Concerns about COVID-19 transmission have led to a global surge in the use of face masks during the coronavirus disease (COVID-19) outbreak. A significant increase in dry eye symptoms has been observed among regular mask users, although the prevalence of this condition has not yet been extensively documented in the literature (1). Prolonged mask-wearing has been associated with a higher likelihood of developing these symptoms (1,2). The irritation of the ocular surface caused by mask use raises concerns about an increased risk of disease transmission via the ocular pathway (2), as a compromised tear film barrier can reduce innate immunity, leaving the eyes more susceptible to disease-causing organisms. 

In a blog post by Darrell E. White, MD, from Ohio, the term "mask-associated dry eye" (MADE) was introduced. In May, Dr. White observed an older patient presenting with dry eye symptoms, despite no prior history of the condition during 20 years of regular consultations. Dr. White described how the patient’s glasses would repeatedly fog up with each breath due to exhaled air escaping from a poorly fitted mask and flowing upward across the eye surface. This phenomenon led Dr. White to coin the term "mask-associated dry eye" or MADE (3).

The widespread use of face masks is a novel occurrence, and the rise in complaints suggestive of dry eye has significant implications for future eye health. The increased reliance on virtual platforms for work and meetings has led to a notable rise in screen time, further exacerbating the problem. Dry eye significantly impacts quality of life, with one of the most common functional impairments being difficulty with activities requiring sustained focus, such as reading (4). Additionally, environmental factors such as high humidity and drafty air may contribute to the deterioration of the ocular surface, aggravating dry eye symptoms (5). Together, these factors point to the emergence of a new condition: MADE.

While existing literature addresses similar conditions in comparable situations, this study aims to establish a correlation between continuous mask use and its effects on the ocular surface. The objective is to better understand this emerging condition, ensure accurate diagnosis, and explore effective management strategies while assessing the potential consequences on eye health.

This cross-sectional descriptive study was conducted in the Department of Ophthalmology at a multispecialty hospital after obtaining ethical clearance. The study was carried out between February 2021 and July 2021, coinciding with the peak of COVID-19 cases in India. The participants included all doctors working in the hospital, with exclusion criteria being unwillingness to participate. The study followed the Tenets of the Declaration of Helsinki, and written informed consent was obtained from all participants before administering the questionnaire. The questionnaire was created using Google Forms, an open-source application, and consisted of closed-ended, multiple-choice questions. It incorporated essential elements of the Ocular Surface Disease Index (OSDI) questionnaire, a validated tool used to evaluate symptoms of ocular irritation and their impact on vision-related performance over the preceding week. The questionnaire was designed to assess dry eye symptoms in two scenarios: while the participant was not wearing a mask and while wearing one. Additionally, demographic information was collected for each participant.

The OSDI questionnaire evaluates ocular symptoms, vision-related function, and environmental triggers through a 12-item survey. Participants rated their symptoms on a scale ranging from 0 to 4, where 0 indicates "none of the time" and 4 indicates "all of the time." Based on the total score, dry eye severity was classified into four categories: normal (0 to 12), mild dry eye disease (13 to 22), moderate dry eye disease (23 to 32), and severe dry eye disease (33 and above). The OSDI questionnaire is widely recognized as a reliable and valid instrument for assessing the severity of dry eye disease. To minimize confounding factors, participants who regularly used contact lenses, spent extended periods on smartphones or other screen devices, or applied eye drops not related to mask usage were excluded. Additional data were collected regarding the type of mask used, the duration of mask wear, the frequency of hand sanitization using trillium or spirit, and any history of refractive surgery, systemic illnesses contributing to dry eye (such as rheumatoid arthritis or Bell’s palsy), or seasonal allergies (6).

The questionnaire was distributed in English through social media and messaging platforms, ensuring accessibility to practicing doctors and residents across India who were willing to participate. Responses were submitted through email, instant messaging, or directly via the web-based form. Each participant completed two OSDI questionnaires: one assessing their ocular symptoms while wearing a mask and another while not wearing a mask. Participants were categorized based on gender, age, duration of mask usage, and any prior history of dry eye disease. Data collection took approximately one month and was analyzed according to OSDI scoring criteria.

An OSDI score greater than 13 out of 100 indicated the presence of dry eye. The scoring system was based on the participants' subjective assessment of symptom severity, with scores ranging from 0 for "none of the time" to 4 for "all of the time." Each participant's symptoms were assessed and scored twice: once while wearing a mask and once without wearing one. If the OSDI score was higher during mask use, the condition was classified as mask-associated dry eye (MADE). This classification was based entirely on the participants’ subjective evaluation of their own symptoms.

The study presents a detailed analysis of demographic factors, dry eye evaluations, and associated variables in a population sample. Among the 136 doctors surveyed, the majority (55.1%) were female doctors, while 43.4% were male, and 1.47% did not specify their gender (Table 2). Most respondents were aged 26-30 years (52.9%), followed by those aged 20-25 years (29.4%), highlighting a predominantly young working population. The mean age of the participants is approximately 27.57 years, and the standard deviation is approximately 4.42 years. (Table 1).

