Mask Associated Dry Eye (MADE) in Healthcare Workers: A Cross-sectional Study

Introduction: The Coronavirus disease-19 (COVID-19) pandemic mediated by Severe Acute Respiratory Syndrome-CoV2 (SARS-CoV2), made the use of face masks mandatory to check the spread of the disease. With the increased use of face masks, more people started presenting to the ophthalmologist with symptoms of dry eye. The proposed mechanism of dry eye was attributed to air blowing upwards from behind the mask into the eyes, especially in loose fitting masks. This air leads to rapid evaporation of tears and disturbance of homeostasis of the tear film.Aim: To measure self reported symptoms of dry eye and to establish mask use as a risk factor for the development of Dry Eye Disease (DED) in healthcare workers in a Tertiary Care Hospital.Materials and Methods: This cross-sectional, observational study was conducted at Nilratan Sircar (NRS) Medical College and Hospital for a duration of three months from December 2021 to February 2022. The study was conducted on 146 participants. An online survey was conducted using Google Forms, sent via email to hospital employees working in different departments of the hospital. All healthcare workers employed at NRS Medical College and Hospital who wore a face mask during duty hours and were willing to participate in the study were included. The Ocular Surface Disease Index (OSDI) questionnaire was used and modified by adding "while wearing a facemask" to the end of each question. To establish face mask use as a causative agent for development of DED, a few other questions related to face mask usage were included in the survey. The data was tabulated in Microsoft Excel and analysed with Statistical Package for Social Sciences (SPSS) version 24. Results: The mean age of the study population was 27.4+/-8.28 years. The mean hours of wearing a mask was 6.38+/-3.04 hours. N95 face mask was the most common type of mask used. The study population included 100 doctors, 14 nursing staff, 18 optometrists, eight group D staff (sweepers and ward attendants), and six dieticians. The mean OSDI score was 14.24. Increased usage of face masks, in particular surgical, more hours of reading significantly correlated with higher incidence of DED. Conclusion: This study showed that increased hours of face mask use in particular surgical was associated with development of DED. To encourage more people to wear face masks, all possible problems arising from face mask use should be promptly identified and dealt with.

Online education and dry eye disease during the COVID-19 pandemic

Objective: The objective of this study was to analyze changes in the frequency and incidence of dry eye disease (DED) and screen exposure times during the onset of online courses, moreover, compare these changes between sexes. Secondarily, correlate online courses screen exposure times with the severity of DED symptoms. Method(s): Four identical surveys, each containing the ocular surface disease index (OSDI) which quantifies DED symptom severity, and questions which categorized screen exposure times, were applied throughout 6 weeks. University students who had transitioned from face-to-face courses to online platforms were included in the study. Result(s): DED frequency among the 97 subjects (54 women and 43 men) peaked on week 4 (82.47%). OSDI scores significantly increased throughout the study (p < 0.0001) (baseline, 27.01 +/- 17.55 versus Week 6, 37.17 +/- 24.64), reflecting symptom worsening along an incidence of 8.5%. This worsening of symptoms occurred with women (p < 0.0001), while, in male subjects, it did not (p = 0.11);significant differences between sexes were found during the baseline (p = 0.01), Week 2 (p = 0.02), and Week 6 (p = 0.008), but not on Week 4 (p = 0.11). Online courses onset significantly increased screen exposure time (p < 0.0001). The baseline hours were 25.52 +/- 11.33 and peaked on Week 2, being 34.62 +/- 10.90. OSDI scores and online courses exposure times correlated significantly (Week 2, R = 0.265;Week 4, R = 0.262;and Week 6, R = 0.205). Conclusion(s): University students suffer from severe DED symptoms, which correlate with online courses onset. Educational institutions should foster ocular health.Copyright © 2022 Authors. All rights reserved.

Effects of Face-Mask Use on Dry Eye Disease Evaluated Using Self-Reported Ocular Surface Disease Index Scores: A Cross-Sectional Study on Nurses in Saudi Arabia.

