Ever since the use of surgical face masks all-day long became essential due to the pandemic and a part of our daily lives, doctors and health care staff all over the world have been complaining of dry eye symptoms. In this study, we aimed to investigate the impact of long-term face mask wearing on T-BUT and dry eye symptoms in health care professionals.
To the best of our knowledge, this is the first study to evaluate the effects of long term face mask wearing on OSDI score and T-BUT. Our findings indicate that both OSDI scores and T-BUT significantly worsened at the end of the day, compared to the morning hours. The reason might be increased evaporation caused by air flow around the eye, especially if the mask is not tight enough. Patients with dry eye syndrome, however, are also known to report discomfort that is more prominent in the evening hours, compared to mornings. In a study with self-made tear strip meniscometry in healthy eyes, Ayaki et al reported that tear meniscus measurements were the highest in the morning and gradually decreased in the evening hours [4]. Therefore, in the current study, to firmly establish that wearing the face mask was the reason for differences in T-BUT and OSDI scores, a matched control group of participants who did not use a surgical face mask throughout the day was necessary. Unfortunately, due to precautions needed during the ongoing COVID-19 pandemic, such a control group cannot be incorporated in the study in the near future and until it is safe to do so.
Giannacare et al. reported in their online survey study with 107 healthy subjects that 10.3% of the participants described the development or worsening in dry eye symptoms [5]. Boccardo reported in a survey study with 3605 subjects that 26.9% of participants with a prior history of dry eye experienced worsening in symptoms while a total of 18.3% of the participants experienced MADE [1]. In the current study, we observed a higher prevalence in the worsening of symptoms (57.6%). This can be due to the inclusion of a more homogenous study population (health care professionals) while the other published survey studies included a more heterogeneous group of people from different professions. All of the participants in the current study were working in a hospital environment with air conditioners, spending a considerable time in front of computers and were strictly adhering to the rules of face mask wearing for long hours. Although 21 (63.7%) of the participants in the current study had higher than normal morning OSDI scores (> 15), none of the participants had previous dry eye syndrome diagnoses or were using artificial tears. Despite the presence of some symptoms of dry eye, 12 (57.1%) of the subjects had normal T-BUT values (> 10 seconds).
Dry eye disease is known to have a higher prevalence amongst women, compared to men [6]. In the present study, dry eye symptoms and T-BUT values did not show any significant difference between male and female participants. This could be related to the identical environmental factors that health care professionals of both genders were subject to. Moreover, all participants were young with a mean age of 34 years and none of them reported any menopausal or hormonal effects [7]. It can also be suggested that the lack of any systemic or dermatologic diseases in either male or female participants might have affected the study outcomes [8–10].
Similar to the use of facial masks, the use continuous positive airway pressure (CPAP) treatment is known to be associated with ocular surface complications related to the increased air flow around the eye [11]. Especially, misplacement of the CPAP mask during sleep was reported to cause more dry eye symptoms in the eye for which the air flow was more prominent [11]. Surgical face masks, on the other hand, were not considered as an additional risk factor for dry eye until the COVID-19 pandemic. Now that surgical face masks are an essential part of our lives and also our health, it is important to use them comfortably for long durations. Since individuals with no history of dry eye have been reporting symptoms with long hours of face mask use, ophthalmologists should be aware of this and should be willing to offer solutions. Lubricants might be beneficial for people with new onset symptoms suggesting MADE. Patients with moderate to severe dry eye might require modifications in their treatment regime.
In the current study, the relationship between use of face masks and Meibomian gland dysfunction was not evaluated. However, anecdotal evidence, including observations in our daily practice suggest a higher prevalence of chalazion than usual. Silkiss et al. reported an increased incidence of chalazion in a retrospective study and implicated increased air flow around the eye and the eyelids with the use of face masks [12]. Further studies are needed to assess the effect of long term surgical mask use on Meibomian gland functions. Ameliorating the symptoms of dry eye might even increase compliance to the use of face mask, prevent the spread of the virus and help protect individuals from COVID-19.