The distribution of dry eye evaluation reveals that 36% of participants experienced Mask-Associated Dry Eye (MADE), while 14.7% had Dry Eye Disease (DED). Among those with DED, 5.14% had DED without MADE, while 9.6% exhibited both DED and MADE. Interestingly, 26.5% of participants with no prior DED developed MADE, indicating the potential impact of mask usage on triggering dry eye symptoms. Over half (55.6%) of the participants reported no symptoms of DED or MADE. Symptom changes with mask use varied, with 53.7% reporting no difference subjectively, and 9.6% each noting either quantitative stability or a reversal of symptoms. This highlights a complex relationship between mask usage, environmental factors, and individual susceptibility to dry eye symptoms (Table 2).

The analysis of contact lens and eye drop usage shows that a significant majority of participants (85.3%) used contact lenses, while only 14.7% did not. Similarly, 80% of participants reported using eye drops, suggesting a high prevalence of awareness or treatment for ocular symptoms among the group. This suggests that the population surveyed is proactive in managing eye health, possibly due to the nature of their work or personal preferences (Table 3). 

In the current study, 66.2% of doctors reported using a properly fitting mask, while 33% wore masks that were neither too tight nor too loose. Notably, 26% of the participants taped the nose bridge of their mask to improve its fit, which could potentially help reduce the evaporative component of dry eye. Regarding mask usage duration, 48.5% of doctors wore masks for more than 6 hours daily, while 25% wore them for 3-6 hours, and the remaining 25% wore them for less than 3 hours (Table 6). These findings suggest that mask fit and usage duration may significantly influence the prevalence of mask-associated dry eye symptoms.

The analysis of Mask-Associated Dry Eye (MADE) incidence reveals distinct patterns based on smartphone usage and face mask duration. According to Figure 1, the highest incidence of MADE (47.8%) was observed in participants who used smartphones for 3-6 hours daily, followed by those using smartphones for more than 6 hours (36%). Participants using smartphones for less than 3 hours had the lowest incidence of MADE (16.2%), suggesting that moderate smartphone usage may exacerbate symptoms compared to shorter usage durations.

Similarly, Figure 5 highlights the association between face mask usage duration and MADE incidence. The highest incidence (48.5%) was seen in participants wearing masks for more than 6 hours daily, while equal incidences (25.7%) were recorded for those using masks for less than 3 hours and 3-6 hours. These findings emphasize that prolonged face mask usage and moderate to extended smartphone usage may significantly contribute to the development or worsening of MADE symptoms.

The analysis of factors affecting dry eye, as shown in Table 4, indicates that the majority of participants (81.6%) had no identifiable underlying conditions contributing to dry eye. Among the reported factors, atopy/allergies were the most common, affecting 10.3% of the participants, followed by a history of refractive surgery, such as LASIK, SMILE, or PRK, reported in 8.1% of participants. Rheumatoid arthritis/Sjögren's syndrome and Bell’s Palsy were rare, each affecting only 0.7% of the participants. These findings suggest that while a few medical or procedural factors contribute to dry eye, the majority of cases may be related to other environmental or behavioral factors rather than pre-existing medical conditions.

Table 5 highlights the symptoms experienced by participants while wearing masks. The majority (53.7%) reported no difference in their symptoms with mask usage, indicating that mask use did not significantly affect their dry eye symptoms for over half of the participants. However, 38.9% of participants experienced a worsening of symptoms while wearing a mask, suggesting that mask-associated factors, such as airflow or humidity changes, could exacerbate dry eye symptoms. Interestingly, 7.4% of participants reported an improvement in symptoms while wearing a mask, which might be attributed to a protective effect against environmental irritants, possibly due to a well-fitted mask.

The analysis of sanitizer usage, as shown in Table 6, reveals that the majority of participants (39.7%) used sanitizers every few hours, followed by 31.6% who used them more than once a day. A smaller percentage (16.2%) reported using sanitizers at least once a day, while 8.1% of participants used them every few minutes, indicating extremely frequent usage. Only 4.4% of the participants reported never using sanitizers. Frequent sanitizer use is known to contribute to altered tear film status, potentially increasing the risk of allergic conjunctivitis due to repeated hand-eye contact with chemical residues from sanitizers. These findings suggest a high prevalence of frequent sanitizer use among the participants, which may contribute to ocular surface issues like dry eye due to increased hand-eye contact with chemical residues from sanitizers.

COVID-19 is associated with significant morbidity and mortality, largely due to its potential to cause severe respiratory infections. This risk is heightened by comorbidities such as cardiovascular diseases, diabetes, chronic respiratory conditions, and cancer. Effective prevention and management strategies for COVID-19 include a thorough understanding of its etiology, pathogenesis, modes of transmission, and clinical manifestations. In addition, hygienic practices such as frequent handwashing, using alcohol-based sanitizers, and maintaining physical distance have proven effective in limiting its spread.

