Dry Eye

Pandemic triggers can bring out dry eye—expect it to linger

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By Alice T. Epitropoulos, MD, FACS

Early in our first lockdown over a year ago, I started noticing a shift. Suddenly, I saw a significant spike in dry eye, chalazia, and hordeola in male and female patients of all ages. Many patients who never had dry eye symptoms in the past scheduled telehealth visits to complain about dry, red, gritty eyes. Working on their computers for 8+ hours a day was becoming more difficult.

Now we’re well into 2021, and I’m still seeing these patients in the clinic. We’ve identified some potential root causes of the spike and we expect to continue treating dry eye in these patients in the clinic for years to come.

Why Dry Eye?

When new circumstances make patients experience symptoms of dry eye disease, I generally conclude that the problem existed asymptomatically and the new situation has tested their eyes beyond a point where they can easily compensate. Some theoretical factors have emerged as potential triggers for dry eye during the pandemic:

  • Masks and mechanical airflow – We’ve read about mask-associated dry eye disease (MADE),1 an idea put forward by Dr Darrelll White that masks funnel airflow across the ocular surface, increasing tear film evaporation, inflammation, redness and other dry eye signs and symptoms. It’s a familiar concept to those of us who read about dry eye research models that use mechanical airflow to induce the condition. Dr Cynthia Matossian demonstrated the same phenomenon among patients who wear CPAP masks.2
  • Masks and ectropion – Looking at my patients in their masks, I’ve noted that masks can change the mechanics of blinking. They sometimes induce ectropion, turning out lower lids, exposing them to more dryness and preventing complete blinking.
  • Screen time – We know all the ocular surface problems that arise from digital device use, when infrequent and incomplete blinking result in excessive evaporation. Take this familiar problem and multiply the hours people have been staring at screens during the pandemic. Then, for those working in the office, add the presence of a mask and new HVAC or open-window strategies for reducing airborne disease. It’s an enormous challenge, even for a healthy ocular surface.
  • Drinking less (and drinking more) – As a doctor who wears a mask all day long in the pandemic environment, I know I can’t pull down the mask to drink water all day long. Neither can many of my patients, which leaves them less hydrated than they should be for optimal health. In addition, Americans are drinking 14% more alcohol, a natural diuretic, during the pandemic, according to a recent survey.

Long-Term Treatment Strategies

We hope masks won’t be required too much longer as more and more people get vaccinated, but dry eye disease isn’t going to go away. I anticipate treating these patients for years, so although I address the immediate problems, I also take a long-term approach to therapy.

I explain to patients that they need masks that fit more securely, with an adjustable nose bridge, to prevent airflow across their eyes. In the office, some of us use paper tape across the top of our masks so our glasses don’t fog up, and we’ve found patients like that. I tell patients to alter their environment to limit exposure to blowing air at work, at home ,and in the car. I also want them to follow the 20-20-20-20 rule (every 20 minutes spent using a screen, try to look away at something that is 20 feet away for a total of 20 seconds, while blinking 20 times) and use lubricating drops throughout the day before their eyes start feeling uncomfortable.

These changes help, but dry eye disease and the meibomian gland dysfunction that underlies it in most cases will continue to plague patients unless we take additional steps. If patients are experiencing an inflammatory flare, they may benefit from short-term steroid use, such as fluorometholone acetate 0.1% (Flarex, Eyevance) or loteprednol etabonate 0.25%  (Eysuvis, Kala). An immunomodulator like cyclosporine (Restasis, Allergan; Cequa, SUN) or lifitegrast (Xiidra, Novartis) and high-quality nutritional supplements3 may help maintain a healthy ocular surface long-term. If meibomian gland dysfunction warrants further treatment, we have thermal pulsation (LipiFlow, Johnson & Johnson Vision), iLux (Alcon), or IPL at our disposal.

The important thing is to recognize the impact that this time of altered circumstances has had on the ocular surface, while at the same time understanding that this chronic condition was probably already present and will require ongoing care. As patients who have delayed treatment continue to return to our practices, we need to be ready to offer the care they need.

1. White DE. MADE: A new coronavirus-associated eye disease. Ocular Surgery News (blog). June 22, 2020.  

2. Matossian C, Song X, Chopra I, et al. The prevalence and incidence of dry eye disease among patients using continuous positive airway pressure or other nasal mask therapy devices to treat sleep apnea. Clin Ophthalmol. 2020;14:3371-3379. 

3. Epitropoulos AT, Donnenfeld ED, Shah ZA, et al. Effect of oral re-esterified Omega-3 nutritional supplementation on dry eyes. Cornea. 2016;35(9):1185-91.


epitropoulousAlice T. Epitropoulos, MD, FACS, is a cataract and refractive surgeon with a dry eye center of excellence at the Ophthalmic Surgeons & Consultants of Ohio and Clinical Assistant Professor at The Ohio State University Wexner Medical Center.

Speaker/Consultant: Allergan, Novartis, SUN, PRN, KALA, Eyevance, J&J, Alcon

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