Caroline Richards, editor, Ophthalmology Times Europe®

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The coronavirus pandemic has triggered a seismic shift in the way ophthalmologists interact with their patients, forcing them to think on their feet and find ways to quickly adapt their workflows. 

However, as the crisis continues, it is becoming apparent that some of the changes they have had to make, such as increasingly opting for virtual consultations, could become more permanent, as evidence of their benefits to doctors and patients alike starts to mount. 

Arguably, the pandemic has paved the way for greater opportunities for positive change within ophthalmology and indeed, in healthcare in general.

I asked Prof. Mariya Moosajee, consultant ophthalmic surgeon and clinical academic ophthalmologist at Moorfields Eye Hospital, London, how her working life has changed and how those who specialise in providing services for genetic eye disorders can continue to provide the best care for their patients both during the pandemic and beyond.

Prof. Moosajee’s speciality is genetic eye disease, so the majority of her patients have been deemed non-urgent during the pandemic. 

A lot of such patients across the UK have seen their appointments cancelled, but Prof. Moosajee decided to consult all her patients virtually from the start of the crisis.

How have you had to adapt your workplace during the pandemic?

I have been able to work from home and consulted patients either by telephone or using ‘NHS attend anywhere,’ a secure web-based platform for patients with pre-arranged video consultation appointments, that was nationally funded by National Health Service (NHS) England and NHS Improvement to support NHS trusts and foundation trusts in their response to the COVID-19 outbreak.

I hold my clinics at the same time as they would have been held pre-COVID-19 and allocate patients to my team. I then meet with my colleagues at the end of every clinic on Microsoft Teams so that they can present each case.

We discuss the patients’ future management as a multidisciplinary team; we have a family support officer; a developmental paediatrician; a genetic counsellor; an extended role orthoptist; a low vision optometrist and a paediatric ophthalmology fellow. If we feel our patients need a low vision assessment or specific paediatric input (as a vast number of genetic eye disease patients have systemic features), then the relevant personnel will follow up the patient with a further phone call. It has worked really well; we have consulted 220 patients in total: 150 children and 70 adults with genetic eye disease.

We are restarting face-to-face clinics in the next month. At that stage we will have prioritised patients that will need to come in for clinical assessment and to give blood samples for genetic testing.

Adults who have had recent ophthalmology assessments locally or in other services at Moorfields can be sent blood packs which enables them to take their own blood without having to travel into London and send the sample back to us so we can process it for genetic testing. In fact, the whole process can be undertaken remotely.

What are your views on virtual consultations?

I have been pushing for virtual consultations in genetics for a long time. Prior to COVID-19 (last April–June 2019), we undertook a patient-reported survey with just over 100 paediatric or adult participants, who were either new or follow-up patients, to ascertain their views on virtual consultations and their acceptability.

We found that over 65% percent of participants prefer to have their investigations carried out locally, followed by a virtual consultation with specialists at Moorfields Eye Hospital for the review of these results. Adult participants favour video calls, with contact via the telephone being the least popular response.

The opposite is true for parents and guardians of children, who prefer contact via telephone over video call. There was no difference between the views of new or follow-up patients. Interestingly, despite most patients preferring virtual contact, the majority do not want to be seen virtually for every appointment until a treatment or trial becomes available.

What innovations do you think might be needed in the future?

I do not think we can go back to the way we were working. We can greatly increase our efficiency and patient experience by a combination of virtual and face-to-face consultations.

Patients do not want to wait for hours to have imaging and see a consultant, but they definitely want to see specialists who know about their rare genetic eye condition and who can assess the results of investigations undertaken locally, as well as inform them of the latest research and trials.

The long, detailed records we take in genetics on the onset and progression of symptoms, and prenatal, birth and family history can all be undertaken virtually. Genetic counselling is also a lengthy process that involves an unrushed conversation to ensure patient understanding of the complex topic of inheritance and genetic mutations, informed consent and family planning.

Studies in cardiac and oncogenetics in the Netherlands showed high levels of patient satisfaction for those receiving virtual genetic counselling. I would strongly recommend Telegenetics moving forwards.

In the UK, genomic medicine services are being introduced across all medical specialities, funding for genetic testing is becoming centralised and whole genome sequencing will soon be available to most patients on the NHS. We are trying to encourage more ophthalmologists around the country to order genetic tests for patients.

