Dry eye disease research review
Do masks exacerbate dry eye disease?

Dry eye disease research review

September 3, 2021 Dr Stuti Misra

Self-reported symptoms of mask-associated dry eye

Boccardo L

Contact Lens and Anterior Eye 2021, 101408.

 

Review: This paper reports the results of a survey of 3,605 people about mask-associated dry eye (MADE) symptoms and ocular discomfort.

 

The primary aim of this observational, descriptive and cross-sectional study was to assess MADE, specifically in relation to age, sex, occupation and the use of spectacles or contact lenses. Over half of the participants (54.3%) experienced some frequency of dry eye symptoms at times. From this symptomatic group of participants, almost 27% reported worsening symptoms, and from the entire group, 18.3% experienced MADE. Although age did not appear to influence the presence or absence of dry eye disease in this cohort, females reported more dry eye symptoms compared with their male counterparts, with mask-wearing causing a worsening of symptoms. No differences were noted between participants with spectacles or contact lenses. Healthcare professionals, teachers, students, office employees and factory workers did not show any statistically significant increase in dry eye symptoms associated with masks compared to without. Only retailers frequently reported MADE. Furthermore, regression analysis did not reveal any association between MADE and age, refractive correction and history of ocular discomfort. Just over a quarter of respondents with existing dry eye symptoms reported an increase in discomfort with mask wear while people without pre-existing symptoms did not experience any change.

 

Comment: With the emergence of the Covid-19 pandemic, the US Centres for Disease Control and Prevention (CDC) recommended using a mask to minimise the personal risk of infection and to help break the chain of transmission of SARS-CoV-2. The regular use of masks has prompted significant concerns in terms of comfort and headache, sweating, difficulty in breathing and fogged glasses.

 

Given the critical nature of masks for health and safety during the pandemic, it is reassuring that overall, this study did not highlight a worsening in dry eye symptoms accompanying regular mask wear for most people, except those with pre-existing dry eye symptoms. However, the study was based only on self-reported symptoms. It is important to consider clinical signs as well as symptoms before diagnosing clinically significant dry eye and offering advice to patients.

 

The effects of a steam warming eye mask on the ocular surface and mental health

Uchino M, Kawashima M, Yamanishi R, Inoue S, Kawashima S, Tagami K, Tsubota K et al

The Ocular Surface 2021.

 

Review: Uchino et al investigated the effects of continuous use of steam warming eye masks on the tear film and ocular surface health, mental health and quality of life. In this double-masked randomised controlled trial, 39 participants were administered warming eye masks while 40 in the control group were given non-warming eye masks. The ocular assessments included measurement of tear break-up time (TBUT), Schirmer’s test without anaesthesia and corneal and conjunctival staining. Additionally, the Hospital Anxiety and Depression Score (Anxiety: HADS-A, Depression: HADS-D) and Subjective Happiness Scale (SHS) were completed by all participants. These variables were repeated on two occasions: at baseline and after two weeks of intervention.

 

The eye mask contained iron and water in a sealed compartment and generated moist heat by the oxidative reaction of iron. These eye masks were individually packed in a pouch which, when opened prompted the oxidative reaction that led to the warming of the mask to approximately 40˚C within five minutes. A temperature of 38-40˚C was maintained for almost 20 minutes. All the participants were instructed to use either the warming or non-warming eye masks once a day for two weeks. Both devices were identical in appearance, but the non-warming eye mask did not generate moist heat.

 

TBUT was statistically significantly lower in the warming eye mask group compared to control at baseline. TBUT, fluorescein staining score and HADS-D showed statistically significant improvement after the two-week intervention period only in the warming eye mask group. However, SHS or Subjective Happiness Scale did not change in either group post-intervention. Analysing the data as a function of age, interestingly, the participants aged over 50 in both groups showed significantly greater improvement in TBUT and fluorescein scores than those in the younger age group.

 

The authors concluded that two weeks’ use of the eye-warming device results in improved ocular surface and depression scores. Since there is a recognised association between dry eye disease and mood disorders, the warming eye mask was presumed to improve mood and related issues by reducing dry eye symptoms.

 

Comment: Dry eye disease (DED) causes poor tear function, poor visual performance that may severely impact a patient’s quality of life, and mood-related disorders. The use of steam warming eye masks may promote relaxation and improve sleep quality; however, confirming a long-lasting improvement in mental health will require longer than a two-week testing period.

 

Conjunctivochalasis and tear osmolarity are associated with reduced conjunctival epithelial thickness in dry eye 

Gumus K and Pflugfelder SC

American Journal of Ophthalmology 2021227, 35-44.

 

Review: This case-control study aimed to compare corneal and bulbar conjunctival epithelial thickness in those with and without dry eye disease (DED) and their association with DED clinical tests. Fifty participants with aqueous deficient (ADDE) or evaporative dry eye (EDE) and 15 control participants underwent an extensive battery of ocular surface assessments.

 

In addition to the two questionnaires – Ocular Surface Disease Index (OSDI) and SANDE visual analogue scale – assessments included videokeratoscopy, tear break-up time (TBUT), corneal and conjunctival fluorescein staining, Schirmer’s test without anaesthesia and tear osmolarity. A fold adjacent to the lid in the temporal and nasal conjunctiva, visible on OCT images of the inferior tear meniscus, indicated the presence of conjunctivochalasis (CCh). Anterior segment optical coherence tomography (AS-OCT) was performed to measure the corneal and conjunctival epithelial thickness (CET) using the digital caliper tool to mark the distance from the epithelial surface to the location of a change in brightness indicating the substantia propria. Three epithelial thickness measurements were recorded at 1.5mm intervals over the central 3mm of each conjunctival image. 

 

The control participants had statistically significantly higher TBUT and Schirmer’s test scores compared to the DED group. In contrast, DED participants exhibited higher tear osmolarity, OSDI and ocular surface staining scores. Lower CET in the temporal and inferior bulbar conjunctiva was noted in those with DED and CCh, compared to DED participants without CCh. No differences in corneal epithelial thickness were found between the DED and the control groups. 

 

The authors concluded that the high-resolution AS-OCT devices provide supplementary information about the ocular surface epithelial thickness. Tear osmolarity, AS-OCT automated software analysis and qualitative clinical evaluation should be collectively considered.  

 

Comment: Tear osmolarity is affected in ADDE and EDE resulting in painful ocular surface disease. This may induce apoptosis of the ocular epithelial cells, prompting inflammatory mediator production by the epithelial and immune cells. Although staining by fluorescein, lissamine green and rose bengal can provide information for the clinician about ocular epithelial health status, AS-OCT offers an additional non-invasive, in vivo technique for cross-sectionally imaging the corneal and conjunctival layers. 

 

Dr Stuti Misra is a senior lecturer in the Department of Ophthalmology at the University of Auckland. Her research revolves around corneal imaging, particularly in-vivo confocal microscopy in corneal disorders and systemic diseases, wide-field imaging and paediatric ocular abnormalities.