Improperly Sealed Face Masks May Worsen Moderate to Severe Dry Eye

Female customer with face mask shopping at a grocery store
African woman wearing protective face mask buying grocery at a supermarket. Female customer shopping at a local grocery store.
Researchers found masking can decrease noninvasive tear film breakup time.

Improper face mask use may decrease tear film stability in patients with moderate to severe dry eye, according to a study published in Cornea. The investigators recommend ophthalmologists help patients fit masks properly to reduce air leakage. Clinicians should also consider increasing treatment for long-term mask users if they have a previous history of dry eye disease (DED), other surface inflammatory diseases, or recent ophthalmic surgery.

With face masks becoming more commonplace due to the COVID-19 pandemic, researchers are reviewing the potential for them to cause  ocular irritation or dryness. Researchers conducted a cross-sectional study of patients with moderate to severe DED to evaluate whether tear film stability worsens with the mask use. 

They analyzed noninvasive tear film breakup time (NITBUT) in patients both while they wore a mask and after 10 minutes without wearing a mask. The study included 31 patients with a mean age of 57.6±11.7 years (range 31–80) and 30 women (97%). Mean first NITBUT with a face mask was 6.2±3.8 seconds (range 2.0-19.8), which increased to 7.8±5.6 seconds (range 2.3-24.0) without the use of mask (P =.029), differences being -1.6±0.7 seconds (CI 95% -3.1075 to -0.1770). Mean average NITBUT with a face mask was 12.3±4.8 seconds (range 4.0-19.4) and increased to 13.8±5 seconds (range 5.5-24.0) without the use of a mask (P =.006), the mean difference being -1.5±0.5 seconds (CI 95%, -2.5290 to -0.4458).

“Increased eye rubbing and face touching behaviors because of discomfort symptoms may alter the ocular surface and worsen tear film breakdown. Dry eye disease may exacerbate in these patients, increasing the risk of secondary infections, keratitis, exposure keratopathy, and other potential epithelial breakdown consequences to prolonged face mask wearing,” the researchers explain.

The study’s authors note a few limitations with their study, including that it only included patients with moderate-to-severe dry eye from one unit and that examination was only performed while wearing a mask to avoid the risk of contagion. Additionally, they acknowledge that there are other variables besides NITBUT that determine DED and dry eye symptoms.

“The use of a face mask is still crucial in this pandemic, and patients with moderate-to-severe dry eye should not be dissuaded from wearing face masks,” investigators report. 

The study advocates for eye care physicians to instruct patients on avoiding mask displacement and incorrect fitting as these contribute to air leaking. However, it also notes that using body tape to keep masks in place may not be ideal for long-term wear as they may interfere with the normal lower eyelid position and potentially induce mechanical ectropion, leading to tear evaporation. “The tape may cause tension in the eyelid, causing lagophthalmos or reducing blinking and risking exposure to keratopathy because of altered tear stability,” according to the report.

Researchers also suggest increasing DED treatments for long-term mask users if they have a history of severe disease.


Arriola-Villalobos P, Burgos-Blasco B, Vidal-Villegas B, et al. Effect of face mask on tear film stability in eyes with moderate-to-severe dry eye disease. Cornea. 2021;40(10):1336-1339. doi:10.1097/ICO.0000000000002734