Prevalence of dry eye syndrome associated to face mask among Tabanan General Hospital Health workers in 2021

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1054 Published by Intisari Sains Medis | Intisari Sains Medis 2021; 12(3): 1054-1057 | doi: 10.15562/ism.v12i3.1135

ORIGINAL ARTICLE

Intisari Sains Medis 2021, Volume 12, Number 3: 1054-1057 P-ISSN: 2503-3638, E-ISSN: 2089-9084

ABSTRACT

Prevalence of dry eye syndrome associated to face mask among Tabanan General Hospital Health

workers in 2021

Rania Ayu Permata Putri Kornia^1*, I Putu Rustama Putra², Ni Wayan Sedani², Cynthia Dewi M²

Background: The continuous development of COVID-19 has made face masks became a mandatory part of our daily routine, but there has been an increase in dry eye syndrome (DES) from the regular used of face masks. Health workers who are obliged to use face masks are the one that has risk factors for experiencing DES, including health workers at Tabanan General Hospital, as one of the COVID-19 referral hospitals in Bali. The purpose of this study was to calculate the prevalence of DES associated to face masks and characteristics of DES among Tabanan General Hospital health workers in 2021.

Methods: This research was a descriptive cross sectional study that conducted at Tabanan General Hospital from March to April 202. The sample was 64 health workers at Tabanan General Hospital with consecutive sampling techniques using the Ocular Surface Disease Index (OSDI) questionnaire. Data were collected by using questionnaire. Data were annalyse

descriptively by using SPSS 25 and the result were provide in table.

Results: The prevalence of DES associated to face masks among Tabanan General Hospital health workers in 2021 was 70.3%, with a prevalence of mild degrees 15.6%, moderate 12.5%, and severe 42.2%. The prevalence of surgical mask users was greater than Filtering Face Piece (FFP) 2 mask users in mild and severe degrees of DES. Characteristics of DES among Tabanan General Hospital health workers in 2021 were found mostly in age 30-39 years old, more in females, without DM history, non-smokers, and without eye surgery history.

Conclusion: Most of the health workers at Tabanan General Hospital experiencing DES associated to face masks, and mostly with a severe degree. Among those with DES, there were more surgical mask users than FFP2 mask users. Future studies are needed to analyze the association between DES and face masks.

Keywords: dry eye syndrome, face mask, COVID-19, health workers.

Cite This Article: Kornia, R.A.P.P., Putra, I.P.R., Sedani, N.W., Dewi, M.C. 2021. Prevalence of dry eye syndrome associated to face mask among Tabanan General Hospital Health workers in 2021. Intisari Sains Medis 12(3): 1054- 1057. DOI: 10.15562/ism.v12i3.1135

1Intern Doctor, Ophthalmology Department, Tabanan General Hospital, Bali, Indonesia

2Ophthalmologist, Ophthalmology Department, Tabanan General Hospital, Bali, Indonesia

*Correspondence:

Rania Ayu Permata Putri Kornia;

Intern Doctor, Ophthalmology Department, Tabanan General Hospital, Bali, Indonesia;

[email protected]

Received: 2021-09-08 Accepted: 2021-11-25 Published: 2021-12-30

Published by Intisari Sains Medis

Open access: http://isainsmedis.id/

INTRODUCTION

Dry eye syndrome (DES) is one of the most common reasons for ophthalmic consultation that affects millions of people worldwide.¹ According to the recent official report of the International Dry Eye Workshop (DEWS) 2017, dry eye was defined as “a multifactorial disease of the ocular surface characterized 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”.² A study in the province

of Riau, Indonesia reported the prevalence rate of one or more of the six dry eye symptoms often or all the time was 27.5%.³

Prevalence of DES increased significantly with age¹, with a gradual increase from aged 50 and a more marked increase beyond the age of 80.A higher prevalence also found in females than males in all studies stratified by sex.⁴ Additionally, a group of risk factors has been reported to be associated with DES, such as diabetes mellitus (DM),^5,6 smoking,⁷ eye surgery such as LASIK (Laser-Assisted in Situ Keratomileusis)⁸ and cataract surgery,⁹ and recently, as the development of COVID-19 (Coronavirus

Disease 2019) continues, the regular use of face masks has made an increase in DES.^10–12

WHO (World Health Organization) declared COVID-19 as a global pandemic on March 11, 2020.¹³ Until now the total number of COVID-19 cases has reached more than 210 million people worldwide, and more than 4 million cases in Indonesia.¹⁴ This continues to develop and since the beginning WHO always recommends keeping ourselves safe from COVID-19 by taking some simple precautions, such as physical distancing, use face masks, and clean hands regularly.¹⁵ Nowadays face masks has become a

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mandatory part of our daily routine, but some recent study indicated a marked increase in dry eye symptoms among face mask users, especially in people who use face masks for long-duration regularly, one of those is health workers who wear it for long period time because of their job.^10,12 A health worker delivers care and services in health facilities directly, such as doctors, nurses, and dentists, or indirectly, such as laboratory technicians, admission staff, medical records staff, helpers, or even medical waste handlers. They wear face masks for at least six hours a day, for at least five days a week. Health workers are recommended to use at least surgical masks, and it could be FFP2 (Filtering Face Piece 2) masks or equivalent (KN95, N95, KF94, etc.), or reusable facepiece respirators.¹⁶ They are obliged to wear it throughout their shift because of the high risk of virus exposure in the work environment to ensure the health of the health workers themselves and the patients, and to prevent and control the spread of infection.

