accurately reflect actual exposure. Studies also differ in the devices included, how myopia is measured, and which other risk factors are considered. The 2025 analysis found substantial differences between studies, and the overall certainty of evidence was rated low.12
This leaves several ongoing debates in the literature. It remains unclear whether there is a true "safe" amount of daily screen time, whether certain devices or types of screen use carry more risk than others, and whether screen exposure plays a greater role in myopia onset or progression. Researchers also continue to debate whether digital screen use is an independent risk factor or whether it mainly reflects the near-work behaviors and lifestyle changes that accompany it.
The bottom line
The evidence connecting screens and myopia is growing, but the relationship is multifactorial. Screen use should be considered within the broader picture of a child's visual environment, including the amount of near work, viewing distance, outdoor exposure, and other established risk factors for myopia.
Clinical red flags in pediatric patients
Children with heavy screen use may present with eyestrain, headaches, tired eyes, intermittent blurred vision, difficulty clearing distance vision after prolonged near work, and dry or irritated eyes. New or worsening distance blur may also indicate a myopic refractive change, particularly in a child already at risk for myopia.
Children do not always describe their visual symptoms clearly. They may simply say that their eyes or head hurt after school, that their eyes feel tired, or that the board looks blurry after working on a tablet or laptop.
Squinting
Parents may notice the behavioral signs first. A child may begin squinting to see the television or classroom board, move progressively closer to screens, rub their eyes, blink excessively, or lose concentration during near tasks. They may also avoid reading. Parents or teachers may notice these changes even when the child does not complain of visual discomfort.
Dry eye
Ocular-surface symptoms are also important to consider. Concentrating on a screen can reduce blink frequency and increase incomplete blinking, contributing to tear-film instability and dry-eye symptoms.14
Pediatric screen use has also been associated with meibomian gland dysfunction.14 Slit lamp exam signs to look for include reduced tear-film stability, conjunctival injection, punctate epithelial staining, lid-margin changes, and meibomian gland dysfunction.
Blurred distance vision after prolonged screen use deserves particular attention. While it may indicate increasing myopia, temporary accommodative dysfunction following sustained near work can produce similar symptoms. A comprehensive examination, including cycloplegic refraction when appropriate, can help distinguish between the two.
Clinical and behavioral red flags include:
- New or progressive distance blur
- Squinting to see the board or television
- Moving closer to screens or holding devices increasingly close
- Headaches or tired eyes after prolonged near work
- Difficulty clearing distance vision after screen use
- Red, dry, irritated, or watery eyes
- Frequent eye rubbing or excessive blinking
- Avoiding reading or other near tasks
- Reduced concentration in homework or reading
- Changes in visual behavior noticed by teachers
These findings should prompt a closer look at the child's refractive status, accommodation and binocular vision, ocular surface and daily screen habits.
Clinical strategies for optometrists
Every good clinical encounter starts with a thorough yet focused case history. Instead of simply asking, "How many hours of screen time does your child get?", it is more useful to understand what the child's entire day looks like and what that screen time consists of.
At school, ask how much time is spent on a computer or tablet, what type of device is used, and whether textbooks and assignments are primarily digital. Are they comfortable reading? Do they lose concentration during homework? Are headaches more common after school? Has a teacher noticed squinting or difficulty seeing the board?
At home, ask what the child does after school. Are they gaming, watching television, or using a tablet? Do they have their own cellphone? How close do they hold their device, and how long do they typically use it without stopping?
Outdoor activity should be part of the same conversation. How much time does the child spend outside during the school week and on weekends? Do they play an outdoor sport? What do they enjoy doing away from screens?
Looking at the child's day in a stepwise approach—school, home, near work, and outdoor activity provides a much more useful picture of their visual environment than simply asking for a total number of hours of screen time.
Lifestyle counseling should become a normal part of the pediatric eye examination. Asking children what sports they play or what they enjoy doing outside can also build clinical rapport and make conversations about screens feel less punitive.
Sample screen-time conversation
A sample conversation with parents may be:
"Screens themselves aren't the only issue; how we use them matters. Hours of up-close work at school followed by more screen use at home can add up quickly. Keep phones and tablets at a comfortable working distance rather than very close to the face, and consider a tablet stand when appropriate. Encourage regular breaks where your child looks into the distance and aim for around 2 hours of outdoor activity each day when possible."
The familiar 20-20-20 rule—every 20 minutes, look at something 20 feet away for at least 20 seconds—is an easy strategy for parents and children to remember. It is best presented as a reminder to take breaks from continuous near fixation to reduce discomfort.
Monitoring the at-risk child for myopia progression
Children with early-onset or progressive myopia should be monitored for more than simply a change in spectacle prescription.
Cycloplegic refraction remains important for accurately measuring refractive change, particularly in younger children. Where available, axial length provides another objective measure of ocular growth and can help identify progression even when refractive changes appear relatively small. Instruments such as the ZEISS IOLMaster, Haag-Streit LENSTAR and OCULUS Myopia Master can be used to monitor axial length over time.
Monitoring should also include distance visual acuity, refractive change, and changes in near-work, screen, and outdoor habits. Parental myopia, age of onset, and the child's previous rate of progression should help determine how closely the child needs to be followed.
For children already receiving myopia-control treatment, follow-up should assess whether refractive error and axial length remain stable or continue to progress. The greatest clinical value comes from following the same child over time rather than interpreting a single axial-length measurement in isolation.
Influence of screen habits on management choice
Lifestyle modification should be part of myopia management regardless of which treatment is chosen. For children spending significant time on digital devices, counseling should include regular breaks from prolonged screen use and near work, maintaining an appropriate working distance, avoiding holding phones and tablets very close to the eyes, increasing daily outdoor time, and having screen-free times.
Once progressive myopia has developed, lifestyle changes should complement active treatment rather than replace it. Depending on the child, evidence-based options may include myopia-control spectacle lenses, myopia-control soft contact lenses, orthokeratology and low-dose atropine.
An important addition to spectacle-based treatment in the US came in 2025, when the FDA authorized Essilor Stellest lenses to correct myopia and slow its progression in children aged 6 to 12 years at the initiation of treatment.15 Stellest lenses use highly aspherical lenslets surrounding a central clear zone to provide a myopia-control signal while maintaining clear central vision.
A subsequent US multicenter randomized clinical trial included 159 children aged 6 to 12 years. Over 24 months, Stellest lenses reduced myopia progression by 71% and axial elongation by 53% compared with single-vision spectacle lenses.16
As screen use and near work increase among children, future research examining the effectiveness of myopia-control spectacle lenses in slowing progression among children with greater screen and near-work exposure would be very valuable.
Conclusion
Screen exposure is one piece of the pediatric myopia puzzle. Although current evidence does not establish that screens directly cause myopia, prolonged near work, short working distances and reduced outdoor time are increasingly part of a child's everyday visual environment and have all been associated with myopia.
For optometrists, asking about screen habits should become part of the pediatric eye examination alongside family history, refraction and myopia progression. Early identification, practical lifestyle counseling and timely myopia management allow us to address both the child's visual environment and long-term ocular health.
As screens become an increasingly integral part of modern life, the goal is not to avoid them, but to build healthier visual habits around the way they are used—and that conversation can begin in the exam room.
