The pandemic is contributing to an influx of ocular problems.
With 2020 turning out to be the year of a pandemic, it seems nearly everyone’s plans have been turned upside-down and our new “normal” may be contributing to an influx of ocular problems.
An increased amount of time at home has meant a boost in hours of digital screen time and home improvement projects for millions of people across the globe. For some healthcare providers and essential workers, the pandemic has also meant an increased amount of time wearing a mask and frequent exposure to cleaning chemicals. In addition, heightened psychological and physical stresses due to sudden changes in routine schedules may play a role in the overall risk of some ocular pathologies seen during the pandemic.
As an optometric provider partially available to emergency patients throughout the quarantine period (and full time since starting back in early May), I have noticed an interesting shift in ocular problems at my practice. Some of the common ocular “emergencies” have presented more frequently over the past several months, including dry eye disease (DED) associated with computer use and ill-fitting masks, corneal abrasions and foreign bodies due to home improvement projects, herpes simplex virus (HSV) and herpes zoster virus (HZV) flare-ups, along with episodes of central serous chorioretinopathy (CSC).
1. Computer-induced dry eye
Trying to avoid the virus that may be lurking on every doorknob, many companies and corporations have transitioned to work-at-home environments. This digital wave and virtual work world appears to be here to stay.
Considering the millions of people who now work on their computers and digital devices full time, it is not surprising to see increases in symptomatic complaints of burning, watering, ocular pain, eye strain, and intermittent blur.
Prolonged use of digital devices is likely associated with decreased blink rates and increased tear evaporation, which can lead to tear film instability and hyperosmolarity.1 This vicious dry eye cycle paired with computer use can eventually lead to a decreased tear break up time, worsening symptoms of DED.1To make matters worse, previous research suggests that subjective dry eye symptoms can be influenced by psychosomatic conditions including stress, anxiety, and depression.2
With an array of treatments, from artificial tears to punctal plugs to pharmacologic options that improve tear film stability, educating patients on the short- and long-term consequences of extended digital computer use can be helpful in stopping the cycle of DED.
It may also be a great time to start sending dry eye questionnaires and information regarding DED associated with digital screen use to patients virtually before their exam. This can help toidentify potential DED factors or problems ahead of the appointment and decrease exposure time in office.
2. Mask-induced dry eye
With the addition of mask mandates across the world, dry eye signs and symptoms have also seemingly been on the rise since mid-March in my practice. Some patients, such as healthcare providers and essential workers, are now wearing masks or facial coverings for upward of 40 hours per week.
Especially worsened with ill-fitting masks, symptoms of mask associated DED is likely due to the constant flow of exhaled air on the exposed eye while breathing. Sometimes presenting with ocular pain and intrapalpebral corneal staining, the escaping air flow can create a windy obstacle affecting tear film stability. The frequency of mask-wearing seems to be correlated with increased frequency of DED recently seen in practice.
Mask-wearing is very effective in lowering the rate of viral transmission. It may be helpful to educate patients on the importance of a properly fitting mask to reduce airflow directed at the eyes. It may also be beneficial to ask questions regarding details of mask usage when considering overall risk factors for DED.
3. Corneal abrasions and foreign bodies
With additional time at home, more people than ever are completing projects and finishing up honey-do lists. Indoor and outdoor projects have resulted in more ocular injuries such as corneal abrasions and foreign bodies.
Ranging from “abrasion caused by mask” to “stick in eye while doing outdoor chores” to “metallic foreign body while grinding metal,” there seems to be an influx of ocular injuries since quarantines began.
As optometrists, it is especially vital to treat these ocular injuries and help keep these patients out of the emergency room, if possible. Of course, it is also important to discuss the importance of wearing safety glasses, but hindsight is 20/20.
4. Herpes simplex virus (HSV) and herpes zoster virus (HZV)
Psychological and physical stresses associated with abrupt changes to daily life may play a role in the overall risk of some ocular pathologies seen in practice, especially in the midst of a pandemic.