BACKGROUND: Wearing face masks has been an essential part of healthcare workers' lives since the coronavirus disease 2019 (COVID-19) pandemic. This study aims to determine the association between prolonged face mask-wearing and dry eye disorder (DED) among female nurses. METHODS: An online questionnaire-based cross-sectional study was conducted at King Abdulaziz University Hospital, Jeddah, Saudi Arabia, between May 2021 and February 2022. It covered sociodemographic data, conditions associated with ocular irritation, and questions related to mask-wearing duration. The Ocular Surface Disease Index (OSDI) survey was used to measure DED severity. Binary logistic regression analysis was done and Odd's ratios (OR) with 95% confidence intervals (CI) were reported. RESULTS: A total of 266 female nurses responded to this study. The majority of the sample (71.1%) fell in the normal-mild DED category (OSDI 0-22), while (28.9%) were categorized as the moderate-severe DED category (OSDI >22). We found a significant independent association of dry eye disorder with wearing a mask for >6 hours/day (OR 2.066, 95% CI: 1.083-3.944). Other significant predictors of DED in this study were wearing corrective eyeglasses (OR 2.382, 95% CI: 1.296-4.376) and having rheumatoid arthritis (OR 17.289, 95% CI: 1.794-166.7). CONCLUSION: Wearing a face mask for > 6 hours/day was significantly associated with moderate to severe DED among female nursing staff. Ophthalmologists should be aware of this adverse effect in order to promote ways to relieve this condition.

Digital Eye Strain and Dry Eye Problemsin Covid-19 Lockdown, At BBMCH, Balangir

PURPOSE: Lockdown guidelines during COVID-19 pandemic increased the e-learning methods and gadgets use, basically to undergo classes, recreation procedures and media news updates, which subsequently upsurgedasthenopic symptoms as digital eye strain (DES) epidemic amid COVID-19 lockdown. This is a descriptive cross-sectional questionnaire based study which is aimed to assess the prevalence, risk factors.Pattern of gadgets used, screen time and symptomatology of Digital eye strain among medical students, teaching doctor faculties and paramedical staff during COVID-19 lockdown at BBMCH, Balangir. METHODS: This e-filled self survey analysed 570 responses from medical students of online classes(200), teachers of online classes (38), paramedical staff (122) and general population(210) .Aprevalidated CVS-Q and OSDI questionnaire regarding screen time spent, was used to calculate the DES score. Median DES Score was compared by medians or non-parametric tests. Categorical variables were compared by Chi Square test and predictors of DES were found by binary logistic regression. SPSS Version 21.0 was used to interpret and analyse the collected data. RESULTS: Majority of survey participants(78%) had at least one symptom of digital eye stain;The reported symptoms during electronic device usage in decreasing frequency were Eye fatigue(65%), Eye strain(52%), Ocular discomfort(50%), headaches(48%), Burning eyes(42%), and Dry eyes(35%), watering(34%), shoulder pain(30%) DES symptoms were found to be more than that of dry eye symptoms. The prevalence of DES in students taking e-learning surpassed to those found with other health staff and general population. DES score was also observed to be on higher side for more screen time users, use of gadgets in dark, screen distance<25cm. Lens or spectacle users suffered worsening of vision and needed change of glasses. No association between DES and exacerbation of pre-existing dry eyes and eye diseases were appreciated due to exclusion of such participants from our survey. CONCLUSION:Eye care tips are needed at periodic intervals to create awareness and to reduce eye strain symptoms, closing of eyes on regular basic, maintaining reading distance between 25-30cm and reducing screen time by breaks can lessen the prevalence of DES. As because, use of gadgets were the major media for learning or communication, so ocular health, hygiene and practical precautions should be kept in mind.

The Impact of Excessive Use of Digital Devices During the Pandemic of Corona Virus Disease (COVID-19) Among Saudi Arabia Population

Background: A substantial increase in using digital devices was observed among the population due to staying at home as a result of the quarantine during the coronavirus pandemic. Consequently, ocular symptoms appeared due to spending several hours of screen time per day. Objective(s): The current study aimed to assess the impact of excessive use of digital devices during the pandemic of coronavirus among the Saudi population. Method(s): A community-based cross-sectional study was carried out from November 2020 to January 2021 among the Saudi population. Data were collected by using Ocular Surface Disease Index (OSDI) questionnaires for the assessment of symptoms related to dry eye and their effect on vision. A logistic regression model was used to evaluate the association between the risk factors and the symptoms of dry eye. SPSS 22nd edition was used, any p-value <0.05 was considered significant. Result(s): Out of 1573 participants, 93.8% used mobile, 42.4% experienced uncomfortable sensitivity to the light. There were 49.15% of the participants who showed that none of the time they felt blurry vision, 54.8% did not report double vision, and 30.5% who felt a headache recently after quarantine. About 48% of the participants did not have any ocular symptoms, while 52% had dry eye symptoms (mild 22.3%, moderate 13.7%, and severe 15.9%). When the logistic regression model of risk factors associated with severe symptoms of dry eye was applied, wearing a contact lens was the most significant variable (p<0.0001). Conclusion(s): Dry eye symptoms increased during the quarantine, which indicated that the digital device users need to learn more about the preventive measures from practitioners in eye healthcare. More studies are warranted to assess the impact of digital device usage on all age groups starting from children up to the elderly population. Copyright © 2022 Almuhwwis et al.