Moorfields Eye Hospital is also hoping to provide a virtual genomic service to ophthalmologists, to offer guidance and advice on how to manage genetic eye disease patients locally without the need to send them to tertiary referral centres unless necessary. I think this will be a huge step forward for patients who have previously not been able to access genetic services due to local funding restrictions.

I have also created an open access web-resource called Gene.Vision, which is an A-Z of genetic eye disease with two interfaces; one for healthcare professionals and the other for patients. The version for patients includes in-depth sections on how to cope with sight loss and associated aspects of daily life that can be affected, such as driving, education and employment.

The aim of the resource is to feature the signs; symptoms; genetic causes; patient management; referral needs; current information on research and trials for a disease/gene; and any support groups that would be beneficial for the patient, for each genetic eye disease. It has been tested by patients with sight loss with input from digital accessibility consultants, one of who is deaf-blind with Usher syndrome. It will be launched next month (www.gene.vision).

How can you best serve your patients during the pandemic?

Most genetic eye disease patients had their appointments cancelled during the lockdown. When you are forced into isolation, it can cause some individuals to focus more strongly on their own health and well-being.

Calls to sight loss charity helplines increased but they had no expertise to answer the medical queries. So, I offered to undertake a voluntary weekly ‘Ask the expert session’ for Retina UK, Microphthalmia, Anophthalmia and Coloboma Support (MACS) charity and Aniridia Network.

I spoke to at least six patients per session and every caller had a valid reason to get in touch; issues raised included not getting access to expert services, deterioration in vision and interestingly, I received a number of calls from patients who were experiencing increased visual hallucinations as part of Charles Bonnet syndrome (CBS). Based on this anecdotal evidence, we undertook a survey of 45 elderly patients with sight loss due to CBS, with over 40% of them having macular-related disease.

Over 55% of patients reported increased frequency of visual hallucinations;

Approximately 50% had alterations in the nature of their hallucinations and emotional response in terms of more sinister hallucinations, with more associated fear and anxiety; and

Nearly 70% felt greater feelings of loneliness but 60% had not accessed support services.

It is clear from this that we must learn to stay connected with our patients, ensuring they do not feel isolated. Sending a letter of cancellation or discharge is not appropriate during these difficult times. A phone call by an eye clinic liaison officer or genetic counsellor can be very gratefully received by patients. Sight loss charities may be able help in this regard but, like many, they have been suffering from reduced income and furloughed staff. 

Prof. Mariya Moosajee, MBBS, BSc, PhD, FRCOphth

E:  m.moosajee@ucl.ac.uk
Professor Moosajee has no financial disclosures.

Articles

COVID-19: How one ophthalmologist is dealing with non-urgent cases 

I interviewed retina expert Dr Konstantinos Balaskas about the applications of 

artificial intelligence (AI) in ophthalmology

. The opportunities for patients and healthcare professionals alike are great, but hurdles remain before AI can be fully integrated in real life: economic, ethical and data-privacy issues to name but a few.

How can AI be applied to retinal diseases?

Well, I think AI is quite a broad term. The type of AI that has generated a lot of excitement in recent years is called ‘deep learning’. This is a process by which software programs learn to perform certain tasks by processing large quantities of data.

Deep learning is what has made ophthalmology a pioneer in the field of implementing AI in medicine, because we are increasingly reliant on imaging tests to monitor our patients. Particularly in my subspecialty of interest, medical retina, imaging tests such as optical coherence tomography (OCT) are performed very frequently and have provided the material to train and test and then apply AI decision support systems.

Measuring visual fields with cloud-based AI platform

In retina particularly, some of the most common causes of visual loss in the Western world, such as age-related macular degeneration (AMD) and diabetic retinopathy, are conditions that require early detection, prompt initiation of treatment and regular monitoring in order to preserve vision. And that is where AI decision support systems can help to improve access to care and ensure optimal clinical outcomes for our patients.

An example is the AI decision support system that was developed in a collaboration between Moorfields Eye Hospital, where I am based, and Google DeepMind. It is able to read OCT scans, interpret them, provide a diagnosis and make management recommendations. The other area where AI shows promise is in the development of personalised treatment plans for patients by being able to predict their response to treatment and their visual outcomes over a period of time.

What do you see as the greatest opportunities for real-life implementation that can improve clinical outcomes?

Referring again to those common conditions that threaten vision, such as AMD and diabetic retinopathy, AI decision support tools, once validated and once they have gained regulatory approval as medical devices, can help improve access to care. They can, for example, assist health practitioners in the community in diagnosing diseases early.

