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Face mask the music


Mask wear affects the ocular surface, periorbital region, and patient-physician relationship

As we pass the 1-year mark of a global pandemic, wearing a face mask to control disease spread has become commonplace. The regulations and recommendations of proper face mask wear remain divisive and variable across continents, countries, and states.

I suspect that in the United States, physicians and patients will continue to wear face masks, at least part-time, into 2022. It seems likely that in high risk environments for disease spread, mask wearing will remain mandatory. Here, I present a collection of information gleaned from physician experiences during this unprecedented time of patient care. Of interest, a March 6, 2021, PubMed search of “face mask 2020” yielded 1223 results.

Health effects of face mask wear

Face mask wear has been associated with facial skin itch,1 worsening of atopic and seborrheic dermatitis, 2 flare-ups of dermatologic rosacea,3 malar rash,4 and possible ear protrusion in mask-clad children.5

In the world of optometry, face mask wearing during visual field studies can induce visual field defects, put patients at risk for endophthalmitis postintravitreal injections, and cause corneal abrasions.6-9 Furthermore, an altered visual field from mask wear increases the risk of falls.10

Mask-associated dry eye

Regarding masks and the ocular surface, face mask wear seems to contribute to patient tear film dysfunction complaints.11 A significant number of patients reported an increase in ocular discomfort when wearing a face mask, leading to the coinage of the acronym MADE: mask-associated dry eye.12

One proposed cause of MADE is mask-directed air blowing across the ocular surface; another is poorly fitted masks causing a lower eyelid ectropion or lagophthalmos. I have noted the latter to be the case especially for those patients with preexisting lower eyelid laxity. Similarly, widespread mask wear corresponds to an increased incidence of chalazion development.13 Mask wear may provide a funnel for increased exposure of the eyelids to bacteria— and fogging eyeglasses—promoting inflammation and chalazion formation.

Recommendations to patients to mitigate the risk of chalazion include the use of an antiseptic mouthwash containing hydrogen peroxide, alcohol, or povidone iodine to reduce bacterial load in the mouth. This may decrease the likelihood of masked breathing patterns altering normal flora of the eyelids and periorbital region.

Good hand hygiene practices, avoidance of face touching, avoidance of excessive mask adjustment, and use of adhesive tape over one’s mask on the bridge of the nose to minimize the upward direction of air toward the eyes may be helpful. The use of a 1% hypochlorous acid solution as part of daily eyelid hygiene may act as a deterrant for both antiviral and antibacterial blepharitis.

Communication challenges

Despite the crucial protective role of face masks, they pose challenges for daily face-to-face communications. Nonverbal communication, such as facial gestures and expressions, constitutes 55% of overall communication.14 The physician-patient relationship is negatively affected by wearing face masks. Covering faces reduces the ability to determine patient emotions and affect physicians’ measured responses to situations.15 Likewise, the patient may miss a physician’s expressions of empathy. Furthermore, people with special needs and hearing disabilities rely on sign language to communicate.

Covering the lower part of the face (nose, cheeks, mouth, and chin) may adversely affect their understanding of communicated information and cause them to feel more disabled and ostracized.16 Sensitivity to these face mask–precipitated fractures in communication, and thoughtful attention to ameliorating them, is necessary for successful doctor-to-patient information sharing and emotional security. It has been a year of challenge and discovery.

Together, remembering subtle yet important face mask–related patient care strategies will get us through this.


1. Krajewski PK, Matusiak Ł, Szepietowska M, Białynicki- Birula R, Szepietowski JC. Increased prevalence of face mask–induced itch in health care workers. Biology (Basel). 2020;9(12):451. doi:10.3390/biology9120451

2. Veraldi S, Angileri L, Barbareschi M. Seborrheic dermatitis and anti-COVID-19 masks. J Cosmet Dermatol. 2020;19(10):2464-2465. doi:10.1111/jocd.13669

3. Chiriac AE, Wollina U, Azoicai D. Flare-up of rosacea due to face mask in healthcare workers during COVID-19. Maedica (Bucur). 2020;15(3):416-417. doi:10.26574/ maedica.2020.15.3.416

4. Nimmo A, Skinner L, Hole B, Taylor DM. Unmasking a malar rash during the COVID-19 pandemic. BMJ Case Rep. 2020;13(9):e239004. doi:10.1136/bcr-2020-239004

5. Zanotti B, Parodi PC, Riccio M, De Francesco F, Zingaretti N. Can the elastic of surgical face masks stimulate ear protrusion in children? Aesthetic Plast Surg. 2020;44(5):1947- 1950. doi:10.1007/s00266-020-01833-9

6. Young SL, Smith ML, Tatham AJ. Visual field artifacts from face mask use. J Glaucoma. 2020;29(10):989-991. doi:10.1097/IJG.0000000000001605

7. Bayram N, Gundogan M, Ozsaygili C, Vural E, Cicek A. The impacts of face mask use on standard automated perimetry results in glaucoma patients. J Glaucoma. 2021;30(4):287- 292. doi:10.1097/IJG.0000000000001786

8. Hadayer A, Zahavi A, Livny E, et al. Patients wearing face masks during intravitreal injections may be at higher risk of endophthalmitis. Retina. 2020;40(9):1651-1656. doi:10.1097/ IAE.0000000000002919

9. Au SCL, Ko CKL. Corneal abrasion from removing face mask during the COVID-19 pandemic. Vis J Emerg Med. 2021;22:100958. doi:10.1016/j.visj.2020.100958

10. Kal EC, Young WR, Ellmers TJ. Face masks, vision, and risk of falls. BMJ. 2020;371:m4133. doi:10.1136/bmj.m4133

11. Moshirfar M, West WB Jr, Marx DP. Face mask–associated ocular irritation and dryness. Ophthalmol Ther. 2020;9(3):397- 400. doi:10.1007/s40123-020-00282-6

12. Boccardo L. Self-reported symptoms of mask-associated dry eye: a survey study of 3,605 people. Cont Lens Anterior Eye. Published online January 20, 2021. doi:10.1016/j. clae.2021.01.003

13. Silkiss RZ, Paap MK, Ugradar S. Increased incidence of chalazion associated with facemask wear during the COVID-19 pandemic. Am J Ophthalmol Case Rep. 2021;22:101032. doi:10.1016/j.ajoc.2021.101032

14. Mohammadi K. The eyes have it: communication and face masks. The Guardian. May 30, 2020. Accessed March 6, 2021. https://www.theguardian.com/lifeandstyle/2020/may/30/ face-mask-eye-contact-commuication-coronavirus

15. Nobilo B. Coronavirus has stolen our most meaningful ways to connect. CNN. June 2020. Accessed March 6, 2021. https://edition.cnn.com/interactive/2020/06/world/ coronavirus-body-language-wellness/

16. Mheidly N, Fares MY, Zalzale H, Fares J. Effect of face masks on interpersonal communication during the COVID-19 pandemic. Front Public Health. 2020;8:582191. doi:10.3389/ fpubh.2020.582191

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