Effect of facemasks on the tear film during the COVID-19 pandemic

Real or MADE-up: Investigating Mask-Associated Dry Eye (MADE) as an emerging syndrome

Mask-Associated Dry Eye (MADE) has emerged as a consequence of widespread face mask usage during the Covid-19 pandemic. This review critically assesses the available evidence. A comprehensive search on PUBMED and EMBASE was conducted to identify studies on MADE, which were then categorized based on their design. A total of 26 studies were critically appraised, with the majority exhibiting poor study design quality. Investigating the impact of mask use on ocular surface irritation faced challenges due to global mask mandates, pandemic-related behavioural changes, and a lack of validated methods to measure the response to mask wear. Among the 15 studies, 12 reported a statistically significant reduction in TBUT associated with mask wear; however, the median decrease of 1.3 s was considered clinically insignificant. Results from Schirmer's test in 8 studies varied, with 5 studies reporting a decrease, contradicting the hypothesis of misdirected airflow. Out of 7 studies on corneal and conjunctival staining, 6 indicated a worsening associated with mask wear. Five studies investigating OSDI scores reported an increase following mask wear, but 3 studies repeated the survey too soon. Limited evidence suggests that masks may cause mild ocular surface irritation, but the quality and certainty of this evidence remain low. Methodological limitations were prevalent across the majority of studies, and the observed changes were minimal. Therefore, it is unlikely that significant ocular surface pathology will develop in the majority of mask wearers. Currently, there is insufficient data to support the establishment of a new syndrome.

Guarding Our Guardians: Navigating Adverse Reactions in Healthcare Workers Amid Personal Protective Equipment (PPE) Usage During COVID-19

The widespread utilization of personal protective equipment (PPE) during the COVID-19 pandemic has been crucial for reducing transmission risk among healthcare workers (HCWs) and the public. However, the extensive use of PPE has brought about potential adverse reactions, particularly among HCWs. This study aims to investigate the prevalence and characteristics of adverse skin reactions associated with PPE use among different categories of HCWs, including faculty, residents, and nursing officers (NOs), in a dedicated tertiary care COVID-19 hospital. The study design was a hospital-based cross-sectional analytical study conducted over one month, involving a total of 240 participants. The participants were required to complete a pre-tested semi-structured questionnaire that covered demographic information, PPE-related data, preventive measures, observed reactions, and self-management strategies. Results indicated that adverse skin reactions were common among HCWs, with reactions reported by all participants. The most commonly used PPE included N95 masks, goggles, gloves, face shields, isolation gowns, and medical protective clothing. Excessive sweating (60% residents, 21.1% NOs, and 16.25% faculties), facial rash, dry palms (>70% of HCWs), and itching were among the most prevalent adverse reactions. Urticarial lesions (28.5% among NOs), pressure marks and pain (100% on the cheek among all HCWs), fungal infections (18.5% among residents at the web space of fingers), and skin breakdown were also reported. Factors such as age, gender, pre-existing skin problems, and oily/acne-prone skin history were found to be significantly associated with adverse skin reactions. In conclusion, the findings highlight the common adverse reactions reported by HCWs during the use of different PPEs. Certain steps taken by HCWs for the prevention of adverse reactions due to PPE emphasize the importance of tailored preventive measures and strategies to mitigate these adverse reactions, such as proper PPE selection, well-fitting equipment, regular breaks, and appropriate skincare practices. These insights contribute to the development of guidelines for optimal PPE usage and support the well-being of HCWs in their essential roles.

Changes in pupil size, ocular wavefront aberrations, and accommodation in healthcare workers using FFP3 masks

PURPOSE

To evaluate changes in pupil size, ocular wavefront aberrations (WA), and accommodation in healthcare workers after 4-h usage of Filtering Facepiece class 3 (FFP3) masks.

MATERIAL AND METHODS

This prospective study included 22 healthy healthcare workers. Pupil size, ocular WA, and accommodation changes before and after FFP3 mask usage were evaluated using a Hartmann Schack aberrometer. Accommodative responses to stimulus ranging from 0 to 5 diopters (D) in increments of 0.5 D were assessed. Ocular high-order aberrations (HOAs) were recorded at baseline and at every accommodative stimulus. Oxygen saturation (SpO2) was measured by pulse oximetry before and after the mask usage.