Stress has been thought to modulate an individual’s immune system through the release of certain molecules such as catecholamines, cytokines, and glucocorticoids.3,4 Such release signals other molecules to alter the host immune system, leaving it susceptible to a primary or recurrent viral infection.3,4
Stress is also thought to contribute to reactivation of latent herpes simplex virus (HSV) and has been considered a trigger for herpes zoster virus (HZV).4,5 This connection with stress and HSV/HZV has been supported by several, but not all, studies.3-5 It would be curious to investigate the effects of phycological and physical stress during a pandemic and its effect on HSV and HZV activation or reoccurrences.
Pre-pandemic, one clue to tip off the practitioner about increased risk for HSV-1 in the eye may have been the obvious fever blister noticed on the lip during an exam. For the time being, wearing a mask hides these important observational details; therefore, it may be important to ask about history of cold sores and fever blisters that may be hidden from view
5. Central serous chorioretinopathy (CSC)
Predominantly, CSC affects young or middle-aged adults (25 to 50 years old) with men more frequently affected than women.6 Often presenting unilaterally with painless blurred vision and a shallow serous retinal detachment, some patients may even be asymptomatic.
Physiological stress is considered one of the most important risk factors for developing CSC.7 One study identified that stress scores, serum homocysteine levels, serum morning and evening cortisol levels, and systolic and diastolic blood pressure were all elevated in CSC patients.7
There have been several other independent studies over the past several decades concluding CSC occurs more frequently in “Type A” men with higher emotional stress, lower frustration tolerance threshold, and poor coping strategies for stressful events.6
The natural course of CSC is typically self-limiting with spontaneous resolution over many weeks or month and a good prognosis in 90 to 95 percent of cases.6 In addition to identifying the stressors, CSC patients should also consider a routine workup with stress score evaluation including measurement of blood pressure, serum homocysteine levels, and serum cortisol levels.7
In conclusion, our new “normal” during the midst of the pandemic may be contributing to an increase of ocular problems that optometrists should keep in mind as differentials.
Considering risk factors such as hours of digital screen time, mask wearing, and overall stress levels may be helpful in identifying those more susceptible to ocular problems.
Keep ocular emergencies that are presenting more frequently in mind—dry eye associated with computer use and ill-fitting masks, corneal abrasions and foreign bodies due to home improvement projects, herpes simplex virus (HSV) and herpes zoster virus (HZV) viral infections and central serous chorioretinopathy (CSC).
Post-pandemic, it will be interesting to seeretrospective data regarding the global incidence of ocular problems more frequently seen since quarantine. For now, it is of vital importance that optometrists treat patients and keep them out of the emergency room.
1. Kim KW, Han SB, Han ER, Woo SJ, Lee JJ, Yoon JC, Hyon JY. Association between depression and dry eye disease in an elderly population. Invest Ophthalmol Vis Sci. 2011 Oct 10;52(11):7954-8.
2. Uchino M, Yokoi N, Uchino Y, Dogru M, Kawashima M, Komuro A, Sonomura Y, Kato H, Kinoshita S, Schaumberg DA, Tsubota K. Prevalence of dry eye disease and its risk factors in visual display terminal users: the Osaka study. Am J Ophthalmol. 2013 Oct;156(4):759-66.
3. Chida Y, Mao X. Does psychosocial stress predict symptomatic herpes simplex virus recurrence? A meta-analytic investigation on prospective studies. Brain Behav Immun. 2009 Oct;23(7):917-25
4. Sainz B, Loutsch JM, Marquart ME, Hill JM. Stress-associated immunomodulation and herpes simplex virus infections. Med Hypotheses. 2001 Mar;56(3):348-356.
5. Glaser R, Kiecolt-Glaser JK. Chronic stress modulates the virus-specific immune response to latent herpes simplex virus type 1. Ann Behav Med. 1997 Spring;19(2):78-82.
6. Semeraro F, Morescalchi F, Russo A, Gambicorti E, Pilotto A, Parmeggiani F, Bartollino S, Costagliola C. Central Serous Chorioretinopathy: Pathogenesis and Management. Clin Ophthalmol. 2019 Dec 2;13:2341-2352.
7. Agarwal A, Garg M, Dixit N, Godara R. Evaluation and correlation of stress scores with blood pressure, endogenous cortisol levels, and homocysteine levels in patients with central serous chorioretinopathy and comparison with age-matched controls. Indian J Ophthalmol. 2016 Nov;64(11):803-805.