In the United Kingdom, where OCT scans are widely available in high street optician practices, an AI tool would be particularly useful to assist them to interpret scans correctly and identify disease at an early stage. Similarly, in diabetic retinopathy, where patients require regular screening and monitoring of their disease, AI tools can significantly increase the efficiency of the screening programmes.

Diabetes and DR: Making progress in the global epidemic

Some such applications already exist, particularly in diabetic retinopathy – they can be of particular use for diabetic retinopathy screening programmes, such as in under-resourced healthcare settings. Other indications for the application of AI monitoring, like AMD, are in advanced stages of development, but have not yet been implemented in real life.

Are there any challenges with integrating AI into retina diagnostics and treatments?

Definitely, there are quite a few. I have a personal academic interest in the field called implementation science, which looks at the gap between developing a medical device such as an AI decision support tool and actually deploying it in real-life clinical practice.

The potential barriers that we need to overcome for the tool to be deployed in a meaningful way to improve outcomes for our patients go beyond testing and validation. These include economic evaluations: how would such an automated decision support model affect the finances of a healthcare system, so that it could provide good value for money or achieve cost savings?

The next consideration is human factors, particularly how these models of care that rely on AI are perceived and accepted by patients and practitioners; what is the level of trust in these technologies? And what level of information and education of patients and the general public is required to build confidence in their use? Then there are considerations around training and the technical infrastructure to support these tools.

AI enhances customised myopic LASIK with ray tracing optimisation

Ethical and data-privacy issues, as well as medico-legal considerations, are also important: who is responsible for decisions made by an AI algorithm rather than a human? How do these tools affect the way healthcare professionals diagnose and manage disease?

There is a phenomenon called automation bias, where practitioners are sometimes more likely to defer to the recommendation of the AI tool, even perhaps against their better judgement. And there is the issue of interpretability—the ‘black box’ phenomenon—in many instances these AI tools are opaque in their functioning.

We do not fully understand how a specific recommendation is reached, whether that is a diagnosis or a management recommendation, and that lack of transparency can exacerbate the medical, legal and ethical issues that were mentioned earlier. In summary, there are several hurdles to overcome before AI tools can be deployed in real life in a way that is safe and will improve clinical outcomes.

How do you envisage life will change for ophthalmologists in the future?

This is an interesting question. I share a positive optimistic vision of AI in medical practice. Our field is becoming increasingly complex and we need to process data from various sources when we are assessing our patients: data from the many imaging modalities, genetic data and the various types of omics, such as proteomics and the emerging field of oculomics, where features on the eye examination can be indicative of problems with systemic health. Even data from home vision monitoring devices will become increasingly available.

Precision management to revolutionise glaucoma diagnosis and treatment

Processing and making sense of all this data in order to develop a personalised treatment plan for each individual patient can be a daunting task. AI could become a very useful aid and, as described in the Topol review on AI commissioned by Health Education England, provide the gift of time to patients and practitioners, giving them the chance to discuss and decide together what the optimal treatment plan is, informed by the processing of high-dimensional complex data sources.

1. Campbell JP, Mathenge C, Cherwek H, et al. AI to reduce ocular health disparities: moving from concept to implementation. 

Konstantinos Balaskas, MB BS, MD, FEBO, MRCOphth

Dr Balaskas is a retinal expert at Moorfields Eye Hospital, London, UK, and director of the Moorfields Ophthalmic Reading Centre and AI Analytics Hub. He has a keen academic interest in new ways of delivering care in ophthalmology, including tele-medicine, ‘virtual’ clinics, remote monitoring and AI decision support. He has no financial disclosures.

Ophthalmology, with its heavy reliance on imaging, is an innovator in the field of artificial intelligence in medicine.

Ophthalmology: A pioneer in the field of artificial intelligence

I spoke to Dr Anthony Khawaja of University College London and Moorfields Hospital, London, UK, about the exciting realm of precision medicine in glaucoma.

How do you define ‘precision management’?

In looking after our patients, most of us review the evidence in the literature. For example, when considering glaucoma patients, I might look at the UK glaucoma treatment study (UKGTS),

 a randomised controlled trial that showed that patients treated with a prostaglandin analogue do better on average than those who are not treated.

Evidence-based medicine tells us how best to treat people on average, but everyone is different. Not everybody in the UKGTS who received latanoprost necessarily benefited from it; in fact, 15% of such patients progressed over 2 years, so they were under-treated. Yet three-quarters of the placebo group did not progress, so some may have been over-treated.

