Wearing a face mask is an important part of preventing the spread of Covid-19, but masks can come with some not-so-great side effects like maskne, foggy glasses, and general irritation around the face. Now, there’s a new side effect on the radar: mask-associated dry eye (MADE).
A report published in the journal Ophthalmology and Therapy in July details how there has been an increase in cases of eye irritation and dry eye among people who regularly wear masks. The report’s authors, who are researchers at the University of Utah, note that they have seen “a marked increase in dry eye symptoms among regular mask users at multiple local clinics.”
As we are now well and truly in Winter the battle against Covid -19 seems set to continue. As a result, people are increasingly required to wear face coverings or masks in public places and sometimes for extended periods of time. The purpose of the mask is to reduce the spread of air outwards from our nose and mouth, however if the mask is fitting poorly it allows the warm air we are breathing out to escape upwards which results in specs steaming or misting up.
However, this warm air can also speed up the evaporation of tears – a bit like a breeze blowing over damp skin, which over time may well cause the front surface of the eyes to become dry. For those who already suffer from dry eyes, this can cause an unwanted increase in symptoms, not only whilst wearing the mask, but possibly for some time after it has been removed as the delicate balance of the tear film has been disrupted.
Prolonged use of masks whilst looking at screens or working in air conditioning can also lead to irritated eyes.
It is important that pharmacy teams assist consumers on how they look after their eyes and do their best to alleviate mask associated dry eye. Those who are worried about their eyes or their symptoms persist, should be urged to seek advice from their Optometrist.
What is Dry Eye?
When addressing MADE, it is helpful to understand the tear film, the liquid layer that coats the eye’s surface. This tiny volume of fluid, equivalent to one-tenth of a single water drop, has a highly complex structure and composition. It lubricates the surface of the eye, allowing smooth and comfortable passage of the eyelid during every blink. Ongoing imbalance in the tear film leads to dry eye disease.
An estimated 10% to 30% of the population older than 40 years suffers from some degree of dry eye disease (DED). The condition tends to affect people above 60, and it is more common in women than men.
Around one in 13 people who are in their fifties experience dry eye syndrome, and the condition becomes more common with age. Up to a third of people age 65 or older may have dry eye syndrome.
DED is a multifactorial disease of the tears and ocular surface that results in discomfort, tear film instability, and visual disturbance, with potential for damage to the ocular surface. DED can be classified as chronic or temporary. DED can be also attributed to Bell palsy, collagen disorders such as rheumatoid arthritis, corneal or eye lid defects, Sjögren syndrome, and thyroid-related eye disease.
The symptoms of dry eye syndrome usually affect both eyes and may include:
• feelings of dryness, grittiness or soreness, which get worse throughout the day
• redness of the eyes
• watering eyes, particularly when exposed to wind
• eyelids that stick together when waking up
These symptoms may get worse in smoky or hot environments.
When a patient presents with symptoms of a dry eye condition, such as irritation, grittiness, burning, soreness, watery eyes and visual disturbances generally affecting both eyes, a detailed history should be recorded by the pharmacist because it may elicit information about contributing factors.
Briefly, this should include details of the signs and symptoms, duration of symptoms and exacerbating factors, such as the environment, changes in humidity or computer use.
It should also record details of topical and systemic medicines taken by the patient, whether the patient wears contact lenses and if the patient has any dermatological, inflammatory or other systemic diseases. A differential diagnosis for other eye conditions (such as conjunctivitis, allergy and acute red eye) should be established
because initial presentation may be similar.
How Face Masks Cause Dry Eye
Mask-associated dry eye is a new condition, and the study’s researchers even point out that there’s no scientific literature on this. Therefore, the exact cause of this has not yet been studied.
However, there are some theories. One cited by the report’s authors is that this mask-induced dry eye is caused by an airflow issue. When you breathe out and your mask doesn’t have a tight fit, air can flow up and across the surface of your eyes. That encourages evaporation and can ultimately dry out your eyes.
But the report’s authors also noted that people who use taped masks for a better seal also had eye issues. Their guess: The tape itself may interfere with the lower eyelid’s normal functioning, leading to dry eye.
An improper mask fit can even interfere with the eyelids’ ability to do their job. Some doctors have also noted that the masks can pull down the lower eyelids slightly, making it difficult for normal blinking to restore the healthy surface of the eye.
Who is Affected?
In addition to those with pre-existing dry eye disease, the general mask-wearing population may find themselves wondering why their eyes are inexplicably irritated. This includes the elderly, who naturally have less efficient tears.
An extensive review demonstrated that wearing contact lenses does not raise the risk of contracting Covid-19, as long as people follow good hygiene and cleaning measures. However, a contact lens can disturb the tear film, potentially making wearers more MADE-susceptible if exhaled air further impacts tear film stability.
Prolonged use of face masks in air-conditioned locations may also trigger MADE. So too could increased digital device use while wearing masks — a rising trend during the pandemic.
Beyond discomfort, MADE presents another risk: it may encourage people to rub their face and eyes for temporary relief. Coronavirus transmission is possible via the mouth and nose, and, to a lesser extent, potentially the eyes. Bringing unwashed hands near the face may increase the likelihood of infection. That is an additional reason to tackle MADE.
There are ways to prevent dry eye, but abandoning the mask isn’t one of them. Normal dryness can be treated, or possibly even prevented, with some simple strategies.
Mask Options for Dry Eye
Encourage sufferers to look for a mask that has a malleable wire integrated along the top edge, which is moulded to the bridge of the nose, so the airflow doesn’t escape and move upward toward the eyes.
Another way to keep the mask secure: Put a piece of tape on the nose bridge or along the top of the mask. Paper medical tape is less irritating to the skin.
If dry eye is especially problematic, some can consider wearing sealed goggles to keep their eyes safe.
Some may wish to apply artificial tears or over-the-counter drops to their eyes before putting on their mask and throughout the day in order to keep them lubricated.
Give eyes a break
Encourage those visiting the pharmacy displaying eye health issues to follow the 20-20-20 rule: After every 20 minutes spent looking at their computer screen, they should look at something 20 feet away for 20 seconds. And be sure to blink consciously — and purposefully — while working on the computer.
OTC Treatments
Pharmacists are in a critical position to identify the pharmacologic agents that can exacerbate or increase the risk of DED and advise patients regarding the most efficacious means of preventing episodes of dry eye.
Additionally, pharmacists can be instrumental in aiding patients by educating and recommending the many OTC products to manage and treat mild to moderate DED as well as direct patients with chronic and severe cases of DED to seek further medical care from an ophthalmologist when warranted.
The ultimate goal of dry eye treatment focuses on symptomatic relief, usually using tear supplements. Despite this, the underlying mechanism of symptomatic improvement with tear supplementation is still poorly understood. It is thought that increased tear volume, improved tear stabilisation, reduced tear osmolarity or a dilution of inflammatory biomarkers or a combination of these factors play a vital role.
Topical ocular lubricants are the mainstay of dry eye treatment, with the choice of tear substitute depending on the severity of the condition. Pharmacological interventions in all forms of dry eye conditions range in formulation, such as drops, sprays, gels and ointments.
For occasional or mild dry eye symptoms, OTC eyedrops (artificial tears) used regularly may provide relief. Preservative-free artificial tears are preferred, as they cause less irritation. Wearing glasses or sunglasses that fit close to the face (wraparound shades) or that have side shields can help slow tear evaporation from the eye surfaces. An indoor air cleaner to filter dust and other particles can help prevent dry eyes, as can a humidifier by adding moisture to the air, avoiding dry conditions, and allowing the eyes to rest when
performing activities that require someone to use their eyes for long periods of time.
