Widespread use of face masks has been determined essential to combat COVID-19’s spread, yet is giving rise to a new phenomenon: increased reports of dry eyes. Experts from the Centre for Ocular Research & Education (CORE) are advising eye care professionals on how to recognize mask-associated dry eye (MADE) and methods to mitigate the condition.
Reports of MADE have circulated since early summer and a recent review  concluded that eye dryness and irritation from mask wear may become a problem for a large percentage of the population.
“Face masks are crucial in the fight against COVID-19, and ECPs are well-positioned to provide patients with advice on appropriate wear in order to maximize eye comfort,” said Dr. Lyndon Jones, director of CORE. “Asking patients about their mask-wearing experiences and providing a few helpful tips takes little time and can make a substantial difference.”
The term “mask-associated dry eye” can be traced back to Darrell E. White, MD, Founder, Skyvision Centers, Westlake, Ohio. Dr. White recalls seeing an elderly patient in May, who was complaining of dry eye symptoms. The man, who was a regular patient for 20 years, had never previously shown any signs or symptoms of dry eye. His glasses would fog with each exhalation, clear as he inhaled, only to fog up all over again, Dr. White outlined in a blog post . Exhaled air was being funneled upward and across the surface of the eyes by a mask that was not tightly fitted to the face. Dr. White called the phenomenon “mask-associated dry eye” or “MADE.”
Masks significantly reduce the outward spread of air. However, exhaled air still needs to disperse; when a mask sits loosely against the face the likely route is upwards. This forces a stream of air over the surface of the eye, creating conditions that accelerate tear film evaporation, leading to dry spots on the ocular surface and discomfort, according to CORE.
In addition to worsening symptoms in patients with pre-existing dry eye disease, MADE can affect a wide-spectrum of others: the elderly who typically have a poorer quality tear film, contact lens wearers, and masked people working extended hours in air-conditioned settings and/or while using digital screens.
Beyond discomfort, MADE may encourage people to rub their eyes for temporary relief—raising the possibility of unwashed hands being brought to the face. In turn, this increases the likelihood of coronavirus infection through the mouth, nose, and to a lesser extent, the eye.
Guidance for Practitioners
CORE suggests that ECPs consider incorporating three MADE-related actions into their examination lane protocols:
- Consider the role of the face mask if there are worsening symptoms and signs in patients with confirmed dry eye disease, or if patients report dry, uncomfortable eyes or variable vision for the first time.
- Routinely ask all patients how their eyes feel while wearing a mask, since many may not think to volunteer their experiences or associate their symptoms with mask use.
- Provide advice on alleviating the symptoms, including using a new CORE-developed infographic to help show how a few simple steps can likely provide relief and minimize reoccurrence.
Tips for Patients
As illustrated in its new MADE infographic (available for download from COVIDEyeFacts.org), CORE recommends that mask wearers experiencing dry eye symptoms try straight-forward solutions:
- Ensure that a mask is worn appropriately, particularly with spectacles or sunglasses. A carefully taped top edge that does not interfere with blinking may help.
- Apply lubricating drops, asking their ECP for recommendations.
- Limit time in air-conditioned environments and take regular breaks from digital devices.
CORE experts are also been quick to state that people should first check with their eye care practitioner for advice and to rule out other cases—a good approach with any new eye-related concern.
Don’t Ditch the Mask
Dr. Jones is adamant that bringing more attention to MADE should not be used to support anti-mask wearing sentiments.
“Responsibly wearing a mask, even when having to contend with eye dryness, is a critical part of overcoming the global pandemic. The good news is that we understand MADE and can address it—an opportunity for ECPs to further communicate their knowledge and ongoing value to patients at a time when sound, scientific guidance is needed more than ever,” he noted.
- Moshirfar, M., West, W.B. & Marx, D.P. Face Mask-Associated Ocular Irritation and Dryness. Ophthalmol Ther 9, 397–400 (2020). https://doi.org/10.1007/s40123-020-00282-6
- White, D.E. MADE: A new coronavirus-associated eye disease. Healio.com. June 22, 2020. Accessed Sept. 10, 2020. https://www.healio.com/news/ophthalmology/20200622/blog-a-new-coronavirusassociated-eye-disease