Dry Eye symptoms during the COVID-19 era

Purpose : Preliminary evidences from the literature, together with our everyday clinical practice and patients reporting, led us to hypothesize that dry eye (DED) symptoms related to some COVID-19 mitigation measures might be a common problem and a relevant issue. We designed this study in order to assess and to monitor DED symptoms' changes from 2019 to 2021, in both DED patients and healthy subjects, and to investigate their relationship with homeworking and facemask wearing. Methods : We retrospectively reviewed the medical records of patients who, between November and December 2019 (V19), had undergone an eye exam including quantification of Ocular Surface Disease Index (OSDI) score at the Eye Clinic San Giuseppe Hospital, Milan. Between November and December 2020, we performed a telephone survey (V20) contacting these patients. The survey was repeated between November and December 2021 (V21). The telephone survey included the OSDI 12-items and a custom-made questionnaire exploring type of job or occupation, home working, screen time, type and average time of face mask-wearing, and recent onset and worsening of DED-related symptoms. We investigated the difference among V21, V20 and V19 DED symptoms, the rate of subjects with OSDI increase > OSDI minimal clinically important difference (MCID), and associations between DED symptoms, face masks wearing, VDT usage and home working. Results : Of 120 subjects with V19 OSDI≤12, 43 (36%) and 39 (32%) showed OSDI>12 at V20 and at V21, respectively. OSDI was significantly correlated with duration of face masks use (V20 r= 0.29;P<0.01. V21 r= 0.23;P<0.01) and heavy mask users had a significantly higher OSDI (P<0.05). V20 and V21 OSDI was significantly higher in home-workers (P<0.05) but we did not find a significant correlation between V21 OSDI and referred number of VDT use (r= 0.07;P=0.41). Of 70 patients with V19 OSDI>12, 18 (26%) and 24 (34%) showed symptoms worsening >MCID at V20 and V21, respectively. The percentage of OSDI worsening >MCID was significantly higher among heavy face masks users (73% vs 12%;P<0.01, Fisher test). The percentage of OSDI worsening >MCID was significantly higher in home workers at V20 but not at V21. Conclusions : Some COVID-19 mitigation strategies seem to have a significant role in triggering DED symptoms onset or worsening. This issue persisted during the second pandemic year, with weaker correlation to presumed trigger factors.

Evaluation of dry eye disease after COVID-19 infection

Purpose : A prospective observational clinical study was performed to evaluate ocular symptoms related to dry eye disease (DED) in patients infected with COVID-19. Methods : The staff of an University Hospital in Londrina city, Brazil, who presented respiratory symptoms and underwent nasal swab PCR test for SARS-CoV-2 detection at the outpatient unit during November to December 2020 was assessed by electronic messages and separated in two groups (PCR test negative or control group-CG, and PCR test positive or COVID-19 group-COVG). Sociodemographic data, presence of ocular and systemic comorbidities, place of treatment (home, infirmary or intensive care unit), and the Ocular Surface Disease Index (OSDI) questionnaire, translated and validated to Portuguese for DED evaluation were performed. OSDI contains 3 subsections including visual-related function (category A), ocular symptoms (category B) and environmental triggers (category C). Scores range from 0 to 100 with 0 to 12 representing normal, 13 to 22 mild DED, 23 to 32 moderate DED and 33 severe DED. The data was submitted to statistical analysis. Results : From 450 electronic messages sent, 113 patients were included. 62(54,85%) had laboratory-confirmed (RT-PCR) Covid-19. The mean age was 36 years, ranging from 21 to 60 years. 83 (73.4%) patients were female. The main systemic comorbidity was smoking (23%), followed by obesity (3.5%) and hypertension (1.76%). The mean OSDI score was 13.85 in the COVG and 5.37 in the CG (p=0.002). The COVG had a mean score of 3.50 related to category A, 1.05 to category B and 2.13 to category C while the CG presented a mean score of 1.41, 0.39 and 0.80 respectively (p = 0.003;p=0.04;p=0.01). Patients who required hospitalization for treatment presented OSDI score proportionally greater than those who were treated at home (25.67) (p=0.052). Conclusions : OSDI score was higher in the COVG and among patients who required hospitalization for treatment. These results suggest association of COVID infection and DED;and increase of DED according to the severity of respiratory symptoms.