Precision management is about going beyond simply what is best for the average group of patients and instead being able to predict, the first time you see a patient, their risk of worsening, and then titrating their treatment accordingly — maybe starting off more intensively in some high-risk patients so that you do not have to observe further vision loss before stepping up treatment. And it is it about choosing no treatment at all for other patients.

This means resources and treatments can be directed only to the people who will benefit, thus sparing the costs and side effects of treatments that will not work. The key here is understanding that one size does not fit all.

Could you expand on what this would look like for glaucoma?

One example of where precision glaucoma management could be useful is trying, the first time you see the patient, to make an assessment about whether they need treatment or not. Take the patient who has high ocular pressure but not glaucoma as of yet. We know from the Ocular Hypertension Treatment Study (OHTS)

 that if you treat such patients, they will do better on average than people who do not receive treatment: fewer of them will convert to glaucoma. But we also know that most of the group that is not treated do not develop glaucoma, so some are being treated unnecessarily.

An OHTS calculator that predicts the risk of conversion to glaucoma already exists,

 which takes into account the age of the patient, baseline pressure, corneal thickness, visual field mean deviation and cup-disc ratio. Unfortunately, this calculator, while helpful, does not really go far enough.

And so what we are looking to do is bring in other new technologies using genetic information or perhaps artificial intelligence (AI) assessments of images to help decide whether a patient will very likely benefit from treatment or, actually, are at such low risk that we can save the costs and the hassle of treatment. This will in turn also free up health service resources so that we can focus on the patients at highest risk.

You can apply this to other aspects of glaucoma care. For somebody with established glaucoma, do you treat or not, and how aggressively do you treat?

Another area which in my opinion can really benefit from the precision management approach in glaucoma is choosing the right treatment. There are so many different types of treatments available, including four major classes of drug, selective laser trabeculoplasty for open angle disease, and a whole spectrum of surgery from the minimally invasive glaucoma surgeries to the traditional incisional surgeries such as trabeculectomy and tube implants.

And if we are honest with ourselves, we do not know who is going to do well with each treatment. As mentioned, some people respond very well to latanoprost, but others do not respond at all and some experience side effects.

In recent years, we have really started to understand what causes glaucoma. In fact, glaucoma is one of the most hereditary of the common diseases in humans; it is about 70% heritable.

This means, in part, that some glaucoma is inherited through generations in an autosomal dominant fashion due to just a single mutation, most commonly in the myocilin gene. But this comprises only about 4% of primary open angle glaucoma (POAG).

The majority of cases are more complex because they are due to a lot of genetic effects, each one small and insufficient in causing glaucoma on its own but when put together cumulatively reach a threshold that causes disease. For years we were unable to identify these small effects, but recently, with large studies, we have been able to identify many more.

For example, 2 years ago, by looking at the pressure in the eyes of around 140,000 people, we identified over 100 points in the genetic code that underlie some people developing high pressure and then glaucoma.

 And what is exciting is that, when you combine the genetic information at all of these points, you can start to predict who is going to get glaucoma, even from the point of birth because our genetic code does not change after that.

Given that it has got such a genetic basis, what we can start to do next is pick out different types of glaucoma, for example, which are currently indistinguishable. So, POAG to us looks pretty uniform. However, genetically speaking there is a subgroup that seems to have a problem particularly located in Schlemm’s canal and collector channels; for another group the problem seems to particularly affect the trabecular meshwork.

If we could work out which of these patients had primarily a trabecular meshwork problem then we would know that treatment targeted to the trabecular meshwork, such as selective laser trabeculoplasty, or the iStent Inject (Glaukos) and trabecular bypass procedures with microstents (Hydrus), is more likely to work.

Conversely, if the issue is predominantly due to a problem with a patient’s collector channels and Schlemm’s canal, then maybe you are better off not targeting the trabecular meshwork. In that way, we can start to use genetic risk scores to be able not only to tell us about the risk of disease progression but also to predict response to treatment.

How exactly would artificial intelligence assist?

Well, in terms of personalising care, there is an awful lot of information that we collect as glaucoma specialists: images that provide detailed information and potential patterns that we recognise. We learned through our training that we can sometimes look at an optic nerve and see when there is a lot of damage and when a person is at high risk, meaning we need to treat them aggressively.

But there are other times where we just get it wrong and do not predict at baseline that somebody is at high risk of getting worse, and they worsen despite our best efforts. Conversely, we might treat other people that are at low risk and we can never know whether they needed that treatment.