RESULTS

The mean age was 36.6 ± 8.5 years. The SpO2 significantly decreased from 98.95 to 97.95% after usage of the FFP3 mask (p < 0.001). The mean pupil size did not significantly differ before (6.22 ± 0.75 mm) and after (6.38 ± 0.83 mm) the 4-h mask usage (p = 0.093). The mean total RMS of the total HOAs was 0.36 ± 0.17 before and 0.39 ± 0.15 after the mask usage (p = 0.071). Post-mask accommodation showed a significant decrease at the 2 D (p = 0.041), 2.5D (p = 0.022), and 3 D (p = 0.025) stimuli.

CONCLUSION

The present study shows that after 4 h-usage of FFP3 mask, both SpO2 and accommodative response to increasing stimuli might be significantly decreased.

Impact of Mask-Associated Dry Eye on Symptom Score

OBJECTIVES

Owing to widespread mask use during the COVID-19 pandemic and clinical reports tying mask use with dryness, this study endeavors to determine if mask use is linked to symptoms of dry eye.

METHODS

A prospective, cross-sectional survey study was performed. The survey used a modified Standard Patient Evaluation of Eye Dryness Questionnaire (SPEED, TearScience, Morrisville, NC) within 15 min of the beginning and discontinuation of mask wear. The survey also asked about mask wear time, mask style, visual correction, age, and gender.

RESULTS

The change in SPEED scores was statistically significant ( P =0.03) between participants with mild SPEED score at baseline (0-9) versus severe SPEED score at baseline (10-28) (n=77: 59 female, 16 male, 1 nonbinary, and 1 declined to answer; range 22-55 years old). Participants in the severe group used masks with nose wire more than the mild group ( P =0.03).

CONCLUSIONS

In this sample, dry eye symptoms were most exacerbated with mask wear in those that had mild initial symptom scores compared with those with severe symptom scores at baseline. The use of nose wire masks may be protective, as the severe group used this type more and had significantly less exacerbation of symptoms postmask wear.

Microbiological Profile of Infectious Keratitis During Covid-19 Pandemic

Purpose

The Covid-19 pandemic introduced significant changes in our daily life, including the widespread use of face masks. The purpose of this study was to assess if significant changes occurred in the microbiological profile of infectious keratitis.

Patients and Methods

A retrospective study was performed, based on a survey review of the electronic medical records of all patients with presumed infectious keratitis, between March 2020 and October 2021. The microbiological isolates in this sample (pandemic group) were compared with those obtained in our center between 2009 and 2018 (pre-pandemic group).

Results

A total of 194 samples were included in the pandemic group. We obtained a culture-positivity rate of 43.3%, which was significantly higher when compared with the pre-pandemic data (35.15%, p = 0.033). Several further significant differences were found between the pandemic and the pre-pandemic groups: the proportion of bacteria, including gram-positive and gram-negative groups, was higher in our sample (pre-pandemic vs pandemic: 76.78% vs 83.33%, p = 0.010; 53.35% vs 60.71%, p = 0.016; 23.43% vs 34.52%, p = 0.005, respectively); two populations of Gram-positive bacteria found in this study were not isolated in the pre-pandemic sample - Dolosigranulum pigrum and Propionibacterium spp.; and two bacterial isolates were significantly increased in our sample - Corynebacterium spp. (18.41% vs 29.76%, p = 0.003) and Pseudomonas aeruginosa (9.00% vs 16.66%, p = 0.012).

Conclusion

In conclusion, significant changes were found in the microbiological profile of infectious keratitis in our center during the Covid-19 pandemic. While these changes could be related to face mask use, more observational and experimental studies are needed to explore this possible association.

Face mask use and effects on the ocular surface health: A comprehensive review

In the COVID-19 period, face masks increased exponentially. Several studies suggest that the rise in ocular discomfort symptoms during the pandemic is mostly part of dry eye disease and that these are due to the effect of face masks, resulting in the newly described term MADE, for "mask-associated dry eye". The most commonly proposed mechanism states that wearing a face mask creates an unnatural upward airflow towards the ocular surface during expiration, although the increased temperature, humidity and levels of carbon dioxide of the exhaled air, stress, increased use of video display terminals, as well as changes in the ocular microbiota may contribute. Evidence supports that the use of face masks causes an increase in dry eye disease symptoms, a decreased tear break-up time, corneal epithelial trauma, periocular temperature changes and inflammatory markers secretion. Given that the use of masks may be frequent in some settings in the near future, it is important to establish its effects and consequences on the ocular surface.