Face-Mask Associated Dry Eye (F-MADE) Symptoms and Ocular Surface Alterations

Purpose : Since the onset of the coronavirus disease 19 (COVID-19) pandemic, people's lives have adapted, with the use of face masks becoming a part of our daily routine. Despite being a useful device to prevent disease contagion, a marked increase in dry eye and stye symptoms has been detected. We aimed to perform an observational correlation analysis between face-mask use and to report both objective and subjective ocular surface measurements performed on a multi-purpose advanced corneal topographer and a high-definition camera. Methods : This study included 25 healthy subjects without any ocular diseases, ages ranging from 19 to 68 years. We measured tear meniscus height, Non-Invasive Tear Breakup Time (NIBUT), overall redness score, and tear film lipid layer characterization using Keratograph 5M (Oculus, Wetzlar, Germany), as well as Ocular Surface Disease Index (OSDI) scores for dry eye symptomatic assessments. Patients were asked the number of hours of mask-use at the moment of enrollment, the average hours of mask use daily, and the type of face mask used. We assessed for differences between OSDI scores and gender and type of mask used, as well as correlation coefficients for all subjective and objective measurements. Results : The mean age of the subjects was 42.44±14.49 years. OSDI scores had no significant differences according to gender (p = 0.1664) or type of mask used (p = 0.0791). Correlation between hours of mask use at the time of testing and ocular surface modifications were minimal. Hours of mask-use at the time of the test and OSDI scores were moderately correlated (r= 0.5047, p=0.01). No correlation was found between the average hours of mask use and any ocular surface measurements or OSDI scores. Conclusions : The use of face masks increased subjectively dry eye symptoms. Nevertheless, ocular surface objective measurements remain unchanged by maskwearing.

Reduction of mask-associated dry eye by using surgical tape to secure the top edge of the mask

Purpose : During the COVID-19 pandemic, mask-associated dry eye (MADE) has increased worldwide possibly because the breath leaks from the top of the masks changes the ocular surface conditions. We tested the hypothesis that surgical taping of the top edge of the mask to the skin reduces the risk of ocular surface damage. Methods : We enrolled 60 volunteers (30 females, 30 males;mean age, 27.1±5.2 years) who wear face masks over 5 hours a day. We measured the fluorescein tear break-up time (FBUT), ocular surface temperature, and conjunctival blood flow before wearing masks, after wearing masks taped on the top edge, and after wearing masks without tape. We used the Ocular Surface Disease Index (OSDI) to record participants' symptoms of MADE and measured their corneal tactile and pain sensitivity using a Cochet-Bonnet esthesiometer. Results : The FBUT with masks without tape (4.4±2.4 seconds) was significantly shorter than that without masks (6.4±3.1 seconds) and with taped masks (5.8±3.2 seconds) (P<0.01 and P=0.05, respectively, Tukey HSD test). There was no significant difference in the FBUT between use of no masks and taped masks (P>0.05). The differences in the corneal and conjunctival temperatures after wearing masks without tape (0.19±0.28 and 0.13±0.28°C, respectively) were significantly higher than after wearing taped masks (0.05±0.27 and 0.06±0.24°C, respectively, P<0.01, paired t-test). The conjunctival blood flow with masks without tape was significantly higher than that of taped masks (P<0.01). Of the 60 subjects, 13 (21.7%) subjects reported MADE symptoms. In the MADE group, the OSDI (P=0.001, analysis of covariance) was significantly higher and the FBUT of masks without tape (P=0.006) was significantly shorter than in the non-MADE group. Pain sensitivity in the MADE group was significantly higher than in the non-MADE group (P<0.01), indicating that subjects in the MADE group were significantly hypersensitive to corneal pain. Conclusions : Wearing masks decreased FBUT and increased ocular surface temperature and blood flow. Taping the top edge of the mask prevented those changes. Fitting masks tightly to the nose or applying tape over the mask may reduce the MADE risk, which can be associated with ocular surface hypersensitivity.

