Effect of screen time and outdoor activities on myopia progression

OBJECTIVE: To assess the impact of screen time and outdoor activities on myopia progression in Lebanese children and to compare age groups. METHODS AND ANALYSIS: This prospective study enrolled 100 myopic children aged 3-17 years who presented to the pediatric ophthalmology service at the American University of Beirut Medical Center from February 2023 to January 2025. Behavioral data were obtained using a questionnaire, and clinical data were collected through retrospective chart review dating back to January 2018. Myopia was defined as a spherical equivalent (SE) ≤ -0.50 diopters (D). Annual myopia progression was compared during and after the COVID-19 lockdown and correlated with screen time and outdoor activity. RESULTS: The mean age was 13.2 ± 3.6 years, with a balanced sex distribution. Myopic progression was significantly higher during the COVID-19 lockdown, with the highest progression in 2020-2021 (0.65 ± 0.07 D/year) compared with 2022-2023 and 2023-2024 (both 0.29 ± 0.05 D/year; p < 0.001). Mean SE became more negative over time, reaching -3.43 ± 0.23 D in 2024 (overall p < 0.001). During lockdown, screen time increased significantly (p < 0.001), while outdoor activity decreased significantly (p < 0.001). Twenty-two percent had more than 8 hours of daily screen exposure. Outdoor activity varied: 38% spent 5-10 hours outdoors weekly and 20% exceeded 10 hours. Younger children preferred tablets (p < 0.001) and spent less time on screens (p < 0.001). Nevertheless, questionnaire-derived daily screen time, weekly outdoor time, and screen‑break variables were not statistically significantly associated with myopia progression during or after the lockdown periods in the overall cohort (all p > 0.05). CONCLUSIONS: Myopia progression rate was higher during the COVID-19 lockdown than in the post-lockdown period, with significantly higher progression rates in 2020-2021 compared with 2022-2023 and 2023-2024. Screen time increased and outdoor time decreased during lockdown, but were not statistically significantly associated with progression in the overall cohort. These findings add evidence from an underrepresented Middle Eastern population, supporting further longitudinal studies of modifiable environmental factors in myopia progression.