The use of hand sanitizers, however, has been implicated in altering tear film status, potentially increasing the risk of allergic conjunctivitis due to frequent hand-eye contact with chemical residues (7,8). Our study found a significant correlation between increased hand sanitizer usage and higher OSDI (Ocular Surface Disease Index) scores, suggesting a link between sanitizer use and dry eye symptoms (p = 0.03).

One of the primary transmission routes for COVID-19 is through salivary droplets or nasal discharge, which can be inhaled. As a result, the widespread use of face masks has become an essential measure to reduce disease transmission and save lives. The World Health Organization (WHO) recommends medical masks for healthcare professionals in clinical settings and for anyone exhibiting symptoms of COVID-19, even mild ones. Masks are also advised for caregivers of individuals with suspected or confirmed COVID-19.

Our study observed an unusual increase in dry eye symptoms among patients during the pandemic, coinciding with the increased use of face masks. To investigate, we assessed whether face mask usage could exacerbate symptoms of dry eye disease (DED) or contribute to ocular discomfort. While DED presents with both clinical and subjective symptoms, the OSDI questionnaire is a useful tool for evaluating the latter. According to the Tear Film and Ocular Surface Dry Eye Workshop II (TFOS DEWS II), DED is characterized by a loss of tear film homeostasis caused by tear instability, hyperosmolarity, ocular surface inflammation, and neurosensory dysfunction.

Giannaccare et al. (9) suggested that poorly fitted masks could redirect exhaled air toward the eyes, accelerating tear evaporation and aggravating dry eye symptoms. Similarly, Hayirci and colleagues (10) reported a comparable mechanism in users of continuous positive airway pressure devices. Scalinci et al. (11) found that prolonged mask usage was associated with increased OSDI scores. In our study, 48.5% of doctors wore face masks for more than six hours daily, and longer durations were significantly correlated with worsening OSDI scores (p = 0.002). OSDI is a standardized test to support dry eye disease diagnosis (11) and a study conducted by R M Schiffman, et al shows the test to be reliable and valid for the detection of the severity of dry eye disease (12).

The pandemic also led to increased screen time, with many individuals spending over five hours per day on electronic devices. A study by Ian Saldanha et al. (4) reported a near-doubling of screen time across various devices. In our study, 47% of participants used smartphones or screens for 3-6 hours daily, while 36.8% reported usage exceeding six hours. Prolonged screen exposure is a well-documented factor contributing to dry eye symptoms(13).

Our findings align with a similar study conducted in the general population, where 16.3% reported worsening dry eye symptoms with mask use, while 72.1% reported no change, and 11.6% felt better. Compared to doctors, the general public used face masks for shorter durations, with only 15.5% wearing them for more than six hours daily. Conversely, a higher proportion of doctors (14.7%) used contact lenses, a known risk factor for dry eye exacerbation.

Interestingly, 7.4% of our participants reported improved symptoms with mask use, possibly due to the use of well-fitted masks. However, further research is needed to confirm this observation. Laura Boccardo (2) also identified a correlation between face mask use and dry eye symptoms, with 26.9% of her study participants reporting worsened symptoms. In contrast to the general population, doctors experienced a higher prevalence of mask-associated dry eye (MADE), likely due to longer working hours and extended mask usage in clinical settings. Despite this, the study acknowledges that dry eye prevalence is not limited to healthcare workers. Shehnaz Bazeer et al. highlighted that professionals across various sectors, including law and business, also reported high incidences of dry eye symptoms (p = 0.001).

The use of correctly fitted masks can mitigate symptoms. In our study, 66.2% of doctors used properly fitted masks, while 33% used masks that were either too tight or too loose. Additionally, 26% taped the nose bridge of their masks to ensure a better fit. Studies by Amin Zand et al. (14) and Sridevi Nair et al. (15) emphasize the benefits of taping the upper edge of masks to alleviate dry eye symptoms. This study aims to shed light on the emerging condition of mask-associated dry eye. It is not intended to discourage the use of masks, which remain a critical tool in preventing the spread of COVID-19 and other infectious diseases. The study also demonstrates the effectiveness of web-based surveys in gathering geographically dispersed data quickly and cost-effectively.

However, certain limitations must be acknowledged. The study relied on self-reported symptoms, which may not always align with clinical diagnoses. Additionally, the OSDI questionnaire assesses symptoms over the past week, limiting its applicability for longitudinal studies. The findings are also limited to healthcare professionals and may not be generalizable to the broader population.

This study demonstrates that wearing face masks for more than three to six hours daily can worsen dry eye symptoms, particularly in individuals with pre-existing DED. Healthcare professionals should be vigilant about recognizing the signs of mask-associated dry eye and provide appropriate care for affected individuals. Ophthalmologists should recommend taping the upper edge of masks to reduce tear evaporation and educate patients about the potential risks of ill-fitted masks. Future research with larger sample sizes is essential to better understand the prevalence and severity of this emerging condition.

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