DRY EYE SYNDROME PREVALENCE RATE DURING COVID-19

Purpose : Dry Eye Syndrome (DES) has been increased during the pandemic, as a result of wearing masks using electronic devices and working remotely. During COVID-19, we conducted a survey to determine the prevalence of dry eye syndrome. Methods : This is a cross-sectional study to determine how frequent DES is during COVID19 in healthy patients in the United States between the ages of 20 and 45. From October 31, 2021, to December 1, 2021, we administered an Ocular Surface Disease Index (OSDI) questionnaire remotely to 40 subjects. The OSDI survey was used to assess DES. Results : Subjects had a mean age of 29 years old ± SD 14.14 and 23 of them were males (57.5%), and 17 were females (42.5%). Low DES, moderate DES, and severe DES had a prevalence rate of 15%, 77.5 %, and 7.5 %, respectively, according to the OSDI Survey. 50 % are White, 35 % are African Americans, 7.5 % are Asian, and 7.5% are Hispanic. The prevalence of mild DES during COVID is 77.5%, with 64.50 % of males and 35.50% of females. Conclusions : The prevalence rate of DES during COVID is high which contribute to the fact of wearing the mask, the use of electronic devices and working remotely.

Innovation of eye care of the critically ill patient within ICU

Introduction: Quality improvement (QI) is a systemic multidimensional approach to ensure the care provided by health professionals is safe, effective, person-centred, timely, efficient and equitable (The Health Foundation 2013). Within critical care, standards are set by organisations to provide up to date good quality care to all patients. The author identified an increase in patient proning over the last 12 months due to the Covid-19 pandemic, resulting in a large increase in incidents of eye injury by 30%, with 2 patients receiving ophthalmology treatment and manual closure of the eye. The cases highlighted could have been potentially avoidable with a standardised approach to care. Objectives: Patients within critical care are high risk for injury due to facial oedema, reduced conscious level and treatment interventions. The Intensive Care Society (ICS) endorsed a guideline to prevent eye injury and increase education surrounding the subject (Intensive Care Society 2020). Variability is still significantly affected in practice with the author's unit demonstrating a low compliance compared to ICS standards of >90% compliance. The specific aim for the author's intervention in practice was to implement changes in practice to increase compliance in line with ICS standards for eye care within critical care in 6 months. Method: Ocular surface disease is common within the author's practice with 20-42% of patients developing corneal epithelial defects (Johnson & Rolls 2014). Cases highlighted as 'severe incidents of harm' within the author's area of practice could have been avoided with a standardised approach to care. Despite the high number of patients effected by this issue there is a severe lack of education and documentation surrounding eye care within critical care. The team implemented structured educational guidance and documentation to improve compliance within critical care to reach ICS standards. Audit of assessment, treatment and documentation of nursing notes was completed at 3, 6 and 12 monthmarks whilst using a formative evaluation approach which looks at the improvement project as it evolves and suggests ways in which it can be improved. Results: Post intervention data identified an increase to 100% of patients receiving eye care. Implementation of the documentation and education to bedside nurses increased assignment of eye grade from 0% to 90% and documentation of eye care increased from 60% to 95%. 95% of nurses were confident in completing eye assessment, grading and relevant treatment compared to 0% pre intervention. Future aims are to monitor all reported eye related injuries and maintain >90% compliance in line with evidenced based practice and national guidelines. Conclusion: The study identified a significant problem in critical care that was causing potential preventable patient harm. The results of this QI project are generalisable to other areas by increasing patient safety and staff education on the potential harm of ineffective eye care within critical care. Further research and work are required to develop awareness surrounding eye care in the critically ill.

Prevalence and Risk Factors Associated with Symptomatic Dry Eye in Nurses in Palestine During the COVID-19 Pandemic.

