Mask Associated Dry Eye (MADE)

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Mask Associated Dry Eye (MADE)

Overview

The first anecdotal observation of mask-associated dry eye (MADE) was made in June 2020, when D.E. White, an American ophthalmologist, described the condition on his blog and coined the acronym “MADE” [1]. Since then, several studies have been published regarding the effect face masks have on dry eye symptoms. It has been well described that face masks decrease the forward spread of respiratory flora from an individual's mouth and nose [2, 3]. However, the use of face masks generates a unique airflow towards the ocular surface. It is thought that this redirection of air accelerates the evaporation of the tear film which results in ocular surface irritation or inflammation [4]. Irritation of the eye via similar mechanisms has been described. Exposure keratopathy due to inappropriate airflow has been reported in the Intensive Care Unit [5]. Additionally, forced airflow has also been associated with dry eye syndrome (DES) in patients using ventilation machines for sleep apnea [6]. Most recently in a case report by Chadwick et al., they describe the effect of an ill-fitting face mask in a post-operative patient in the setting of the anaesthetized cornea. In this case report, the authors proposed that face masks inadvertently expose the vulnerable ocular surface to exposure keratopathy and thus increase the potential for post-operative infection [7].

Epidemiology

In a recent survey study of 3,605 people, 658 participants (18.3 %) experienced self-reported mask-associated dry eye. This was the first study to describe the prevalence of MADE [8]. Moreover, the 2017 report of the Tear Film and Ocular Surface Society (TFOS) Dry Eye Workshop (DEWS) II Epidemiology subcommittee found the prevalence of DES was more consistent when based on symptom reporting rather than those including signs [9].

Risk Factors

It has been well documented that aging, female sex, and Asian race are risk factors for DES [9]. However, in a recent survey study involving MADE it was noted subjects who experienced DES more frequently were more likely to report a worsening of their condition while wearing a mask when compared to participants who had symptoms only sometimes [8]. It has also been noted that additional care may be necessary in patients using masks for extended periods, have a prior history of DES, had a recent ophthalmic surgery, or have been diagnosed with other surface inflammatory diseases [4].

Evaluation

See Dry Eye Syndrome (section Diagnostic testing for dry eye disease)

Prevention

Prior studies have demonstrated qualitatively that taping the superior edge of a face mask with a medical adhesive tape can effectively block airflow directed to the ocular surface to undetectable levels [10]. However, Moshirfar et al. warn that the tape adhering to the skin of the upper cheek may interfere with the normal excursion of the lower eyelid, possibly inducing mechanical ectropion with secondary lagophthalmos [4]. In the setting of post-operative care, Chadwick et al. suggests using a 24 h post-operative dressing and minimizing face mask usage in the immediate post-operative period. Additionally, the early use of ocular lubricants has been recommended for MADE, mirroring the advice to reduce dry eye symptoms following refractive laser eye surgery [4, 7, 11]. For patients experiencing MADE it has been recommended to take breaks every few hours by removing one’s mask and reapplying lubricant eye drops. Due to the suggested pathophysiology of MADE, emollient eye drops may be the most effective in preventing symptoms by preserving tear film. Finally, blinking exercises may also be beneficial for MADE [4].

References

(1) White, D., 2020. BLOG: MADE: A new coronavirus-associated eye disease. [Blog] Healio, Available at: <https://www.healio.com/news/ophthalmology/20200622/blog-a-new-coronavirusassociated-eye-disease>.

(2) McLure HA, Talboys CA, Yentis SM, Azadian BS. Surgical face masks and downward dispersal of bacteria. Anaesthesia. 1998;53(7):624-626.

(3) Philips B, Fergusson S, Armstrong P, Anderson F, Wildsmith J. Surgical Face Masks Are Effective In Reducing Bacterial Contamination Caused By Dispersal From The Upper Airway. British Journal of Anaesthesia. 1992;69(4):407-408.

(4) Moshirfar M, West WB, Marx DP. Face Mask-Associated Ocular Irritation and Dryness. Ophthalmology and Therapy. 2020;9(3):397-400..

(5) Kousha O, Kousha Z, Paddle J. Exposure keratopathy: Incidence, risk factors and impact of protocolised care on exposure keratopathy in critically ill adults. Journal of Critical Care. 2018;44:413-418.

(6) 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;31(6):604-608.

(7) Chadwick O, Lockington D. Addressing post-operative Mask-Associated Dry Eye (MADE). Eye. 2020.

(8) Boccardo L. Self-reported symptoms of mask-associated dry eye: A survey study of 3,605 people. Contact Lens and Anterior Eye. 2021.

(9) Stapleton F, Alves M, Bunya VY, et al. TFOS DEWS II Epidemiology Report. The Ocular Surface. 2017;15(3):334-365.

(10) Hadayer A, Zahavi A, Livny E, et al. Patients Wearing Face Masks During Intravitreal Injections May Be At A Higher Risk Of Endophthalmitis. Retina. 2020;40(9):1651-1656.

(11) Raoof D, Pineda R. Dry Eye after Laser In-Situ Keratomileusis. Seminars in Ophthalmology. 2014;29(5-6):358-362.