Therefore, health workers are the ones that has risk factors for experiencing DES related to face masks, including health workers at Tabanan General Hospital, as one of the COVID-19 referral hospitals in Bali province. This study was conducted to calculate the prevalence of DES associated to face masks and characteristics of DES among Tabanan General Hospital health workers in 2021.

METHODS

This study was a cross-sectional descriptive study conducted at Tabanan General Hospital from March to April 2021. This study has been approved by the Ethical Committee of Tabanan General Hospital (no. 800/1085/Kepeg/BRSUD).

The inclusion criteria were health workers who worked actively in Tabanan General Hospital, wear face masks for at least six hours a day, for at least five days a week, in productive ages (between 15-64 years old), willing to be a research respondent, and filled out the questionnaire completely. Otherwise, incomplete adata, and unregistered patients were xcluded.

Sampling was done by consecutive sampling technique, with a minimum number of 57 samples.

The data were obtained directly (primary data) with interviews conducted using a questionnaire after obtaining approval by the respondents by signing the informed consent form. Respondents were asked few questions which are about their age, sex, type of face mask they used, history of DM, smoking, and eye surgery, as well as the OSDI (Ocular Surface Disease Index) questionnaire. In this study, DES was determined based on an objective calculation of dry eye symptoms using the OSDI questionnaire.

The final score is calculated by multiplying the sum of all the scores by 25 and then dividing the total by the number of questions answered. Scores range from 0 to 100 with 0 to 12 representing normal and ≥13 representing DES, with 13 to 22 mild degrees, 23 to 32 moderate degrees, and 33 to 100 severe degrees.¹⁷ Descriptive statistics were used to summarize the results. Statistical analyzes were performed using SPSS version 25.

RESULTS

A total of 64 questionnaires from 64 respondents were collected and analyzed.

The respondent’s age ranged from 24 to 56 years old (median: 39) and there were more females (73.4%) than male respondents (26.6%). There were 51.6% (n=33) who used surgical masks and 48.4% (n=31) who used FFP2 masks.

Based on the OSDI questionnaire that has been filled out by respondents, the prevalence of DES associated to face masks among Tabanan General Hospital health workers in 2021 was 70.3%. Based on the degrees by OSDI questionnaire, the highest prevalence was found in severe degrees of DES (Table 1). The prevalence of surgical mask users was greater than FFP2 mask users in mild and severe degrees of DES, but the prevalence of surgical mask users and FFP2 mask users in a moderate degrees of DES was equal (Table 2).

This study also looks for the characteristics of DES in Tabanan General Hospital health workers in 2021 based on age, sex, DM history, smoking history, and eye surgery history (Table 3). Most of the respondents with DES in this study were in the age group 30-39 years old (35.6%), more in females (71.1%), more found in those without DM history (95.6%), non- smokers (84.4%), and without eye surgery history (93.3%). There were 3 samples with DES with a history of eye surgery in this study, specifically 1 with cataract surgery and 2 with hordeolum surgeries.

DISCUSSION

The results in this study are consistent with the previous study¹⁰ which found 70.1% reported ocular symptoms in face mask-wearing, and health workers had the highest prevalence of eye complaints

Table 1. Prevalence of DES-based on the degree by OSDI questionnaire

DES Degrees Frequency (n=64) Percentage (%)

Normal ModerateMild

Severe

1910 278

29.715.6 12.542.2

Table 2. Prevalence of DES-based on the degree by OSDI questionnaire in different mask type group

DES Degrees Mask Type

Total Surgical mask FFP2 mask

Normal 7 (10.9%) 12 (18.8%) 19 (29.7%)

Mild 7 (10.9%) 3 (4.7%) 10 (15.6%)

Moderate 4 (6.3%) 4 (6.3%) 8 (12.5%)

Severe 15 (23.4%) 12 (18.8%) 27 (42.2%)

Total 33 (51.6%) 31 (48.4%) 64 (100%)

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with the most severe clinical features due to the prolonged usage of personal protective equipment which becomes a necessity because of their job. There was a positive correlation between the time of mask usage with the presence and severity of the complaints. A review also said that people who use face masks for long-duration regularly are more likely to show symptoms of DES, including the immunocompromised, elderly, and health workers who wear face masks most of the time.¹²

When we exhale, the airflow is likely going upwards, passing over the upper border of the face mask to the ocular surface, especially when a mask is used loosely to the face. The air temperature is around 36-37⁰C, and this direct hot airflow leads to instability, increased evaporation, hyperosmolarity, and a decline in tear film turnover and clearance and results in ocular damage and DES complaints.

