We Can’t Undo What COVID Has MADE

Lifestyle modifications resulting from COVID-19 have affected the ocular health of our patients, changing the dynamics of what might otherwise have been routine office visits. Two notable causes are increased use of face masks and increased screen time in association with the pandemic.

In this article, I discuss recent research on mask-associated dry eye (MADE), our increased dependence on digital devices, and what these phenomena may mean for optometric practice in the months and years ahead.

FACE MASKS AND OCULAR SURFACE DISEASE

When the world turned to face masks to reduce the transmission of COVID-19, a number of ocular conditions emerged,^1-4 and eye care providers noted a marked increase in dry eye symptoms among their patients.¹ Face masks are still required in many environments, and if your patients are wearing a mask for several hours a day, they are at increased risk of developing or exacerbating ocular dryness and irritation, even if they were previously asymptomatic.¹ This phenomenon is known as MADE (Figure).

When air blows upward instead of outward with face mask use, it has a drying effect on the ocular surface, which accelerates evaporation¹ and leads to ocular irritation and discomfort.⁴ Poorly fit face masks often contribute to the cause.⁵ Many patients try to prevent lens fogging and other airflow annoyances by taping the top of their masks to their faces; this can make matters worse by interfering with blinking⁵ and the normal excursion of the lower lid, possibly leading to secondary lagophthalmos.¹ For this reason, masks with pliable nose wires are the preferred alternative.¹

Because MADE has become so common, I’ve found it useful to add questions about face-mask wearing to the patient history and to look for clinical signs of MADE during my examinations.

Whether or not patients are experiencing symptoms, it is appropriate to discuss preventive strategies. For example, I remind patients to take their masks off every few hours, if possible, to rest their eyes, and to hydrate. I also suggest that patients carry lubricant eye drops and apply them before putting on their face masks and again when they take them off, or as needed.

Additionally, we need to emphasize to patients the importance of ocular hygiene and a daily eye wellness routine. Remind patients that they need to cleanse their lids for the same reason they need to brush their teeth: to keep them clean and pristine. For some patients, thorough cleaning can be achieved with conventional products used to remove debris, makeup, and lotions. However, many patients may prefer gentle eyelid wipes, which can be less irritating to sensitive eyes and more effective for makeup removal. For patients with blepharitis or other types of lid disease, I suggest using a hypochlorous acid spray. Finally, I recommend that patients use a moist heat compress regularly. Using the dental model, this is the equivalent of flossing, insofar as it helps clear away buildup. Plus, patients genuinely enjoy the relaxing experience and the relief it brings.

This three-step routine: wipe, spray, warm, serves as preventive wellness and can also be used as a complementary intervention for patients who need more aggressive therapy, such as immunomodulators, topical steroids, or in-office procedures such as thermal pulsation or lid exfoliation.

WHAT OUR DEVICES HAVE CREATED

Face masks aren’t the only thing causing a spike in dry eye. Virtual school and remote work have exposed patients to more screen time, which is a well-established risk factor for dry eye disease.^3,5 Several large-scale studies have shown that prolonged device use is associated with dry eye^3,6-8 and meibomian gland dysfunction (MGD).^9-11 For example, one study compared “regular” screen time of > 4 hours daily with a control group spending ≤ 4 hours daily and found that lid margin abnormalities, meibum quality, and gland dropout were all higher in the regular screen time group.¹⁰ In that study, MGD was also associated with more corneal staining and faster tear breakup time.¹⁰

Oculomotor stress associated with device use can also lead to uncomfortable eye strain.⁹ Commonly called computer vision syndrome, this spectrum of issues related to the use of visual display terminals has become part of the fabric of modern civilization due to our dependence on digital devices.^9,12 Identifying and managing computer vision syndrome is a public health concern that can lead to improved well-being and better workplace productivity.^8,9,13 The American Academy of Ophthalmology and American Optometric Association both advocate the 20:20:20 rule (after 20 minutes of device use, focus on an object that’s more than 20 feet away for 20 seconds) to minimize digital eye strain.^14,15 Because incomplete blink is common and mean blink rate is reduced with device use, blinking exercises also may offer patients some relief.^16-18

RECOGNIZE THE NEW NORMAL

Even as some of us go back to our workplaces, videoconferencing has taken over conference call culture and likely won’t disappear any time soon. Similarly, our patterns and behaviors have changed, making many of us more reliant on digital devices than we were 2 years ago. Practitioners need to recognize this new normal, look for signs and symptoms, and proactively intervene to prevent patient discomfort and disease progression.