The real power of AI in medicine so far is the ability to classify images, which it can do better than any single human grader. AI has the potential to see patterns in an image that no human being, no matter how expert they are, can see: an interesting study that supports this concept is one from the Google Brain group.

They trained an AI algorithm to look at photos of the retina of healthy participants in a couple of studies, including the UK Biobank study, and to predict sex. The algorithm is 97% accurate in identifying whether a fundus photo is from a man or a woman. Is there is one glaucoma specialist or retinal specialist or human in the world who can do that?

The enticing thought is that if AI can see patterns beyond what humans can appreciate currently, it can predict the future. I can definitely see AI working together with genomics in the future, providing much more individualised care.

I have set my research group an ambitious target: by 4 years’ time we will have developed proven algorithms that can predict the risk of glaucoma progression and response to two different treatments. Once we have got this tool, we need to make it easily accessible and understandable to general glaucoma doctors and physicians, and even patients.

We will need to test it prospectively to see whether it does improve decision making. Glaucoma trials can take quite a long time—at least 2 years—and so I think we are looking at an estimated 5 years to get the proof of principle and a pilot tool that will then need to be proven over a few years before something can be rolled out.

In parallel to this, we need genetic data to be available. Currently, most of our patients do not come with genetic data, although increasing numbers of people are obtaining it from direct-to-consumer genetic tests. There are already platforms where healthcare services can interact with genetic databases to pull out the information they need, with the patient’s consent. So, this is one possibility.

This type of testing can cost less than £50 and when done on scale might be nearer to £20 per person, which is excellent value. And if that one £20 test can tell you whether you should be screened for glaucoma, which treatment you should have and whether you need treatment at all, it could provide a similar picture for other diseases.

For example, it could also tell you, say, whether you should take statins if you have got high lipid levels. Should you be screened for breast cancer or should it be delayed? And for prostate cancer? This is just scratching the surface.

The £20 test can inform a whole gamut of health-related decisions. It will really become a question of 

 you test and obtaining genetic information for all people who interact with healthcare services will become routine.

The people in the aforementioned study were all of European descent and we can predict with a certain degree of accuracy someone’s risk of glaucoma if they are European. This prediction works quite well for Asian people too, but not so well for people of African descent.

If we are to develop a new, better way of managing glaucoma, which means that people get the best treatment for them from the get go and that we spare people who do not need treatment, can we really offer it if it only works in people of certain ethnicities? And I think we all know the answer to that is no.

So, one of the challenges is the need to make sure that we are getting enough data and information on people of all ethnicities. And this is why, having started the Moorfields Glaucoma BioResource, I am pleased to be able to recruit patients from all backgrounds due to London’s very diverse population.

The other challenge is to come up with a better way of managing glaucoma so that expertise is widely distributed and not clustered in certain centres of excellence where there are genetics experts. Such care needs to be delivered by any doctor and to an extent that even patients can understand.

It needs to be accessible and rolled out everywhere, equitably, to people of all ethnicities and backgrounds. And that is the key: we need to make this an equitable innovation.

Anthony Khawaja, MA (Cantab), PhD, FRCOphth

Dr Khawaja is associate professor at UCL Institute of Ophthalmology and honorary consultant ophthalmic surgeon at Moorfields Eye Hospital NHS Foundation Trust, London, UK. He reports acting as consultant to Aerie, Allergan, Google Health, Novartis, Reichert and Santen and has received lecturing fees from Grafton Optical and travel support from Thea.

Garway-Heath DF, Crabb DP, Bunce C, et al. Latanoprost for open-angle glaucoma (UKGTS): a randomised, multicentre, placebo-controlled trial. 

Gordon MO, Beiser JA, Brandt JD, et al. The Ocular Hypertension Treatment Study: baseline factors that predict the onset of primary open-angle glaucoma. 

Gordon MO, Torri V, Miglior S, et al. Validated prediction model for the development of primary open-angle glaucoma in individuals with ocular hypertension.

Khawaja AP, Cooke Bailey JN, Wareham NJ, et al. Genome-wide analyses identify 68 new loci associated with intraocular pressure and improve risk prediction for primary open-angle glaucoma. 

Poplin R, Varadarajan A V., Blumer K, et al. Prediction of cardiovascular risk factors from retinal fundus photographs via deep learning. 

Artificial intelligence and genetic testing are expected to facilitate choosing the best treatment for each unique glaucoma patient within the next decade. This will not only lead to the best outcomes for individuals but will also spare them the costs and side effects of suboptimal treatments.