The Ocular Surface Symptoms and Tear Film Parameters during and after COVID-19 Infection

PURPOSE

This study aimed to evaluate the ocular surface parameters of post-COVID-19 patients when compared to healthy controls.

METHODS

Patients after symptomatic SARS-CoV-2 infection, as confirmed by a PCR test of their nasopharyngeal swab sample, were enrolled. Complete ophthalmic examination, including visual acuity test, intraocular pressure measurement (IOP), slit-lamp examination, tear osmolarity test, central corneal thickness, endothelial cell number measurements, non-invasive keratograph break-up time (NIKBUT), meniscus height, and the Schirmer's test were performed and compared with the controls.

RESULTS

It must be noted that there were 36 COVID-19 patients and 25 control subjects included in the study. Eye itching and burning (19%) were the most common symptoms of COVID-19 infection, followed by a subjective decrease in vision (17%), conjunctivitis and eye pain were present in 11%, and 6% of the patients had episcleritis. The mean time from initial infection was 6.5 ± 3.9 (range 1-24 weeks). Meniscus height was not significantly changed between the COVID-19 (0.34 ± 0.13 mm) group and the control (0.33 ± 0.12 mm, p = 0.88) group. In addition, the NIKBUT-1 (p = 0.88; 7.22 ± 4.60 s and 6.91 ± 4.45 s) and NIKBUT average (p = 0.91, 12.30 ± 5.86 s and 11.77 ± 4.97 s) test results showed no significant change either. Neither was a significant result found in the IOP (p = 0.17, 14.56 ± 2.10 mmHg and 14.11 ± 1.96 mmHg); the Schirmer test (p = 0.18, 20.22 ± 7.92 mm and 20.02 ± 7.17 mm); Tosm (p = 0.16, 294.42 ± 54.51 mOsm/dL and 299.33 ± 5.65 mOsm/dL); CCT (p = 0.06, 549.15 ± 28.98 vs. 539.21 vs. 29.08 µm); nor the endothelial cell density (p = 0.07, 2516.64 ± 287.61 vs. 2454.21 ± 498.60 cells/mm²).

CONCLUSIONS

Through this study it was not revealed that there were any significant differences between the post-COVID group and control group in the objective measurements of ocular surface conditions, when performed after the acute phase of COVID-19. The exact incidence and mechanism of ocular findings, especially dry eye disease, in correlation with SARS-CoV-2 requires further research.

Comparison of the Pre-Lens Tear Film Stability and Visual Performance of a Novel and Two Other Daily Disposable Contact Lenses in Healthcare Professionals Wearing Facial Masks for Prolonged Time

OBJECTIVE

To compare a novel daily disposable contact lens (DDCL) verofilcon A with other DDCL materials in terms of pre-lens tear film (PLTF) stabilization and visual performance for prolonged use in healthcare professionals with the use of masks.

METHODS

Subjects aged 20-40 years old were prospectively randomized into three study groups. Group 1: verofilcon A, group 2: nesofilcon A and group 3: senofilcon A. The subjects were evaluated at baseline with best corrected visual acuity (BCVA), non-invasive tear break up time (NIBUT) of pre-lens tear film, and high order aberrations (HoAs). After 28 days of CL use, NIBUT at 1, 4, 8, and 12 h, HoAs, contrast sensitivity (CS) with CVS100-E and contact lens dry eye questionnaire-8 (CLDEQ-8) were evaluated.

RESULTS

Between August and September 2021, 147 eyes of 77 subjects were included in the three study groups. At day 28, the CS scores at 18 cycles per degree, spatial frequencies, and the mean NIBUT scores at 4, 8, and 12 h were higher in the verofilcon A group compared to the nesofilcon A and at 12 h were higher compared to the senofilcon A (p < 0.05). The mean HoAs and CLDEQ-8 test scores were higher in the nesofilcon A group (p < 0.001).

CONCLUSION

The results of this study suggest the superiority of the PLTF stabilization ability of verofilcon A in healthcare professionals with prolonged use of mask. The improved CS and NIBUT scores of this lens could be explained by a new and unique surface technology with greater than 80% water content.