How face masks affect the eyes—and how doctors of optometry can provide relief

Since the outbreak of COVID-19, public health officials have recommended the wearing of masks, along with social distancing and handwashing, as a first line of defense during the pandemic. According to a recent review in Ophthalmology and Therapy, this has brought about a corresponding increase in mask-associated ocular irritation and dry eye.

“As society continually adapts to the ever-developing circumstances surrounding the coronavirus disease 2019 (COVID-19) pandemic, a new article of clothing has become part of our daily routine: the face mask,” say the  authors, affiliated with the University of Utah in Salt Lake City and the Hoopes Vision Research Center in Draper, Utah. “We wholeheartedly support the necessity of face masks for a safe reopening of communities; however, as with any intervention, there may be sequelae of regular mask use in the general population.

 “Over recent weeks, we have become aware of potential effects on the eye specifically. In our community and patient population, we have seen a marked increase in dry eye symptoms among regular mask users at multiple local clinics. This group includes individuals who have never previously suffered from dry eyes. Individuals using masks regularly for an extended duration appear more likely to show symptoms. This group includes the elderly, immunocompromised, and clinic staff who wear masks almost full-time.”

Among their other concerning findings: 

• Irritation of the ocular surface associated with mask use raises concerns for increased risk of disease transmission through the ocular route.
• Patients wearing masks for extended periods may be more likely to experience these symptoms.
• Eye protection and management of dryness and irritation is an important consideration for long-term mask users.

Patients and staff described “subjective worsening” in symptoms measured by the Ocular Surface Disease Index. They also detected a decline in corneal staining and a “distinct” increase in post-operative dryness in cataract patients.

“If our observations of mask-associated ocular dryness and irritation prove to be consistent in all mask wearers, patients and providers need to be aware of these potential ramifications,” they said. “Lubricant eye drops and eye protection, such as goggles, should be used in conjunction with masks. Additional care should be taken by individuals using masks for extended periods and by patients with prior history of dry eye disease, recent ophthalmic surgery, or other surface inflammatory diseases, such as Sjogren syndrome.

“Masks with a pliable nose-wire should be used, with attention toward fitting the shape of the wire to prevent air being directed toward the eyes,” they add. “Masks can also be taped at the top to impede upward airflow, but care should be taken to ensure that lower lid excursion is not inhibited. Patients experiencing dry eye symptoms from extended mask wear should take breaks every few hours to remove the mask, allow the eyes to recover, and reapply lubricant eye drops. Emollient eye drops may be the most effective in preventing symptoms by preserving tear film. Blinking exercises may also be beneficial.”

Ask patients about dry eye

More research is being done on the subject, but the onset of dryness symptoms with extended mask wearing is being called MADE (mask associated dry eye), says Kelly Nichols, O.D., Ph.D., M.P.H., dean of the School of Optometry at The University of Alabama at Birmingham, and widely recognized dry eye authority.

“Upward air flow out of the top of a mask, over the ocular surface, is thought to be part of the concern,” Dr. Nichols says. “Taping the top of the mask or using a mask with a nose wire abates, but does not prevent, the problem. In addition to that, continuous screen time, with Zoom and other platforms, is also complicating existing dry eye, or even MADE.

“Awareness of dry eye symptoms and seeing an eye care practitioner for diagnosis and management can help,” she says. “There are options. Doctors can ask about mask use and screen time during routine examinations and discuss options. I agree with the authors’ recommendations to discuss dry eye prevention and to be on the lookout for dry eye, either with or without mask wearing. Dry eye can be simplified—ask, look and do something.”

Michael Duenas, O.D., AOA chief public health officer, agrees.

“Air flow leakage from masks, aggravating ocular structures, has become more commonplace during the COVID-19 pandemic, but dealing with it is something that is very routine among doctors of optometry,” Dr. Duenas says.

A visit to their doctors by concerned patients also presents an opportunity for doctors to detect or rule out some conditions.

Some conditions that can be ruled out include, but are not limited to: upper lid ptosis, lower lid ectropion, blepharochalasis, trichiasis, infectious keratitis, chronic dry eye, recurrent erosion, keratoconus, and progressive endotheliopathy.  The eyelids may show an incomplete closure or there may be an incomplete touch of the lower lid to the eye, Dr. Duenas says. This may become more bothersome during the pandemic and may cause the individual to rub their eyes, something that should be avoided as the eye is a route of SARS-CoV-2 exposure.

“Once the nature of the problem is identified by the eye doctor, simple treatments can be prescribed to counteract the airflow disturbance,” Dr. Duenas says. “These may be in the form of medications or other therapies or may simply be in some less extreme cases resolved by choosing the proper mask with an adjustable nose guard to limit air leakage.”

MADE is a warning, he says.

“It does not mean the individual should stop wearing a mask during a pandemic,” Dr. Duenas says.