In this session of Interventional Mindset, three leaders in the dry eye field—Dr. Preeya K. Gupta, Dr. Darrell E. White, and Dr. Alice Epitropoulos—share their experiences and findings on the effect of the pandemic on dry eye disease (DED) and its treatment.
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Pandemic-related causes of DED
During the height of COVID-19, eyecare professionals began seeing an increase in both new dry eye symptoms and an intensification of preexisting symptoms. During the mandatory lockdown, Dr. Epitropoulos found the number one reason for telehealth calls to be individuals eager to discuss their dry eye. To best address this trend, ophthalmologists and optometrists first had to find the factors leading to this escalation.
Though we are no longer at the height of the pandemic, lasting changes—such as increased screen time and residual stress—still exist and play a role in the current state of ocular surface health. Several factors came into play during the pandemic that intensified both the number of dry eye sufferers and the acuteness of symptoms.
Masks
When it comes to the onset of dry eye complaints, the addition of masks to the daily wardrobe is perhaps the most obvious culprit. Masks negatively impact the eye by drying out the ocular surface via misdirected airflow, altering blink mechanics, decreasing daily hydration, and potentially changing the microbiome.
Misdirected airflow
Dr. White first noticed the phenomenon in May of 2020 during a follow-up exam on a longtime patient. The elderly gentleman, with no history of dry eye disease, suddenly had the typical hallmark symptoms associated with the condition.
During the course of their discussion, Dr. White became aware that the gentleman’s glasses were continuously fogging up and, in a lightbulb moment, realized the mask was redirecting the airflow directly into the patient’s eyes. As many studies have shown, the alteration in the mechanical airflow can increase inflammation and speed the evaporation of the tear film.
Altered blink mechanics
Masks encourage partial blinking. In addition, wearing a mask for long periods of time can potentially induce change in the normal lid position through altered pressure around the lower lid and cheek areas. Therefore, patients need to be encouraged to consciously blink more as well as to make certain an ill-fitting mask was not pulling their lower lids down.
Decreased hydration
Simply put, wearing a mask made drinking difficult. Consequently, people reduced their water intake. This decreased hydration can translate to less moisture in the eyes.
Changes in the microbiome
One of the more interesting theories is that mask-wearing subtly changed the ocular surface microbiome—the bacteria, viruses, and fungi that cohabitate in the eye.
The confluence of the above-mentioned mask-associated dry eye components could work together to cause an imbalance of bacteria, which seems to have created a more hospitable growing environment for the Demodex mite and non-traditional bacteria that may induce more inflammation along the eyelids and meibomian glands.
Increased screen time
The role of increased screen time in intensifying dry eye cannot be overestimated. With COVID, the vast majority of activities, both work and social, were relegated to online. Add in the hours spent binging television and gaming to pass the time, and you have most individuals spending an alarming amount of hours with their eyes glued to a screen, resulting in digital eye strain, which compounds dry eye symptoms.
Dr. White’s conservative estimate was that, throughout COVID, most patients were looking at a screen at least 50% more than they had prior. To counteract this, Dr. Epitropoulos shared the 20-20-20 rule with her patients: Follow every 20 minutes of looking at a screen with 20 seconds of focusing on an object 20 feet away.
Stress
For several years, studies have noted a link between dry eye and stress as well as dry eye and sleep quality, which is influenced by stress. Stress-related hormonal imbalances can be drivers of both meibomian gland health and overall ocular surface health. Therefore, the undeniable rise in stress levels across people of all ages throughout the pandemic likely worsened dry eye symptoms.
Rise in chalazion
The surgeons also noticed an increased incidence of chalazion during COVID-19. It has been hypothesized that alterations in the microbial flora involving the lids, lashes, and conjunctiva could be to blame. Several members of CEDARS/ASPENS, including Dr. Epitropoulos, and in cooperation with Lexitas, are participating in an Institutional-Review-Board-approved retrospective trial to evaluate related ICD-10 codes to prove this heightened prevalence.
Treating dry eye in the age of COVID-19
The pandemic found all three ophthalmologists taking their baseline treatment to a higher level and looking for ways to balance multiple treatments to achieve optimal results. In handling this amplified dry eye, each realized the critical nature of triaging patients and customizing treatment to address their most immediate needs.
Steroids
All three surgeons agree that, with COVID-related dry eye and its magnified symptoms, they have been more liberal with the use of steroids as part of the treatment regimen, especially for those suffering from “moderate plus” DED.
Because of its ability to penetrate the target structures, Eysuvis (Alcon), the first FDA-approved ocular corticosteroid (loteprednol) for the short-term treatment of DED signs and symptoms, presents an effective and efficient way to handle dry eye flare-ups, especially in those with an aggressive inflammatory component.
According to Dr. White, using steroids when starting an immunomodulator is key to ensuring the patient “feels better faster” and continues treatment. The doctors also found steroids to be an invaluable tool in preparing the ocular surface for surgery—a process that often increased from the normal 2 weeks to up to 8 due to the complexity of COVID-related dry eye symptoms.
In-office treatments to treat dry eye caused by COVID-19
As patients during the pandemic did not want a treatment plan that would involve multiple office visits, Dr. Gupta found herself taking a more direct approach and recommending an in-office treatment in conjunction with steroids and/or an immunomodulator.
As dry eye is not a single-treatment disease, she assessed all available technologies to determine the best first step and then formulated which treatments should follow. During the first COVID-timed visit, after an assessment, she offered the in-office procedure that could treat their particular form of dry eye most effectively with maximum relief on the spot, knowing additional treatments would accompany it.
Intense pulsed light (IPL) therapy
Oftentimes the doctors turned first to IPL to address the inflammatory aspect of DED. And, as chalazion is an inflammatory lesion of the eyelid, it responds very well to IPL.
Therefore, in lieu of the traditional incision and drainage for chalazion, which damages the meibomian glands, the surgeons performed direct-to-lesion IPL with very positive results. In addition, they touted IPL as being very complementary to many other treatment technologies.
Other in-office procedures to treat dry eye caused by COVID-19
For obvious obstruction, the trio of ophthalmologists turned to thermal-driven treatments. For blepharitis, microblepharoexfoliation or BlephEx, was their go-to. In addition to these in-office procedures, patients were urged to be compliant with their immunomodulators, nutritional supplements, preservative-free artificial tears, and the 20-20-20 rule.
Conclusion
The lessons gleaned during the pandemic have influenced the way these doctors continue to treat patients, and dry eye in particular. First, having many patients report that they were the only doctor they had seen since the lockdown, each more fully realized the role of eyecare professionals in primary care.
Second, even as COVID is still present and smoldering to date, these ophthalmologists are all more aggressive and comprehensive in their dry eye treatment offerings and regimen.
