Orthoptist Jonathan Russell explains children and screen time eyestrain

1. “When an eight-year-old sits down with a tablet for two hours straight, what is actually happening inside their visual system physically? Could you walk us through a specific case where a young patient came in showing direct physical symptoms of screen fatigue?”

There are two major things happening when a child looks at a screen up close. First, the eyes are accommodating, which is essentially the focusing mechanism that allows us to see clearly at near. At the same time, the eyes are converging toward the near target. When accommodation and convergence are sustained for long periods, it can produce visual fatigue, contribute to accommodative spasm, or potentially unmask a previously well-controlled binocular vision problem.

We’re also investigating another physical effect of screen use at Rady Children’s Hospital: pediatric dry eye disease. Our research includes more than 500 children whom we surveyed about their digital screen exposure and evaluated for dry eye. We found an association between increased screen exposure and dry eye disease. This is particularly interesting because children don’t always describe their symptoms as ‘dry eye’. Clinically, we may instead hear about eye rubbing, excessive blinking, intermittent blur, headaches or tired eyes following prolonged screen use.

2. “Parents often wonder why reading a physical book isn’t flagged the same way screen time is. What does the scientific research tell us about how digital screens alter a child’s natural blink rate, focal distance, or accommodative effort compared to traditional paper?”

The difference isn’t really that a screen is bad and a book is good. Both are near tasks requiring accommodation and convergence.

One of the major differences is the immersive nature of digital media. A child can spend hours gaming or watching videos without naturally taking a break changing their viewing distance. Handheld devices can also gradually move closer to the face, increasing accommodative and convergence demand.

There is also an effect on blinking. AAPOS notes that children often blink less when concentrating on screens, which can contribute to dry eyes, discomfort and intermittent blurred vision.

The other major issue is what screen time can replace. A child spending several hours indoors on a tablet isn’t spending that time outdoors. So the focus is less on whether the near target is paper or a screen and more on how close, how long and how often the child is using it.

3. “In your work with strabismus and amblyopia, have you seen instances where heavy screen use caused a minor, hidden binocular vision issue to suddenly flare up into noticeable eye misalignment or double vision?”

Yes. One case that particularly stands out involved a child who was on a long road trip. Her parents allowed her to use an iPad continuously for approximately six hours! Following that prolonged period of near work, she developed a noticeable esotropia (crossing of the eye) and double vision.

Unfortunately, in this particular case, the esotropia persisted and ultimately required strabismus surgery with the pediatric ophthalmologist. Thankfully, the surgery went very well, the eyes were realigned and her binocular fusion was restored.

Cases like this are a good reminder that when a new eye turn or double vision appears after heavy screen use, we shouldn’t simply dismiss it as screen fatigue. The child needs a comprehensive evaluation with a pediatric ophthalmologist.

4. “Myopia rates among children have skyrocketed worldwide. What specific clinical studies or longitudinal data best demonstrate the link between early device use and progressive short-sightedness, and how does outdoor light scientifically counter that process?”

There is good evidence linking intensive near work and insufficient outdoor time with myopia. The 2025 WSPOS Myopia Consensus Statement highlights that prolonged near work, particularly sessions over 30 minutes, are associated with greater myopia risk. 

Outdoor time is protective. Natural daylight is far brighter than typical indoor lighting and may influence retinal dopamine signaling, which is thought to help regulate axial eye growth. WSPOS recommends around two hours outdoors per day, regular breaks from prolonged near work, and avoiding excessively close viewing distances. So the message to parents is not simply “no screens,” but rather to encourage healthy viewing distance, regular breaks, and meaningful daily outdoor activity.

5. “Have you treated cases where kids experienced temporary accommodation spasms or difficulty relaxing their focus after long gaming sessions? What did that look like clinically, and how was it resolved?”

Yes, and it happens more often than people might think. I’ve seen multiple children following periods of excessive gaming present with what initially appears to be myopia. Their distance vision is blurred, but the problem is actually that their accommodative system is having difficulty relaxing after being engaged at near for such a prolonged period.

We first need to determine the child’s true prescription and exclude other refractive or binocular problems. Cycloplegic eye drops are particularly useful because they temporarily relax accommodation and allow us to accurately measure the underlying refractive error.

