DRY EYE DISEASE: WHAT CHANGED WITH COVID-19

Up to 50% of people in the Northern Hemisphere suffer from Dry Eye Disease (DED), with or without symptoms. These impressive numbers, published in the TFOS DEWS II Report Executive Summary, can be even more substantial. In some populations, DED prevalence was higher and more variable, reaching up to 75%.

The same report states that “Dry eye is a multifactorial disease of the ocular surface characterised by a loss of homeostasis of the tear film, and accompanied by ocular symptoms, in which tear film instability and hyperosmolarity, ocular surface inflammation and damage, and neurosensory abnormalities play etiological roles.” The term “multifactorial disease” recognises DED as a significant and complex functional disorder that cannot be characterised by a single process, sign or symptom.

The pandemic's sudden behavioural and lifestyle changes resulted in the escalation of people with dry eye symptoms. It may have triggered the appearance of other variations of Dry Eye Disease.

The current DED concept was recently coined in 2017 (2). However, the pandemic’s sudden behavioural and lifestyle changes resulted in the escalation of people with dry eye symptoms. It may have triggered the appearance of other variations of Dry Eye Disease. .

The ophthalmologist, corneal surgeon and Deputy Director of the Faculty of Medicine at the Coimbra University, Maria João Quadrado, observes that there are two major causes for the growth of DED prevalence during the pandemic: the misuse of facial masks – leading to what specialists have coined as Mask Associated Dry Eye or MADE –  and the increased use of digital platforms (3).

According to Quadrado, the incorrect positioning of the mask can diffuse air around the eyes, leading to rapid evaporation of tears. “Before the beginning of the pandemic, 75% of our daily activities involved a computer. With remote working, the usage of screens has increased significantly. If Computer Vision Syndrome (CVS) was already an emerging, epidemic, and global public health issue, with a prevalence of 60-90% in computer users, we believe that to date, this number has skyrocketed,” estimates the ophthalmologist.

Mask Associated Dry Eye (MADE)

In August 2020, researchers from the Centre for Ocular Research & Education (CORE) at the University of Waterloo’s School of Optometry and Vision Science raised concerns about a new phenomenon: increased reports of dry, uncomfortable eyes known as mask associated dry eye (MADE). CORE specialists advise eye care professionals (ECPs) on recognizing MADE symptoms and methods to mitigate the condition (4).

As Professor James Loughman wrote recently in his blog, face masks may cause ocular dryness and irritation due to increased airflow from under the face cover. It accelerates the evaporation of the tear film and may result in ocular surface irritation or inflammation.

Dr Lyndon Jones, CORE’s director, highlights that “Face masks are crucial in the fight against COVID-19, and ECPs are well-positioned to provide patients with advice on appropriate wear to maximize eye comfort. Asking patients about their mask-wearing experiences and providing a few helpful tips takes little time and can make a substantial difference.”

Experts from the Centre for Ocular Research & Education (CORE) are advising eye care professionals (ECPs) on how to recognize mask-associated dry eye (MADE) and methods to mitigate the condition.

According to CORE, MADE not only can worsen symptoms in patients with pre-existing dry eye disease but affect the elderly who typically have a poorer quality tear film, contact lens wearers and masked people working extended hours in air-conditioned settings and/or while using digital screens.  With this novel form of dry eye, CORE suggests practitioners incorporate three MADE-related actions into their examination protocols:

  1. Consider the role of the face mask if there are worsening symptoms and signs in patients with confirmed dry eye disease or if patients report dry, uncomfortable eyes or variable vision for the first time.
  2. Routinely ask all patients how their eyes feel while wearing a mask, since many may not think to volunteer their experiences or associate their symptoms with mask use.
  3. Provide advice on alleviating the symptoms, including using a new CORE-developed infographic to help show how a few simple steps can likely provide relief and minimize reoccurrence.
Asking patients about their mask-wearing experiences and providing a few helpful tips takes little time and can make a substantial difference.

Computer Vision Syndrome: COVID-19 and the oldie but goodie 20/20/20 rule

According to the American Optometric Association (AOA), Computer Vision Syndrome (CVS), also referred to as digital eye strain, ”describes a group of eye- and vision-related problems that result from prolonged computer, tablet, e-reader and cell phone use. Many individuals experience eye discomfort and vision problems when viewing digital screens for extended periods. The level of discomfort appears to increase with the amount of digital screen use.” (5)

Since the pandemic started, CVS’s symptoms seem to be more prevalent, as people spend more time on screens while working from home, for entertainment and for staying in touch with friends and family, as per an article in Forbes Magazine (6).

If screen time reduction is not possible, the '20-20-20' rule is worth trying: take a 20-second break to view something 20 feet away every 20 minutes.

Barbara L. Horn, O.D., President of the AOA, explains in the same report that “Our eyes were not designed to use computers especially for long periods, and as a result, many people who spend long hours reading or working on a computer experience eye discomfort and vision problems. Focusing on tiny type for hours on end can cause eye strain, fatigue and headaches. Staring at screens for long periods can also leave eyes parched, red and gritty-feeling.”

On the prevention of the vision problems associated with digital eye strain, Horn recommends control lighting and glare on the device screen, establishing proper working distances and posture for screen viewing. If screen time reduction is not possible, the ’20-20-20′ rule is worth trying: take a 20-second break to view something 20 feet away every 20 minutes.

References:

  1. https://www.tearfilm.org/public/TFOSDEWSII-Executive.pdf
  2. https://spcare.pt/sindrome-de-olho-seco-na-era-covid/
  3. https://www.ajmc.com/view/evolving-knowledge-of-the-unmet-needs-in-dry-eye-disease
  4. https://core.uwaterloo.ca/news/core-alerts-practitioners-to-mask-associated-dry-eye-made/
  5. https://www.aoa.org/healthy-eyes/eye-and-vision-conditions/computer-vision-syndrome?sso=y
  6. https://www.forbes.com/sites/victoriaforster/2020/06/01/are-your-eyes-hurting-during-the–coronavirus-pandemic-you-may-have-computer-vision-syndrome/?sh=6f7307f26cf9

Wes McCann, Doctor of Optometry, owns six practices in Ontario, Canada. A graduate of Western University and Nova Southeastern University, he has earned three Honors Bachelor of Science degrees, an accelerated MBA and a Doctorate of Optometry. McCann is also a professional consultant for Johnson & Johnson and has experience lecturing on topics such as contact lenses, dry eye, pharmaceuticals, and medical equipment for J&J, B&L, Labtician and ZEISS. From 2016-2018, he served on the Board of Directors of the Ontario Association of Optometrists. In 2017, Wes was nominated for the Top 20 Under 40 Award for business achievements and community involvement in London, Ontario, Canada.