Why ODs should discuss mask-associated dry eye with patients


With timely information, ODs can better inform patients about OSD

Mask associated dry eye (MADE) has been in the news since University of Waterloo’s Center for Ocular Research and Education (CORE) released recommendations on how to educate patients in August 2020.

With the world’s population wearing masks for the foreseeable future and many continuing to work at home, the risk of ocular surface disease is increasing. I have personally seen an increase in lid disease, including acute hordeolum and preceptal cellulitis. The air stream moving past the eyes out of the mask that fogs of spectacles is partially to blame, in addition to the mask’s proximity to the eyelid and increasing screen times with working online.

A recent publication sparked the media blitz.1 Anyone with continuous positive airway pressure (CPAP) patients is familiar with the phenomenon in which a mask increases clinically symptomatic ocular surface disease.2 Not only is the air current annoying to anyone wearing glasses and anyone talking to someone with glasses that continually fog, it increases the likelihood that patients will touch their eyes. This may increase the risk for transmission of COVID-19. Masks with a nose wire to better fit the shape of the nose were recommended, as was taping the top of the mask. Breaks from wearing the masks should be taken. Emollient eye drops and blinking exercises were also recommended.

Related: What I have learned from the COVID-19 pandemic

The following month, an article in The Conversationalist reviewed how masks may dry out the eyes and suggested ways to combat the problem.3 People with existing dry eye disease reported worsening symptoms recently, and this was termed “mask-associated dry eye.” Not long after this aforementioned article was published, CORE’s MADE infographic was seen all over social media.

CORE’s website reports, “Since late August, CORE’s MADE insights have been published or broadcast in more than 20 countries on six continents, with a potential audience approaching 1 billion people.”4 Congratulations to CORE for attracting the spotlight. 

Tips and suggestions

Recommendations for eyecare practitioners included:

· Consider the role of face masks in patients with a history of dry eye disease and patients who report symptoms for the first time

· Ask patients how their eyes feel while wearing a mask

· Give patients advice on alleviating symptoms

Related: FDA authorizes first COVID-19 point-of-care antibody test

To avoid or mitigate MADE symptoms, patients can:

· Ensure the mask fits tightly on the top of the nose, particularly while wearing spectacles

· Tape the top edge of the mask to the face for periods of longer wear. Note patients should be careful that the tape does not interfere with natural blinking and that no dermatitis results from the tape adhesive

· Apply lubricating drops as recommended based upon the doctor’s examination

· Limit time in environments with dry eye (air conditioning in summer, heated areas in winter)

· Take regular breaks from digital devices

· Shift phones to night mode with reduced blue light

I think it is important that eyecare practitioners use this timely information to better inform patients about Ocular Surface Disease (OSD). Share the information on your practice’s social media. Create posters to hang in exam rooms for patients to read while they dilate alone because dilation “party rooms” are closed due to COVID-19. Create handouts for patients to receive at completion of the visit.

In addition, consider the pandemic’s effect on your patients’ eyes while you examine them and consider what advice you can give to help them remain comfortable over the next few months.

Related: COVID-19 stole optometry’s 2020 thunder, but not all of it

  • Look at the patient lids, conjunctivae, and cornea with fluorescein and Lissamine green stain. Apply pressure to the glands using a cotton swab or gloved finger. (Make sure the 90 percent alcohol-based sanitizer is dry.)What Is the baseline level of ocular surface disease now?
  • Examine the patients. Are they working with a mask? Do they wear their masks every day, all day? How are they wearing the masks now: correctly or incorrectly? When they smile, does it hit their lids (like mine does 100 times per day)? Assess the risk for MADE.
  • Consider your regional environment. Do you live in the southeast where allergy season is a nightmare or in the north where winter lasts 8 months of the year? How will the winter affect your patients when we turn on the heat?
  • Assess the patients’ overall risk for increased OSD. If they rarely leave home and have mild meibomian gland dysfunction (MGD), suggest hot compresses and warn patients about MADE. If they have mild disease now but wear a mask all day and work in a hospital, make recommendation for better ocular health over the winter.

I typically suggest my normal level of treatment at the visit but discuss 2 levels “up” if they become symptomatic. For example, I may suggest omega-3 supplements and oil-based tear supplements now to resolve a complaint of fluctuating vision with no physical symptoms. However, if symptoms increase over winter, I discuss considering topical medication, hypochlorous acid preparations, and in-office treatments like intense pulsed light (IPL) and manual debridement.

If ODs inform patients of risks and symptoms increase, patients are more likely to call the office to request an appointment. They are more likely to trust you when you correctly predict the future. While we do not know what the next 6 months have in store for us, ODs can help our patients to better manage OSD. We do not normally make the international spotlight as eyecare practitioners. Let’s enjoy it.

More by Dr. Schroeder Swartz: Know the ocular effects of tear gas


1. Moshirfar M, West WB Jr, Marx DP. Face Mask-Associated Ocular Irritation and Dryness. Ophthalmol Ther. 2020;9(3):397-400.

2. Hayirci E, Yagci A, Palamar M, Basoglu OK, Veral A. The effect of continuous positive airway pressure treatment for obstructive sleep apnea syndrome on the ocular surface. Cornea. 2012 Jun;31(6):604-8. doi: 10.1097/ICO.0b013e31824a2040. PMID: 22410644.

3. Jones L. Why face masks can make eyes feel dry, and what you can do about it. The Conversation; 2020. Available at https://theconversation.com/why-face-masks-can-make-eyes-feel-dry-and-what-you-can-do-about-it-143261. Accessed 10/9/20.

4. Lewis AJ. CORE’s Mask-Associated Dry Eye (MADE) Infographics Now Available in 22 Languages. Available at: https://www.visionmonday.com/eyecare/coronavirus-briefing/crisis-response-tactics/article/cores-maskassociated-dry-eye-infographics-now-in-22-languages. Accessed 10/9/20.

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