Introduction: Working in closed wards at hospitals during night-time shifts and using electronic health records may raise the risk of dry eye disease in nurses. Objective: The purpose of the current study was to assess the prevalence and associated factors of dry eye disease among hospital nurses in the North West Bank, Palestine. Methods: A descriptive cross-sectional study. The study included 300 nurses who work at hospitals in the North West Bank, Palestine. The Ocular Surface Disease Index (OSDI) questionnaire on dry eye disease was used to estimate the prevalence of symptomatic dry eye disease. Results: The percentage of dry eye disease prevalence among study participants was 62% with an OSDI score of >13 (mild to moderate and severe OSDI status). Nurses who wore contact lenses worked during the night-time, and worked in the intensive care unit were more likely to report significantly higher OSDI scores (p < .05). Moreover, gender, smoking, and computer use were not statistically associated with dry eye disease (p > .05). Conclusion: Symptomatic dry eye disease is one of the most common ocular diseases among hospital nurses in Palestine.

Role of Neutrophils on the Ocular Surface.

The ocular surface is a gateway that contacts the outside and receives stimulation from the outside. The corneal innate immune system is composed of many types of cells, including epithelial cells, fibroblasts, natural killer cells, macrophages, neutrophils, dendritic cells, mast cells, basophils, eosinophils, mucin, and lysozyme. Neutrophil infiltration and degranulation occur on the ocular surface. Degranulation, neutrophil extracellular traps formation, called NETosis, and autophagy in neutrophils are involved in the pathogenesis of ocular surface diseases. It is necessary to understand the role of neutrophils on the ocular surface. Furthermore, there is a need for research on therapeutic agents targeting neutrophils and neutrophil extracellular trap formation for ocular surface diseases.

The 17-Item Computer Vision Symptom Scale Questionnaire (CVSS17): Translation, Validation and Reliability of the Italian Version.

BACKGROUND: To validate the 17-item Computer Vision Symptom Scale questionnaire (CVSS17) in Italian. METHODS: Cross-sectional validation study on video terminal (VDT) users and a reference sample of subjects not working at a VDT (control group), cognitively able to respond to a health status interview. The Italian self-administered version of the CVSS17 questionnaire was administered to all participants. The reliability and validity of the Italian translation of the CVSS17 were tested using standard statistical methods for questionnaire validation. The Rasch analysis was performed as well. RESULTS: A total of 216 subjects were enrolled. Concerning the reliability, the Cronbach's alpha coefficient was 0.925 (from 0.917 to 0.924), and the test-retest stability was 0.91 (<0.001). Concerning the validity, the control group had significantly better scores, and there were good correlations between responses to the CVSS17 and analogous domains of the GSS. CONCLUSION: The Italian version of the CVSS17 has shown psychometric properties comparable to those of the Spanish version, having good validity, discriminatory power, internal consistency and reliability. The questionnaire is a specific measure of vision-related quality of life in Italian-speaking VDT workers and can be used both in clinical practice and for research purposes.

Spontaneous face- and eye-touching: Infection risk versus potential microbiome gain.

The COVID-19 pandemic has piqued interest in spontaneous face-touch as a possible route of microbial infection, with eye-touch of particular importance since the ocular surface is a likely portal of human Coronavirus infection. Spontaneous face-touching is a poorly understood, ingrained habit for humans, who engage in this activity on average between 9 to 162 times per hour. Nearly half of spontaneous face-touches involve mucous membranes, and one third of those involve the eyes. The infective sequelae of self-touch are well documented in ophthalmological conditions such as infectious conjunctivitis, with risks for ocular surface disease beyond primary infection from pathogens such as human papillomavirus. Through tear film conveyance via the nasolacrimal duct, ocular surface pathogens may furthermore have access to the nasopharynx, oropharynx, and respiratory/gastrointestinal systems beyond. Ocular surface and face self-touch therefore represent a concerning possible method of not only local, but also systemic, self-inoculation. Conversely, microbial diversity in the mutualistic microbiome is being increasingly implicated as integral for developing immunity, and protecting against endocrinological and neurodegenerative disease, including those that affect the eye. Spontaneous face-touch brings the hands, the part of the body most in contact with the external world and with the highest temporal diversity, into direct contact with the body's multiple microbiomes. The authors hypothesise that spontaneous self-touch may represent an important mechanism by which the skin, ocular surface, gastrointestinal, and respiratory tracts maintains microbial diversity and prevents dysbiosis. It may be that whilst the eyes are at risk of infection through self-touch, they may paradoxically benefit through the acquisition of a mutualistic microbiome, protective not only for the eyes, but for the body as a whole.