People who wear glasses are usually more aware of this, shown by the fogging lens of the spectacles that often occur when breathing under the face mask.^10,18

In this study, the prevalence of surgical mask users was greater than FFP2 mask users in DES, it was thought to be due to the difference of the face seal fit or the contact between mask and face.¹⁶ The usage of the surgical mask has a loose gap between mask and face, and it can

make the air blowing upwards from mask to the eyes. This increased airflow likely accelerates the evaporation of the tear film, which when it happens continuously, may result in irritation or inflammation of the ocular surface.¹² Instead, the usage of the FFP2 mask has a tight contact between mask and face, and it prevents the airflow from passing over the top of the mask, resulting in fewer eye complaints.¹⁰

The use of face masks is still an important part of our defense to fight the spread of COVID-19, so it is important not to underestimate all symptoms that could discourage the population from using them, including eye complaints such as DES. It can be prevented by a few simple steps, especially in those with prolonged use of face masks. Ensure the face mask is worn appropriately, especially when wearing spectacles. A close-fitted face mask, or face mask in which the upper edge is taped without interfering with blinking, or a face mask with pliable wire in the nose area that is adjusted to the shape of the nose so that it is fit and tight, may help direct air blowing downwards instead upwards to the eyes. It is also advised to take a break to remove the mask in a safe area every few hours and let the eyes recover for a while. Lubricant eye drops may help to preserve the tear film and can be reapplied.^11,12,18

Characteristic of DES-based on age in this study were found mostly at the age 30-39 years old, similar to another study which found a relative peak in the age group 31-40 years.¹⁹ It was said that it means environmental exposures can be related to DES, which in this age group is the most active group on the job and exposed a lot to the environment.

In this study, DES was found more common in females than males. Another study also found the same thing, said females were 1.5 times more at risk of developing DES than males. This could be due to the use of hormones in young women for contraception or infertility and the impact of these hormones on women’s lacrimal glands, goblet cell function, and ocular surface sensitivity that can lead to DES complaints. In older women, DES can be caused by lower androgen and estrogen levels that can make insufficient lacrimal gland secretion.²⁰

DES correlated with DM, specifically with the presence of retinopathy and the duration of DM. It was said that the signs of DES in DM patients might be a sequel of decreased corneal sensitivity and disrupted homeostasis because of the progression of DM itself.⁴ Cigarette smoking was found as a risk factor for DES in few studies,^3,19,21 1.4 times more prevalent in smokers than non-smokers.

The basis for it is because cigarette smoke is an irritant that irritates the surface of the eyes directly. In contrast to those studies, characteristics in this study were found that only a small percentage had history of DM and were smokers.

From 45 respondents with DES, 3 people had a history of eye surgery, specifically 1 with cataract surgery and 2 with hordeolum surgeries. Postoperative DES after cataract surgery has been attributed to the abnormality in the lipid layer of the tear film and corneal sensory nerve damage due to the incision.⁹ However, there were no studies about hordeolum surgery in association with DES.The limitation of this study was the lack of clinical confirmation of DES and the small number of samples. Further studies are needed to analyze the relationship between DES and face masks, including duration of usage and the type of mask.

Table 3. Characteristics of DES in Tabanan General Hospital health workers in 2021

Characteristics Frequency (n=45) Percentage (%) Age group (years)

20-29 30-39 40-49 50-59

8 16 11 10

17.8 35.6 24.4 22.2 Sex

Male Female

13 32

28.9 Diabetes mellitus history 71.1

With Without

2 43

4.4 Smoking history 95.6

Smokers Non-smokers

7 38

15.6 84.4 Eye surgery history

With Without

3 42

6.7 93.3

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CONCLUSION

Most of the health workers at Tabanan General Hospital in 2021 experiencing DES associated to face masks, and mostly with a severe degrees. Among those with DES, there were more surgical mask users than FFP2 mask users. Characteristics of respondents with DES in this study were found mostly in age 30-39 years old, more in females, without DM history, non- smokers, and without eye surgery history.

Future studies are needed to analyze the association between DES and face masks.

ACKNOWLEDGEMENT

The authors would like to thank the Ophthalmology Department of Tabanan General Hospital, Bali for the opportunity and guidance provided in the writing of this research.

CONFLICT OF INTEREST

There is no conflict of interest in writing this research.

FUNDING

The author is responsible for funding this research without involving grants, sponsors, or other funding sources.

AUTHORS CONTRIBUTION

All authors contributed equally in all phases of the research.

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