Management then depends on the individual child. It can include substantially reducing prolonged near work and giving the accommodative system an opportunity to relax. In some cases, eyedrops or glasses are given.

6. “Is a toddler’s visual development fundamentally more vulnerable to screen glare and rapid focal demands than a twelve-year-old’s? What scientific consensus exists around critical windows for binocular vision development?”

A toddler’s visual system is exceptionally sensitive, and in those early years it is vital that we protect their vision. They are at a much higher risk of developing amblyopia or strabismus than a twelve-year-old because the brain and visual system are still developing. PEDIG studies show that this plasticity decreases with age, although meaningful visual improvement can still occur later in childhood. 

7. “Special blue-light glasses are everywhere in retail. From a rigorous clinical perspective, what does current peer-reviewed evidence actually say about blue light damage versus simple near-work fatigue, and have you had parents bring in kids wearing unhelpful gear?”

There isn’t convincing clinical evidence to support routinely recommending blue-light-filtering glasses to children for digital eye strain.

A lot of what parents interpret as “blue-light strain” is much more likely to involve prolonged near work, sustained accommodation and convergence, and reduced blinking.

AAPOS recommends something much simpler: remind children to blink more. If blinking doesn’t resolve the dryness, lubricating artificial tears can be used to help keep the ocular surface moist.

8. “Children rarely say, ‘Mom, my accommodative capacity is exhausted.’ What real behavioral signals or physical cues, like head tilting, squinting, or sudden academic changes, have parents in your practice reported before discovering a vision problem?”

That’s one of the difficulties with pediatric eye care: children often don’t know what abnormal vision feels like. If they’ve always seen a certain way, they assume that’s normal.

Parents may notice squinting, excessive blinking or eye rubbing, closing one eye, moving unusually close to a book or screen, an eye intermittently drifting, or an unusual head turn or head tilt. Older children may complain of headaches, intermittent blurred vision or double vision, while others may simply start avoiding reading or struggling with visually demanding schoolwork.

However, some significant pediatric eye problems produce very few obvious behavioral signs. Amblyopia, for example, can go unnoticed because a child with good vision in one eye may function normally while the brain suppresses the poorer-seeing eye.

Ultimately, if there’s a concern, the best assessment is a comprehensive evaluation with a pediatric ophthalmologist.

9. “The 20-20-20 rule sounds great on paper, but kids rarely follow it. Can you share a practical example of a screen routine or environmental change that has actually worked for real families struggling to manage device habits?”

I think the 20-20-20 rule is useful, but the bigger message is that we need to change children’s relationship with digital media. Expecting a young child who’s completely immersed in a game to independently remember to look away every twenty minutes isn’t always realistic.

Fortunately, parents can now use built-in parental controls and apps to help manage this. They can set time limits for individual apps, schedule breaks or downtime, and place a daily limit on how long a child can use the device overall. That takes some of the responsibility away from the child and makes breaks part of the routine.

It’s also important for parents to be aware of pediatric screen-time guidance. The AAP recommends discouraging screen media in children younger than 18 months. For children aged 2 to 5, screen use should generally be limited to one hour or less per day of high-quality programming.

From an eye-health perspective, WSPOS recommends approximately two hours outdoors per day and regular breaks during near work. Its guidance also supports the 20-20-20 approach as a practical way of interrupting prolonged near viewing.

I also encourage a simple environmental change. If a child is going to watch something, consider putting it on a television across the room rather than automatically giving them a phone or tablet held close to their face. Increasing the viewing distance reduces the sustained near accommodative and convergence demand.

Nighttime habits are important as well. The AAP and AAPOS recommend stopping screen use at least one hour before bedtime.

We don’t need to make technology the enemy; we need to use it more intelligently. The message I give parents is simple: distance, breaks, outdoor time, and putting the screens away before bed.

 Jonathan Russell

The Lead Orthoptist at Rady Children’s Hospital, with more than a decade of experience in pediatric ophthalmology. His clinical interests include strabismus and pediatric dry eye disease. Prior to working in the United States, Jonathan worked at King’s College Hospital in London. He also holds an MBA, complementing his clinical background with expertise in healthcare leadership and improvement.

Sept. 23, 2026

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