I spoke with Prof. Christophe Baudouin, president of the European Dry Eye Society to find out more about the complex nature of dry eye disease.

Could you tell me more about the pathogenesis of dry eye disease?

Dry eye is a very complex disease. It is not just a question of lack of water and so it is impossible to treat patients just by lubricating the eye with water. It is a disease that involves a series of self-stimulating biological events, and the lack of tears, insufficient tear quality or their instability results in direct mechanical and/or osmotic stress, which causes further damage.

In addition, goblet cell loss results in further tear film instability or imbalance and thus, dryness. The drier the eyes become, the more inflammatory they become and the greater the inflammation, the more the eyes continue to dry out, i.e., a vicious cycle occurs (see Figure 1).

To give more context on the vicious cycle theory, the dryness of the eye stimulates the nerves, the inflammatory reaction and inflammatory cells, and those act as stimulation for further damage, and so tears and their quality are reduced further, resulting in the disease becoming chronic.

Overall, the disease is very complex, with many risk factors, causes and aetiologies having been defined. As a result, it is difficult to resolve.

How are primary and secondary inflammatory processes involved in the disease?

There is a constant state of inflammation with the most severe dry eye cases, and this can be primary; for example, as seen with Sjogren syndrome, where inflammatory cells infiltrate and block the lacrimal glands, as well as the conjunctiva and cornea, and thus invade the whole ocular surface. Secondary processes are also involved: the various types of stress including mechanical and osmotic factors also stimulates inflammatory cells and results in a chronic inflammatory state.

What do you think future treatment strategies need to focus on?

The increasing interest in the idea of the vicious cycle allows us to discriminate between different levels of events: the mechanical stress, the osmotic stress and the inflammatory stress, for example. This new way of understanding the disease may allow the physician firstly to try to prevent the patient from entering the cycle, which is important and can be made possible by controlling the environment, improving the eyelid and decreasing inflammation. Secondly, each part of the loop can be targeted with a specific approach such as lubrication, eyelid hygiene, anti-inflammatory strategies and maybe even Omega-3.

And so there are different complementary approaches that can improve the patient’s symptoms. That said, sometimes it is very difficult to help the patient and they can suffer a lot.

To discuss a further complication of dry eye, we are increasingly starting to understand the concept of neuropathic pain in dry eye disease. Sometimes, the overstimulation of the nerve causes chronic pain and so even when the cornea and tears have been improved, patients can continue to suffer.

And once neuropathic pain has been stimulated, it can be very difficult to control it. Therefore, a good future treatment approach would be to find the best ways of relieving pain symptoms either locally or systemically.

Another consideration is in how we treat and control inflammation. In Europe, there is only one ciclosporin formulation indicated for severe dry eye disease with corneal damage, Ikervis (Santen), whilst the United States market has the prescription eyedrop Restasis (Allergan).

Another medication for the treatment of signs and symptoms of dry eye, which is available in some countries, is lifitegast (Xiidra, Takeda Pharmaceutical), which blocks the activation of lymphocytes. Unfortunately, this drug is not available in Europe and so other anti-inflammatory strategies are needed here.

In addition, the eyelids are likely to be the location of a lot of inflammation and so represent potential targets. In fact, various strategies to treat the eyelids have been developed, based on pulse light or warming and massaging devices, and are certainly a good way of relieving the patient’s symptoms.

Has the incidence of dry eye disease increased during the COVID-19 pandemic as screen time has increased?

We do not yet have epidemiological data to assess, however, it is clear that long hours working at, or reading on, a computer do affect dry eye and there is a clear association between the two. So, most likely, patients who have dry eye are suffering more during this time.

Furthermore, it has also been found that wearing a mask seems to interfere with eyelids and lead to meibomian gland dysfunction, perhaps by blocking the lymphatics at the level of the eyelids or by focusing an air flow on the eyes, so some people are finding that their dry eyes have been worsening due to their mask use.


Prof. Baudouin is professor and chair of ophthalmology at Quinze-Vingts National Eye Hospital & Vision Institute, University Paris Saclay, Paris, France. He has no financial interest in the subject matter.

The vicious cycle theory is a new way of understanding dry eye disease and may help improve prevention and treatment strategies. 

Author | Caroline Richards, editor, Ophthalmology Times Europe®

Articles

Ophthalmology: A pioneer in the field of artificial intelligence

Precision management to revolutionise glaucoma diagnosis and treatment

How dry eye disease can become a complex vicious cycle

COVID-19: How one ophthalmologist is dealing with non-urgent cases